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

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

Epidemiology

Epidemiology: Incidence Pediatric Spinal Cord Injury (SCI) is rare Of Population: ~1 in 1,000,0001 or 1,000 per year3 Of Fractures: 1-2%, but highest mortality2 Of Trauma: 1-2% 5,6 Of All SCI: Accounts for <10%, <15 years old 1 Likely under-reported3,4 Male : Female 2:1 Population adjusted incuidence Adult 17 in 1,000,000

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

Epidemiology: Age Most frequent in: 15-24 year age group4 In under 15 year olds, mean age is 8 @ CHOA, mean age 11

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.

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.

Epidemiology: Age The younger the child the… higher the lesion higher mortality7

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.

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.

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.

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

Epidemiology: Mechanisms

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

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

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

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

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

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

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

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

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

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

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

Anatomy: Pediatric vs Adult

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

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

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 and >=8

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

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

Types of Injury

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

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

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

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

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

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

Types of Injury Traumatic Atlantoaxial Instability Tear in transverse ligament Rare

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

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

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

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

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

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

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

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*

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 SCI3

Who can be cleared clinically?

Which 7 yo can you clinically clear? 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 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. 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

Which 7 yo can you clinically clear? 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 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. 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

Which 7 yo can you clinically clear? 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 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. 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

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

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

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

NEXUS: Study Definitions Distracting Injury Significant, painful injury Skin Large 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

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

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

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

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

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

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

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

How to clinically clear patient with neck pain?

Imaging choices

Imaging choices Plain Film Xrays CT Scan Neck 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

Imaging choices Flexion and Extension Lateral Xrays MRI 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

An approach to clearing the c-spine following injury

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

Lateral Plain Film

C-Spine Radiograph Lateral Plain Film Film adequacy C-spine alignment and curves Inter-vertebral spaces: discs and joints Pre-vertebral space Pre-dental space aka atlantodens interval (ADI)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cases

Case 1 4 year old female, restrained, back seat Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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

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

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

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

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

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

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

Case 4 5 year old male, sitting in seatbelt, front seat Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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

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

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

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

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

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

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

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

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