associated with a hypoplastic dens This leads to a risk of increased mobility and cord injury at the C1–C2 level and may require surgical stabilization This condition can be confused with a fracture at the base of the odontoid The ossiculum terminale is a small ossicle at the tip of the dens ( Fig 112.36 ) It is seen in most children, fusing with the rest of the dens by adolescence This ossicle can be large and associated with a hypoplastic dens, as previously described FIGURE 112.35 Example of os odontoideum Note the hypoplastic dens and overgrown ossiculum terminale or ossiculum odontoideum (O ) The arrow indicates posterior displacement, attesting to instability of the lesions (Reprinted with permission from Swischuk L Emergency Radiology of the Acutely Ill or Injured Child 2nd ed Baltimore, MD: Williams & Wilkins; 1986:717.) Spinal epidural hematomas are also seen in the pediatric population These hematomas are venous bleeds that compress the adjacent spinal cord and present hours or days after a sometimes minor traumatic event, with ascending neurologic symptoms as the bleed progresses An MRI scan can be helpful in evaluating these patients ( Fig 112.37 ) Rapid evaluation and surgical decompression are mandatory Treatment of children with suspected cervical spine injuries may involve basic and advanced life-support measures, initiation and/or maintenance of immobilization, and neurosurgical or orthopedic consultation Airway support for patients with traumatic quadriplegia should be anticipated because they will develop respiratory failure as their respiratory muscles fatigue Children may present in spinal shock (hypotension, bradycardia, peripheral flush) from the loss