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 1,000 per 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
Population adjusted incuidence
Adult 17 in 1,000,000

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 Surgery 39(3):
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 Surgery 36(8):

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 Surgery 39(3):
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 Surgery 36(8):

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 Surgery 36(2):

11. Epidemiology: Age
Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2):

12. Epidemiology: Age
Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2):

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

14. Epidemiology: Mechanisms

18. Epidemiology: Mechanisms
Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics 119: e
Epidemiology: Mechanisms

19. Epidemiology: Mechanisms
Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics 119: e
Epidemiology: Mechanisms

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

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

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

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

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

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

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

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

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

29. Anatomy: Pediatric vs Adult

30. \

31. 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?

32. 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

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

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

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

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

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

38. Types of Injury

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

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

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

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

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

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

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

46. Types of Injury Odontoid fracture
Most common fractures of cspine in children
Usually through the subdental synchondrosis in young children

47. Types of Injury Odontoid fracture
Most common fractures of cspine in children
Usually through the subdental synchondrosis in young children

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

49. Types of Injury Pars interarticularis Fracture 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

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

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

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

53. Types of Injury: SCIWORA
Spinal
Cord
Injury
With
Out
Radiographic
Abnomality
First described in 1980’s before advancements in MRI
Subsequent literature suggest up to 30% all pediatric cord injuries*

54. Types of Injury: SCIWORA
Evolving Definition:
Positive neurological findings
weakness, paresthesias, lightening/burning sensation
down the spine/extremity or related to neck movement
AND
Xray (-) , CT (-), MRI (+) 6% of SCI OR
Xray (-) , CT (-), MRI (-) 1% of SCI3

55. Who can be cleared clinically?

56. Which 7 yo can you clinically clear?
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity.
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

57. Which 7 yo can you clinically clear?
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity.
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

58. Which 7 yo can you clinically clear?
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity.
7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

59. Who can be cleared clinically?
National Emergency Medicine XRay Utilization Study (NEXUS) 9
Prospective
Evaluation of c-spine injury in children
Identify patients at low risk

60. NEXUS : Study Definitions
Low Risk Patient
Those with none of the following criteria:
Midline cervical tenderness
Focal neurologic deficits
Altered level of alertness
Evidence of intoxication
Distracting painful injury

61. NEXUS : Study Definitions
High Risk Patient
Those with any of the following criteria:
Midline cervical tenderness
Focal neurologic deficits
Altered level of alertness
Evidence of intoxication
Distracting painful injury
Instability or inability to assess

62. NEXUS: Study Definitions
Distracting Injury
Significant, painful injury
Skin Large lacerations or heavy bleeding
Soft tissue Crush injuries
Muscle
Bone Any long bone fracture
Vascular structures
Viscera Injury requiring surgical consultation
Any injury causing acute functional impairment

63. NEXUS : Study Results
Of 3,065 children enrolled, 30 had c-spine injuries (0.98%)
All 30 were classified as: “high-risk”
No child from the “low-risk” group had a c-spine injury

64. NEXUS : Study Results Value (95% CI) Sensitivity 100% (87.8 – 100%)
Negative Predictive Value
100% (99.2 – 100%)

65. Not so fast…
Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

66. Not so fast…
Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

67. Ehrlich et al Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients 2009

68. Ehrlich et al Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients 2009

69. Which 7 yo can you clinically clear?
None of them!
Next step…

70. How to clinically clear patient with neck pain?

71. Imaging choices

72. Imaging choices Plain Film Xrays CT Scan Neck
Pro: Less radiation than CT. Can be done in trauma bay. Can pick up most injuries if good technique. Less costly.
Con: Poor technique may lead to repeat shots. Can be difficult to get odontoid view in a young patient
CT Scan Neck
Pro: Highly sensitive for fracture.
Con: Higher radiation dose to neck. In current facility have to move patient to another area. More costly.
Issue of initial CT Head and CT Neck versus Ct Head and Plain Film Neck: (Jimenez et al 2008) Plain film first, then CT if needed

73. Imaging choices Flexion and Extension Lateral Xrays MRI
Pro: Can help diagnose ligmentous injury not seen on Xray or CT
Con: Patient must Actively move their head. Muscle spasm often limits this test
Should not perform Passive Flex/Ex on unconscious patient
If patient has normal static cervical spine radiographs, addition flex-ext are of questionable use (Dwek, et al Chung 2000)
MRI
Pro: “Gold Standard” (Munchow RD et al 2008) Highly sensitive for spinal cord injury. Helps with unconscious pts in whom there is high clinical suspicion of C-Spine injury . Visualizes the extradural space and integrity of the ligaments
Con: Higher cost, time

74. An approach to clearing the c-spine following injury

75. Eubanks, J. D. , A. Gilmore, et al. (2006)
Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following

76. Lateral Plain Film

77. C-Spine Radiograph Lateral Plain Film Film adequacy
C-spine alignment and curves
Inter-vertebral spaces: discs and joints
Pre-vertebral space
Pre-dental space aka atlantodens interval (ADI)

78. C-Spine Radiograph Lateral film Anteroposterior film
Open-mouth odontoid view

79. Adequacy Visualize entire cervical spine
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Adequacy
Visualize entire cervical spine
Count 7 cervical bodies and 1 thoracic body

80. Adequacy Visualize entire cervical spine
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Adequacy
Visualize entire cervical spine
Count 7 cervical bodies, and 1 thoracic body

81. Adequacy Visualize entire cervical spine
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Adequacy
Visualize entire cervical spine
Count 7 cervical bodies, and 1 thoracic body

82. Adequacy Visualize entire cervical spine
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Adequacy
Visualize entire cervical spine
Count 7 cervical bodies, and 1 thoracic body

83. Alignment C-Spine Curves
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Alignment
C-Spine Curves
Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14:

84. Alignment C-Spine Curves Anterior Vertebral Bodies
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Alignment
C-Spine Curves
Anterior Vertebral Bodies
Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14:

85. Alignment C-Spine Curves Anterior Vertebral Bodies
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Alignment
C-Spine Curves
Anterior Vertebral Bodies
Anterior Spinal Canal
Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14:

86. Alignment C-Spine Curves Anterior Vertebral Bodies
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Alignment
C-Spine Curves
Anterior Vertebral Bodies
Anterior Spinal Canal
Posterior Spinal Canal
Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14:

87. Alignment C-Spine Curves Anterior Vertebral Bodies
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Alignment
C-Spine Curves
Anterior Vertebral Bodies
Anterior Spinal Canal
Posterior Spinal Canal
Spinous Process Tips
Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14:

88. Inter-vertebral spaces
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Inter-vertebral spaces
Disc spaces
Cartiledge
Apophyseal joints

89. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-vertebral space

90. Pre-vertebral space Space between vertebral bodies and air column
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-vertebral space
Space between vertebral bodies and air column

91. Pre-vertebral space Space between vertebral bodies and air column
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-vertebral space
Space between vertebral bodies and air column

92. Pre-vertebral space Space between vertebral bodies and air column
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-vertebral space
Space between vertebral bodies and air column
Must measure space above the glottis

93. Pre-vertebral space Space between vertebral bodies and air column
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-vertebral space
Space between vertebral bodies and air column
Must measure space above the glottis
Normal size
~1/2 to 2/3 of adjacent vertebral body
Can be abnormal if
non-inspiratory film
Intubated
Often normal in C-Spine injuries

94. Pre-Dental Space: aka: atlantodens interval (ADI)
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-Dental Space: aka: atlantodens interval (ADI)

95. Space between Dens of C2 and anterior side of C1 ring
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-Dental Space
Space between Dens of C2 and anterior side of C1 ring

96. Space between Dens of C2 and anterior side of C1 ring
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-Dental Space
Space between Dens of C2 and anterior side of C1 ring

97. Space between Dens of C2 and anterior side of C1 ring
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Pre-Dental Space
Space between Dens of C2 and anterior side of C1 ring
Must be less than or equal to 5 mm

98. Cases

99. Case 1 4 year old female, restrained, back seat
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
4 year old female, restrained, back seat
High speed, head on car crash – car versus tree
Eye witnesses noted the passengers’ heads violently snapped forward
The driver died at the scene
C-spine immobilized
Minimally responsive
Intubated
Ng-tube placed

100. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

101. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Fracture at pedicle of C2

102. Case 2 18 month old female, unrestrained, front seat Car accident
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
18 month old female, unrestrained, front seat
Car accident
Sitting in babysitter’s lap, babysitter died at scene
C-spine ‘immobilized’ by gauze strapped with tape over child’s head
Alert and awake
Severe respiratory distress, with decreased breath sounds on right chest
No movement of lower extremities

103. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

104. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Distraction injury

106. Case 3 A 7 year old child High speed MVC
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
A 7 year old child
High speed MVC

107. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

108. Prevertebral Bleeding
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Glottis
Prevertebral Bleeding

109. Case 4 5 year old male, sitting in seatbelt, front seat
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
5 year old male, sitting in seatbelt, front seat
25 mph head-on car crash
Airbag deployed
C-spine immobilized
Alert and awake
Numerous abrasions to face, neck and left shoulder and arm
Left arm limp and without sensation

110. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

111. Ruptured Transverse Ligament
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Ruptured Transverse Ligament

112. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
C2 - Axis

113. v
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
C1 - Atlas

114. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
ANTERIOR
ANTERIOR
POSTERIOR

115. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
ANTERIOR
ANTERIOR
POSTERIOR

116. Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
ANTERIOR
ANTERIOR
POSTERIOR

117. Wrap It Up Epidemiology Anatomy: Pediatric vs Adult Types of injuries
Who can be cleared clinically
Imaging Choices
An approach to the clearing the cspine
Lateral Plain Film
Cases
Wrap Up

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