Patients often arrive in the ED with full or partial cervical spine immobilization already in place An immediate assessment of this immobilization is imperative Several important issues should be considered: (i) Is the patient appropriately and fully immobilized? (ii) Is the cervical collar of the correct size and type for the patient? (iii) Is the patient’s neck in a neutral position? (iv) Is the patient securely strapped to a long spine board? (v) Has there been a shift in the patient or the immobilization during the prehospital or interfacility transport that might diminish effective immobilization, cause hyperflexion or hyperextension of the cervical spine, or compromise excursion of the chest with respiration? and (vi) Does the immobilization interfere with the assessment or management of the ABCs? If these or other immobilization difficulties are identified, they should be immediately addressed If the patient requires initiation of full spinal stabilization and use of a long spine board, he or she should be secured to the board using tape or straps that cross the forehead and chin area of the cervical collar Appropriate straps should be used to secure the patient to the board at the bony prominences of the shoulders, pelvis, and lower extremities Incorrect immobilization may impede respiration by obstructing chest rise or contributing to secondary spinal injury by hyperextending the neck When a child is immobilized on a spine board, the clinician must remember that the child’s head is disproportionately large compared with that of the adult This disparate growth of the head and trunk causes the neck to be forced into relative kyphotic position when a child is placed on a hard spine board ( Fig 112.12 ) This is distinctly different from the adult patient whose neck is in 30 degrees of lordosis, the neutral position, when immobilized on a hard spine board Figure 112.13 demonstrates how cervical spine alignment can be greatly affected and improved with proper positioning of the pediatric patient on the spine board Finally, remove the spine board as soon as practicable to avoid complications such as pressure sores, pain, or respiratory compromise Consideration of cervical spine radiographic evaluation is the next step in assessment The cervical spine has anterior (vertebral bodies, intervertebral discs, ligaments) and posterior (lamina, pedicles, neural foramen, spinous processes, ligaments) components ( Fig 112.14 ) which require evaluation The provider should be familiar with criteria to potentially clear a child’s cervical spine clinically ( Fig 112.15 ), but recall that regardless of the clearing algorithm embraced or imaging studies performed, they should never clear the cervical spine in an unconscious or obtunded patient in the ED If one is unable to determine whether an injury (and associated pain) are indeed distracting, or if neck pain or