1. Pediatric C-Spine Injury
Joshua Rocker, MD
Schneider Children’s Hospital
LIJ Medical Center

2. Anatomical Considerations
Embryology
Risk Factors
Causes of Injury
Immobilization
Symptoms and Physical Exam
Radiography
Prediction Rules

3. Anatomical Considerations

4. Children <8 years old
Relatively larger heads than body
Head circumference 50% adult by 2 yrs vs chest circumference, 8 yrs

5. Children <8 years old
Cervical spine fulcrum
Moves caudally
C2-C3 at birth
C5-6 at 8 yr and older

6. Children <8 years old
Weaker cervical musculature and increased laxity of ligaments
Immature vertebral joints
Horizontally inclined articulating facets
Facilitate sliding of upper c-spine

7. Children’s C-spine Injuries
More susceptible to:
fractures through growth plates
ligamentous injuries
Why
Growth centers fragile to sheer forces during rapid decel or flex/ext
(particularly at the synchondrosis b/n odontoid and body of C2)

8. SCIWORA “Spinal Cord Injury without Radiological Abnormality”
Theoretical increase risk in children
Young spinal column more elastic than spinal cord- can handle more distraction before rupture
5cm vs 5-6mm

9. Children 8yrs and older Equivalent to adult
Most injuries to vertebral bodies and arch
Lower C-spine

10. Embryology and why pediatric C-spines are difficult to interpret

11. Embryological Considerations
C1 (Atlas) formed by 3 ossification sites
Anterior arch and 2 neural arches

12. Embryology: C1
Anterior arch fuses with neural arches by 7 yrs. Before this non-fusion can be mistaken as fracture

13. Embryology: C2 C2 (Axis) has four ossification centers 2 neural arches
1 for the body
1 odontoid

14. Embryology: C2 Body fuses with dens at 3-6 yrs
The fusion line or remnant of cartilagenous synchondrosis can be seen till 11 yrs

15. Embryology: C3-C7 Same developmental pattern 3 ossification centers
Neural arches fuse posteriorly 2-3 yrs
Body fuses with arches 3-6 yrs

16. Embryology
Coronal view: Notice synchondroses

17. Predisposing risk factors

18. Congenital abnormalities
Downs Syndrome
15% with atlantoaxial instability

19. Congenital abnormalities
Klippel-Feil
Fusion of cervical vertebrae

20. Congenital abnormalities
Morquio (MPS IV)
No galctose 6-sulfatase
Hypoplasia of odontoid

21. Congenital abnormalities
Larsen’s Syndrome
skeletal dysplasia with multiple joint dislocations, short stature, abnormal facial features

22. At Risk by History
Spinal Cord surgery
C-spine arthritis

23. Causes of Injuries

24. Causes of Injuries: By age
Infants
Birth Trauma
1-8 yrs
MVAs and falls
> 8 yrs
Sports Injuries and MVAs

25. Causes of Injuries: Direct severe force to neck Diving
Acceleration-deceleration

26. Causes of Injuries: Mechanism
Hyperflexion
Hyperextension
Axial Load
Roatational
Blow to Chin

27. Causes of Injuries: Hyperflexion
Most common
Cause wedge fracture of anterior vertebral bodies
Disruption of posterior elements
Ex:
Clay-shoveler’s,
anterior teardrop fracture

28. Hyperflexion: Clay-shoveler’s
Sudden load on a flexed spine, avulsion at C7 or T1

29. Hyperflexion: Teardrop fracture of anteroinferior portion of vertebral body

30. Causes of Injuries: Hyperextension
Compression of posterior elements
Disruption of anterior longitudinal ligament
Ex:
Hangman’s

31. Hyperextension: Hangman’s Fracture
anterior subluxation of C2 on C3 and bilateral pedicle fractures of C2

32. Causes of injuries: Axial Load
Direct load on top of head
May cause burst or comminuted fracture of C1.
May also cause injury caudal to C-spine
Ex:
Jefferson fracture

33. Axial Load: Jefferson fracture

34. Causes of Injuries Rotational Chin Trauma
Usually associated with additional injuries
Chin Trauma
Fractures of posterior teeth and mandibular condyles seen as a single injury pattern

35. Immobilization

36. Indications Mechanism PE Severe force Diving Accel-dec AMS
Neuro deficits
Multi-system trauma
Neck pain/tenderness
Distracting injuries

37. Ouch!!!!
3-25% of patients with SC injury develop neurological deficits caused by manipulation during resuscitation or transport

38. Immobilize Neck- in collar Body- on long backboard Stif-Neck
Philadelphia
ProSplint
Body- on long backboard

39. Neutral Position Not well defined
“anatomical position of the head and torso that one assumes when standing and looking straight ahead”
External auditory meatus is in line with the shoulder in the coronal plane
“Supine without rotating or bending the spinal column” ATLS

40. Neutral Position Adults (>8 yrs) Children
Require occiput elevation ( , 2cm)
Children
Special allowance b/c relatively large heads
Special peds boards with depressed area for head
Elevate back with padding (2.5cm)

41. Protocols Do not reduce obvious deformities
Keep helmets in place unless need airway
Log roll onto board with support of head/neck and torso
Place wedges beside head to limit lateral movement

42. Protocols: Airway
Jaw-thrust maneuver with in-line traction

43. Protocol: Surgical Airway
Nasotracheal intubation
Contraindicated: apnea, facial injuries (?fx of cribiform plate)
Orotracheal intubation with in-line stabilization
Surgical airway
Maxillofacial or laryngotracheal trauma

44. Symptoms and Physical Exam

45. Symptoms Classic Triad
Local pain, muscle spasm and decreased ROM
Transient or persistent parasthesias or weakness
SCIWORA

46. Symptoms “Burning hands” Asymptomatic Seen with football players
Transient burning in hands/fingers
Hyperextension of C-spine with SC contusion
Asymptomatic
Significant mechanism or distracting injury

47. Physical Exam
Essentials
Vital Signs
Neuro
Neck

48. Physical Exam Vitals Apnea or hypoventilation Spinal Shock
Injuries to C3-C5
Spinal Shock
Hypotension, bradycardia, temperature instability

49. Physical Exam Neuro exam Tone, strength, sensation and reflexes
Up to 50% of children with C-spine injuries have neuro deficits

50. Tone Loss of spontaneous breathing if injury above C4 Hypotonia
Lower motor neuron deficit
Spinal shock

51. Tone Rectal tone Absence- poor prognostic sign
Bulbocavernous reflex (S3-S4)
Squeezing glans, tapping on mons pubis, pulling on foley
Stimulate trigone of the bladder  reflex contraction of anal sphincter

52. Strength Dorsiflexion of the wrist Extension of the elbowC6
Extension of the elbow C7
Extension of the knee
L2-L4
Dorsiflexion of the great toe L5

53. Sensory Most common deficit with SC injuries
Level of sensory impairment localizes level of injury

54. Reflexes Areflexia indicates spinal shock
Usually lasts less than 24 hours

55. Specific Injuries Anterior Cord Syndrome
Hyperflexion and anterior cord compression
Paralysis and loss of pain WITHOUT loss of light touch or proprioception

56. Specific Injuries Central Cord Syndrome Hyperextension Injuries
Weakness greater in upper vs lower extremities

57. Specific Injuries Brown-Sequard syndrome Cord Hemisection Ipsilateral
Paralysis, Loss of proprioception and light touch
Contralateral
Loss of pain and temperature

58. Specific Inuries Horner’s Syndrome
Disruption of cervical sympathetic chain
Ptosis, miosis and anhidrosis

59. Neck Exam Maintain in-line stabilization Palpate spinous processes
Assess muscle spasm
Assess for deformities

60. Radiography

61. What to do? If your suspicion of injury is high If low to moderate
get CT!!! (>98% sensitive)
If low to moderate
get 3 view radiographs
AP, cross table lateral, odontoid (open mouth)
Lateral view identifies approx % of fx, dislocations and subluxations

62. Plain Radiographs Lateral Must visualize all 7 cervical vertebrae
Include C7-T1 junction
If difficult visualizing
Gentle traction on arms (?)
Transaxillary (swimmer’s) view

63. Lateral view: 4 curvilineal contour lines
Anterior vert body
Posterior vert body
Spinolaminar line
Tips of spinous
processes

65. Psuedosubluxation
C2 on C3
20-40% of children
C3 on C4
14%

66. Swischuk line line from the anterior aspect of C1-C3 spinous processes
anterior C2
spinous process
within 2 mm

67. Soft tissue spaces Prevertebral space/ Retropharngeal C2- <6mm
C3/C4
<8 yrs < ½-2/3 diameter
of AP vertebral body
>8 yrs < 7mm
Hematoma, abscess, bony injury

68. Soft tissue spaces Predental space Represents: <8 yrs < 4-5mm
Atlantoaxial instability or
rotational sublux or Jefferson fx

69. AP View
Height of vertebral
bodies similar
Spinous processess
aligned

70. Odontoid Equal amounts of space on each side of the dens
Lateral aspects of C1
should line up with the
lateral aspects of C2

71. Odontoid fractures Types 1 2 3 Apex of dens Base of dens
Extends into body of C2

72. Odontoid Fracture types

73. Flexion-Extension View
May identify cervical instability, atlantoaxial joint instability or ligamentous injury
If suspicion still present with negative films
Adds little to evaluation

74. Oblique View
Better visualization of pedicules, facet alignment and posterior lamina or articular mass fractures
Usually add nothing

75. Prediction Rules

76. Prediction Rules
In alert and stable trauma patients establish rule to avoid irradiating low risk patients

77. Canadian C-Spine Rule Stiell, et al JAMA, 2001
Prospective, but Canadian…
8924
Blunt trauma
GCS- 15
Stable vitals
SCI in 151 (1.7%)
Rule 100% sensitive

78. Canadian Rule High risk > 65 yrs Dangerous mechanism
Fall >1m/5 stairs
Axial load
MVA >100km/hr
Motorized recreational vehicle
Bicycle vs immobile object
Paresthesias in extremities

79. Canadian Rule Low risk if : Simple rear end MVA Sitting position in ER
Ambulatory at scene
No neck pain at scene
Absence of mid-line tenderness

80. Canadian Rule If low risk…
Voluntarily and actively rotate neck 45 degrees both left and right
If able- no Xray

81. Canadian Rule Validated study 8923 enrolled 169 with SCI (2%)
Sensitivity = 99.4%
Specificity = 45.1%
But…

82. Canadian C-Spine Rule
In adults!!!!!!!!

83. NEXUS: National Emergency X-Radiography Utilization Study
Hoffman, et al, NEJM, 2000
Prospective
34,069 enrolled
Blunt trauma

84. NEXUS Rule Get radiography unless all are met: No midline tenderness
Not intoxicated
No AMS
No focal neuro deficits
No distracting injuries

85. NEXUS Rule
SCI- 818 (2.4%)
Sensitivity = 99.6%
Specificity = 12.9%

86. Comparing Canadian and NEXUS
Canadian rule more sensitive and more specific
Neither have been validated in settings other than where they were established

87. NEXUS- Children Viccellio, et al, Pediatrics, 2001
NEXUS data, extract pediatric info
3065 pts (9% of total)
<18 yrs
SCI- 30 (0.98%)

88. Viccellio, et al SCIWORA- 0% SCI
Only 4/30= 13.3% were younger then 9 yrs (said population made up 29.5% of total)
0/30= 0% younger than 2 yrs (2.9% of total)

89. Viccellio, et al NEXUS decision rule 100% sensitive
Low risk- 603 of 3065
Reduction of Xrays in 19.7%

90. Viccellio, et al Conclusion: NEXUS is sensitive for peds
Need a prospective study of 80,000 cases to improve CI and even more for youngest peds
Can only be generalized for the adolescent population
SCIWORA more common in adults

91. Viccellio, et al Discussion: Rarity of SCI in infants
Doesn’t occur or lethal because of anatomy (damage to higher C-spine)

92. Jaffe, et al Ann Emerg Med, 1987
Retrospective review of 206 children <16
8 variables: neck pain, neck tenderness, limited ROM, hx of trauma to neck, abnl reflexes/sensation or MS.
98% sensitive if 1 positive
Avoided radiation in 38%

93. SO……..

94. Remember Anatomy Risk factors Mechanism Symptoms If Radiography
Ossification centers

95. Thank you!!!