Clinical Practice Guidelines

Cervical spine assessment

  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  •  All children under 16 years of age with major trauma (including confirmed or highly suspected spinal cord injury) should have ongoing management at Royal Children's Hospital. See State Trauma Guidelines

    In Victoria, the Paediatric Infant Perinatal Emergency Retrieval (PIPER) service is available to retrieve critically injured children from referral hospitals and provide safe, expert, emergency inter-hospital retrieval. The earlier contact is made with PIPER, the earlier assistance can be dispatched to the hospital.

    See also:

    Major paediatric trauma – The primary survey


    Traumatic injuries of the cervical spine (C-spine) are uncommon in children.  However, it is typical to assume there is a cervical spine injury until examination and/or radiological investigation demonstrate otherwise.  It is often challenging to assess and immobilise children when a C-spine injury is suspected.

    • Frequent reassurance is required to help keep the child still and reduce their anxiety levels.
    • If the child is anxious or uncooperative and a thorough examination is not possible, try and maintain in line C-spine immobilisation.
    • Early provision of simple analgesia (paracetamol / ibuprofen) and early review by a senior clinician who is experienced in the management of paediatric C-spine assessment may avoid prolonged periods in C-spine collars.

    Patients requiring cervical spine immobilisation

    Any patient with a history of trauma requires C-spine immobilisation, if the patient:

    • Is unconscious (GCS <13)
    • Is complaining of neck pain or midline tenderness or has limitation of movement
    • Is using their hands to support neck
    • Has any neurological deficit
    • Has significant head /facial/upper torso injuries
    • Has traumatic torticollis
    • Is substance affected (not analgesia) with suspicious mechanism
    • Has any conditions known to predispose to C-spine injury including rheumatological, congenital, metabolic, genetic conditions or previous C-spine surgery. These patients may sustain C-spine injury with a less severe mechanism.

    Note: ‘Distracting Injury’ is not a contraindication for removal of the cervical collar. Any injury below the upper torso should not be regarded as a distracting injury for the purpose of C-spine assessment.

    Mechanism is more relevant in patients who are unable to be adequately assessed ie preverbal, disoriented/confused, developmental delay etc. Any patient who cannot be adequately assessed for clinical signs AND could have any of the following mechanisms of injury should be immobilised:

    • Pedestrian / cyclist hit > 30km/hr.
    • Passenger – MVA collision > 60km/hr.
    • Fall - more than 3 metres.
    • Kicked by, or fall from a horse.
    • Backed over by a car.
    • Thrown from vehicle.
    • Severe electric shock.


    Patients with suspected or possible C-spine injury must have their neck immobilised until formal assessment occurs.

    Sand bags and tape are NOT recommended in the hospital setting

    Spinal boards: all children should be taken off spinal board at time of transfer from ambulance trolley.

    Thoracic Elevation Device (TED): Children have a head which is disproportionately larger than their neck and bodies.  When placed flat on a firm surface the size of the head tends to force the neck into flexion losing the desired neutral spine position and potentially obstructing the airway.  Children less than 8 years should be placed on a TED

    Immobilisation technique:

    1. Apply manual in-line immobilisation
    2. Apply a one piece hard collar: ensure appropriate sizing or check sizing of collar in situ.
    3. If any of the following apply, manual in-line immobilisation without a collar should be maintained:
      • Uncooperative patient - constant reassurance is required to reduce anxiety.  If a thorough examination is not possible, seek senior assistance.
      • Infant/baby too small for one-piece collar
      • Child with traumatic torticollis (child with a significant injury will hold their neck in a position of comfort – maintain inline immobilisation in this position)
    4. Ensure adequate analgesia is provided.
    5. Occipital-cervical dissociation is more prevalent in children less than 8 age years of age and is not made stable by applying a collar.  If a patient is intubated, unconscious or there is a high suspicion of this type of C-spine injury (e.g. in a high velocity motor vehicle accident) – lateral bolsters can be applied (e.g. rolled up towels on each side of the patient’s head.) Sandbags/tape should NOT be used.

    Assessment of the C-spine

    If abnormal neurology – contact neurosurgery immediately

    To be able to adequately assess the patient, he/she must:

    • Be conscious
    • Be cooperative
    • Not be affected by alcohol or recreational drugs
    • Be developmentally able to engage in the assessment process.

    C-spine assessment, clearance and X-ray interpretation ought to be conducted in consultation with a senior clinician with sufficient experience in the assessment of the paediatric C-spine. 

    • Prior to palpation, ask the patient if he/she has any neck pain, weakness, paralysis or paraesthesia with age appropriate questioning.  If there is abnormal neurology, consult with Neurosurgery.  
    • Whilst maintaining in-line immobilisation, gently palpate the posterior midline of the neck – feeling from the nuchal ridge to the 1st thoracic vertebra (The most prominent spinal process arises from the C7 vertebra).  Repeat the process lateral to the midline on both sides.  Tenderness laterally may indicate muscular or soft tissue injury.
      • If there is no midline tenderness and no abnormal neurology, assess the active range of movement of the neck by asking the patient to slowly rotate his/her head 45 degrees to the left and right, stopping if this causes pain or abnormal sensations in their arms.
      • If the patient is able to move the neck without pain and without developing any neurological symptoms, the collar may be removed, and the C-spine cleared.
    • If the assessment reveals midline C-spine tenderness or painful or limited neck movements, the cervical collar / immobilisation should be reapplied and X-rays obtained of the C-spine.  X-rays should be reviewed by a senior clinician who has also examined the patient.
    • If the x-rays are normal and there has been resolution of the midline tenderness or limitation of movement, the C-spine can be cleared.
    • Abnormal x-rays require discussion with the appropriate surgical team.  Patients should be immobilised in an appropriately sized two piece collar (eg Aspen / Philadelphia collar)

    If patient is unable to be assessed, immobilisation should be maintained. 


    Patients with signs and symptoms suggestive of possible C-spine injury or those with suspicious mechanism who cannot be reliably assessed, require plain x-rays.
    It is imperative that the senior person making the clinical decision regarding clearing the c-spine has both examined the patient and viewed the films.
    All patient transfers (on/off x-ray tables, CT scan etc.) must be done using a patient-slide, with clinical staff maintaining in-line immobilisation.
    The collar and TED pad should remain in place with the patient during the cervical spine x-ray series.


    SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) is an outdated term, but refers to a patient sustaining significant injury without bony fractures. Therefore, a “normal” xray and CT does not exclude spinal injury. This occurs in children, predominantly less than eight years of age, and may be the result of lax ligamentous support and immature bony structures or cord ischemia due to vascular injury or hypoperfusion.  The presence of neurological symptoms, even if there is  a normal x-ray and normal CT, requires consultation with a senior Emergency Department doctor initially, and neurosurgery if required.

    What to x-ray

    • ≤5yrs = AP and lateral x-ray only
    • 6yrs or older = AP, lateral and odontoid x-rays
    • Lateral X-rays should include Occiput to T1 (may require shoulder traction to visualize this level)

    Lateral c-spine

    • Most important view.
    • Portable film can be taken (e.g.: in resuscitation bay)
    • If the cervico-thoracic C7-T1 junction has not been satisfactorily imaged, a single attempt at a swimmer’s view may be obtained.
    • Flexion and extension views should not be performed

    AP and Odontoid (Peg) view

    • Non urgent - may be taken after priority CT imaging of other body regions if required
    • For odontoid view the collar may be opened – but ensure in line neck immobilisation is maintained.

    Further imaging of C-Spine

    • Patients with abnormalities on plain c-spine x-rays should be discussed immediately with the orthopaedic team (RCH) or neurosurgical team (MMC).
    • All intubated patients requiring CT brain should be discussed with neurosurgery to see if a CT cervical spine is also indicated.
    • A normal CT of the cervical spine does not exclude injury in the unconscious patient and an MRI scan may be required.
    • Patients in whom the cranio-cervical or cervico-thoracic junction remain obscured after a single extra view should not have repeated attempts at plain imaging but have a CT of the relevant area


    Patients with normal x-rays should be reassessed clinically for:

    • Posterior Midline Tenderness
    • Range of Motion of cervical spine
      • Flexion/extension
      • Lateral Flexion (left and right)
      • Lateral Rotation (left and right)

    If there is no tenderness and afull range of motion is preserved then the collar may be removed.    

    Patients with persistent posterior midline tenderness, or unable to be clinically assessed, but with normal x-rays of the cervical spine can be classified as below:

    The Ambulant, Otherwise Well Patient with Midline Tenderness +/- Decreased Range of Movement:

    • These patients should be placed in a 2 piece collar within 4 hours of arrival in ED
    • The patient may be discharged home wearing the 2 piece collar and reviewed clinically in the Orthopaedic Fracture clinic in 1-2 weeks.
    • If there is persistent midline tenderness at the 1-2 week follow-up
      • Spine can be deemed stable with normal flexion-extension x-rays, and the collar removed

     -     2-piece collars should only be fitted by those staff trained to do so

     -     A handout should be provided to the family  

    Patients with Other Significant Injuries and Decreased Range of Motion/Midline Tenderness:

    -      The cervical spine cannot be safely cleared in a patient with midline tenderness/decreased     range of motion and other significant injuries. 

    • A 2 piece collar should be fitted before departure from ED
    • Immobilisation should be maintained if surgery is required.  Regular reassessment by the treating surgical team is required (within 12 hours) and MRI ordered if the spine cannot be cleared clinically.  

    The Obtunded/intubated Multi-Trauma Patient:

    • A 2 piece collar should be fitted before departure from ED
    • These patients lack protective sensation and have a higher risk of collar-related ulcers and pressure areas
    • MRIof the cervical spine should be performed as soon as the patient has been stabilized and can safely transferto the radiology department.
    • Cervical spinal precautions may be ceased with a normal MRI (no clinical assessment is needed)

    Ongoing care

    The following should be documented following discussion with the managing unit:

      C -spine T- Spine L- spine
    Area of suspected/identified injury


      Yes No
    2-piece collar on at all times
    Strict bed rest and log-roll if mobilization of patient needed for nursing/examination – maintain reverse Trendelenburg tilting
    TED mattress should be kept in situ
    Bed can be tilted from the hips
    Can ambulate with collar in situ

    Pressure area care is important for all patients requiring immobilisation, and should be considered from initial presentation. Air mattresses are not recommended until c-spine has been cleared.


    When to consider transfer to tertiary centre:

    • All children with major trauma, including suspected or confirmed spinal injury should have ongoing management in the major trauma centre (RCH).
    • Child requiring care beyond the comfort level of the hospital.
    • For advice and inter-hospital (including ICU level) transfers ring PIPER: 1300 137 650 

    Information specific for RCH

    Documentation: Use the Major Trauma management record for documentation of spinal assessment and plan

    Further imaging (including CT, MRI) must be discussed with the Emergency Consultant or Orthopaedic/Neurosurgery Registrar, and the Medical Imaging Fellow/Consultant. 
    Intubated patients requiring CT brain should be discussed with Neurosurgery.


    • Neurological Signs/Symptoms with C-spine injury or unable to assess in ED due to head injury = Neurosurgery
    • Patients with abnormal/equivocal Radiology (X-ray or MRI) or high clinical suspicion of C-spine injury = Orthopaedics.
    • Outpatient follow-up for ambulant patients = Orthopaedics 


    Patients with multiple injuries are admitted under General Surgery with Neurosurgical and/or Orthopaedic input.
    Patients with isolated spinal cord injury are admitted under Neurosurgery.

    Information specific for monash health

    The Neurosurgery Unit at Monash Children’s provides a service for assessment of paediatric patients with brain and spinal injuries. All patients with suspected injury should be discussed with the Neurosurgery Unit (03 9594 6666).

     Flowchart: Assessment of the cervical spine

    Assessment of the Cervical Spine