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Pediatric Cervical Spine Injuries Daniel A. Hirsh, MD Emory University School of Medicine Children’s Healthcare of Atlanta.

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Presentation on theme: "Pediatric Cervical Spine Injuries Daniel A. Hirsh, MD Emory University School of Medicine Children’s Healthcare of Atlanta."— Presentation transcript:

1 Pediatric Cervical Spine Injuries Daniel A. Hirsh, MD Emory University School of Medicine Children’s Healthcare of Atlanta

2 2 Objectives  Epidemiology  Anatomy: Pediatric vs Adult  Types of injuries  Who can be cleared clinically  Imaging Choices  An approach to clearing a c-spine  Lateral Plain Film  Cases  Wrap Up

3 3 Epidemiology

4 4 Epidemiology: Incidence Pediatric Spinal Cord Injury (SCI) is rare Of Population: ~1 in 1,000,000 1 or 1,000 per year 3 Of Fractures: 1-2%, but highest mortality 2 Of Trauma: 1-2% 5,6 Of All SCI: Accounts for <10%, <15 years old 1 Likely under-reported 3,4 Male : Female 2:1

5 5 Epidemiology: Incidence @ CHOA *Trauma Registry Patients: All patients that have a Trauma ICD9 code, admitted for greater than 24 hours, or transferred, or admitted to OR or ICU regardless of length of stay. **Based on ICD-9 Codes

6 6 Epidemiology: Age  Most frequent in: 15-24 year age group 4  In under 15 year olds, mean age is 8  @ CHOA, mean age 11

7 7 Epidemiology: Age Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery 39(3): 483-486. Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery 36(8): 1107-1114.

8 8 Epidemiology: Age Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery 39(3): 483-486. Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery 36(8): 1107-1114.

9 9 Epidemiology: Age  The younger the child the… higher the lesion higher mortality 7

10 10 Epidemiology: Age Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

11 11 Epidemiology: Age Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

12 12 Epidemiology: Age Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

13 13 Epidemiology: Mechanisms 1.Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

14 14 Epidemiology: Mechanisms

15 15

16 16

17 17

18 18 Epidemiology: Mechanisms Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics 119: e275-283

19 19 Epidemiology: Mechanisms Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics 119: e275-283

20 20 Epidemiology: Mechanisms Leonard, M., J. Sproule, et al. (2007). "Paediatric spinal trauma and associated injuries." Injury 38(2): 188-193.

21 21 Epidemiology: Mechanisms 1.Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

22 22 Epidemiology: Mechanisms 1.Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

23 23 Epidemiology: Mechanisms 1.Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

24 24 Epidemiology: Mechanisms Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

25 25 Epidemiology: Mechanisms Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

26 26 Epidemiology: Mechanisms Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

27 27 Epidemiology: Associated Injuries Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612. ~40% of SCI have associated injuries

28 28 Epidemiology: Associated Injuries Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612. ~40% of SCI have associated injuries

29 29 Anatomy: Pediatric vs Adult

30 30 \\

31 31 37 yo driver lap/shoulder/airbag restrained and her 7 yo son backseat lap/shoulder restrained involved in head on accident. Both in a c-collar. Both have neck pain. What are this boy’s anatomic disadvantages compared with his mom? Anatomy: Pediatric vs Adult

32 32  Proportionally larger, heavier head= higher center of gravity: “..the human head reaches 50% of its adult circumference by age 18 months, whereas thoracic circumference does not reach this milestone until 8 years of age.”  Weaker and underdeveloped neck musculature  Greater elasticity and laxity of ligaments  More horizontal orientation of facet joints  Fulcrum of Cervical Spine Motion Pediatric: C2-C3 Adult: C5-C6 Anatomy: Pediatric vs Adult

33 33 Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564. Anatomy: Pediatric vs Adult

34 34 Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

35 35 Anatomy: Pediatric vs Adult  Biomechanical and anatomic difference Begins to disappear at 8 years old Completes at 15-17 years old  Literature suggest 2 distinct groups =8

36 36 Anatomy: Pediatric vs Adult  Higher prevalence of lesions above C4  More cervical distraction injuries  Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)

37 37 Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

38 38 Types of Injury

39 39 Types of Injury  Atlanto-occipital injuries High energy Typically fatal More prevalent in young children than adults

40 40 Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

41 41 Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539 1 2 3 4 anterior longitudinal ligament.

42 42 Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539 1 2 3 4 anterior longitudinal ligament.

43 43 Types of Injury  Atlas Fracture Axial load (like Jefferson burst fracture in adults) Open synchondrosis

44 44 Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

45 45 Types of Injury  Traumatic Atlantoaxial Instability Tear in transverse ligament Rare

46 46 Types of Injury  Odontoid fracture Most common fractures of cspine in children Usually through the subdental synchondrosis in young children

47 47 Types of Injury  Odontoid fracture Most common fractures of cspine in children Usually through the subdental synchondrosis in young children

48 48 Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

49 49 Types of Injury  Pars interarticularis Fracture of C2 Hangman’s (hyperextension) Extremely rare  Distraction Injuries Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

50 50 Pseudosubluxation  Children have normal physiologic displacement @ C2-3 and C3-4 spaces Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

51 51 Pseudosubluxation Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

52 52 Pseudosubluxation  Children have normal physiologic displacement @ C2-3 and C3-4 spaces Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

53 53 Types of Injury: SCIWORA Spinal Cord Injury With Out Radiographic Abnomality  First described in 1980’s before advancements in MRI  Subsequent literature suggest up to 30% all pediatric cord injuries*

54 54 Types of Injury: SCIWORA Evolving Definition: Positive neurological findings weakness, paresthesias, lightening/burning sensation down the spine/extremity or related to neck movement AND Xray (-), CT (-), MRI (+) 6% of SCI OR Xray (-), CT (-), MRI (-) 1% of SCI 3

55 55 Who can be cleared clinically?

56 56 Which 7 yo can you clinically clear? 1.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck 2.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity. 3.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

57 57 Which 7 yo can you clinically clear? 1.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck 2.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity. 3.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

58 58 Which 7 yo can you clinically clear? 1.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck 2.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity. 3.7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

59 59 Who can be cleared clinically?  National Emergency Medicine XRay Utilization Study (NEXUS) 9 Prospective Evaluation of c-spine injury in children Identify patients at low risk

60 60 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

61 61 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

62 62 NEXUS: Study Definitions Distracting Injury Significant, painful injury 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

63 63 NEXUS : Study Results  Of 3,065 children enrolled, 30 had c-spine injuries (0.98%)  All 30 were classified as: “high-risk”  No child from the “low-risk” group had a c-spine injury

64 64 NEXUS : Study Results Value (95% CI) Sensitivity100% (87.8 – 100%) Negative Predictive Value100% (99.2 – 100%)

65 65 Not so fast… 1.Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

66 66 Not so fast… 1.Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

67 67 Ehrlich et al Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients 2009

68 68 Ehrlich et al Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients 2009

69 69 Which 7 yo can you clinically clear?  None of them!  Next step…

70 70  How to clinically clear patient with neck pain?

71 71 Imaging choices

72 72 Imaging choices  Plain Film Xrays Pro: Less radiation than CT. Can be done in trauma bay. Can pick up most injuries if good technique. Less costly. Con: Poor technique may lead to repeat shots. Can be difficult to get odontoid view in a young patient  CT Scan Neck Pro: Highly sensitive for fracture. Con: Higher radiation dose to neck. In current facility have to move patient to another area. More costly.  Issue of initial CT Head and CT Neck versus Ct Head and Plain Film Neck: (Jimenez et al 2008) Plain film first, then CT if needed

73 73 Imaging choices  Flexion and Extension Lateral Xrays Pro: Can help diagnose ligmentous injury not seen on Xray or CT Con: Patient must Actively move their head. Muscle spasm often limits this test Should not perform Passive Flex/Ex on unconscious patient If patient has normal static cervical spine radiographs, addition flex- ext are of questionable use (Dwek, et al Chung 2000)  MRI Pro: “Gold Standard” (Munchow RD et al 2008) Highly sensitive for spinal cord injury. Helps with unconscious pts in whom there is high clinical suspicion of C-Spine injury. Visualizes the extradural space and integrity of the ligaments Con: Higher cost, time

74 74 An approach to clearing the c-spine following injury

75 75 Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following

76 76 Lateral Plain Film

77 77 C-Spine Radiograph Lateral Plain Film 1.Film adequacy 2.C-spine alignment and curves 3.Inter-vertebral spaces: discs and joints 4.Pre-vertebral space 5.Pre-dental space aka atlantodens interval (ADI)

78 78 C-Spine Radiograph  Lateral film  Anteroposterior film  Open-mouth odontoid view

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

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

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

82 82 Adequacy Visualize entire cervical spine Count 7 cervical bodies, and 1 thoracic body Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

83 83 Alignment  C-Spine Curves Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

84 84 Alignment C-Spine Curves 1.Anterior Vertebral Bodies Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

85 85 Alignment C-Spine Curves 1.Anterior Vertebral Bodies 2.Anterior Spinal Canal Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

86 86 Alignment C-Spine Curves 1.Anterior Vertebral Bodies 2.Anterior Spinal Canal 3.Posterior Spinal Canal Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

87 87 Alignment C-Spine Curves 1.Anterior Vertebral Bodies 2.Anterior Spinal Canal 3.Posterior Spinal Canal 4.Spinous Process Tips Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

88 88 Inter-vertebral spaces Disc spaces Cartiledge Apophyseal joints Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

89 89 Pre-vertebral space Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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

91 91 Pre-vertebral space Space between vertebral bodies and air column Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

92 92 Pre-vertebral space Space between vertebral bodies and air column Must measure space above the glottis Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

93 93 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

94 94 Pre-Dental Space: aka: atlantodens interval (ADI) Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

95 95 Pre-Dental Space Space between Dens of C2 and anterior side of C1 ring Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

96 96 Pre-Dental Space Space between Dens of C2 and anterior side of C1 ring Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

97 97 Pre-Dental Space Space between Dens of C2 and anterior side of C1 ring Must be less than or equal to 5 mm Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

98 98 Cases

99 99 Case 1  4 year old female, restrained, back seat  High speed, head on car crash – 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

100 100 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

101 101 Fracture at pedicle of C2 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

102 102 Case 2  18 month old female, unrestrained, front seat  Car accident  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

103 103 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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

105 105

106 106 Case 3  A 7 year old child  High speed MVC Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

107 107 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

108 108 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Prevertebral Bleeding Glottis

109 109 Case 4  5 year old male, sitting in seatbelt, front seat  25 mph head-on car crash  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

110 110 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

111 111 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Ruptured Transverse Ligament

112 112 C2 - Axis Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

113 113 v C1 - Atlas Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

114 114 ANTERIOR POSTERIORANTERIOR Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

115 115 ANTERIOR POSTERIORANTERIOR Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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

117 117 Wrap It Up Epidemiology Anatomy: Pediatric vs Adult Types of injuries Who can be cleared clinically Imaging Choices An approach to the clearing the cspine Lateral Plain Film Cases Wrap Up

118 118 1.Reilly, C. (2007). "Pediatric Spine Trauma." J Bone Joint Surg Am 89(Suppl 1): 98-107. 2.Leonard, M., J. Sproule, et al. (2007). "Paediatric spinal trauma and associated injuries." Injury 38(2): 188-193. 3.Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612. 4.Vitale MG, G. J., Matsumoto H, Roye DP Jr. (2006). "Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000." Journal of pediatric orthopedics 26(6): 745-749. 5.Meyer, P.-G., F. Meyer, et al. (2005). "Combined high cervical spine and brain stem injuries: a complex and devastating injury in children." Journal of Pediatric Surgery 40(10): 1637-1642. 6.Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery 36(8): 1107-1114. 7.Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376. 8.Kadesky, K. M., C. Manarey, et al. (1998). "Cougar attacks on children: Injury patterns and treatment." Journal of Pediatric Surgery 33(6): 863-865. 9.Viccellio, P., H. Simon, et al. (2001). A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics 108: e20-. 10.Orenstein, J., B. Klein, et al. (1994). "Age and outcome in pediatric cervical spine injury: 11-year experience." Pediatric Emergency Care(3): 132-7. 11.Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery 39(3): 483-486. 12.Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564 13.Stiell, I. G., G. A. Wells, et al. (2001). The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. 286: 1841-1848. 14.Mower, W. R. and J. Hoffman (2004). "Comparison of the Canadian C-Spine rule and NEXUS decision instrument in evaluating blunt trauma patients for cervical spine injury." Annals of Emergency Medicine 43(4): 515-51 7 15.Platzer P et al. (2007). “Cervical Spine Injuries in Pediatric Patients” The Journal of Trauma 62 (2) : 389 16.Bilston LE et al (2007) “Pediatric spinal Injury Type and Severity are Age and Mechanism Dependant. Spine. 32 (21) 2339- 2347 17.Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494 18.Dewk JR et al (2000) “Radiography of Cervical Spine Injury in Children: Are Flexion– Extension Radiographs Useful for Acute Trauma?” American Journal of Roentgenology. 174 (6):1617 19.Pitt Et al (2005) “Role of flexion /extension radiography in paediatric neck injuries.” Emergency Medicine Journal. 22 : 1992- 197 20.Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539 21.Muchow (2008) “Magnetic Resonance Imaging (MRI) in the Clearance of the Cervical Spine in Blunt Trauma: A Meta- Analysis.” The Journal of Trauma 64 (1):179 22.Treme et al (2008). “Cervical Spine Alignment in the Youth Football Athlete” The American Journal of Sports Medicine 36: 1582 23.Jimenez et al (2008) “CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks? “ Pediatric Radiology 38 (6): 635 24.Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics 119: e275-283 25.Feldman et al (2008) “Cervical Spinal Cord Injury in Abused Children. “ Pediatric emergency Care 24 (4) 222 26.Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700


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