Original Article

OPEN: Incidence of Pediatric Cervical Spine Injuries in Iraq and Afghanistan

Authors: Xandria Gutierrez, BA, Michael April, MD, DPhil, Joseph Maddry, MD, Guyon Hill, MD, Tyson Becker, MD, Steven Schauer, DO, MS


Objective: Military providers frequently treat civilians, including pediatric patients. Cervical spine injuries in pediatric trauma patients occur infrequently, with limited data on the incidence. The aim of this study was to describe the incidence of cervical spine injuries in pediatric patients in Iraq and Afghanistan.

Methods: We queried the Department of Defense Trauma Registry for all pediatric encounters from January 2007 to January 2016. We searched within that dataset for all cervical spine fractures.

Results: From January 2007 through January 2016 there were 3439 pediatric encounters. There were 36 subjects identified (1.0%) with a cervical spine fracture. Of those with a cervical spine fracture, 6 (17%) had a prehospital cervical collar placed, which did not improve survival to hospital discharge (collar, 66.7% vs no collar, 83.3%, P = 0.573). Of those with a cervical spine fracture, 6 (17%) had a documented spinal cord injury. The median age of subjects with a cervical spine fracture was 9.5 years and the majority (63.9%) were male. Most were injured by explosion (41.7%). The median composite injury score was higher in subjects with a cervical spine fracture compared with those without one (16.5 vs 10, P < 0.001). Subjects with a cervical spine fracture had longer lengths of stay in the intensive care unit (median 3 days vs 1, P = 0.012) and a trend toward worse survival to hospital discharge (80.6%, n = 29, vs 90.3%, n = 3074, P = 0.079).

Conclusions: Cervical spine injuries occurred infrequently in pediatric patients in Iraq and Afghanistan. When a fracture was present, almost one in five patients had spinal cord involvement. The pediatric prehospital literature would benefit from the development of a clinical decision tool to guide prehospital personnel as to when a cervical collar is indicated. Moreover, appropriate size equipment should be available when caring for host national civilians.

Full Article

Having trouble viewing the article content below? Click here to open it directly.


Table 1. Demographics and outcome data of subjects with a cervical spine fracture

Download Image

Table 2. Serious injuries (AIS ≥3) by body region

Download Image


1. McGuigan R, Spinella PC, Beekley A, et al. Pediatric trauma: experience of a combat support hospital in Iraq. J Pediatr Surg 2007;42:207-210.
2. Creamer KM, Edwards MJ, Shields CH, et al. Pediatric wartime admissions to US military combat support hospitals in Afghanistan and Iraq: learning from the first 2,000 admissions. J Trauma 2009;67:762-768.
3. Mikrogianakis A, Grant V. The kids are alright: pediatric trauma pearls. Emerg Med Clin North Am 2018;36:237-257.
4. Kenefake ME, Swarm M, Walthall J. Nuances in pediatric trauma. Emerg Med Clin North Am 2013;31:627-652.
5. Seid T, Ramaiah R, Grabinsky A. Pre-hospital care of pediatric patients with trauma. Int J Crit Illn Inj Sci 2012;2:114-120.
6. Bauman BH, McManus JG, Jr. Pediatric pain management in the emergency department. Emerg Med Clin North Am 2005;23:393-414.
7. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics 2001;108:793-797.
8. Kokoska ER, Keller MS, Rallo MC, et al. Characteristics of pediatric cervical spine injuries. J Pediatr Surg 2001;36:100-105.
9. Baker C, Kadish H, Schunk JE. Evaluation of pediatric cervical spine injuries. Am J Emerg Med 1999;17:230-234.
10. Platzer P, Jaindl M, Thalhammer G, et al. Cervical spine injuries in pediatric patients. J Trauma 2007;62:389-396.
11. Partrick DA, Bensard DD, Moore EE, et al. Cervical spine trauma in the injured child: a tragic injury with potential for salvageable functional outcome. J Pediatr Surg 2000;35:1571-1575.
12. Patel JC, Tepas JJ, 3rd Mollitt DL, et al. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg 2001;36:373-376.
13. Ribeiro da Silva M, Linhares D, Cacho Rodrigues P, et al. Paediatric cervical spine injures. Nineteen years experience of a single centre. Int Orthop 2016;40:1111-1116.
14. Finch GD, Barnes MJ. Major cervical spine injuries in children and adolescents. J Pediatr Orthop 1998;18:811-814.
15. Browne LR, Schwartz H, Ahmad FA, et al. Interobserver agreement in pediatric cervical spine injury assessment between prehospital and emergency department providers. Acad Emerg Med 2017;24:1501-1510.
16. Leonard JC, Mao J, Jaffe DM, et al. Potential adverse effects of spinal immobilization in children. Prehosp Emerg Care 2012;16:513-518.
17. Schauer SG, Hill GJ, Naylor JF, et al. Emergency department resuscitation of pediatric trauma patients in Iraq and Afghanistan. Am J Emerg Med 2018;36:1540-1544.
18. Schauer SG, April MD, Hill GJ, et al. Prehospital interventions performed on pediatric traumapatients in Iraq and Afghanistan. Prehosp Emerg Care 2018;22:624-629.
19. Glenn MA, Martin KD, Monzon D, et al. Implementation of a combat casualty trauma registry. J Trauma Nurs 2008;15:181-184.
20. O'Connell KM, Littleton-Kearney MT, Bridges E, et al. Evaluating the Joint Theater Trauma Registry as a data source to benchmark casualty care. Mil Med 2012;177:546-552.
21. d'Amato C. Pediatric spinal trauma: injuries in very young children. Clin Orthop Relat Res 2005;( 432 ):34-40.
22. Leonard JR, Jaffe DM, Kuppermann N, et al. Cervical spine injury patterns in children. Pediatrics 2014;133:e1179-e1188.
23. Mohseni S, Talving P, Branco BC, et al. Effect of age on cervical spine injury in pediatric population: a National Trauma Data Bank review. J Pediatr Surg 2011;46:1771-1776.
24. Jain A, Brooks JT, Rao SS, et al. Cervical fractures with associated spinal cord injury in children and adolescents: epidemiology, costs, and in-hospital mortality rates in 4418 patients. J Child Orthop 2015;9:171-175.
25. Eleraky MA, Theodore N, Adams M, et al. Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg 2000;92( 1 suppl ):12-17.
26. Chan M, Al-Buali W, Singh RN, et al. Cervical spine injuries and collar complications in severely injured paediatric trauma patients. Spinal Cord 2013;51:360-364.
27. Sundstrøm T, Asbjørnsen H, Habiba S, et al. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma 2014;31:531-540.
28. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 9th ed. Chicago: American College of Surgeons; 2012.
29. Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in Cooperation with the Committee on Trauma of the American College of Surgeons. Prehospital Trauma Life Support (PHTLS). 7th ed. Burlington, MA: Jones & Bartlett Learning; 2010.
30. Hauswald M, Braude D. Spinal immobilization in trauma patients: is it really necessary? Curr Opin Crit Care 2002;8:566-570.
31. National Emergency X-Radiography Utilization Study Group. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-99.