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Pediatric C-Spine Injuries Harold K. Simon, MD, MBA Professor, Emory Department of Pediatrics & Emergency Medicine.

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Presentation on theme: "Pediatric C-Spine Injuries Harold K. Simon, MD, MBA Professor, Emory Department of Pediatrics & Emergency Medicine."— Presentation transcript:

1 Pediatric C-Spine Injuries Harold K. Simon, MD, MBA Professor, Emory Department of Pediatrics & Emergency Medicine

2 Objectives Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Immobilization Techniques Clinical versus radiograph clearance CT versus Plain Films Interpreting the cervical spine radiograph –Cases

3 Inspiration Yet Reality

4

5 Objectives Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Immobilization Techniques Clinical versus radiograph clearance CT versus Plain Films Interpreting the cervical spine radiograph –Cases

6 Epidemiology : Age Mean age is 8-9 years old, 2:1 male to female < 8 years old mainly, ligamentous injuries > 8 years old mainly fractures Infants under 1 year old with Cervical Spine Injuries are rare

7 Epidemiology : Mechanism 67% occur with motor vehicle collision –33% occupant –23% bicyclist vs. auto –11% pedestrian vs. auto 30% occur with falls and sports injuries < 3% occur with gunshot wounds

8 Epidemiology : Associated Injuries Of 45 children with Cervical Spine Injuries Pulmonary Contusion10 Femur Fracture8 Hemoperitoneum6 Tibial Fracture 5 Arm Fracture 4 Rib Fracture3 Splenic Laceration3 Ruptured Kidney2 Pelvis Fracture2 Clavicle fracture, pneumothorax,1 each hemothorax, flail chest, liver laceration, bowel wall edema, limb amputation Note: 40% of children with cervical spine injury have no trauma to an other body part Orestein et al.

9 Objectives Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Immobilization Techniques Clinical versus radiograph clearance CT versus Plain Films Interpreting the cervical spine radiograph –Cases

10 Anatomy : Pediatric versus Adult Proportionally larger and heavier head Weaker and underdeveloped neck musculature Higher center of gravity –Pediatric : C2-C3 –Adult: lower cervical vertebrae Greater elasticity and laxity of ligaments in children More horizontal orientation of facet joints

11 Anatomy : Pediatric versus Adult Relatively wedged anterior vertebral bodies Biomechanical and anatomic difference begin to disappear around 8-10 years old, but are not fully gone until 15-17 years old

12 Anatomy : Implications Ligamentous laxity –Allows the spine to absorb and cushion traumatic forces, thus protecting the bones and spinal cord –More cervical distraction injuries, as well as hyperflexion-extension injuries in rapid deceleration accidents (high energy injuries) –Children may have spinal cord injury in the absence of radiographic abnormality (SCIWORA)

13 Objectives Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Immobilization Techniques Clinical versus radiograph clearance CT versus Plain Films Interpreting the cervical spine radiograph –Cases

14 Question 28 month old male Fell from shopping cart, landed on head Arrives in C-collar Primary survey is normal Patient is crying and uncooperative How would you clear his cervical spine?

15 Which Trauma Patients Should Be Immobilized Severe or high risk mechanism of injury, instability, or inability to assess Altered level of consciousness, altered alertness, or inebriated No Neurologic abnormality at any time post- injury No Complaints of neck pain No Cervical spine tenderness (or other painful injuries which might mask neck pain No Limited or painful neck motion No Clinical evaluation without radiographs No Immobilize, radiographic evaluation Yes Immobilize, radiographic evaluation Yes Immobilize, radiographic evaluation Yes Immobilize, radiographic evaluation Yes Immobilize, radiographic evaluation Yes Immobilize, radiographic evaluation Yes

16 Immobilization Techniques Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Immobilization Techniques Clinical versus radiograph clearance CT versus Plain Films Interpreting the cervical spine radiograph –Cases

17

18 Immobilization Techniques t Cervical collars - soft foam, firm foam, and rigid plastic t Sandbags/foam cushions/towels/tape t Backboards/Kendricks extrication device/Extriboard t Combinations usually used in the pre-hospital setting

19 Immobilization Techniques Pediatric patients have disproportionally large heads that actually cause neck flexion on a rigid backboard. Padding under the shoulders and back, or a recessed area for the head is recommended to keep the patient in the neutral position.

20 Immobilization Techniques t Pediatric backboards with recessed head areas t Pre-hospital : Use a rigid or firm foam collar in combination with other padding, on a rigid backboard, with tape to provide the best initial immobilization

21 Immobilization Techniques t Never attempt to straighten a cervical deformity when immobilizing a child! t Cervical collar alone DOES NOT provide full immobilization if moving about uncontrollably! ç It may however be an option for a totally cooperative patient not moving about and for lower risk situations. ç Only mobilization necessary for most in-hospital situations

22 Immobilization Techniques Flexion Extension Rotation Lateral Pediatric Control 35° 45° 80° 16° Infant Control 35° 38° >90° 40° Range of neck motion in mannequins

23 Degrees of Motion Allowed From Neutral Position in Mannequin Models Collar FlexionExtensionRotationLateralSummed Score*(%) ± Infant Infant car seat, padding, tape With foam collar 812 2°3°25 (64) Head Brace3538 4 ° 1 ° 78 (205) With Foam Collar1119 2 ° 2 ° 34(87) Half-Spine board, tape1 1 4 ° 6 ° 12(23) With Foam Collar1 1 2 ° 4 ° 8(17) Kendrick Extriction1210 19 ° 9 ° 50(92) With Foam Collar 1 1 4 ° 1 ° 7(11) Pitfalls of Pediatric Immobilization:

24 Child Control Head Immobilizer Foam cushions to spine board111826 ° 3 ° 58(122) With Vertebrace1014 1 ° 1 ° 26(66) Head Brace1612 2 ° 1 ° 31(82) With Flex-Support7 9 5 ° 2 ° 23(58) Kendricks Extrication6 8 4 ° 2 °20(53) With Flex-Support4 3 1 ° 2 °10(31) Extriboard Disposable Extrication device9 7 5 ° 4 °24 (73) With Vertebrace3 2 2 ° 1 ° 8(20) Half-Spine board & tape10 1 4 ° 7 °22 (79) With Flex-Support & Tape2 3 1 ° 2 ° 8(26) Full-Spine board & Tape412 5 ° 3 °24 (63) Tape, Beanbag & Flex-Sup10 9 3 ° 2 ° 24(66) Tape, Beanbag5 5 0 ° 1 ° 11 (31) * Summed score, arithmatic sum of degrees of motion in each direction. Degrees of motion allowed ±Summed of score, arithmatic sum of percentage of control motion. Control In each direction

25 Pitfalls of Pediatric Immobilization: Degrees of Motion Allowed From Neutral Position in Mannequin Models Collar FlexionExtensionRotationLateralSummed Score*(%) ± Infant Control (no collar)353818040293(400) Prosplints Cervical Collar1119 1220 62(138) Child Control (no collar)3545 8016176(400) Foam Extrication3545 1611107(289) Disposable Foam2432 7 5 68(180) Ferno-Fit3631 8 6 81(217) Standard2123 10 357(142) Hare354512 698(253) Thomas2421 6 758(168) Flex-Support 3” 4-way1719 4 646(134) Flex-Support 2” 4-way2323 7 558(157) Vertebrace2018 9 754(152) Stiff Neck2018 6 852(155) Philadelphia2315 51255(180)

26 Objectives Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Immobilization Techniques Clinical versus radiograph clearance CT versus Plain Films Interpreting the cervical spine radiograph –Cases

27 National Emergency Medicine X-ray Utilization Study 23 Center National Cooperative Study Viccellio P, Simon HK, Pressman B, Shah M, Mower W, Hoffman J, for the NEXUS Group. A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics August 2001;108: e20 NEXUS

28 NEXUS : Study objectives Examine the spectrum of cervical spine (c-spine) injuries in children Evaluate the efficacy of a decision instrument designed to identify which patients are at “low risk” for radiographic c-spine injury

29 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

30 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

31 NEXUS: Study Definitions Distracting Injury Significant, painful injuryExamples –SkinLarge 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

32 NEXUS : Study Results 34,069 patients enrolled –3,065 Pediatric Patients (9%) were < 18 yrs 603 (19.7%) were “Low-risk”

33 Age distribution in years - All Nexus Patients 102 96 90 84 78 72 66 60 54 48 42 36 30 24 18 12 6 0 Number 1000 800 600 400 200 0 NEXUS : Study Results

34 Age distribution in years - All Nexus Patients 102 96 90 84 78 72 66 60 54 48 42 36 30 24 18 12 6 0 Number 1000 800 600 400 200 0 NEXUS : Study Results n = 3,065n = 31,004 N = 34,069

35 600 Age distribution in years 1716 151413 1211109876543210 # of patients 500 400 300 200 100 0 NEXUS : Study Results Age Distribution of Pediatric Patients N = 3,065

36 600 Age distribution in years 1716 151413 1211109876543210 # of patients 500 400 300 200 100 0 NEXUS : Study Results Age Distribution of Pediatric Patients N = 3,065 <2 y.o., n = 88

37 600 Age distribution in years 1716 151413 1211109876543210 # of patients 500 400 300 200 100 0 NEXUS : Study Results Age Distribution of Pediatric Patients N = 3,065 2-8 y.o., n = 817 <2 y.o., n = 88

38 600 Age distribution in years 1716 151413 1211109876543210 # of patients 500 400 300 200 100 0 NEXUS : Study Results Age Distribution of Pediatric Patients N = 3,065 9-17 y.o., n = 2160 2-8 y.o., n = 817 <2 y.o., n = 88

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

40 Clinical Features+- N/A Tenderness2145 Neuro deficits8193 Altered LOC6213 Intoxication0273 Distracting injury11172 Of the 30 children with c-spine injuries NEXUS : Study Results

41 Clinical Features+- N/A Tenderness2145 Neuro deficits8193 Altered LOC6213 Intoxication0273 Distracting injury11172 Of the 30 children with c-spine injuries NEXUS : Study Results

42 Clinical Features+- N/A Tenderness2145 Neuro deficits8193 Altered LOC6213 Intoxication0273 Distracting injury11172 Of the 30 children with c-spine injuries NEXUS : Study Results

43 Clinical Features+- N/A Tenderness2145 Neuro deficits8193 Altered LOC6213 Intoxication0273 Distracting injury11172 Of the 30 children with c-spine injuries NEXUS : Study Results

44 Clinical Features+- N/A Tenderness2145 Neuro deficits8193 Altered LOC6213 Intoxication0273 Distracting injury11172 Of the 30 children with c-spine injuries NEXUS : Study Results

45 Clinical Features+- N/A Tenderness2145 Neuro deficits8193 Altered LOC6213 Intoxication0273 Distracting injury11172 Of the 30 children with c-spine injuries NEXUS : Study Results

46 Clinical Features+- N/A Tenderness11791333523 Neuro deficits1762611248 Altered LOC5202326189 Intoxication1102730195 Distracting injury8781915242 Of the 3,035 children without c-spine injuries NEXUS : Study Results

47 Age SexFracture type 2FC2 type III odontoid fracture 3MOccipital condyle fracture 6MCranio-cervical dissociation 8MC1 & C2, fractures 9MC4 flexion tear drop fracture 11MCranio-cervical dissociation 11FC7 burst fracture 11MC5 body fracture 11MC1 lateral mass fracture 12FC2 spinous process fracture 13MC6 spinous process fracture 14MC7 wedge compression 14FC4 - C5 subluxation, C5 - C6 subluxation, C5 body and,posterior element fractures, C4-6 cord contusion 16FC7 compression fracture 16FC6 - C7 fracture 16MC6 burst fracture and bilateral laminar fractures, C7 body fractures 16MC5 burst fracture and bilateral laminar fractures; C5 – C6 subluxation 16MC5 body fracture; C5-6 sublux 16MC5 & C6 trabecular fractures, C3 - C7 interspinous ligament injury 16MC6 facet fracture; C6 compression fracture; C5 – C6 interfacetal dislocation; C5 – C6 cord contusion 16MC1 posterior arch fracture 16MC4 compression fracture; C3 – C4 subluxation; C3 – C4 cord contusion 16FC4 burst fracture; C4-C5 subluxation; C4-C5 cord contusion 17MC7 spinous process fracture 17FC7 body fracture 17MC6 - C7 facet and capsular injury 17MC5 laminar fracture, C6 body fracture, C5 – C6 nterfacetal dislocation, C5 – C6 cord contusion

48 NEXUS : Study Results Age SexFracture type 2FC2 type III odontoid fracture 3MOccipital condyle fracture 6MCranio-cervical dissociation 8MC1 & C2, fractures 9MC4 flexion tear drop fracture 11MCranio-cervical dissociation 11FC7 burst fracture 11MC5 body fracture 11MC1 lateral mass fracture 12FC2 spinous process fracture 13MC6 spinous process fracture 14MC7 wedge compression 14FC4 - C5 subluxation, C5 - C6 subluxation, C5 body and,posterior element fractures, C4-6 cord contusion 16FC7 compression fracture 16FC6 - C7 fracture 16MC6 burst fracture and bilateral laminar fractures, C7 body fractures 16MC5 burst fracture and bilateral laminar fractures; C5 – C6 subluxation 16MC5 body fracture; C5-6 sublux 16MC5 & C6 trabecular fractures, C3 - C7 interspinous ligament injury 16MC6 facet fracture; C6 compression fracture; C5 – C6 interfacetal dislocation; C5 – C6 cord contusion 16MC1 posterior arch fracture 16MC4 compression fracture; C3 – C4 subluxation; C3 – C4 cord contusion 16FC4 burst fracture; C4-C5 subluxation; C4-C5 cord contusion 17MC7 spinous process fracture 17FC7 body fracture 17MC6 - C7 facet and capsular injury 17MC5 laminar fracture, C6 body fracture, C5 – C6 nterfacetal dislocation, C5 – C6 cord contusion

49 NEXUS : Study Results Age SexFracture type 2FC2 type III odontoid fracture 3MOccipital condyle fracture 6MCranio-cervical dissociation 8MC1 & C2, fractures 9MC4 flexion tear drop fracture 11MCranio-cervical dissociation 11FC7 burst fracture 11MC5 body fracture 11MC1 lateral mass fracture 12FC2 spinous process fracture 13MC6 spinous process fracture 14MC7 wedge compression 14FC4 - C5 subluxation, C5 - C6 subluxation, C5 body and,posterior element fractures, C4-6 cord contusion 16FC7 compression fracture 16FC6 - C7 fracture 16MC6 burst fracture and bilateral laminar fractures, C7 body fractures 16MC5 burst fracture and bilateral laminar fractures; C5 – C6 subluxation 16MC5 body fracture; C5-6 sublux 16MC5 & C6 trabecular fractures, C3 - C7 interspinous ligament injury 16MC6 facet fracture; C6 compression fracture; C5 – C6 interfacetal dislocation; C5 – C6 cord contusion 16MC1 posterior arch fracture 16MC4 compression fracture; C3 – C4 subluxation; C3 – C4 cord contusion 16FC4 burst fracture; C4-C5 subluxation; C4-C5 cord contusion 17MC7 spinous process fracture 17FC7 body fracture 17MC6 - C7 facet and capsular injury 17MC5 laminar fracture, C6 body fracture, C5 – C6 nterfacetal dislocation, C5 – C6 cord contusion

50 NEXUS : Study Results Value (95% CI) Sensitivity100% (87.8 – 100%) Negative Predictive Value100% (99.2 – 100%)

51 NEXUS : Study Results Value (95% CI) Sensitivity100% (87.8 – 100%) Negative Predictive Value100% (99.2 – 100%)

52 Item of interest Age <18yrsAge ≥18yrs Total # of cases3,06531,004 # with c-spine injury30788 Injury Rate0.98%2.54% “Missed injuries”08 (all negative criteria) # of cases with all (-) criteria20%12% NEXUS : Study Results Pediatric versus Adult

53 Item of interest Age <18yrsAge ≥18yrs Total # of cases3,06531,004 # with c-spine injury30788 Injury Rate0.98%2.54% “Missed injuries”08 (all negative criteria) # of cases with all (-) criteria20%12% NEXUS : Study Results Pediatric versus Adult

54 Item of interest Age <18yrsAge ≥18yrs Total # of cases3,06531,004 # with c-spine injury30788 Injury Rate0.98%2.54% “Missed injuries”08 (all negative criteria) # of cases with all (-) criteria20%12% NEXUS : Study Results Pediatric versus Adult

55 Item of interest Age <18yrsAge ≥18yrs Total # of cases3,06531,004 # with c-spine injury30788 Injury Rate0.98%2.54% “Missed injuries”08 (all negative criteria) # of cases with all (-) criteria20%12% NEXUS : Study Results Pediatric versus Adult

56 NEXUS : Study Results Take Home –No c-spine injuries occurred in children prospectively identified at “low-risk” –NEXUS decision instrument could have safely reduced c-spine imaging by nearly 20% –Limited data on under 2 years old

57 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

58 Canadian c-spine algorithm

59 Objectives Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Immobilization Techniques Clinical versus radiograph clearance CT versus Plain Films Interpreting the cervical spine radiograph –Cases

60 Advantages –CT is more sensitive for detecting C-Spine Injuries than plain film –Depending on age may save time Disadvantages –Radiation –Cost –May increase time if sedation required Helical CT vs Plain Films

61 Randomized trial 136 children 0-14yr Increased radiation in HCT group No reduction in the amount of sedation or LOS in the HCT group 34% crossover from assigned group secondary to perceived advantages Adelgais KM, Grossman D, et al. Academic Emerg Med March 2004

62 Helical CT vs Plain Films OutcomeHelical CT (n=97)Plain Film (n=39) Mean ED time (min)243 (CI 143, 343)174 (CI 154,194) Mean Radiation time (min)89 (CI 60, 118)88 (CI 76, 99) Radiographic cost total RVU17.3 (CI 15, 19)10.7 (CI 8.5, 12.9) Total $657 (CI 570, 737)407 (CI 323, 494) C-Spine RVU5.9 (CI 5.8, 6.1)1.8 (CI 1.4, 2.2) C-Spine $224 (CI 220, 232)68 (CI 53, 84) Rad dose (nRem)432 (CI 340, 465)127 (CI 117, 138)

63 Helical CT vs Plain Films OutcomeHelical CT (n=97)Plain Film (n=39) Mean ED time (min)243 (CI 143, 343)174 (CI 154,194) Mean Radiation time (min)89 (CI 60, 118)88 (CI 76, 99) Radiographic cost total RVU17.3 (CI 15, 19)10.7 (CI 8.5, 12.9) Total $657 (CI 570, 737)407 (CI 323, 494) C-Spine RVU5.9 (CI 5.8, 6.1)1.8 (CI 1.4, 2.2) C-Spine $224 (CI 220, 232)68 (CI 53, 84) Rad dose (nRem)432 (CI 340, 465)127 (CI 117, 138)

64 Helical CT vs Plain Films OutcomeHelical CT (n=97)Plain Film (n=39) Mean ED time (min)243 (CI 143, 343)174 (CI 154,194) Mean Radiation time (min)89 (CI 60, 118)88 (CI 76, 99) Radiographic cost total RVU17.3 (CI 15, 19)10.7 (CI 8.5, 12.9) Total $657 (CI 570, 737)407 (CI 323, 494) C-Spine RVU5.9 (CI 5.8, 6.1)1.8 (CI 1.4, 2.2) C-Spine $224 (CI 220, 232)68 (CI 53, 84) Rad dose (nRem)432 (CI 340, 465)127 (CI 117, 138)

65 Helical CT vs Plain Films OutcomeHelical CT (n=97)Plain Film (n=39) Mean ED time (min)243 (CI 143, 343)174 (CI 154,194) Mean Radiation time (min)89 (CI 60, 118)88 (CI 76, 99) Radiographic cost total RVU17.3 (CI 15, 19)10.7 (CI 8.5, 12.9) Total $657 (CI 570, 737)407 (CI 323, 494) C-Spine RVU5.9 (CI 5.8, 6.1)1.8 (CI 1.4, 2.2) C-Spine $224 (CI 220, 232)68 (CI 53, 84) Rad dose (nRem)432 (CI 340, 465)127 (CI 117, 138)

66 Helical CT vs Plain Films OutcomeHelical CT (n=97)Plain Film (n=39) Mean ED time (min)243 (CI 143, 343)174 (CI 154,194) Mean Radiation time (min)89 (CI 60, 118)88 (CI 76, 99) Radiographic cost total RVU17.3 (CI 15, 19)10.7 (CI 8.5, 12.9) Total $657 (CI 570, 737)407 (CI 323, 494) C-Spine RVU5.9 (CI 5.8, 6.1)1.8 (CI 1.4, 2.2) C-Spine $224 (CI 220, 232)68 (CI 53, 84) Rad dose (nRem)432 (CI 340, 465)127 (CI 117, 138)

67 Helical CT vs Plain Films OutcomeHelical CT (n=97)Plain Film (n=39) Mean ED time (min)243 (CI 143, 343)174 (CI 154,194) Mean Radiation time (min)89 (CI 60, 118)88 (CI 76, 99) Radiographic cost total RVU17.3 (CI 15, 19)10.7 (CI 8.5, 12.9) Total $657 (CI 570, 737)407 (CI 323, 494) C-Spine RVU5.9 (CI 5.8, 6.1)1.8 (CI 1.4, 2.2) C-Spine $224 (CI 220, 232)68 (CI 53, 84) Rad dose (nRem)432 (CI 340, 465)127 (CI 117, 138)

68 Objectives Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Clinical versus radiograph clearance –NEXUS Study –Canadian Rules CT versus Plain Films Interpreting the cervical spine radiograph –Cases

69 C-Spine Radiograph Lateral film Anteroposterior film Open-mouth odontoid view

70 Lateral Film –Most injuries picked up with lateral film >80% –Odontoid view utility questionable in small children Basic Information –Jefferson Fracture – axial compression Burst of C1 ring –Hangman Fracture – hyperextension, then flexion C2 pedicle fracture –Physiologic dislocation Usually under 16 years of age Anteriorly displacement of C2 on C3 C-Spine Radiograph

71 Focus on the lateral neck 1.Film adequacy 2.C-spine alignment and curves 3.Inter-vertebral spaces: discs and joints 4.Pre-vertebral space 5.Pre-dental space

72 C1 “Atlas” C2 “Axis” C4C5C6C7 C3 Brief anatomic review Bodies Dens

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

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

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

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

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

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

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

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

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

82 Alignment C-Spine Curves Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

83 Alignment C-Spine Curves –Anterior Vertebral Bodies Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

84 Alignment C-Spine Curves –Anterior Vertebral Bodies –Anterior Spinal Canal Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

85 Alignment C-Spine Curves –Anterior Vertebral Bodies –Anterior Spinal Canal –Posterior Spinal Canal Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

86 Alignment C-Spine Curves –Anterior Vertebral Bodies –Anterior Spinal Canal –Posterior Spinal Canal –Spinous Process Tips Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

87 Inter-vertebral spaces –Disc spaces –Cartiledge –Apophyseal joints Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

88 Pre-vertebral space Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

89 Pre-vertebral space –Space between vertebral bodies and air column Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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

91 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 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

92 Pre-Dental Space Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

93 Pre-Dental Space –Space between Dens of C2 and anterior, interior side of C1 ring Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

94 Pre-Dental Space –Space between Dens of C2 and anterior, interior side of C1 ring

95 Pre-Dental Space –Space between Dens of C2 and anterior, interior side of C1 ring –Must be less than or equal to 5 mm –Cause of increased space transverse ligament injury burst fracture of C1 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

96 Objectives Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Clinical versus radiograph clearance –NEXUS Study –Canadian Rules CT versus Plain Films Interpreting the cervical spine radiograph –Cases

97 Case 1 4 year old female, restrained, back seat High speed, head on, 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 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

98

99

100 Fracture at base of dens with anterior displacement Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

101 Case 1 The greater elasticity and laxity of ligaments in children allow for more hyper flexion and extension injuries Children with hypoplasia of dens, ie: Trisomy 21 Children with rheumatoid arthritis, are at higher risk for atlanto-axial dislocation Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

102 Case 2 18 month old female, unrestrained, front seat 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 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

103

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

105

106 Case 2 C-spine injuries in children are rare Up to 40% of children with c-spine injury have trauma to another body part Must learn to properly immobilize the c-spine Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

107 Case 3 A 4 year old child, fell from shopping cart, no loc Fever, sore throat, strep positive yesterday Not tolerating liquids or solid food Temperature=104 Alert, awake and talking with hoarse voice Drooling, mild increased work of breathing He complains of neck pain Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

108

109 Glottis Abscess Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

110 Case 3 The pre-vertebral space can be enlarged with a hematoma post c-spine trauma or general edema Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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

112

113 Ruptured Transverse Ligament Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

114 C2 - Axis Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

115 v C1 - Atlas Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

116 ANTERIOR POSTERIORANTERIOR Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

117 ANTERIOR POSTERIORANTERIOR Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

118 ANTERIOR POSTERIORANTERIOR Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

119 ANTERIOR POSTERIORANTERIOR Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

120 ANTERIOR POSTERIOR Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

121 Case 4 The safest place for any aged child is the back seat –Air bags can be lethal to children –AAP Recommends: Children ages 12 and younger should ride in the back seat Must wear seat belts Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

122 Summary Epidemiology Anatomy: Pediatric versus Adult Who should be immobilized Immobilization Techniques Clinical versus radiograph clearance CT versus Plain Films Interpreted the cervical spine radiograph


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