Cervical Spine Injuries

in ChildrenArturo S. Gastañaduy M.D.

Associate Professor of PediatricsLouisiana State University Health

Sciences CenterJuly 2010

Objectives

Importance Epidemiology Mechanisms of Injury Differences: Children vs. Adults Clinical Presentation Initial Management

of Cervical Spine Injuries in Children

Christopher Reeve as Superman

Christopher Reeve Paralyzed

Cervical Spine Injuries (CSI) in Children

EpidemiologyKokoska E. Patel J. Martin B.

Data Source NPTR 1994-1999

NPTR 1988-1998

TARN 1989-2000

Age (years) 0 - 20 0 - 20 0 - 15

Injured Children

24,740 75,172 19,538

CSI number (%)

408 (1.6) 1098 (1.5) 662 (3.4)

Males (%) 59 61 58

Cord Injury (%)

35 29 21.9

Mortality (%) 17 17 13

Cervical Spine Injuries in ChildrenMechanism of Injury

Mechanism

Kokoska E.

Patel J. Martin B.

MVA (%) 44 42 49.8

Sports (%) 16 14 7.4

Falls (%) 14 13 37.6

Pedestrian (%)

11 14 -

Bicycle (%)

6 5 -

Cervical Spine Injury in Children

Mechanism of Injury and Age

Mechanism

Young 0 - 10

Old11 - 20

p

MVA(%) 44 43 ns

Falls (%) 17 12 < .01

Pedestrian (%)

18 4 < .001

Bicycle (%) 3 8 < .01

Sports (%) 6 25 < .001

Cervical Spine Injuries in ChildrenType of Injury

Injury Type Kokoska E.%

Patel J.%

Fracture 56 56

Dislocation 25 22

Fracture/Dislocation

- 5

SCIWORASpinal cord injury

without radiological abnormality

19 17

Head and Cervical Spine Differences Children vs.

Adults Characterist

icsChildren Adults

Head/Body Large Small

Fulcrum C2 – C3 C5 – C6

Neck muscles, spine

ligaments

Weak, lax and elastic

Strong, stiff, ↓ elasticity

Vertebral bodies

Anterior wedging

Cartilaginous

No wedgingossified

Articulating facets

More horizontally

oriented

Vertically oriented

Head and Cervical Spine Differences Children vs.

Adults

Cervical Spine Injuries in Children

Age and Level of Injury

AgeYoung0 -10 years

Old11 -20 years

P

HighC1 – C4

85 56 < .01

LowC5 – C7

15 43 < .01

CSI in ChildrenAge and Type of Injury (from

Kokoska)Type Young

0 - 10Old

11 - 20 p

Fractures (%)

42 65 < .01

Dislocations (%)

31 20 < .01

SCIWORA (%)

27 15 < .01

Cervical Spine Injury in Children

Clinical Presentation Varies widely from: A four year old boy without history

of trauma, who was perfectly well before going to bed last night and woke up with pain to the neck and holds his head tilted to the right.

An unconscious 18 year old brought by EMS after a major MVA with history of multiple trauma including the head and neck.

What do we do?

Cervical Spine Injury ManagementFirst Things First

ABCs Protect Cervical Spine. “All children

with head and neck injuries, multiple trauma, neurological deficits have CSI until proven otherwise”

Goals: Stabilize primary injury and prevent secondary injuries.

Remember 3% - 25% of CSI occur during transit or early in the course of management.

Clearing the C-Spine is not an immediate goal.

Cervical Spine Injury ManagementObtain History

Details of events from patient and others

Mechanism of Injury Signs and symptoms Specific neurologic signs or

symptoms Drug ingestion or intoxication PMH: Previous trauma or surgery

Arthritis, syndromes, others

Cervical Spine Injury in ChildrenPhysical Exam

Motor deficit Sensory deficit Altered mental status Neck tenderness Torticollis Limitation of motion Neck muscle spasm Abnormal reflexes Clonus without rigidity

Diaphragmatic breathing without retractions

Spinal shock ↓BP + ↓HR

Priapism Decreased bladder

control Fecal retention Unexplained ileus Labile BP, flushing,

sweating Temperature

instability

Cervical Spine Immobilization

Hard collar + Spine Board Became familiar with the ones used

in your area Tallest collar that not hyperextend

the neck Backboard with occipital recess or

padding under shoulders and body Straps over the forehead, chin,

shoulders, hips, thighs and ankles. Be ready to log roll the patient if

vomit occurs

Cervical Spine Immobilization Assessment

Is the patient appropriately and fully immobilized?

Is the collar the correct size and type? Is the patient neck in neutral

position? Is the patient securely strapped to the

spine board? Has there been a shift in the patient

or the immobilization during transport?

Does immobilization interfere with the assessment and management of the ABCs?

Cervical Spine Clearing in Pediatric Trauma Patients

Slack SE, Clancy MJ: Comprehensive literature search of the studies on the subject (2004)

241 papers, 71 relevant No “Gold Standard” to identify all

CSI Many papers did not include clinical

follow up Only the National Emergency X-

Radiography Utilization Study NEXUS was considered valid for its purpose.

Clinical Clearing of the Cervical Spine

The NEXUS Study Prospective Observational Study:

34,000 pts. Radiographs were ordered at the

discretion of examining physician Mix of participating institutions Imaged patients received at least

cross-table lateral, AP and open mouth odontoid views.

Treating physicians completed data forms with demographics and the presence or absence of 5 low risk criteria.

Clinical Clearing the Cervical Spine

NEXUS Low-Risk Criteria

No midline cervical tenderness

No evidence of intoxication

No altered level of alertness

No focal neurological deficit

No distracting painful injury

Clinical Clearing the Cervical Spine

Results of NEXUS Study

< 18 years

≥ 18 years

Total

Number of cases

3,065905 < 9 years

31,004 34,069

CSI Patients 30 (0.98%)

4 < 9 years

788 (2.54%)

818 (2.4%)

Low-risk patients

603 (19.7%)

3706 (12.0%)

4309 (12.6%)

Low-risk patients with

CSI

0 8 8

Clinical Clearing the Cervical Spine

Results of NEXUS Study (cont.)Pediatric Group

Overall

Sensitivity 95% CI

100 %87.8 - 100

99. 2 %98.0 – 99.6

NPV 95% CI

100 %99.2 - 100

99.8 %99.6 - 100

Specificity95% CI

19.9 %18.5 – 21.3

12.93 %

PPV95% CI

1.2 %0.8 – 1.8

2.72 %

Clinical Clearing the Cervical Spine

NEXUS Study Conclusions No CSI was identified in the

pediatric group without at least one NEXUS risk factor

About 20% less radiographs would have been performed

However there were few pediatric patients with CSI. Lower end of CI: 87.8

Only 4 injured patients were younger than 9 yrs.

NEXUS criteria can be used with caution in pediatric patients ≥ 8 years.

If cervical spine can not be cleared clinically

Cervical Spine Radiographs

Maintain Cervical Spine Immobilization

C1-C7 Cross-table lateral: 80% of bony

lesions AP: lateral mass fractures Odontoid views in ≥ 9 yr. Waters

< 9yr Tree views: Dx 90% of CS

fractures

The ABCS of Radiographic Cervical Spine Evaluation

A. Alignment: Lordotic curves, malalignment, subluxation, distraction.

B. Bones: Fractures, anterior and posterior cervical columns, ossification centers

C. Cartilage: Intervertebral disk spaces, ossification centers

S. Soft Tissues: Prevertebral, predental spaces.

Clearing Cervical Spine by X Rays

Cervical Spine Flexion Injury

Flexion teardrop fracture Flexion of spine +

vertical axis compression

Anterior-inferior fracture of vertebral body

Anterior displacement of the fragment

Significant posterior ligament disruption

Extremely unstable

Cervical Spine Flexion Injury

Clay Shoveler Fracture Avulsion fracture

of the spinous process

Abrupt neck flexion in muscular individuals

Usually lower vertebrae

Fragment easily seen in lateral view

Stable

Cervical Spine Flexion Injury

Anterior subluxation Posterior ligament

complex rupture Anterior

longitudinal ligament preserved

No bony injury Widening of

interspinous processes distance

Anterior column intact

Stable in extension unstable in flexion

Posterior Cervical Line (PCL) of Swischuk

PCL connects the anterior aspect of the spinous processes of C1 and C3

If subluxation of C2 on C3, draw PCL

(A) No subluxation. PCL cannot be applied

(B) Subluxation: Anterior aspect of C2 spinous process misses PCL >2 mm (hangman’s fracture)

(C) Pseudosubluxation: Anterior aspect of C2 spinous process <2 mm or touches PCL

Cervical Spine Flexion Injury

Bilateral Facet Dislocation Involves annulus

and anterior & posterior ligaments

Upper vertebra inferior facets pass above and anterior to lower facets

Body displacement > half anterior-posterior diameter

Extremely unstable, disk herniation during reduction

Odontoid Fractures

Better seen in open mouth views.

Type I: fracture at the tip of the odontoid.

Type II: Fracture at the base of the odontoid.

Type III: Fracture extends to the body of the odontoid

Odontoid Process (Dens) Fracture

Fracture through base of dens. Dens and C1 posterior to C2

Indications forFlexion and Extension Views

To diagnose ligament injuries Alert patients No neurologic deficits Normal Cervical Spine (3 views) Neck pain or muscle spasm Patient able to actively flex and

extend neck

CT/MRI Indications

Altered mental status, risk factors C-spine incompletely visualized on plain films Abnormal or suspicious C-spine films Suspicion of injuries despite normal

radiographs CT Sensitivity and Specificity ≥ 98% MRI: better than CT for soft tissues:

SCIWORA

Cervical Spine Extension Injury

C1 Posterior arch fracture Neck

hyperextension C1 posterior arch

compressed by occiput and C2 spinous process

Lateral view: fracture line through posterior arch

No widening of pre-dental space

Two year old boy after major MVASpine CT

Same patient MRIDiagnosis: SCIWORA

Limitations for the routine use of the CT and MRI in the

evaluation of cervical spine in children

Cervical spine injuries are rare in children

CT radiation dose is 10 times > plain films

CT is more costly MRI availability is limited MRI difficult for critically ill child

C-spine injury Treatment

Stabilize primary injury and prevent secondary injuries

No Treatment Guidelines Neurosurgery ASAP Closed reduction + Halo

immobilization Surgery for ligament injuries Steroids: Controversial, no data for

children

Management Pitfalls for CSI

(from Haizlip JA; Scherrer PD) “I didn’t think she needed a cervical

collar, she was walking around at the scene of the accident”

“They secured him on an adult board without anything under him, since he is already secured we’ll just leave him like that”

She is 5 years old, said her neck didn’t hurt, so I thought it was OK to take her out of the collar”

Management Pitfalls for CSI

continued… “I am pretty sure that line on the x-

ray is just a growth plate. He looks fine and CS fractures in children are rare anyway”

“The x-ray tech can’t get this little girl to hold still and open her mouth for the odontoid view”

“The boy you sent for flexion-extension films says his neck hurts to bend. What shall we do?

Management Pitfalls for CSI

continued… “To be in the safe side, I get a CT in

every child with neck trauma”

“All her films were clear and she seems fine, I told the parents they have nothing to worry about”

“She is unconscious, however her x-rays and CT are normal thus I am going to take the collar off”

Selected References

Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of Pediatric Cervical Spine Injuries. J Pediatr Surg 2001; 36: 100-106

Patel JC, Tepas JJ, Mollit DL, Pieper P: Pediatric Cervical Spine Injuries: Defining the Disease. J Pediatr Surg 2001; 36: 373-376

Martin BW, Dykes E, Lecky FE: Patterns and risks in spinal trauma.Arch Dis Child 2004; 89: 860-865

Selected References

Viccellio P, Simon H, Pressman B, et al: A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics 2001; 108: 20-26

Slack SE, Clancy MJ: Clearing the Cervical Spine of Paediatric Trauma Patients. Emerg Med J. 2004; 21:189-193

Hadley MN: Management of Pediatric Cervical Spine and Spinal Cord Injuries. Neurosurgery 2002; 50 (3) S85-S99

Selected References

Haizlip JA, Scherrer PD: Emergency Evaluation of the Pediatric Cervical Spine. Pediatric Emergency Medicine Practice 2008; 5 (7) 1-24