The retrospective review of children with low falls described eight children who had CSI after a low fall. (42) All eight patients had neck symptoms at the time of diagnosis. Unfortunately, the time of onset of these symptoms was not reported in the series.
Additionally, the data on SCIWORA reveal that any neurologic symptoms can be markers of SCIWORA. The data from one group report that all 32 patients in that series with SCIWORA had symptoms upon initial presentation, although some were isolated sensory deficits. (22) The data by another author note a percentage of children with SCIWORA that had a normal examination on presentation yet had neurologic deterioration days later. (46,47)
In summation, a review of all the significant published series of children with CSI does not identify any criteria or criterion that will assure that a child, especially a pre-verbal or pre-cooperative child, is at low risk of an unstable CSI. Because SCIWORA exhibits a spectrum of presentations, the clinician must maintain diagnostic vigilance in any child with any neurologic symptoms. This is in contrast to the adult, in which one may consider transient, painful, radicular symptoms to be markers of Peripheral nerve injury due to neck loading (i.e., the football player with a "stinger").
While noting from the above information that neck tenderness and possibly pain suggest a high-risk group, the converse is not tree. How shall the clinician identify a high-risk group deserving radiographic evaluation among those without neck symptoms, those without neurologic symptoms, or those who are pre-verbal or pre-cooperative? The clinician must have a rough idea of the type of impact necessary to cause CSI, especially in the infant and toddler. Table 3 combines an arbitrary definition of high impact with somewhat arbitrary clinical criteria to produce guidelines for identifying children who may need radiographic evaluation of the Cervical spine.
Radiographic Evaluation. Once the decision is made to obtain radiographic imaging, what are the appropriate studies to obtain? Authors vary on the routine studies for evaluation of the cervical spine. Some authors recommend a lateral view that visualizes the atlanto-occipital joint to the [C.sub.7]-[T.sub.1] joint, an Antero-posterior (AP) view, and an open-mouth odontoid in the cooperative patient. (12,48) Others advocate the three-view series for all patients. (10) A recently published survey of 432 pediatric radiologists notes that 40% of responders do not obtain the odontoid view in children younger than 5 years of age. (49) Another 25% only make one attempt at obtaining that view. Older recommendations suggested a five-view series for all patients, which included oblique views in addition to the standard three views. (50)
New data are available that suggest that computed tomography (CT) scanning of the cervical spine may be faster than obtaining plain films, especially in the patient who is to have a post-traumatic CT Scan of another body region. (51-53) However, the role and accuracy of this technique have not been defined outside the multiple trauma patient.
