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Clearing the Pediatric C-Spine Kelly R. Millar, MD, FRCPC Emergency Physician, Alberta Children’s Hospital Assistant Professor, University of Calgary.

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Presentation on theme: "Clearing the Pediatric C-Spine Kelly R. Millar, MD, FRCPC Emergency Physician, Alberta Children’s Hospital Assistant Professor, University of Calgary."— Presentation transcript:

1 Clearing the Pediatric C-Spine Kelly R. Millar, MD, FRCPC Emergency Physician, Alberta Children’s Hospital Assistant Professor, University of Calgary

2 Overview Epidemiology Epidemiology Anatomic considerations Anatomic considerations Clearing the pediatric c-spine Clearing the pediatric c-spine Who needs imaging? Who needs imaging? What films should be ordered? What films should be ordered? Who needs a CT/MRI? Who needs a CT/MRI? Interpretation of Pediatric c-spine films Interpretation of Pediatric c-spine films Cases Cases

3 Epidemiology of Pediatric Cervical Spine Injury 5% of all spinal cord injuries occur in children 5% of all spinal cord injuries occur in children 1000 pediatric spinal cord injuries in the US each year 1000 pediatric spinal cord injuries in the US each year 80% of spinal injuries in children < 8 yrs are cervical (vs 30-40% in adults) 80% of spinal injuries in children < 8 yrs are cervical (vs 30-40% in adults)

4 Epidemiology Many small case series Many small case series Often include up to age 20, so data very skewed to older “children” Often include up to age 20, so data very skewed to older “children” 2 recent large pediatric data sources have fair number of younger children: 2 recent large pediatric data sources have fair number of younger children: The largest prospective series is the pediatric subset of the NEXUS trial The largest prospective series is the pediatric subset of the NEXUS trial The largest retrospective series comes from the National Pediatric Trauma Registry The largest retrospective series comes from the National Pediatric Trauma Registry

5 How common are pediatric C-spine injuries?

6 National Pediatric Trauma Registry Prospective, multi-center database Prospective, multi-center database Includes ages 0-20 Includes ages 0-20 Primary diagnosis traumatic injury Primary diagnosis traumatic injury Patel et al (2001) J Ped Surg 10 yr review ( ) 10 yr review ( ) > 75,000 pediatric injuries in database > 75,000 pediatric injuries in database 1.5% had cervical spine injury (N = 1098) 1.5% had cervical spine injury (N = 1098)

7 National Pediatric Trauma Registry National Pediatric Trauma Registry Kokoska et al (2001) J Ped Surg 6 year review of same database 6 year review of same database 1994 – – 99 Age distribution of Age distribution of c-spine injuries → c-spine injuries → Younger age groups well represented Younger age groups well represented Age (yrs)

8 Do children have the same injury patterns as adults? NO! Injuries differ in location and type Injuries differ in location and typeWhy? Developing spine has unique anatomy Developing spine has unique anatomy

9 Anatomic Considerations Large head Large head Torque and acceleration stress occur higher in the c-spine Torque and acceleration stress occur higher in the c-spine Fulcrum of motion C2-C3 in young children (vs C5-C6 in adults) Fulcrum of motion C2-C3 in young children (vs C5-C6 in adults) Younger children have an increased incidence of high C-spine injury Younger children have an increased incidence of high C-spine injury

10 Location of Injury Location of Injury National Pediatric Trauma Registry Kokoska et al (2001) J Ped Surg Age yrs Age > 10 yrs C1 – C4 injury 85%57% Patel et al (2001) J Ped Surg Age

11 anterior wedging of vertebral bodies anterior wedging of vertebral bodies horizontal alignment of facet joints horizontal alignment of facet joints Children prone to anterior dislocation Children prone to anterior dislocation Young Child Mature University of Hawaii (www.hawaii.edu/medicine/pediatrics/pemxray)

12 Underdeveloped neck musculature Underdeveloped neck musculature Ligamentous laxity Ligamentous laxity Younger children have an increased incidence of ligamentous injury Younger children have an increased incidence of ligamentous injury

13 Believed that the laxity of the peds spine acts to protect against spinal fracture in low energy trauma, however, may lead to SCIWORA in high-energy trauma Believed that the laxity of the peds spine acts to protect against spinal fracture in low energy trauma, however, may lead to SCIWORA in high-energy trauma More on SCIWORA in a moment… More on SCIWORA in a moment…

14 Type of injury Age yrs Age > 10 yrs Fractures42%65% Dislocations31%20% SCIWORA27%15% National Pediatric Trauma Registry: Kokoska et al (2001) J Ped Surg

15 How common are neuro deficits? National Pediatric Trauma Registry: Patel et al (2001) J Ped Surg

16 What is SCIWORA? Def: Spinal cord injury without radiographic abnormality on plain film or CT Def: Spinal cord injury without radiographic abnormality on plain film or CT Mechanism: transient vertebral displacement with subsequent realignment resulting in damaged spinal cord and normal appearing vertebral column Mechanism: transient vertebral displacement with subsequent realignment resulting in damaged spinal cord and normal appearing vertebral column Young spinal column can stretch up to 5cm Young spinal column can stretch up to 5cm Spinal cord ruptures after 5mm of traction Spinal cord ruptures after 5mm of traction

17 SCIWORA How common is it? How common is it? Literature extremely inconsistent with definition and incidence Literature extremely inconsistent with definition and incidence Reported as 0-50% of peds spinal cord injuries Reported as 0-50% of peds spinal cord injuries National Pediatric Trauma Registry: 17% National Pediatric Trauma Registry: 17% NEXUS: none!! NEXUS: none!!

18 SCIWORA – case series Common themes: Up to half may have delayed onset of symptoms (usually within 48 hrs) Up to half may have delayed onset of symptoms (usually within 48 hrs) SCI can be severe SCI can be severe Chance of recovery low if complete Chance of recovery low if complete May be related to spinal cord infarction May be related to spinal cord infarction

19 Epidemiology: Bottom Line C-spine injuries in children are rare, but they do occur in about 1.5% of blunt trauma patients C-spine injuries in children are rare, but they do occur in about 1.5% of blunt trauma patients In young children, be on look out for: In young children, be on look out for: High c-spine injury High c-spine injury Ligamentous injury Ligamentous injury

20 How can we protect the pediatric C-spine?

21 Begins in Prehospital Setting: Immobilization Aim for “neutral position” Aim for “neutral position” Big head Big head When laying flat on backboard, neck is flexed When laying flat on backboard, neck is flexed Must accommodate large occiput, using either an occipital depression or padding under the torso Must accommodate large occiput, using either an occipital depression or padding under the torso

22 Immobilization Best immobilization achieved by modified spine board, rigid collar and taping Best immobilization achieved by modified spine board, rigid collar and taping Too large a collar can distract the neck and worsen an injury – blocks are preferable to a poorly fitting collar Too large a collar can distract the neck and worsen an injury – blocks are preferable to a poorly fitting collar

23 OK… Now the collar’s on… How do I get it off? Challenges: Preverbal or crying children: Preverbal or crying children: Difficult to assess tenderness Difficult to assess tenderness Difficult to perform detailed neurologic exam Difficult to perform detailed neurologic examQuestions: Who needs imaging? Who needs imaging? What type of imaging is needed? What type of imaging is needed? When do I need a CT or MRI? When do I need a CT or MRI?

24 Clearing the Pediatric C-Spine PART 1: Who needs imaging? Is there any pediatric evidence? 1 prospective study 1 prospective study Peds subset of NEXUS – Peds subset of NEXUS – Viccellio et al 1 retrospective study 1 retrospective study Isolated head injuries – Isolated head injuries – Laham et al

25 Imaging – Peds subset of NEXUS Imaging – Peds subset of NEXUS Viccellio et al (2001) Pediatrics Prospective study of patients with blunt trauma + cervical spine radiography Prospective study of patients with blunt trauma + cervical spine radiography Used 5 low-risk criteria: Used 5 low-risk criteria: No midline cervical tenderness No midline cervical tenderness No evidence of intoxication No evidence of intoxication No altered level of consciousness No altered level of consciousness No focal neurological deficit No focal neurological deficit No painful distracting injury No painful distracting injury If all 5 criteria met – considered low risk If all 5 criteria met – considered low risk

26 NEXUS – peds subset 3065 patients < 18 years (9% of NEXUS) 3065 patients < 18 years (9% of NEXUS) Total # c-spine injuries: 30 Total # c-spine injuries: / 3065 considered “low risk” (20%) 603 / 3065 considered “low risk” (20%) All low risk patients had negative radiographic evaluations (100% sensitive) All low risk patients had negative radiographic evaluations (100% sensitive)

27 NEXUS – peds subset Problem: Numbers are small, so 95% CI for sensitivity: 87.8% - 100% Problem: Numbers are small, so 95% CI for sensitivity: 87.8% - 100% Problem: Very few injuries in younger kids Problem: Very few injuries in younger kids Grouped as follows: Grouped as follows: 0-2 (lack of verbal skills) N = 88 (0) 0-2 (lack of verbal skills) N = 88 (0) 3-8 (immature cervical spine)N = 817 (4) 3-8 (immature cervical spine)N = 817 (4) 9-17 (older children) N = 2150 (26) 9-17 (older children) N = 2150 (26)

28 NEXUS – peds subset Bottom line: Bottom line: Authors “cautiously endorse” the use of the NEXUS criteria in children over age 8 Authors “cautiously endorse” the use of the NEXUS criteria in children over age 8 Not enough power to ensure that the tool is safe to use in younger children Not enough power to ensure that the tool is safe to use in younger children However, authors state that there is not a single case in the medical literature of a child with a c-spine injury who would have been classified as low risk using NEXUS However, authors state that there is not a single case in the medical literature of a child with a c-spine injury who would have been classified as low risk using NEXUS

29 Laham et al (1994) Ped Neurosurg Retrospective review of 268 children with apparent isolated HI Retrospective review of 268 children with apparent isolated HI 2 high risk criteria = incapable of verbal communication (due to age or HI) and neck pain 2 high risk criteria = incapable of verbal communication (due to age or HI) and neck pain Did x-rays in all kids Did x-rays in all kids No abnormal x-rays in low risk group No abnormal x-rays in low risk group 7.5% abnormal in high risk group 7.5% abnormal in high risk group Authors concluded: In isolated HI with no neuro deficits, no x-rays needed if child can communicate and has no neck pain Authors concluded: In isolated HI with no neuro deficits, no x-rays needed if child can communicate and has no neck pain

30 What about the Canadian C-Spine Rules? Have not been evaluated for use in patients < 16 years Have not been evaluated for use in patients < 16 years

31 Are there any consensus statements or guidelines? American Association of Neurosurgeons (Guidelines committee of the section on disorders of the spine) [AANS] American Association of Neurosurgeons (Guidelines committee of the section on disorders of the spine) [AANS] Management of Pediatric Cervical Spine and Spinal Cord Injuries Neurosurgery 2002;50(3) March supp Guidelines based on available evidence and expert opinion Guidelines based on available evidence and expert opinion

32 AANS Bottom Line: Children > 8 years Evidence supports the use of NEXUS criteria: Evidence supports the use of NEXUS criteria: Image if any one of: Image if any one of: Midline tenderness Midline tenderness Focal neurological deficit Focal neurological deficit Altered level of consciousness Altered level of consciousness Evidence of intoxication Evidence of intoxication Painful distracting injury Painful distracting injury

33 AANS Bottom Line: Children 8 years and under who are conversant Although evidence is lacking, expert opinion supports the use of the NEXUS criteria Although evidence is lacking, expert opinion supports the use of the NEXUS criteria Given lack of evidence, and possible communication barriers in young children, it would be reasonable to consider imaging in high risk mechanisms: high speed MVC fall > 8 ft axial load injury

34 What should we do with infants? NEXUS – 88 patients < 2 yo – no injuries NEXUS – 88 patients < 2 yo – no injuries NPTR – children < 2 yo : ~ 8 injuries per yr NPTR – children < 2 yo : ~ 8 injuries per yr No studies with large enough numbers to generate evidence- based practice recommendations No studies with large enough numbers to generate evidence- based practice recommendations Have to go to expert opinion Have to go to expert opinion

35 AANS Bottom Line: Non-conversant Children Advise obtaining images in all non- conversant children who have “experienced trauma” Advise obtaining images in all non- conversant children who have “experienced trauma” Practically, this is not what’s done in most Canadian pediatric EDs Practically, this is not what’s done in most Canadian pediatric EDs

36 What should we do with infants? See them quickly See them quickly Assess for altered LOC, neuro deficit, distracting injury Assess for altered LOC, neuro deficit, distracting injury If no injury apparent, remove immobilization equipment in protected environment If no injury apparent, remove immobilization equipment in protected environment Observe for spontaneous movement of neck Observe for spontaneous movement of neck Most small children will “clinically clear” themselves Most small children will “clinically clear” themselves

37 Clearing the Pediatric C- Spine PART 2: What films do I need?

38 General agreement that a lateral and AP c-spine film are necessary General agreement that a lateral and AP c-spine film are necessary The sensitivity of the lateral film alone in peds is comparable to the adult literature ~85% The sensitivity of the lateral film alone in peds is comparable to the adult literature ~85%

39 Odontoid views? Many authors have questioned the need Many authors have questioned the need Swischuk surveyed 984 pediatric radiologists (432 responses) Swischuk surveyed 984 pediatric radiologists (432 responses) Obtained reports of 46 pediatric fractures that were missed on lateral view and seen on odontoid view Obtained reports of 46 pediatric fractures that were missed on lateral view and seen on odontoid view Calculated a miss rate of per year per radiologist Calculated a miss rate of per year per radiologist

40 Odontoid views? - Retrospective review of all c-spine injuries in children< 16 yrs over 10 year period at 4 Detroit trauma centres Buhs et al (2000) J Ped Surg - Retrospective review of all c-spine injuries in children< 16 yrs over 10 year period at 4 Detroit trauma centres AGENOcc/C1/2Lat/AP Missed occip – C (40%) 13 (87%) 2 – both odont # - plain odont unobtainable (seen on CT or MRI) (25%) 23 (65%) 2 – both odont # - 1 seen on odont / 1 on CT can’t r/o fracture with AP/lat alone

41 But odontoid views are hard to get in young children!!! Consider: 0-3 years: 50% of injuries are at C1 / C2 level 4-12 years: 8% of injuries are at C1 / C2 level Bottom line: If you are worried enough to image the c-spine, you need to get a good look at C1 / C2 ~need odontoid view or CT

42 Oblique views? Ralston et al (2003) Ped Emerg Care: Blinded retrospective review (8 year period) Blinded retrospective review (8 year period) Blunt trauma patients ≤16 yrs Blunt trauma patients ≤16 yrs AP/Lat + oblique views AP/Lat + oblique views N = 109 N = 109

43 Oblique views? All with normal AP/Lat had normal obliques All with normal AP/Lat had normal obliques (N = 78) (N = 78) If AP/Lat normal, obliques unlikely to add additional information 4 obliques resulted in revision of impression: 4 obliques resulted in revision of impression: 3 from equivocal to normal 3 from equivocal to normal 1 from equivocal to abnormal (final dx = no injury) 1 from equivocal to abnormal (final dx = no injury) May be of assistance in equivocal situation

44 Flexion-Extension views? Flexion-Extension views? Ralston et al (2001) Acad Emerg Med Blinded retrospective review (6 year period) Blinded retrospective review (6 year period) Blunt trauma patients ≤16 yrs Blunt trauma patients ≤16 yrs AP/Lat (+ odont in 83%) + flex/ex views AP/Lat (+ odont in 83%) + flex/ex views N = 129 N = patients had initial AP/Lat read as normal – all had normal flex/ex views (no revision of impressions) 45 patients had initial AP/Lat read as normal – all had normal flex/ex views (no revision of impressions) If primary series is normal…flex/ex views do not add info 84 patients had initial AP/Lat read as abnormal (including loss of lordosis -79 had revision of impression) 84 patients had initial AP/Lat read as abnormal (including loss of lordosis -79 had revision of impression)

45 Revision of Impressions Impression After Lat/AP Impression After Lat/AP + Flex/ex Final Diagnosis (considering CT, MRI, clinical) Loss of lordosis [N=50]Normal[N=50] SCIWORA (2) Ligament injury (2) Disc injury (1) Subluxation ? or Segmental kyphosis [N=22] + Subluxation (3) Ligamentous injury (2) Normal (19) (1) Fracture (1) Soft Tissue Swelling [N=5] Normal (5)

46 Flexion-Extension views? Normal flex-ex views do not rule out an injury Normal flex-ex views do not rule out an injury, more sensitive modalities are warranted (CT +/- MRI) If plain films worrisome, more sensitive modalities are warranted (CT +/- MRI) May consider flex-ex after to look for major instability quality of flex-ex view likely limited due to pain and they cannot be used to “rule out” an injury If the concern is significant pain despite normal plain films, quality of flex-ex view likely limited due to pain and they cannot be used to “rule out” an injury

47 To CT or not to CT…. Routinely used in adults trauma patients to examine c-spine Routinely used in adults trauma patients to examine c-spine There are significant concerns that exposing children to CT radiation may lead to an increased lifetime risk of cancer There are significant concerns that exposing children to CT radiation may lead to an increased lifetime risk of cancer Try to be much more selective with the use of CT in children Try to be much more selective with the use of CT in children Limit scans to specific areas of interest Limit scans to specific areas of interest

48 Indications for CT Valuable for: Valuable for: Defining anatomy in regions where an abnormality is suspected on plain film Defining anatomy in regions where an abnormality is suspected on plain film Viewing regions not visualized on plain film Viewing regions not visualized on plain film ie – skullbase to C3 in intubated patient ie – skullbase to C3 in intubated patient Remember: a large proportion of young children with c-spine injury will have an isolated ligamentous injury, a normal CT cannot be used to exclude a c-spine injury Remember: a large proportion of young children with c-spine injury will have an isolated ligamentous injury, a normal CT cannot be used to exclude a c-spine injury CT can miss odontoid # CT can miss odontoid #

49 Evidence for early CT? Evidence for early CT? Keenan et al (2001) AJR Retrospective study of 63 kids Retrospective study of 63 kids Head injury + C-spine plain films Head injury + C-spine plain films 21/63 had early CT c-spine with initial head CT 21/63 had early CT c-spine with initial head CT 42/63 had plain films alone - often repeat attempts 42/63 had plain films alone - often repeat attempts Analyzed multiple patient factors + total radiation dose received in process of imaging c-spine Analyzed multiple patient factors + total radiation dose received in process of imaging c-spine Found kids in high speed MVC with GCS <8 had same radiation with repeated plain films as with early CT (new generation, helical CT with recons) Found kids in high speed MVC with GCS <8 had same radiation with repeated plain films as with early CT (new generation, helical CT with recons)

50 How about MRI ??? Keiper et al (1998) Neurorad Retrospective case review Retrospective case review Children with hx of blunt c-spine trauma Children with hx of blunt c-spine trauma Normal plain films + normal CT Normal plain films + normal CT One of: One of: Persistent or delayed neuro symptoms Persistent or delayed neuro symptoms Persistent significant neck pain Persistent significant neck pain N = 52 N = 52 MRI abnormal in 16/52 (31%) MRI abnormal in 16/52 (31%) 4 went on to operative management 4 went on to operative management

51 MRI ??? Flynn et al (2002) J Peds Ortho 237 Blunt c-spine trauma 163 Cleared on plain films/CT + clinical assess 64 Normal Film/CT Neck pain Neuro abn Non-verbal/↓LOC 15 Abnormal MRI Needing Tx (5 stabilized) 49 Normal MRI 10 Equivocal film / CT 10 Normal MRI

52 What do these MRI studies mean for me? (…I can’t just order an MRI!) In children with normal plain films and normal CT who have either: In children with normal plain films and normal CT who have either: 1. Neurologic deficit 2. Significant persistent neck pain ~ they may still have a significant injury, so discuss case with referring neurosurgeon Those with neuro deficits likely need urgent MRI Those with neuro deficits likely need urgent MRI Those with ++ pain may benefit from one or more of Aspen collar, outpatient MRI, and neurosurg follow-up (at discretion of neurosx) Those with ++ pain may benefit from one or more of Aspen collar, outpatient MRI, and neurosurg follow-up (at discretion of neurosx)

53 Clearing the Pediatric C- Spine PART 3: Now I know what tests to do… How do I interpret pediatric C-spine films?

54 Follow same general approach as in adult c-spine films: Follow same general approach as in adult c-spine films: A – alignment A – alignment B – bones B – bones C – cartilage C – cartilage D – dens D – dens S – soft tissues S – soft tissues Are some unique features in children that are important to recognize Are some unique features in children that are important to recognize

55 Alignment – Subluxation of C2/C3? University of Hawaii (www.hawaii.edu/medicin e/pediatrics/pemxray)

56 Alignment - Pseudosubluxation 24% C2 on C3 24% C2 on C3 14% C3 on C4 14% C3 on C4 (Age <7 years) Swischuk’s line: posterior arch of C1 to C3 – should come within 1 mm of post arch of C2 Swischuk’s line: posterior arch of C1 to C3 – should come within 1 mm of post arch of C2 University of Hawaii (www.hawaii.edu/medicine/pediatrics/pemxray)

57 Bones Wedge shaped vertebral bodies Wedge shaped vertebral bodies Ossification centres Ossification centres Can appear like tear- drop fractures of the vertebral bodies University of Hawaii (www.hawaii.edu/medicin e/pediatrics/pemxray)

58 Dens Predental space – allow up to 5 mm in young children Predental space – allow up to 5 mm in young children Subdental synchondrosis - lucency at base of dens Subdental synchondrosis - lucency at base of dens Dens fuses with body of C2 between ages years Dens fuses with body of C2 between ages years A thin lucency may be appreciable on the lateral view for many years (50% up to age 11) A thin lucency may be appreciable on the lateral view for many years (50% up to age 11) May have ossification centre at tip of dens May have ossification centre at tip of dens University of Hawaii (www.hawaii.edu/medicin e/pediatrics/pemxray)

59 Prevertebral Soft Tissues Allowable thickness changes with age Allowable thickness changes with age In general: In general: Above glottis: ½ vertebral body Below glottis: 1 vertebral body Often falsely thickened 2° to neck flexion (big occiput) or expiration Often falsely thickened 2° to neck flexion (big occiput) or expiration University of Hawaii (www.hawaii.edu/medicine/pedia trics/pemxray)

60 Radiographically, most of the adult characteristics are present by age 8 Radiographically, most of the adult characteristics are present by age 8 Characteristics of peds c-spine injuries trend towards that of adults at about age 8-10 years Characteristics of peds c-spine injuries trend towards that of adults at about age 8-10 years not equal to adults until about 15 years not equal to adults until about 15 years

61 Clearing the Pediatric C- Spine PART 4: Specific injuries to watch for

62 Case 1 5 yo girl 5 yo girl Hit by car while riding bike Hit by car while riding bike VSA at scene VSA at scene Vitals recovered by EMS Vitals recovered by EMS Rose et al, Am J Surg 2003;185(4)

63 Atlanto-Occipital Dislocation 2.5 x more common in children than adults 2.5 x more common in children than adults Due to small occipital condyles and horizontal atlanto-occipital joints Due to small occipital condyles and horizontal atlanto-occipital joints Suspect if distance between occipital condyles and C1 is > 5mm at any point Usually have ++ soft tissue swelling Usually have ++ soft tissue swelling

64 Wackenheim Clivus Line The Encyclopaedia of Medical Imaging Line from clivus should just touch posterior odontoid tip

65 Case 2 2 yo female 2 yo female High speed MVA High speed MVA Closed HI (GCS 11) Closed HI (GCS 11) Proctor (2002) Crit Care Med

66 C1 – C2 Subluxation Predental space Predental space = 8mm Prevertabral soft tissue swelling > ½ vertebral body Prevertabral soft tissue swelling > ½ vertebral body

67 Case 3 3 yo male 3 yo male Fell out of barn loft Fell out of barn loft Alert, crying but consolable Alert, crying but consolable Says his head hurts Says his head hurts Makes no attempt to voluntarily move neck Makes no attempt to voluntarily move neck University of Hawaii (www.hawaii.edu/medicine/pe diatrics/pemxray)

68 Dens Fracture Suspicious for dens fracture: Suspicious for dens fracture: widening of the synchondrosis widening of the synchondrosis anterior tilting of the odontoid anterior tilting of the odontoid (may be posteriorly tilted in normal children) (may be posteriorly tilted in normal children)

69 Dens Fracture Often lack neuro symptoms as spinal canal is wide at that level Often lack neuro symptoms as spinal canal is wide at that level Most common symptoms: Most common symptoms: Occipital pain (injury to greater occipital nerve) Occipital pain (injury to greater occipital nerve) Refusal to extend neck Refusal to extend neck Believed to have high miss rate – can lead to chronic problems Believed to have high miss rate – can lead to chronic problems

70 What injuries should you be watching for in children < 8 years? Occiput █ ~ atlanto-occipital dislocation █ ~ atlanto-occipital dislocation C1 C1 █ ~ C1-C2 subluxation █ ~ C1-C2 subluxation C2 ~ odontoid fractures C2 ~ odontoid fractures █ C3-C7 ~ ligamentous injury

71 References Patel et al: J Ped Surg 2001;36(2): Viccellio et al: Pediatrics 2001;108(2):e Kokoska et al: J Ped Surg 2001;36(1): Radiology Cases in Pediatric Emergency Medicine, University of Hawaii (www.hawaii.edu/medicine/pediatrics/pemxray)www.hawaii.edu/medicine/pediatrics/pemxray Laham et al: Ped Neurosurg 1994;21: Swischuk et al: Ped Radiol 2000;30: Buhs et al: J Ped Surg 2000;35(6): Ralston et al: Ped Emerg Care 2003;19(2): Ralston et al: Acad Emerg Med 2001;8(3): Keenan et al: AJR 2001;177: Keiper et al: Neurorad 1998;40(6): Dare et al J: Neurosurg 2002;97(suppl 1): Rose et al, Am J Surg 2003;185(4) The Encyclopaedia of Medical Imaging (www.amershamhealth.com)www.amershamhealth.com Proctor: Crit Care Med 2002;30(11)


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