Cervical spine fracture, subluxation of the vertebral bodies, or SCIWORA syndrome may result from high-risk mechanisms of injury (e.g., motor vehicle collision, pedestrian struck by motor vehicle, falls from heights, or high-impact sports activities). The larger head size, weaker neck muscles, and increased ligamentous laxity render children more likely to sustain injury in the upper cervical area as compared with adults, who are more likely to sustain lower cervical injuries.

Cervical spine injury should be suspected in the patient with a high-risk mechanism of injury or suggestive signs or symptoms: pain on neck palpation, neck muscle spasm, limited range of motion, torticollis, transient or persistent sensory changes, hyporeflexia, muscle weakness or flaccidity, priapism, bladder or bowel dysfunction, or hypotension with bradycardia (spinal shock). In addition, in the nonverbal or uncooperative child or the child who has an altered mental status or an associated severe head injury, the physical examination may be difficult or unreliable. In these children, the possibility of cervical spine injury should be considered at the outset of the evaluation and spinal immobilization and precautions maintained until proved otherwise.

Suspected cervical spine injury generally requires emergent evaluation. The child should be immobilized with a rigid cervical collar. The evaluation should begin by assessing the patient’s respiratory and hemodynamic status. Then, a complete sensory and motor neurologic exam should be performed. In some alert, verbal, and cooperative children, an attempt to “clinically clear” the cervical spine may be made through a careful physical examination. A careful examination of the cervical spine with the collar removed, but with manual immobilization maintained, should yield no tenderness or deformity. At this point, the patient may be
allowed to attempt active (not passive) neck flexion, extension, and lateral rotation. Any limitation or complaint of pain with range of motion should prompt the immediate reinstitution of cervical spine immobilization followed by cervical radiography. The radiographic evaluation should include a minimum of three views: the lateral, anteroposterior, and open-mouth (odontoid) radiographs. Flexion and extension views are used to assess for ligamentous injury in a child with persistent neck pain after a normal three-view series. Computed tomography (CT) scan provides excellent bone detail, whereas magnetic resonance imaging (MRI) scan is used to evaluate the soft tissues and spinal cord.

The odontoid process of the second cervical vertebrae is normally positioned squarely within the ring of C1, and the two vertebrae are secured by the transverse and alar ligaments. The increased laxity and longer lengths of the ligaments renders children more susceptible to traumatic cervical spine injury than their adult counterparts.

As the name implies, in patients with rotary subluxation, C1 and C2 are rotationally malpositioned. This commonly results from a minor traumatic mechanism, as might occur during light wrestling or gymnastics. Some conditions such as tonsillectomy (Grisel syndrome), upper respiratory infections, or juvenile rheumatoid arthritis may cause inflammation and laxity of the transverse ligament, resulting in C1—C2 instability with rotary subluxation. In addition, certain conditions such as Down syndrome or congenital odontoid dysplasias may predispose to rotary subluxation.

Patients commonly present with neck pain or stiffness. Physical examination reveals torticollis, tender paracervical muscles, and decreased range of motion of the neck. The torticollis results as the ipsilateral sternocleidomastoid muscle attempts to reestablish normal positioning. Rotary subluxation is a stable cervical spine injury, rarely causing spinal cord impingement, and neurologic signs are infrequently encountered.

The lateral radiograph may be normal or show distorted anatomy. Particular attention should be paid to check the predental space that may be widened. The diagnostic modality of choice, however, is the static and dynamic neck CT scan. A static CT scan usually shows the asymmetric location of the dens within the anterior arch of C1. In the dynamic CT, the rotation of C2 on C1 is fixed, persisting despite lateral rotation of the head to both directions.