Initial Management at Presentation
Cervical spine injury should be suspected in a child if the history suggests an appropriate mechanism (e.g., MVA, fall from a height, sporting injury) or if there is unexplained neck pain or a neurological deficit following trauma of any kind.
- ABCs: The principles of emergency trauma management should be followed with an initial emphasis on securing an adequate airway and then maintaining sufficient breathing and blood circulation.
- Immobilize the spine: Immobilization of the cervical spine is imperative. In situations of polytrauma, whole spine immobilization on a spinal board should be instituted at the scene and maintained pending radiological investigations.
- Adjust treatment to fracture: Once the child is stabilized and the spine injury assessed the treatment is then adjusted to fracture and the degree of instability – see Treatment of Spine Injuries in Children.
- Analgesia: Appropriate pain relief should be prescribed. The efficacy of analgesia needs to be regularly monitored. Simple analgesics (acetaminophen, paracetamol and non-steroidal anti-inflammatory drugs) may suffice in more minor injuries.
- Cervical collar: Rigid cervical collars are the most appropriate initial means of immobilization in most subaxial cervical injuries. Collars should be securely fitting and tight enough to restrict movement without causing discomfort.
- Halo-body vest: This is the most effective form of external cervical immobilization and is particularly indicated for high cervical injuries. In children halo vests are best applied under general anesthesia with x-ray imaging to ensure optimal traction and alignment of the craniocervical region.
- Initial follow-up within two weeks: Most cervical spine injuries in children do not require surgical intervention and can be effectively treated with external immobilization alone. If neck pain and tenderness have completely resolved and full range of movement restored with no neurological symptoms after two weeks, then further follow-up is not required.
- X-rays at initial follow-up: If initial radiological investigations revealed a fracture, then repeat imaging is indicated to ensure that spinal alignment has not deteriorated or fracture displacement worsened. If no initial injury was demonstrated yet symptoms persist in spite of conservative measures, then repeat imaging may also be required. Dynamic X-rays or MRI need to be considered in such cases.
- Skin integrity must be monitored: Rigid collars can lead to pressure sores. Halo pin sites need to be inspected for signs of infection or loosening. Collars should be replaced if they become soiled, deformed, or broken.