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Cervical Spine Injuries in Children Arturo S. Gastañaduy M.D. Associate Professor of Pediatrics Louisiana State University Health Sciences Center July.

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Presentation on theme: "Cervical Spine Injuries in Children Arturo S. Gastañaduy M.D. Associate Professor of Pediatrics Louisiana State University Health Sciences Center July."— Presentation transcript:

1 Cervical Spine Injuries in Children Arturo S. Gastañaduy M.D. Associate Professor of Pediatrics Louisiana State University Health Sciences Center July 2010

2 Objectives Importance Importance Epidemiology Epidemiology Mechanisms of Injury Mechanisms of Injury Differences: Children vs. Adults Differences: Children vs. Adults Clinical Presentation Clinical Presentation Initial Management Initial Management of Cervical Spine Injuries in Children

3 Christopher Reeve as Superman

4 Christopher Reeve Paralyzed

5 Cervical Spine Injuries (CSI) in Children Epidemiology Kokoska E. Patel J. Martin B. Data Source NPTR NPTR TARN Age (years) Injured Children 24,74075,17219,538 CSI number (%) 408 (1.6) 1098 (1.5) 662 (3.4) Males (%) Cord Injury (%) Mortality (%)

6 Cervical Spine Injuries in Children Mechanism of Injury Mechanism Kokoska E. Patel J. Martin B. MVA (%) Sports (%) Falls (%) Pedestrian (%) Bicycle (%) 65-

7 Cervical Spine Injury in Children Mechanism of Injury and Age MechanismYoung Old p MVA(%)4443ns Falls (%) 1712 <.01 Pedestrian (%) 184 <.001 Bicycle (%) 38 <.01 Sports (%) 625 <.001

8 Cervical Spine Injuries in Children Type of Injury Injury Type Kokoska E. % Patel J. % Fracture5656 Dislocation2522 Fracture/Dislocati on -5 SCIWORA Spinal cord injury without radiological abnormality 1917

9 Head and Cervical Spine Differences Children vs. Adults CharacteristicsChildrenAdults Head/BodyLargeSmall Fulcrum C2 – C3 C5 – C6 Neck muscles, spine ligaments Weak, lax and elastic Strong, stiff, elasticity elasticity Vertebral bodies Anterior wedging Cartilaginous No wedging ossified Articulating facets More horizontally oriented Vertically oriented

10 Head and Cervical Spine Differences Children vs. Adults

11 Cervical Spine Injuries in Children Age and Level of Injury AgeYoung years Old years P High C1 – C <.01 Low C5 – C <.01

12 CSI in Children Age and Type of Injury (from Kokoska) TypeYoung Old p Fractures (%) 4265 <.01 Dislocations (%) 3120 <.01 SCIWORA (%) 2715 <.01

13 Cervical Spine Injury in Children Clinical Presentation Varies widely from: 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. 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. 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? What do we do?

14 Cervical Spine Injury Management First Things First ABCs ABCs Protect Cervical Spine. All children with head and neck injuries, multiple trauma, neurological deficits have CSI until proven otherwise 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. Goals: Stabilize primary injury and prevent secondary injuries. Remember 3% - 25% of CSI occur during transit or early in the course of management. Remember 3% - 25% of CSI occur during transit or early in the course of management. Clearing the C-Spine is not an immediate goal. Clearing the C-Spine is not an immediate goal.

15 Cervical Spine Injury Management Obtain History Details of events from patient and others Details of events from patient and others Mechanism of Injury Mechanism of Injury Signs and symptoms Signs and symptoms Specific neurologic signs or symptoms Specific neurologic signs or symptoms Drug ingestion or intoxication Drug ingestion or intoxication PMH:Previous trauma or surgery PMH:Previous trauma or surgery Arthritis, syndromes, others

16 Cervical Spine Injury in Children Physical Exam Motor deficit Motor deficit Sensory deficit Sensory deficit Altered mental status Altered mental status Neck tenderness Neck tenderness Torticollis Torticollis Limitation of motion Limitation of motion Neck muscle spasm Neck muscle spasm Abnormal reflexes Abnormal reflexes Clonus without rigidity 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

17 Cervical Spine Immobilization Hard collar + Spine Board Hard collar + Spine Board Became familiar with the ones used in your area Became familiar with the ones used in your area Tallest collar that not hyperextend the neck Tallest collar that not hyperextend the neck Backboard with occipital recess or padding under shoulders and body Backboard with occipital recess or padding under shoulders and body Straps over the forehead, chin, shoulders, hips, thighs and ankles. Straps over the forehead, chin, shoulders, hips, thighs and ankles. Be ready to log roll the patient if vomit occurs Be ready to log roll the patient if vomit occurs

18 Cervical Spine Immobilization Assessment Is the patient appropriately and fully immobilized? Is the patient appropriately and fully immobilized? Is the collar the correct size and type? Is the collar the correct size and type? Is the patient neck in neutral position? Is the patient neck in neutral position? Is the patient securely strapped to the spine board? Is the patient securely strapped to the spine board? Has there been a shift in the patient or the immobilization during transport? Has there been a shift in the patient or the immobilization during transport? Does immobilization interfere with the assessment and management of the ABCs? Does immobilization interfere with the assessment and management of the ABCs?

19 Cervical Spine Clearing in Pediatric Trauma Patients Slack SE, Clancy MJ: Comprehensive literature search of the studies on the subject (2004) Slack SE, Clancy MJ: Comprehensive literature search of the studies on the subject (2004) 241 papers, 71 relevant 241 papers, 71 relevant No Gold Standard to identify all CSI No Gold Standard to identify all CSI Many papers did not include clinical follow up Many papers did not include clinical follow up Only the National Emergency X-Radiography Utilization Study NEXUS was considered valid for its purpose. Only the National Emergency X-Radiography Utilization Study NEXUS was considered valid for its purpose.

20 Clinical Clearing of the Cervical Spine The NEXUS Study Prospective Observational Study: 34,000 pts. Prospective Observational Study: 34,000 pts. Radiographs were ordered at the discretion of examining physician Radiographs were ordered at the discretion of examining physician Mix of participating institutions Mix of participating institutions Imaged patients received at least cross-table lateral, AP and open mouth odontoid views. 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. Treating physicians completed data forms with demographics and the presence or absence of 5 low risk criteria.

21 Clinical Clearing the Cervical Spine NEXUS Low-Risk Criteria No midline cervical tenderness No midline cervical tenderness No evidence of intoxication No evidence of intoxication No altered level of alertness No altered level of alertness No focal neurological deficit No focal neurological deficit No distracting painful injury No distracting painful injury

22 Clinical Clearing the Cervical Spine Results of NEXUS Study < 18 years 18 years 18 yearsTotal Number of cases 3, < 9 years 31,00434,069 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 088

23 Clinical Clearing the Cervical Spine Results of NEXUS Study (cont.) Pediatric Group Overall Sensitivity 95% CI 100 % % 98.0 – 99.6 NPV 95% CI 100 % % Specificity 95% CI 19.9 % 18.5 – % PPV 95% CI 1.2 % 0.8 – %

24 Clinical Clearing the Cervical Spine NEXUS Study Conclusions No CSI was identified in the pediatric group without at least one NEXUS risk factor No CSI was identified in the pediatric group without at least one NEXUS risk factor About 20% less radiographs would have been performed About 20% less radiographs would have been performed However there were few pediatric patients with CSI. Lower end of CI: 87.8 However there were few pediatric patients with CSI. Lower end of CI: 87.8 Only 4 injured patients were younger than 9 yrs. Only 4 injured patients were younger than 9 yrs. NEXUS criteria can be used with caution in pediatric patients 8 years. NEXUS criteria can be used with caution in pediatric patients 8 years.

25 If cervical spine can not be cleared clinically Cervical Spine Radiographs Maintain Cervical Spine Immobilization Maintain Cervical Spine Immobilization C1-C7 C1-C7 Cross-table lateral: 80% of bony lesions Cross-table lateral: 80% of bony lesions AP: lateral mass fractures AP: lateral mass fractures Odontoid views in 9 yr. Waters < 9yr Odontoid views in 9 yr. Waters < 9yr Tree views: Dx 90% of CS fractures Tree views: Dx 90% of CS fractures

26 The ABCS of Radiographic Cervical Spine Evaluation A.Alignment:Lordotic curves, malalignment, subluxation, distraction. A.Alignment:Lordotic curves, malalignment, subluxation, distraction. B.Bones:Fractures, anterior and posterior cervical columns, ossification centers B.Bones:Fractures, anterior and posterior cervical columns, ossification centers C.Cartilage: Intervertebral disk spaces, ossification centers C.Cartilage: Intervertebral disk spaces, ossification centers S.Soft Tissues: Prevertebral, predental spaces. S.Soft Tissues: Prevertebral, predental spaces.

27 Clearing Cervical Spine by X Rays Clearing Cervical Spine by X Rays

28 Cervical Spine Flexion Injury Flexion teardrop fracture Flexion of spine + vertical axis compression Flexion of spine + vertical axis compression Anterior-inferior fracture of vertebral body Anterior-inferior fracture of vertebral body Anterior displacement of the fragment Anterior displacement of the fragment Significant posterior ligament disruption Significant posterior ligament disruption Extremely unstable Extremely unstable

29 Cervical Spine Flexion Injury Clay Shoveler Fracture Avulsion fracture of the spinous process Avulsion fracture of the spinous process Abrupt neck flexion in muscular individuals Abrupt neck flexion in muscular individuals Usually lower vertebrae Usually lower vertebrae Fragment easily seen in lateral view Fragment easily seen in lateral view Stable Stable

30 Cervical Spine Flexion Injury Anterior subluxation Posterior ligament complex rupture Posterior ligament complex rupture Anterior longitudinal ligament preserved Anterior longitudinal ligament preserved No bony injury No bony injury Widening of interspinous processes distance Widening of interspinous processes distance Anterior column intact Anterior column intact Stable in extension unstable in flexion Stable in extension unstable in flexion

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

32 Cervical Spine Flexion Injury Bilateral Facet Dislocation Involves annulus and anterior & posterior ligaments Involves annulus and anterior & posterior ligaments Upper vertebra inferior facets pass above and anterior to lower facets Upper vertebra inferior facets pass above and anterior to lower facets Body displacement > half anterior-posterior diameter Body displacement > half anterior-posterior diameter Extremely unstable, disk herniation during reduction Extremely unstable, disk herniation during reduction

33 Odontoid Fractures Better seen in open mouth views. Better seen in open mouth views. Type I: fracture at the tip of the odontoid. Type I: fracture at the tip of the odontoid. Type II: Fracture at the base of the odontoid. Type II: Fracture at the base of the odontoid. Type III: Fracture extends to the body of the odontoid Type III: Fracture extends to the body of the odontoid

34 Odontoid Process (Dens) Fracture Fracture through base of dens. Dens and C1 posterior to C2

35 Indications for Flexion and Extension Views To diagnose ligament injuries To diagnose ligament injuries Alert patients Alert patients No neurologic deficits No neurologic deficits Normal Cervical Spine (3 views) Normal Cervical Spine (3 views) Neck pain or muscle spasm Neck pain or muscle spasm Patient able to actively flex and extend neck Patient able to actively flex and extend neck

36 CT/MRI Indications Altered mental status, risk factors Altered mental status, risk factors C-spine incompletely visualized on plain films C-spine incompletely visualized on plain films Abnormal or suspicious C-spine films Abnormal or suspicious C-spine films Suspicion of injuries despite normal radiographs Suspicion of injuries despite normal radiographs CT Sensitivity and Specificity 98% CT Sensitivity and Specificity 98% MRI: better than CT for soft tissues: SCIWORA MRI: better than CT for soft tissues: SCIWORA

37 Cervical Spine Extension Injury C1 Posterior arch fracture Neck hyperextension Neck hyperextension C1 posterior arch compressed by occiput and C2 spinous process C1 posterior arch compressed by occiput and C2 spinous process Lateral view: fracture line through posterior arch Lateral view: fracture line through posterior arch No widening of pre- dental space No widening of pre- dental space

38 Two year old boy after major MVA Spine CT

39 Same patient MRI Diagnosis: SCIWORA

40 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 Cervical spine injuries are rare in children CT radiation dose is 10 times > plain films CT radiation dose is 10 times > plain films CT is more costly CT is more costly MRI availability is limited MRI availability is limited MRI difficult for critically ill child MRI difficult for critically ill child

41 C-spine injury Treatment Stabilize primary injury and prevent secondary injuries Stabilize primary injury and prevent secondary injuries No Treatment Guidelines No Treatment Guidelines Neurosurgery ASAP Neurosurgery ASAP Closed reduction + Halo immobilization Closed reduction + Halo immobilization Surgery for ligament injuries Surgery for ligament injuries Steroids: Controversial, no data for children Steroids: Controversial, no data for children

42 Management Pitfalls for CSI (from Haizlip JA; Scherrer PD) I didnt think she needed a cervical collar, she was walking around at the scene of the accident I didnt 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 well just leave him like that They secured him on an adult board without anything under him, since he is already secured well just leave him like that She is 5 years old, said her neck didnt hurt, so I thought it was OK to take her out of the collar She is 5 years old, said her neck didnt hurt, so I thought it was OK to take her out of the collar

43 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 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 cant get this little girl to hold still and open her mouth for the odontoid view The x-ray tech cant 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? The boy you sent for flexion-extension films says his neck hurts to bend. What shall we do?

44 Management Pitfalls for CSI continued… To be in the safe side, I get a CT in every child with neck trauma 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 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 She is unconscious, however her x-rays and CT are normal thus I am going to take the collar off

45 Selected References Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of Pediatric Cervical Spine Injuries. J Pediatr Surg 2001; 36: Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of Pediatric Cervical Spine Injuries. J Pediatr Surg 2001; 36: Patel JC, Tepas JJ, Mollit DL, Pieper P: Pediatric Cervical Spine Injuries: Defining the Disease. J Pediatr Surg 2001; 36: Patel JC, Tepas JJ, Mollit DL, Pieper P: Pediatric Cervical Spine Injuries: Defining the Disease. J Pediatr Surg 2001; 36: Martin BW, Dykes E, Lecky FE: Patterns and risks in spinal trauma.Arch Dis Child 2004; 89: Martin BW, Dykes E, Lecky FE: Patterns and risks in spinal trauma.Arch Dis Child 2004; 89:

46 Selected References Viccellio P, Simon H, Pressman B, et al: A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics 2001; 108: Viccellio P, Simon H, Pressman B, et al: A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics 2001; 108: Slack SE, Clancy MJ: Clearing the Cervical Spine of Paediatric Trauma Patients. Emerg Med J. 2004; 21: Slack SE, Clancy MJ: Clearing the Cervical Spine of Paediatric Trauma Patients. Emerg Med J. 2004; 21: Hadley MN: Management of Pediatric Cervical Spine and Spinal Cord Injuries. Neurosurgery 2002; 50 (3) S85-S99 Hadley MN: Management of Pediatric Cervical Spine and Spinal Cord Injuries. Neurosurgery 2002; 50 (3) S85-S99

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


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