1. Traumatic Spine and Spinal Cord Injuries
Dafina M. Good, MD
Emory University School of Medicine
Children’s Healthcare of Atlanta
Pediatric Emergency Medicine Fellow

2. Objectives
To review the epidemiology of Spinal Cord Injuries (SCI) in children
To review the Anatomy of the spine and spinal cord
To review pertinent history and physical exam findings involved in SCI’s
To review the radiologic evaluation of spinal trauma
To review traumatic spine fractures
To review some partial spinal cord syndromes

3. Epidemiology of Spinal Trauma in Children
Spinal injury is rare in children
Higher mortality in children
Pediatric vertebral injuries occur 60-80% of the time in the cervical region (30-40% of all vertebral injuries in adults)
Overall incidence of spinal injury in children is 1-2%
Almost 1500 children are admitted to US hospitals each year for treatment of SCI’s
Motor Vehicle Accidents are the leading cause of pediatric SCI (60% of cases)…with falls and sports injuries (football and diving) thereafter
M:F ratio of 2:1
Avg age is 14 to 15 yrs old
2006 study from the NTDB & the KID found that almost 70% of children injured in MVA’s from were not wearing a seatbelt and in 30% of those cases alcohol or drugs were involved

4. Cervical Spine Anatomy

5. Spine Vertebrae Anatomy

6. Spine Vertebrae Anatomy

7. Cervical Spine Anatomy

8. Cervical Spine Anatomy

9. Atlas-Dens Relationship

10. Anatomy of the Spinal Columns

11. Pediatric vs. Adult Spine Anatomy ……..Not just little adults!
Children younger than 8yrs are more susceptible to C-spine injuries because;
Larger head to body proportion
Higher fulcrum……. “point of maximal mobility” (C2-3 at birth, C3-5 at 8-12yrs old to C5-6 at 12yrs old and adults)
Weaker cervical musculature
Increased ligamentous laxity leading to greater mobility of the c-spine
Immature joints and Ossification centers
Horizontal facet joints that facilitate sliding of the upper C-spine
More susceptible to subluxation and distraction injuries
Spinal columns are more elastic than the spinal cord (tolerating more distraction before rupture……. Thus leading to SCIWORA

12. Key History and PE Components
Cause…. MVA, Sports (Football/Diving), Falls
Mechanism….. Hyperflexion (Clay shoveler’s or Teardrop Fx’s), hyperextension (Hangman’s Fx), Rotational (Jumped Facets), Compression or axial loading (Jefferson/Burst Fx)
Symptoms….. Numbness, tingling, or weakness during any time since accident even if resolved
Predisposing conditions….. 15% Down’s Syndrome pts have atlantoaxial instability, Achondroplasia (Cervicomedullary Junction stenosis)
Vital signs
Hypotension, Bradycardia….. Can be signs of Neurogenic shock
Physical Exam
Testing for motor or sensory deficits and levels if present
DTR’s and rectal tone
High index for Multisystem trauma (40% of cases have associated intrabdominal injuries)

13. Radiologic Evaluation of Spine Injuries
Are Xrays indicated?
NEXUS Study Criteria (National Emergency X-Radiography Utilization Study)
Based on 5 low-risk criteria that allows physicians to avoid Xray evaluation
Must have absence of….. Midline cervical tenderness, evidence of intoxication, altered level of alertness, focal neurological deficit, and a distracting painful injury.
Lateral, AP and Odontoid view
3 views picks up >90% of all unstable C-spine injuries
Lateral is the most important view. Lateral alone has a very high sensitivity
Difficult to obtain odontoid views in pediatrics
Swimmer’s view used as adjunct to Lateral if not able to visualize C7-T1 junction
Flexion-Extension views
Indicated if normal 3views of the c-spine but focal neck pain persists….. ie. Concerns for ligamentous injury
Only in conscious patients who can limit their neck motion
CT C-spine
Excellent sensitivity for identifying fractures (Sensitivity of 97%)
Limited in showing ligamentous injury
MRI
Indicated in any patient with neurological deficits

14. C-spine film evaluation
Measurable Parameters of Normal Cervical Spine Radiographs
Adequacy of C-spine views
C1- top of T1
3 views vs. Single Lateral view
Swischuk's Lines- 4 Lordotic curves aligned
Predental space (5 mm or less)
C2-C3 pseudosubluxation (4 to 5 mm or less)
Retropharyngeal or Prevertebral space (1/2 to 2/3 vertebral body)
Intervertebral disk space symmetry
If a C-spine fracture found….. Requires radiologic evaluation of entire spine.
Approximately 10% of patients with a C-spine fracture have a second vertebral column fracture

15. C-spine Lateral View

16. C-spine AP View

17. C-spine Odontoid View

18. C-spine Odontoid View

19. Swischuk’s Lines
LINES OF LIFE: There are 4 basic parallel lines to evaluate alignment that help determine c-spine injuries.
Anterior vertebral body line
Posterior vertebral bodyline
Spinal Laminar line
Posterior spinous process

20. C-spine Films

21. Space should be no more than 5mm
Predental Space
Space should be no more than 5mm

22. Intervertebral Disk Spaces

23. “7yr old fell off her bunk bed 3 days ago and still has a crook in her neck”

24. C1-C2 Rotary Subluxation

25. Abnormal Odontoid View

26. Abnormal Odontoid View

27. Jefferson Fracture (C1 Burst Fracture)
Axial loading or vertebral compression
Displaced lateral masses of C1
Predental space increased
Moderately unstable

28. Transverse Ligament Rupture

29. Transverse Ligament Rupture

30. Transverse Ligament Rupture

31. Atlanto-occipital Dislocation

32. Atlanto-Occipital Dislocation
Widening of the atlanto-occipital joint >5mm
Prevertebral swelling
Usually fatal
Patients usually apneic at the scene
5X more common in children

33. Odontoid View

34. Type II Dens Fracture

35. Hangman’s Fracture

36. Clay-Shoveler’s Fracture
Spinous process avulsion fracture
Very stable

37. Flexion Teardrop Fracture
Sudden hyperflexion with axial compression
Involves disruption of all columns
Usually presents with neurological impairment
(Anterior cord syndrome)
Highly unstable

38. Bilateral Facet Dislocation
Hyperflexion with Rotation (MVA/Diving)
Disruption of all the spinal ligamentous columns
Highly unstable
Almost always quadriplegic (Poor prognosis)

39. Chance Fracture
AP Thoracic Spine

40. Chance Fracture Hyperflexion injury Lap belt injury
Transverse fractures through the VB
50% associated with intrabdominal organ injuries
Posterior column disruption

41. Spinal Cord Injury Without Radiographic Abnormality SCIWORA
First described in 1982
Defined as traumatic myelopathy in the absence of findings on plain radiographs, flexion-extension radiographs and cervical CT scan.
Almost unique to pediatrics. Occurs most often in children younger than eight years of age
Pediatric predominance likely related to the high elasticity of the spinal column in comparison to the spinal cord
Usual mechanism is acceleration-deceleration or rotation injury
Almost 20-50% of SCI’s in children have no radiographic abnormalities
Almost 30-50% of patients have delayed onset of neurologic deficits from 30mins-4 days
If SCIWORA is suspected then an MRI should be done
These patients require immobilization to prevent secondary insults to the spinal cord

42. Traumatic Spinal Cord Syndromes
Review of
Traumatic Spinal Cord Syndromes

43. Motor Innervation of the Nervous System

44. Sensory Innervation of the Nervous System

45. 3 Main Spinal Cord Tracts
Corticospinal tract carries motor fibers to the ipsilateral side of the body
Posterior columns carry fine touch, vibration, proprioception, and pressure from the ipsilateral side.
Spinothalamic tract carries pain and temperature fibers from the contralateral side of the body.

46. Partial Cord Syndromes

47. Central Cord Syndrome Most common of the partial cord syndromes
Hyperextension injury in athletes
Ligamentum flavum buckles and increases pressure on the cord
Bilateral motor paresis greater in the upper than lower extremities
Shawl distribution pain and temperature loss
Sparing of light touch and proprioception
Good prognosis

48. 3 Main Spinal Cord Tracts
Corticospinal tract carries motor fibers to the ipsilateral side of the body
Posterior columns carry fine touch, vibration, proprioception, and pressure from the ipsilateral side.
Spinothalamic tract carries pain and temperature fibers from the contralateral side of the body.

49. Anterior Cord Syndrome
Crush Injury or compression from a hematoma
Compression of the Anterior Spinal artery
Paraplegia below the lesion
Pain and temperature loss below the lesion
Sparing of dorsal column sensation

50. Brown Sequard Syndrome
Hemisection of the spinal cord
Usually from penetrating trauma
Ipsilateral plegia below the lesion
Ipsilateral proprioception and light touch loss below the lesion
Contralateral pain and temperature loss below the lesion
Rare injury