Cervical Spine Injuriesin Children Arturo S. Gastañaduy M.D. Associate Professor of Pediatrics Louisiana State University Health Sciences Center July 2010
Objectives Importance Epidemiology Mechanisms of Injury Differences: Children vs. Adults Clinical Presentation Initial Management of Cervical Spine Injuries in Children
Cervical Spine Injury in ChildrenClinical 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
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 Injury in ChildrenPhysical Exam
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 SpineNEXUS 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 clinicallyCervical 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.
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 InjuryClay 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 InjuryC1 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
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 CSIcontinued… “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 CSIcontinued… “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 PediatrSurg 2001; 36: 100-106 • Patel JC, Tepas JJ, Mollit DL, Pieper P: Pediatric Cervical Spine Injuries: Defining the Disease. J PediatrSurg 2001; 36: 373-376 • Martin BW, Dykes E, Lecky FE: Patterns and risks in spinal trauma.ArchDis 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