obtaining unnecessary CT scans of the cervical spine introduces increased risk of malignancy due to ionizing radiation exposure, especially for the thyroid, that is 5- to 35-fold higher in children than in adults undergoing the same study with risk inversely proportional to age and increased in female patients The issue of radiation exposure needs to be considered when developing institution-specific protocols The CT scan images soft tissue well; however, it does not approach the intrathecal, ligamentous, disc, or vascular detail that can be obtained with an MRI scan MRI scans are more appropriate when evaluating the subacute or chronic stages of injury, ligamentous instability or disruption, or, as recommended by the American Academy of Neurological and Orthopaedic Surgeons when looking for an acute problem with cord or root impingement Acute MRI evaluation is increasing in popularity in the cervical spine evaluation of patients with altered mental status However, MRI does not image the cortical bone well and should not be used as a primary tool to evaluate the cervical spine for fractures Additionally, many children may require sedation Thus, the C-spine is better evaluated by CT or plain radiograph Debate and practice variation exists regarding the clearing of the cervical spine in a persistently obtunded patient This should not be an ED debate or practice, since obtunded pediatric patients should not have their cervical spine cleared in the ED Clinical Considerations Clinical Recognition The clinician must assume that all children who sustain multiple trauma, including infants with suspected abusive head trauma, have significant head or neck injuries, possible neurologic impairment, and a cervical spine injury until proven otherwise The devastating nature of a cervical cord injury makes it imperative not to miss a potentially unstable cervical spine injury Triage Considerations Patients with potential cervical spine injury should be evaluated in an expeditious manner and placed in a hard collar to immobilize their cervical spine Their evaluation will potentially include radiographic and laboratory studies, specialty consultation, and continued close monitoring in the ED Removal of a hard spine board should occur as soon as possible to avoid unnecessary pain, risk of pressure sores and skin breakdown, and respiratory compromise Early transfer to a