1. Toddler Takes a Tumble Pediatric Cervical Spine Injury Gary R. Strange, MD, FACEP Department of Emergency Medicine University of Illinois

2. Gary R. Strange, MD Teaching points to be addressed What is the proper technique for immobilization of the cervical spine in the pediatric patient? Is it possible to clinically clear the cervical spine of the pediatric patient? Can the NEXUS criteria be used? What radiographic views are required to adequately evaluate the pediatric patient who has sustained neck trauma? What are the most common abnormal radiographic findings for the pediatric cervical spine? What are the common normal findings that confound the x-ray diagnosis in pediatric patients?

3. Gary R. Strange, MD Case Presentation A 3-year-old child is playing with some older children on a backyard trampoline He falls from the trampoline and strikes his head on the support Transient loss of consciousness and a minor laceration just below the mandible on the right side He is able to walk inside He is brought by his mother to the ED for evaluation

4. Gary R. Strange, MD Emergency Department Course He is alert, crying and resists examination He has a small right submandibular laceration which does not require suturing and a right parietal contusion The rest of the physical examination, including the neurological, is normal He is discharged to the care of his mother who is given routine head injury instructions

5. Gary R. Strange, MD Emergency Department Course Second Visit Twenty-four hours later He will not move his neck Mother states that he cries and says that his neck hurts when he moves it He is rigidly holding his neck in neutral position and is tender to palpation of the upper cervical spine area His neurological examination remains intact

6. Gary R. Strange, MD Emergency Department Course Second Visit Immobilized on a long spine board Cervical spine radiographs are obtained Fracture is diagnosed Transferred to a pediatric trauma center

7. Gary R. Strange, MD Pediatric Cervical Spine Injuries Incidence Overall Incidence for All Ages: 10,000 per Year

8. Gary R. Strange, MD Cervical Spine Injuries Male-Female Distribution Percentage

9. Gary R. Strange, MD Pediatric Cervical Spine Injury Etiology CAUSE ADULTPEDIATRIC MVC6040 Falls2520 Sports1220 Assaults15 Obstetric010 Other2 5

10. Gary R. Strange, MD Pediatric Cervical Spine Trauma Immobilization Adult on Backboard Neck in Neutral Position

11. Gary R. Strange, MD Pediatric Cervical Spine Trauma Immobilization Child on Backboard Neck in Flexion Semi-Rigid Collar decreases Flexion but does not Eliminate It

12. Gary R. Strange, MD Pediatric Cervical Spine Trauma Immobilization Special Board with Recessed Area for the Occiput Padding Under the Chest and Back Age < 4: 27 mm Age > 4: 22 mm Age > 8: none

13. Gary R. Strange, MD Pediatric Cervical Spine Trauma Clinical Clearance NEXUS Criteria Midline Cervical Tenderness Altered Level of Alertness Evidence of Intoxication Neurological Abnormality Presence of Painful Distracting Injury

14. Gary R. Strange, MD Pediatric Cervical Spine Trauma NEXUS Criteria Prospective multicenter study of 3,065 patients < 18 years of age NEXUS Criteria identified all CSI No infants < age 2 in the study population

15. Gary R. Strange, MD Pediatric Cervical Spine Trauma Screening Radiographs Cross-Table Lateral View Sensitivity 82% Negative Predictive Value 97% Lateral and Anteroposterior Views Sensitivity 87%

16. Gary R. Strange, MD Pediatric Cervical Spine Trauma Screening Radiographs Transoral Odontoid Views Difficult to obtain in a child < 8 years Not necessary for diagnosis (Buhs) Not recommended by CONS for children < 8

17. Gary R. Strange, MD Factors Complicating Radiographic Interpretation Ossification Centers Synchondroses Hypermobility Normal Variants

18. Gary R. Strange, MD Factors Complicating Radiographic Interpretation -- Atlas Ossification Centers Anterior Arch by Age 1 Year Posterior Arch en Utero Synchondroses Spinous process fuses at age 3 Neurocentral fuses at age 7

19. Gary R. Strange, MD Factors Complicating Radiographic Interpretation -- Axis Ossification Centers Body en Utero Arches en Utero Summit of Odontoid by 3-6 Years Inferior Epiphyseal Ring at Puberty

20. Gary R. Strange, MD Factors Complicating Radiographic Interpretation -- Axis Synchondroses Spinous Process fuses at age 3-6 years Neurocentral fuses at age 3-6 years Base of Odontoid fuses by 3-6 Years 1/3 have visible fusion line throughout life Summit of the Odontoid fuses by age 12 years Inferior Epiphyseal Ring fuses by age 15

21. Gary R. Strange, MD Factors Complicating Radiographic Interpretation – C3 to C7 Ossification Centers Secondary Centers for Bifid Spinous Processes appear at Puberty Superior and Inferior Epiphyseal Rings appear at Puberty

22. Gary R. Strange, MD Factors Complicating Radiographic Interpretation – C3 to C7 Synchondroses Anterior Aspect of Transverse Processes fuse by Age 6 Years Spinous Processes fuse by Age 3 Years Neurocentral fuses by age 3-6 Years Epiphyseal Rings fuse by Age 25 Years

23. Gary R. Strange, MD Factors Complicating Radiographic Interpretation -- Hypermobility Ligamentous Laxity Horizontal Articulations Facet joints at 30 0 for Age < 8; 60 0 in Adults Large Head Underdeveloped Muscles

24. Gary R. Strange, MD Radiographic Interpretation Hypermobility Anterior Pseudo- subluxation of C2 on C3 (46%) Marked in 9% Accentuated in Flexion Posterior pseudo- subluxation with extension (14%) Anterior Pseudo- subluxaiton of C3 on C4 (14%)

25. Gary R. Strange, MD Radiographic Interpretation Hypermobility Widening of Atlanto- Dens Interval (20%) > 3 mm is abnormal Over-Riding of Anterior Arch of C1 on the Odontoid with Extension (20%)

26. Gary R. Strange, MD Radiographic Interpretation Hypermobility Absence of Uniform Angulation between Vertebrae (16%) Simulates disruption of interspinous or posterior longitudinal ligaments Reduced with extension Absent Lordosis in Neutral Position (14%) Simulates acute muscle spasm

27. Gary R. Strange, MD Radiographic Interpretation Anterior Wedging Present at Multiple Levels Simulates Wedge Compression Fracture < 3 mm ▲in Anterior and Posterior Body Height is Normal

28. Gary R. Strange, MD Progressive Maturation of Vertebral Bodies Oval (immature) Anterior wedging Rounded upper corner Rectangular (mature)

29. Gary R. Strange, MD Pre-Vertebral Soft Tissue Space Abnormal if > ¾ the Antero-Posterior Width of the Adjacent Vertebra < 7 mm @ C2-C3 Increased with Flexion Decreased with Extension

30. Gary R. Strange, MD Pediatric Vertebral Fractures Level of Fracture by Age AGE (years)PERCENT @ C1-C2 > 1230 8-1270 < 890

31. Gary R. Strange, MD Pediatric Vertebral Fractures Mortality by Level of Fracture LEVEL OF FRACTUREMORTALITY (%) C117 C29 C34.3 C43.7 C5-C70

32. Gary R. Strange, MD Common Pediatric Cervical Spine Injuries Fracture or Subchondral Separation of the Odontoid Hangman’s Fracture Atlanto-Axial Rotatory Subluxation Occipito-Atlantal Dislocation Jefferson Fracture Physeal Injuries SCIWORA (17%)

33. Gary R. Strange, MD Odontoid Fracture Common pediatric cervical spine fracture Shearing forces Infants in forward-facing car seats Falls Subdental synchondrosis most vulnerable Often no neuro deficit Usually heals without problems

34. Gary R. Strange, MD Hangman’s Fracture Fracture through the Pedicles of the Axis (C2) Subluxation of the Body of C2

35. Gary R. Strange, MD Hangman’s Fracture Posterior Cervical Line (Swischuk) Useful in Differentiating Occult Hangman’s Fx from Pseudosubluxation Connects the bases of the spinous processes of C1 – C3 Positive if misses anterior aspect of the spinous process of C2 by 2 mm or more

36. Gary R. Strange, MD Atlanto-Axial Rotatory Subluxation Displacement of the odontoid within the ring of the atlas Disruption of the transverse ligament Possible displacement of the lateral mass of C1 relative to that of C2 Traumatic torticollis Neurological deficit unlikely

37. Gary R. Strange, MD Occipito-Atlantal Dislocation Disruptions of: Musculature Apical ligament Atlantooccipital joints Tectorial membrane* C1-2:C2-3 > 2.5 C1-C2 > 10 mm Spinal cord High rate of neurological deficit and mortality

38. Gary R. Strange, MD Jefferson Fracture Vertical impact Falls, dives, striking the head on roof of car in MVC Often no neuro deficit Break in the ring of C1 If through unossified areas, difficult to see Lateral masses of C1 extend beyond those of C2

39. Gary R. Strange, MD Physeal Injuries Superior and inferior epiphyseal plates do not fuse until about age 25 years Zone of relative weakness at the junction of the epiphyseal cartilage and vertebral ossification Inferior growth plate more vulnerable Most common in adolescents Separation and displacement of a plate-like piece of bone usually at the inferior aspect of the vertebral body

40. Gary R. Strange, MD Summary Thoracic elevation or occipital recess is required to properly immobilize a child 8 years of age or younger in the desired neutral position. It is possible to safely clear a child’s cervical spine using careful history and physical examination techniques and the NEXUS criteria have performed well in this regard. Radiographic evaluation of the cervical spine of a child 9 years of age or older, an open-mouth cervical spine x-ray is also obtained.

41. Gary R. Strange, MD Summary Radiographic diagnosis of cervical spine injuries in the pediatric patient is complicated by the presence of: Ossification centers Synchondroses Ligamentous laxity Hypermobility Hypermobility frequently results in: Pseudosubluxation of C2 on C3 Pseudosubluxation of C3 on C4 Widening of the atlanto-dens interval Over-riding of the anterior arch of C1 on the odontoid Absence of uniform angulation between vertebrae

42. Gary R. Strange, MD Summary Common abnormal radiographic findings in children, in addition to soft tissue swelling, include: Rotatory subluxation of the odontoid Jefferson fracture Odontoid fracture Hangman’s fracture

43. Questions??? FERNE www.ferne.orgwww.ferne.org GStrange@uic.edu