Potentially Life-Threatening Causes Neck trauma is a common cause of neck pain and stiffness (see Chapter 112 Neck Trauma ) Fortunately, serious injuries to the cervical spine (fractures, subluxations, and spinal cord injuries) are uncommon, especially in children younger than years Because of a higher fulcrum of the cervical spine and relative weakness of the neck muscles compared to adults, these injuries generally occur in the upper cervical spine in younger children, as opposed to more widely across the cervical spine in older children and adolescents Neck injuries in children most commonly result from high kinetic energy mechanisms, such as motor vehicle–related collisions, sports injuries, and falls Fractures of the Cervical Spine Fractures of the cervical spine in children are very uncommon, occurring in 1% to 3% of hospitalized pediatric trauma patients Although some children with fractures of the cervical spine are unresponsive at the time of evaluation, most are alert and verbal, limit their neck movement secondary to pain, and have no demonstrable neurologic deficits At the minimum, the cervical spine should be immobilized and imaging of the cervical spine should be obtained on any child with an altered level of consciousness, pain or stiffness of the neck, midline neck tenderness on examination, any neurologic deficits, or distracting painful injuries after blunt trauma Imaging should also be obtained in those who are unable to perceive pain (e.g., as a result of alcohol or drugs) or describe their symptoms A large prospective study, the National Emergency X-Radiography Utilization Study (NEXUS), of blunt trauma victims identified five criteria (posterior midline cervical tenderness, altered alertness, distracting injury, intoxication, and focal neurologic signs) that identified all children with cervical spine injuries; however, there were few children younger than years and none younger than years with cervical spine injuries in that study A multicenter attempt to retrospectively validate the NEXUS criteria among a different cohort of children (including those younger than years) demonstrated a lower sensitivity, suggesting the need for refinement of these criteria before routine use in children A case-control study of 540 children with cervical spine injuries identified eight important risk factors: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle collision mechanisms A study to prospectively refine risk factors, particularly in younger children, is currently underway Results of the pilot study suggest that a prediction rule in children is feasible