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Toddler Takes a Tumble Pediatric Cervical Spine Injury

Toddler Takes a Tumble Pediatric Cervical Spine Injury. Gary R. Strange, MD, FACEP Department of Emergency Medicine University of Illinois. Teaching points to be addressed. What is the proper technique for immobilization of the cervical spine in the pediatric patient?

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Toddler Takes a Tumble Pediatric Cervical Spine Injury

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  1. Toddler Takes a TumblePediatric Cervical Spine Injury Gary R. Strange, MD, FACEP Department of Emergency Medicine University of Illinois

  2. Teaching points to be addressed • What is the proper technique for immobilization of the cervical spine in the pediatric patient? • Is it possible to clinically clear the cervical spine of the pediatric patient? Can the NEXUS criteria be used? • What radiographic views are required to adequately evaluate the pediatric patient who has sustained neck trauma? • What are the most common abnormal radiographic findings for the pediatric cervical spine? • What are the common normal findings that confound the x-ray diagnosis in pediatric patients?

  3. Case Presentation • A 3-year-old child is playing with some older children on a backyard trampoline • He falls from the trampoline and strikes his head on the support • Transient loss of consciousness and a minor laceration just below the mandible on the right side • He is able to walk inside • He is brought by his mother to the ED for evaluation

  4. Emergency Department Course • He is alert, crying and resists examination • He has a small right submandibular laceration which does not require suturing and a right parietal contusion • The rest of the physical examination, including the neurological, is normal • He is discharged to the care of his mother who is given routine head injury instructions

  5. Emergency Department Course Second Visit • Twenty-four hours later • He will not move his neck • Mother states that he cries and says that his neck hurts when he moves it • He is rigidly holding his neck in neutral position and is tender to palpation of the upper cervical spine area • His neurological examination remains intact

  6. Emergency Department CourseSecond Visit • Immobilized on a long spine board • Cervical spine radiographs are obtained • Fracture is diagnosed • Transferred to a pediatric trauma center

  7. Pediatric Cervical Spine InjuriesIncidence Overall Incidence for All Ages: 10,000 per Year

  8. Cervical Spine InjuriesMale-Female Distribution Percentage

  9. Pediatric Cervical Spine InjuryEtiology

  10. Pediatric Cervical Spine TraumaImmobilization • Adult on Backboard • Neck in Neutral Position

  11. Pediatric Cervical Spine TraumaImmobilization • Child on Backboard • Neck in Flexion • Semi-Rigid Collar decreases Flexion but does not Eliminate It

  12. Pediatric Cervical Spine TraumaImmobilization • Special Board with Recessed Area for the Occiput • Padding Under the Chest and Back • Age < 4: 27 mm • Age > 4: 22 mm • Age > 8: none

  13. Pediatric Cervical Spine TraumaClinical Clearance • NEXUS Criteria • Midline Cervical Tenderness • Altered Level of Alertness • Evidence of Intoxication • Neurological Abnormality • Presence of Painful Distracting Injury

  14. Pediatric Cervical Spine TraumaNEXUS Criteria • Prospective multicenter study of 3,065 patients < 18 years of age • NEXUS Criteria identified all CSI • No infants < age 2 in the study population

  15. Pediatric Cervical Spine TraumaScreening Radiographs • Cross-Table Lateral View • Sensitivity 82% • Negative Predictive Value 97% • Lateral and Anteroposterior Views • Sensitivity 87%

  16. Pediatric Cervical Spine TraumaScreening Radiographs • Transoral Odontoid Views • Difficult to obtain in a child < 8 years • Not necessary for diagnosis (Buhs) • Not recommended by CONS for children < 8

  17. Factors Complicating Radiographic Interpretation • Ossification Centers • Synchondroses • Hypermobility • Normal Variants

  18. Factors Complicating Radiographic Interpretation -- Atlas • Ossification Centers • Anterior Arch by Age 1 Year • Posterior Arch en Utero • Synchondroses • Spinous process fuses at age 3 • Neurocentral fuses at age 7

  19. Factors Complicating Radiographic Interpretation -- Axis • Ossification Centers • Body en Utero • Arches en Utero • Summit of Odontoid by 3-6 Years • Inferior Epiphyseal Ring at Puberty

  20. Factors Complicating Radiographic Interpretation -- Axis • Synchondroses • Spinous Process fuses at age 3-6 years • Neurocentral fuses at age 3-6 years • Base of Odontoid fuses by 3-6 Years • 1/3 have visible fusion line throughout life • Summit of the Odontoid fuses by age 12 years • Inferior Epiphyseal Ring fuses by age 15

  21. Factors Complicating Radiographic Interpretation – C3 to C7 • Ossification Centers • Secondary Centers for Bifid Spinous Processes appear at Puberty • Superior and Inferior Epiphyseal Rings appear at Puberty

  22. Factors Complicating Radiographic Interpretation – C3 to C7 • Synchondroses • Anterior Aspect of Transverse Processes fuse by Age 6 Years • Spinous Processes fuse by Age 3 Years • Neurocentral fuses by age 3-6 Years • Epiphyseal Rings fuse by Age 25 Years

  23. Factors Complicating Radiographic Interpretation -- Hypermobility • Ligamentous Laxity • Horizontal Articulations • Facet joints at 300 for Age < 8; 600 in Adults • Large Head • Underdeveloped Muscles

  24. Radiographic InterpretationHypermobility • Anterior Pseudo-subluxation of C2 on C3 (46%) • Marked in 9% • Accentuated in Flexion • Posterior pseudo-subluxation with extension (14%) • Anterior Pseudo-subluxaiton of C3 on C4 (14%)

  25. Radiographic InterpretationHypermobility • Widening of Atlanto-Dens Interval (20%) • > 3 mm is abnormal • Over-Riding of Anterior Arch of C1 on the Odontoid with Extension (20%)

  26. Radiographic InterpretationHypermobility • Absence of Uniform Angulation between Vertebrae (16%) • Simulates disruption of interspinous or posterior longitudinal ligaments • Reduced with extension • Absent Lordosis in Neutral Position (14%) • Simulates acute muscle spasm

  27. Radiographic InterpretationAnterior Wedging • Present at Multiple Levels • Simulates Wedge Compression Fracture • < 3 mm ▲in Anterior and Posterior Body Height is Normal

  28. Progressive Maturation of Vertebral Bodies • Oval (immature) • Anterior wedging • Rounded upper corner • Rectangular (mature)

  29. Pre-Vertebral Soft Tissue Space • Abnormal if > ¾ the Antero-Posterior Width of the Adjacent Vertebra • < 7 mm @ C2-C3 • Increased with Flexion • Decreased with Extension

  30. Pediatric Vertebral FracturesLevel of Fracture by Age

  31. Pediatric Vertebral FracturesMortality by Level of Fracture

  32. Common Pediatric Cervical Spine Injuries • Fracture or Subchondral Separation of the Odontoid • Hangman’s Fracture • Atlanto-Axial Rotatory Subluxation • Occipito-Atlantal Dislocation • Jefferson Fracture • Physeal Injuries • SCIWORA (17%)

  33. Odontoid Fracture • Common pediatric cervical spine fracture • Shearing forces • Infants in forward-facing car seats • Falls • Subdental synchondrosis most vulnerable • Often no neuro deficit • Usually heals without problems

  34. Hangman’s Fracture • Fracture through the Pedicles of the Axis (C2) • Subluxation of the Body of C2

  35. Hangman’s Fracture • Posterior Cervical Line (Swischuk) • Useful in Differentiating Occult Hangman’s Fx from Pseudosubluxation • Connects the bases of the spinous processes of C1 – C3 • Positive if misses anterior aspect of the spinous process of C2 by 2 mm or more

  36. Atlanto-Axial Rotatory Subluxation • Displacement of the odontoid within the ring of the atlas • Disruption of the transverse ligament • Possible displacement of the lateral mass of C1 relative to that of C2 • Traumatic torticollis • Neurological deficit unlikely

  37. Occipito-Atlantal Dislocation • Disruptions of: • Musculature • Apical ligament • Atlantooccipital joints • Tectorial membrane* • C1-2:C2-3 > 2.5 • C1-C2 > 10 mm • Spinal cord • High rate of neurological deficit and mortality

  38. Jefferson Fracture • Vertical impact • Falls, dives, striking the head on roof of car in MVC • Often no neuro deficit • Break in the ring of C1 • If through unossified areas, difficult to see • Lateral masses of C1 extend beyond those of C2

  39. Physeal Injuries • Superior and inferior epiphyseal plates do not fuse until about age 25 years • Zone of relative weakness at the junction of the epiphyseal cartilage and vertebral ossification • Inferior growth plate more vulnerable • Most common in adolescents • Separation and displacement of a plate-like piece of bone usually at the inferior aspect of the vertebral body

  40. Summary • Thoracic elevation or occipital recess is required to properly immobilize a child 8 years of age or younger in the desired neutral position. • It is possible to safely clear a child’s cervical spine using careful history and physical examination techniques and the NEXUS criteria have performed well in this regard. • Radiographic evaluation of the cervical spine of a child < 8 years of age consists of anteroposterior and lateral cervical spine x-rays. For children > 9 years of age or older, an open-mouth cervical spine x-ray is also obtained.

  41. Summary • Radiographic diagnosis of cervical spine injuries in the pediatric patient is complicated by the presence of: • Ossification centers • Synchondroses • Ligamentous laxity • Hypermobility • Hypermobility frequently results in: • Pseudosubluxation of C2 on C3 • Pseudosubluxation of C3 on C4 • Widening of the atlanto-dens interval • Over-riding of the anterior arch of C1 on the odontoid • Absence of uniform angulation between vertebrae

  42. Summary • Common abnormal radiographic findings in children, in addition to soft tissue swelling, include: • Rotatory subluxation of the odontoid • Jefferson fracture • Odontoid fracture • Hangman’s fracture

  43. Questions??? FERNE www.ferne.org GStrange@uic.edu

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