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

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

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 1997-2000 were not wearing a seatbelt and in 30% of those cases alcohol or drugs were involved

Cervical Spine Anatomy

Spine Vertebrae Anatomy

Spine Vertebrae Anatomy

Cervical Spine Anatomy

Cervical Spine Anatomy

Atlas-Dens Relationship

Anatomy of the Spinal Columns

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

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)

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

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

C-spine Lateral View

C-spine AP View

C-spine Odontoid View

C-spine Odontoid View

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

C-spine Films

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

Intervertebral Disk Spaces

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

C1-C2 Rotary Subluxation

Abnormal Odontoid View

Abnormal Odontoid View

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

Transverse Ligament Rupture

Transverse Ligament Rupture

Transverse Ligament Rupture

Atlanto-occipital Dislocation

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

Odontoid View

Type II Dens Fracture

Hangman’s Fracture

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

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

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

Chance Fracture AP Thoracic Spine

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

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

Traumatic Spinal Cord Syndromes Review of Traumatic Spinal Cord Syndromes

Motor Innervation of the Nervous System

Sensory Innervation of the Nervous System

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.

Partial Cord Syndromes

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

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.

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

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