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Pediatric Cervical Spine Injuries

Pediatric Cervical Spine Injuries. Daniel A. Hirsh, MD Emory University School of Medicine Children’s Healthcare of Atlanta. Objectives. Epidemiology Anatomy: Pediatric vs Adult Types of injuries Who can be cleared clinically Imaging Choices An approach to clearing a c-spine

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Pediatric Cervical Spine Injuries

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  1. Pediatric Cervical Spine Injuries Daniel A. Hirsh, MD Emory University School of Medicine Children’s Healthcare of Atlanta

  2. Objectives • Epidemiology • Anatomy: Pediatric vs Adult • Types of injuries • Who can be cleared clinically • Imaging Choices • An approach to clearing a c-spine • Lateral Plain Film • Cases • Wrap Up

  3. Epidemiology

  4. Epidemiology: Incidence Pediatric Spinal Cord Injury (SCI) is rare Of Population: ~1 in 1,000,0001 or 1,000per year3 Of Fractures: 1-2%, but highest mortality2 Of Trauma: 1-2% 5,6 Of All SCI: Accounts for <10%, <15 years old 1 Likely under-reported3,4 Male : Female 2:1

  5. Epidemiology: Incidence @ CHOA *Trauma Registry Patients: All patients that have a Trauma ICD9 code, admitted for greater than 24 hours, or transferred, or admitted to OR or ICU regardless of length of stay. **Based on ICD-9 Codes

  6. Epidemiology: Age • Most frequent in: 15-24 year age group4 • In under 15 year olds, mean age is 8 • @ CHOA, mean age 11

  7. Epidemiology: Age Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery39(3): 483-486. Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery36(8): 1107-1114.

  8. Epidemiology: Age Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery39(3): 483-486. Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery36(8): 1107-1114.

  9. Epidemiology: Age • The younger the child the… • higher the lesion • higher mortality7

  10. Epidemiology: Age Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery36(2): 373-376.

  11. Epidemiology: Age Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery36(2): 373-376.

  12. Epidemiology: Age Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery36(2): 373-376.

  13. Epidemiology: Mechanisms • Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

  14. Epidemiology: Mechanisms

  15. Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics 119: e275-283 Epidemiology: Mechanisms

  16. Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics119: e275-283 Epidemiology: Mechanisms

  17. Epidemiology: Mechanisms Leonard, M., J. Sproule, et al. (2007). "Paediatric spinal trauma and associated injuries." Injury 38(2): 188-193.

  18. Epidemiology: Mechanisms • Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

  19. Epidemiology: Mechanisms • Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

  20. Epidemiology: Mechanisms • Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

  21. Epidemiology: Mechanisms Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

  22. Epidemiology: Mechanisms Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

  23. Epidemiology: Mechanisms Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

  24. Epidemiology: Associated Injuries Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612. ~40% of SCI have associated injuries

  25. Epidemiology: Associated Injuries Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612. ~40% of SCI have associated injuries

  26. Anatomy: Pediatric vs Adult

  27. \

  28. Anatomy: Pediatric vs Adult 37 yo driver lap/shoulder/airbag restrained and her 7 yo son backseat lap/shoulder restrained involved in head on accident. Both in a c-collar. Both have neck pain. What are this boy’s anatomic disadvantages compared with his mom?

  29. Anatomy: Pediatric vs Adult • Proportionally larger, heavier head= higher center of gravity: • “..the human head reaches 50% of its adult circumference by age 18 months, whereas thoracic circumference does not reach this milestone until 8 years of age.” • Weaker and underdeveloped neck musculature • Greater elasticity and laxity of ligaments • More horizontal orientation of facet joints • Fulcrum of Cervical Spine Motion • Pediatric: C2-C3 • Adult: C5-C6

  30. Anatomy: Pediatric vs Adult Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564.

  31. Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

  32. Anatomy: Pediatric vs Adult • Biomechanical and anatomic difference Begins to disappear at 8 years old Completes at 15-17 years old • Literature suggest 2 distinct groups <8 and >=8

  33. Anatomy: Pediatric vs Adult • Higher prevalence of lesions above C4 • More cervical distraction injuries • Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)

  34. Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

  35. Types of Injury

  36. Types of Injury • Atlanto-occipital injuries • High energy • Typically fatal • More prevalent in young children than adults

  37. Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

  38. Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539 4 anterior longitudinal ligament. 1 2 3

  39. Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539 4 anterior longitudinal ligament. 1 2 3

  40. Types of Injury • Atlas Fracture • Axial load (like Jefferson burst fracture in adults) • Open synchondrosis

  41. Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

  42. Types of Injury • Traumatic Atlantoaxial Instability • Tear in transverse ligament • Rare

  43. Types of Injury • Odontoid fracture • Most common fractures of cspine in children • Usually through the subdentalsynchondrosis in young children

  44. Types of Injury • Odontoid fracture • Most common fractures of cspine in children • Usually through the subdentalsynchondrosis in young children

  45. Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

  46. Types of Injury • Pars interarticularisFracture of C2 • Hangman’s (hyperextension) • Extremely rare • Distraction Injuries Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

  47. Pseudosubluxation • Children have normal physiologic displacement @ C2-3 and C3-4 spaces Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

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