Toddler Takes a Tumble Pediatric Cervical Spine Injury

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

2. 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. 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. 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. 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. Emergency Department CourseSecond Visit • Immobilized on a long spine board • Cervical spine radiographs are obtained • Fracture is diagnosed • Transferred to a pediatric trauma center

7. Pediatric Cervical Spine InjuriesIncidence Overall Incidence for All Ages: 10,000 per Year

8. Cervical Spine InjuriesMale-Female Distribution Percentage

9. Pediatric Cervical Spine InjuryEtiology

10. Pediatric Cervical Spine TraumaImmobilization • Adult on Backboard • Neck in Neutral Position

11. Pediatric Cervical Spine TraumaImmobilization • Child on Backboard • Neck in Flexion • Semi-Rigid Collar decreases Flexion but does not Eliminate It

12. Pediatric Cervical Spine TraumaImmobilization • 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. Pediatric Cervical Spine TraumaClinical Clearance • NEXUS Criteria • Midline Cervical Tenderness • Altered Level of Alertness • Evidence of Intoxication • Neurological Abnormality • Presence of Painful Distracting Injury

14. Pediatric Cervical Spine TraumaNEXUS 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. Pediatric Cervical Spine TraumaScreening Radiographs • Cross-Table Lateral View • Sensitivity 82% • Negative Predictive Value 97% • Lateral and Anteroposterior Views • Sensitivity 87%

16. Pediatric Cervical Spine TraumaScreening 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. Factors Complicating Radiographic Interpretation • Ossification Centers • Synchondroses • Hypermobility • Normal Variants

18. 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. 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. 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. 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. 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. Factors Complicating Radiographic Interpretation -- Hypermobility • Ligamentous Laxity • Horizontal Articulations • Facet joints at 300 for Age < 8; 600 in Adults • Large Head • Underdeveloped Muscles

24. Radiographic InterpretationHypermobility • 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. Radiographic InterpretationHypermobility • Widening of Atlanto-Dens Interval (20%) • > 3 mm is abnormal • Over-Riding of Anterior Arch of C1 on the Odontoid with Extension (20%)

26. Radiographic InterpretationHypermobility • 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. Radiographic InterpretationAnterior Wedging • Present at Multiple Levels • Simulates Wedge Compression Fracture • < 3 mm ▲in Anterior and Posterior Body Height is Normal

28. Progressive Maturation of Vertebral Bodies • Oval (immature) • Anterior wedging • Rounded upper corner • Rectangular (mature)

29. 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. Pediatric Vertebral FracturesLevel of Fracture by Age

31. Pediatric Vertebral FracturesMortality by Level of Fracture

32. 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. 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. Hangman’s Fracture • Fracture through the Pedicles of the Axis (C2) • Subluxation of the Body of C2

35. 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. 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. 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. 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. 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. 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 < 8 years of age consists of anteroposterior and lateral cervical spine x-rays. For children > 9 years of age or older, an open-mouth cervical spine x-ray is also obtained.

41. 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. 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.org GStrange@uic.edu