Spinal injuries in children are a clinical challenge for emergency medicine providers. On one hand, spinal injuries are relatively rare and children are at an increased risk for an oncologic process after radiation exposure. On the other hand, spinal injuries can cause significant morbidity and mortality. A thorough history and physical examination can help risk-stratify imaging assessment to detect serious injury. This evidence-based, state-of-the art review will help clinicians understand best practices in imaging decision making for cervical and thoracolumbar spinal injuries in children.