5Cervical Spine Injuries (CSI) in Children Epidemiology Kokoska E.Patel J.Martin B.Data SourceNPTRNPTRTARNAge (years)0 - 200 - 15Injured Children24,74075,17219,538CSI number (%)408 (1.6)1098 (1.5)662 (3.4)Males (%)596158Cord Injury (%)352921.9Mortality (%)1713We all know that cervical spine injuries can produce severe and permanent neurological deficit. Fortunately CSI in children are uncommon. Three large studies, 2 in USA using data from the National Pediatric Trauma Registry and one in the United Kingdom with data from the Trauma Audit and Research Network
6Cervical Spine Injuries in Children Mechanism of Injury Kokoska E.Patel J.Martin B.MVA (%)444249.8Sports (%)16147.4Falls (%)1337.6Pedestrian (%)11-Bicycle (%)65In these studies the most common mechanisms were …
7Cervical Spine Injury in Children Mechanism of Injury and Age Young0 - 10OldpMVA(%)4443nsFalls (%)1712< .01Pedestrian (%)184< .001Bicycle (%)38Sports (%)625As expected age plays a role in the mechanism of injury. MVA account for > 40% of injuries in young and older children, falls and pedestrian accidents are more common in younger children while bicycle and sports related accidents are more common in older children.
8Cervical Spine Injuries in Children Type of Injury Injury TypeKokoska E.%Patel J.Fracture56Dislocation2522Fracture/Dislocation-5SCIWORASpinal cord injury without radiological abnormality1917The most common types of CSI injuries in children are … but spinal cord injuries without radiological abnormalities account for almost 1/5 of CSI
9Head and Cervical Spine Differences Children vs. Adults CharacteristicsChildrenAdultsHead/BodyLargeSmallFulcrumC2 – C3C5 – C6Neck muscles, spine ligamentsWeak, lax andelasticStrong, stiff,↓ elasticityVertebral bodiesAnterior wedgingCartilaginousNo wedgingossifiedArticulating facetsMore horizontallyorientedVertically orientedThere are anatomical differences that influence the type of injuries. Children have
10Head and Cervical Spine Differences Children vs. Adults Here you can see wedge shaped vertebral bodies and more horizontal articulating facets as compare with the adult.
11Cervical Spine Injuries in Children Age and Level of Injury Young0 -10 yearsOldyearsPHighC1 – C48556< .01LowC5 – C71543High CSI injuries occur more frequently than lower CSI in children, and the frequency is even higher in the younger group.
12CSI in Children Age and Type of Injury (from Kokoska) Young0 - 10OldpFractures (%)4265< .01Dislocations (%)3120SCIWORA (%)2715The anatomical differences also account for a higher proportion of dislocations and sciwora in younger children
13Cervical Spine Injury in Children Clinical 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?
14Cervical Spine Injury Management First Things First ABCsProtect 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.Always,
15Cervical Spine Injury Management Obtain History Details of events from patient and othersMechanism of InjurySigns and symptomsSpecific neurologic signs or symptomsDrug ingestion or intoxicationPMH: Previous trauma or surgeryArthritis, syndromes, othersThen, …
16Cervical Spine Injury in Children Physical Exam Motor deficitSensory deficitAltered mental statusNeck tendernessTorticollisLimitation of motionNeck muscle spasmAbnormal reflexesClonus without rigidityDiaphragmatic breathing without retractionsSpinal shock ↓BP + ↓HRPriapismDecreased bladder controlFecal retentionUnexplained ileusLabile BP, flushing, sweatingTemperature instabilitySimultaneously, proceed to our secondary survey and look for specific neurological signs and symptoms.
17Cervical Spine Immobilization Hard collar + Spine BoardBecame familiar with the ones used in your areaTallest collar that not hyperextend the neckBackboard with occipital recess or padding under shoulders and bodyStraps over the forehead, chin, shoulders, hips, thighs and ankles.Be ready to log roll the patient if vomit occurs
18Cervical 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?Frequently the patient arrives already with collar and board, in that case we need to asses the immobilization.
19Cervical Spine Clearing in Pediatric Trauma Patients Slack SE, Clancy MJ: Comprehensive literature search of the studies on the subject (2004)241 papers, 71 relevantNo “Gold Standard” to identify all CSIMany papers did not include clinical follow upOnly the National Emergency X-Radiography Utilization Study NEXUS was considered valid for its purpose.The next question is: Can we clear the Cervical Spine?
20Clinical Clearing of the Cervical Spine The NEXUS Study Prospective Observational Study: 34,000 pts.Radiographs were ordered at the discretion of examining physicianMix of participating institutionsImaged 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.
21Clinical Clearing the Cervical Spine NEXUS Low-Risk Criteria No midline cervical tendernessNo evidence of intoxicationNo altered level of alertnessNo focal neurological deficitNo distracting painful injury
22Clinical Clearing the Cervical Spine Results of NEXUS Study < 18 years≥ 18 yearsTotalNumber of cases3,065905 < 9 years31,00434,069CSI Patients30 (0.98%)4 < 9 years788 (2.54%)818 (2.4%)Low-risk patients603 (19.7%)3706 (12.0%)4309 (12.6%)Low-risk patients with CSI8Patients were divided in two groups: younger and older than 18 years. There were 3065
23Clinical Clearing the Cervical Spine Results of NEXUS Study (cont.) Pediatric GroupOverallSensitivity95% CI100 %99. 2 %98.0 – 99.6NPV99.8 %Specificity19.9 %18.5 – 21.312.93 %PPV1.2 %0.8 – 1.82.72 %The Nexus Criteria has high sensitivity and negative predictive value both overall and in the pediatric group, which makes it a good screening tool.
24Clinical Clearing the Cervical Spine NEXUS Study Conclusions No CSI was identified in the pediatric group without at least one NEXUS risk factorAbout 20% less radiographs would have been performedHowever there were few pediatric patients with CSI. Lower end of CI: 87.8Only 4 injured patients were younger than 9 yrs.NEXUS criteria can be used with caution in pediatric patients ≥ 8 years.
25Maintain Cervical Spine Immobilization C1-C7 If cervical spine can not be cleared clinically Cervical Spine RadiographsMaintain Cervical Spine ImmobilizationC1-C7Cross-table lateral: 80% of bony lesionsAP: lateral mass fracturesOdontoid views in ≥ 9 yr. Waters < 9yrTree views: Dx 90% of CS fractures
26The ABCS of Radiographic Cervical Spine Evaluation A. Alignment: Lordotic curves, malalignment, subluxation, distraction.B. Bones: Fractures, anterior and posterior cervical columns, ossification centersC. Cartilage: Intervertebral disk spaces, ossification centersS. Soft Tissues: Prevertebral, predental spaces.
28Cervical Spine Flexion Injury Flexion teardrop fracture Flexion of spine + vertical axis compressionAnterior-inferior fracture of vertebral bodyAnterior displacement of the fragmentSignificant posterior ligament disruptionExtremely unstable
29Cervical Spine Flexion Injury Clay Shoveler Fracture Avulsion fracture of the spinous processAbrupt neck flexion in muscular individualsUsually lower vertebraeFragment easily seen in lateral viewStable
30Cervical Spine Flexion Injury Anterior subluxation Posterior ligament complex ruptureAnterior longitudinal ligament preservedNo bony injuryWidening of interspinous processes distanceAnterior column intactStable in extension unstable in flexion
31Posterior Cervical Line (PCL) of Swischuk PCL connects the anterior aspect of the spinous processes of C1 and C3If 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 PCLNow that we are talking of subluxations, there is a common apparent subluxation of C2 on C3 in children
32Cervical Spine Flexion Injury Bilateral Facet Dislocation Involves annulus and anterior & posterior ligamentsUpper vertebra inferior facets pass above and anterior to lower facetsBody displacement > half anterior-posterior diameterExtremely unstable, disk herniation during reduction
33Odontoid 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
34Odontoid Process (Dens) Fracture Fracture through base of dens. Dens and C1 posterior to C2
35Indications for Flexion and Extension Views To diagnose ligament injuriesAlert patientsNo neurologic deficitsNormal Cervical Spine (3 views)Neck pain or muscle spasmPatient able to actively flex and extend neck
36CT/MRI Indications Altered mental status, risk factors C-spine incompletely visualized on plain filmsAbnormal or suspicious C-spine filmsSuspicion of injuries despite normal radiographsCT Sensitivity and Specificity ≥ 98%MRI: better than CT for soft tissues: SCIWORA
37Cervical Spine Extension Injury C1 Posterior arch fracture Neck hyperextensionC1 posterior arch compressed by occiput and C2 spinous processLateral view: fracture line through posterior archNo widening of pre-dental space
40Limitations for the routine use of the CT and MRI in the evaluation of cervical spine in children Cervical spine injuries are rare in childrenCT radiation dose is 10 times > plain filmsCT is more costlyMRI availability is limitedMRI difficult for critically ill child
41C-spine injury Treatment Stabilize primary injury and prevent secondary injuriesNo Treatment GuidelinesNeurosurgery ASAPClosed reduction + Halo immobilizationSurgery for ligament injuriesSteroids: Controversial, no data for children
42Management 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”
43Management 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”“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?
44Management Pitfalls for CSI continued… “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”
45Selected ReferencesKokoska 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:Martin BW, Dykes E, Lecky FE: Patterns and risks in spinal trauma.Arch Dis Child 2004; 89:
46Selected ReferencesViccellio P, Simon H, Pressman B, et al: A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics 2001; 108: 20-26Slack 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
47Selected ReferencesHaizlip JA, Scherrer PD: Emergency Evaluation of the Pediatric Cervical Spine. Pediatric Emergency Medicine Practice 2008; 5 (7) 1-24