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Pediatric C-Spine Trauma: Clearing the C-Spine

Pediatric C-Spine Trauma: Clearing the C-Spine. John K. Birknes, M.D. Neurological Surgery Children’s Hospital of the King’s Daughters. Outline. Anatomy: Different from adults (e.g. head:body ratio) Anatomic variants mistaken for injury (e.g. pseudosubluxation)

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Pediatric C-Spine Trauma: Clearing the C-Spine

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  1. Pediatric C-Spine Trauma: Clearing the C-Spine John K. Birknes, M.D. Neurological Surgery Children’s Hospital of the King’s Daughters

  2. Outline • Anatomy: • Different from adults (e.g. head:body ratio) • Anatomic variants mistaken for injury (e.g. pseudosubluxation) • Work-up for patient w/ neck pain • Exam • X-rays • When to Refer for further work-up

  3. Cervical Spine Injuries • Rare in children - < 1% of children’s fractures • Rates of neurologic injury in children’s C spine injuries vary: “rare” to 44% in large series • Relatively larger head • Child’s neck very mobile – ligamentous laxity and more horizontal facet joints (esp upper) • < age 7 – majority of C spine injuries are upper cervical, esp. craniocervical junction • > age 7 – lower C spine injuries predominate

  4. C Spine Immobilization for Transport in Children • Large head will cause increased flexion of C spine on standard backboard • Bump beneath upper T spine or cutout in board for head to transport child with spine in neutral alignment • MVA & falls

  5. Important Pediatric Differences • Anatomical differences-facets horizontal • Radiologic differences-Psuedosubluxation • Increased elasticity • Immobilization well tolerated

  6. RADIOGRAPHIC PARAMETERS WHAT IS PATHOLOGIC IN AN ADULT CAN BE NORMAL IN A GROWING CHILD GROWTH CENTERS ARE NOT FRACTURES OS-ODONTOIDIUM ADI PSEUDOSUBLUXATION C 2-3 (C3/4)

  7. C Spine Radiographic Evaluation in Children • Be aware of normal ossification centers and synchondroses • Can mimic fx • Look for smooth cortical margins • Lack hematoma on CT • Absence of cervical lordosis • Mimics splinting of injury • Anterior wedging of VBs • Contributes to C2/3 pseudosubluxation

  8. Anatomy – C1 • 3 ossification centers at birth – body and 2 neurocentral arches • Neurocentral synchondroses (F) fuse at about 7 years of age

  9. Anatomy – Lower Cervical Vertebrae C3 – C7 • Neurocentral synchondroses (F) fuse at age 3-6 years • Ossified vertebral bodies wedge shaped until square at about age 7 • Superior and inferior cartilage endplates firmly attached to disc

  10. Anatomy – C2 • 4 ossification centers at birth – body, 2 neural arches, dens • Neurocentral synchondroses (F) fuse at age 3-6 years • Synchondrosis between body and dens (L) fuses age 3 – 6 years • Thus no synchondrosis should be visible on open mouth odontoid view in child older than 6 years

  11. Anatomy – C2 • Summit ossification center (H) appears at age 3 – 6 and fuses around age 12 • Do not confuse with os odontoideum • ALL OSSIFICATION CENTERS FUSED @ 7y/o

  12. Os Odontoideum • Etiology(?) • May result in C1-C2 instability • TIP OF ODONTOID IS DIVIDED • Apical segment lacks basilar support • RARE • X-RAY – oval ossicle, smooth margins • REFER to Neurosurgeon

  13. Os Odontoideum

  14. RADIOGRAPHIC PARAMETERS ADI (Atlanto-Dens Interval) Measure on lateral flex/ext films, voluntary motion in awake patient Ant aspect of dens to post aspect of the ant ring of C1 NL: < 5mm kids, <3mm adults Why ADI increase in kids? ↑ ligamentous laxity ↑ cartilage component of dens and atlas

  15. PSEUDOSUBLUXATION Ant Displacement of C2 on C3 C3/4 less common 9% of kids 1-7yo CAUSES Horizantal facets Esp. in upper ↑ RELATIVE HEAD SIZE ↑ LIG LAXITY

  16. PSEUDOSUBLUXATION • Spinolaminar line of Swischuk • Line from ant aspect of C1 posterior arch to same on C3 • Should lie within 2mm of ant cortex of C2 spinous process • Treatment: Do Nothing

  17. C Spine Evaluation in Children • Adult protocol as basis: NEXUS criteria x-rays in all trauma pts except: • No post midline tenderness • No distracting injury • No neurologic deficit • Clearly lucid • Consider mechanism of injury • Physical exam – tenderness (age, distracting injuries), neurological exam, ROM (flex-ex, rotation, lateral) • C Spine series: AP, lateral, open-mouth odontoid • Possible flexion-extension

  18. X-rays • C-spine series • AP • Lateral • Open-mouth odontoid • Possible flex-ex

  19. When to Refer • Any neurologic finding • True abnormality on x-rays • If they have normal x-rays but have neck tenderness that is not simply paraspinal muscle sprain. • Any question

  20. Key Points • Ossification centers fused at 7 y/o • Os odontoideum potentially unstable Refer • Increased ADI in peds • Increased ligamentous laxity • Pseudosubluxation (C2/3 & C3/4) • Wedging of VBs, lig laxity, horizontal facets

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