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Cervical Spine Injuries in Children

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Presentation on theme: "Cervical Spine Injuries in Children"— 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 Epidemiology Mechanisms of Injury
Differences: Children vs. Adults Clinical Presentation 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) 0 - 20 0 - 15 Injured Children 24,740 75,172 19,538 CSI number (%) 408 (1.6) 1098 (1.5) 662 (3.4) Males (%) 59 61 58 Cord Injury (%) 35 29 21.9 Mortality (%) 17 13 We 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

6 Cervical Spine Injuries in Children Mechanism of Injury
Kokoska E. Patel J. Martin B. MVA (%) 44 42 49.8 Sports (%) 16 14 7.4 Falls (%) 13 37.6 Pedestrian (%) 11 - Bicycle (%) 6 5 In these studies the most common mechanisms were …

7 Cervical Spine Injury in Children Mechanism of Injury and Age
Young 0 - 10 Old p MVA(%) 44 43 ns Falls (%) 17 12 < .01 Pedestrian (%) 18 4 < .001 Bicycle (%) 3 8 Sports (%) 6 25 As 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.

8 Cervical Spine Injuries in Children Type of Injury
Injury Type Kokoska E. % Patel J. Fracture 56 Dislocation 25 22 Fracture/Dislocation - 5 SCIWORA Spinal cord injury without radiological abnormality 19 17 The most common types of CSI injuries in children are … but spinal cord injuries without radiological abnormalities account for almost 1/5 of CSI

9 Head and Cervical Spine Differences Children vs. Adults
Characteristics Children Adults Head/Body Large Small Fulcrum C2 – C3 C5 – C6 Neck muscles, spine ligaments Weak, lax and elastic Strong, stiff, ↓ elasticity Vertebral bodies Anterior wedging Cartilaginous No wedging ossified Articulating facets More horizontally oriented Vertically oriented There are anatomical differences that influence the type of injuries. Children have

10 Head 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.

11 Cervical Spine Injuries in Children Age and Level of Injury
Young 0 -10 years Old years P High C1 – C4 85 56 < .01 Low C5 – C7 15 43 High CSI injuries occur more frequently than lower CSI in children, and the frequency is even higher in the younger group.

12 CSI in Children Age and Type of Injury (from Kokoska)
Young 0 - 10 Old p Fractures (%) 42 65 < .01 Dislocations (%) 31 20 SCIWORA (%) 27 15 The anatomical differences also account for a higher proportion of dislocations and sciwora in younger children

13 Cervical 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?

14 Cervical Spine Injury Management First 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. Always,

15 Cervical Spine Injury Management Obtain 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 Then, …

16 Cervical Spine Injury in Children Physical Exam
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 Simultaneously, proceed to our secondary survey and look for specific neurological signs and symptoms.

17 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

18 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? Frequently the patient arrives already with collar and board, in that case we need to asses the immobilization.

19 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. The next question is: Can we clear the Cervical Spine?

20 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.

21 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

22 Clinical Clearing the Cervical Spine Results of NEXUS Study
< 18 years ≥ 18 years Total Number of cases 3,065 905 < 9 years 31,004 34,069 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 8 Patients were divided in two groups: younger and older than 18 years. There were 3065

23 Clinical Clearing the Cervical Spine Results of NEXUS Study (cont.)
Pediatric Group Overall Sensitivity 95% CI 100 % 99. 2 % 98.0 – 99.6 NPV 99.8 % Specificity 19.9 % 18.5 – 21.3 12.93 % PPV 1.2 % 0.8 – 1.8 2.72 % The Nexus Criteria has high sensitivity and negative predictive value both overall and in the pediatric group, which makes it a good screening tool.

24 Clinical Clearing the Cervical Spine NEXUS 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.

25 Maintain Cervical Spine Immobilization C1-C7
If cervical spine can not be cleared clinically Cervical 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

26 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.

27 Clearing Cervical Spine by X Rays

28 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

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

30 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

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 (hangman’s fracture) (C) Pseudosubluxation: Anterior aspect of C2 spinous process <2 mm or touches PCL Now that we are talking of subluxations, there is a common apparent subluxation of C2 on C3 in children

32 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

33 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

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 Alert patients No neurologic deficits Normal Cervical Spine (3 views) Neck pain or muscle spasm Patient able to actively flex and extend neck

36 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

37 Cervical Spine Extension Injury C1 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

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 CT radiation dose is 10 times > plain films CT is more costly MRI availability is limited MRI difficult for critically ill child

41 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

42 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”

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” “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?

44 Management 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”

45 Selected References 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: 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: 20-26 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

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

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