Toddler Takes a TumbleToddler Takes a TumblePediatric Cervical Spine InjuryPediatric Cervical Spine Injury

Gary R. Strange, MD, FACEP

Department of Emergency Medicine

University of Illinois

Gary R. Strange, MD

Teaching points to be addressedTeaching 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?

Gary R. Strange, MD

Case PresentationCase 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

Gary R. Strange, MD

Emergency Department CourseEmergency 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

Gary R. Strange, MD

Emergency Department Course Emergency Department Course Second VisitSecond 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

Gary R. Strange, MD

Emergency Department CourseEmergency Department CourseSecond VisitSecond Visit

• Immobilized on a long spine board

• Cervical spine radiographs are obtained

• Fracture is diagnosed • Transferred to a

pediatric trauma center

Gary R. Strange, MD

Pediatric Cervical Spine InjuriesPediatric Cervical Spine InjuriesIncidenceIncidence

050

100150200250300350400450500

Age < 5 Age 5-7 Age 8-15

Cases per Year

Overall Incidence for All Ages: 10,000 per Year

Gary R. Strange, MD

Cervical Spine InjuriesCervical Spine InjuriesMale-Female DistributionMale-Female Distribution

0

10

20

30

40

50

60

70

80

Adult Pediatric

Male

Female

Percentage

Gary R. Strange, MD

Pediatric Cervical Spine InjuryPediatric Cervical Spine InjuryEtiologyEtiology

CAUSE ADULT PEDIATRIC

MVC 60 40

Falls 25 20

Sports 12 20

Assaults 1 5

Obstetric 0 10

Other 2 5

Gary R. Strange, MD

Pediatric Cervical Spine TraumaPediatric Cervical Spine TraumaImmobilizationImmobilization

• Adult on Backboard• Neck in Neutral

Position

Gary R. Strange, MD

Pediatric Cervical Spine TraumaPediatric Cervical Spine TraumaImmobilizationImmobilization

• Child on Backboard• Neck in Flexion• Semi-Rigid Collar

decreases Flexion but does not Eliminate It

Gary R. Strange, MD

Pediatric Cervical Spine TraumaPediatric Cervical Spine TraumaImmobilizationImmobilization

• 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

Gary R. Strange, MD

Pediatric Cervical Spine TraumaPediatric Cervical Spine TraumaClinical ClearanceClinical Clearance

• NEXUS Criteria• Midline Cervical Tenderness• Altered Level of Alertness• Evidence of Intoxication• Neurological Abnormality• Presence of Painful Distracting Injury

Gary R. Strange, MD

Pediatric Cervical Spine TraumaPediatric Cervical Spine TraumaNEXUS CriteriaNEXUS 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

Gary R. Strange, MD

Pediatric Cervical Spine TraumaPediatric Cervical Spine TraumaScreening RadiographsScreening Radiographs

• Cross-Table Lateral View• Sensitivity 82%• Negative Predictive Value 97%

• Lateral and Anteroposterior Views• Sensitivity 87%

Gary R. Strange, MD

Pediatric Cervical Spine TraumaPediatric Cervical Spine TraumaScreening RadiographsScreening Radiographs

• Transoral Odontoid Views• Difficult to obtain in a child < 8 years• Not necessary for diagnosis (Buhs)• Not recommended by CONS for children < 8

Gary R. Strange, MD

Factors Complicating Radiographic Factors Complicating Radiographic InterpretationInterpretation

• Ossification Centers• Synchondroses• Hypermobility• Normal Variants

Gary R. Strange, MD

Factors Complicating Radiographic Factors Complicating Radiographic Interpretation -- AtlasInterpretation -- 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

Gary R. Strange, MD

Factors Complicating Radiographic Factors Complicating Radiographic Interpretation -- AxisInterpretation -- Axis

• Ossification Centers• Body en Utero• Arches en Utero• Summit of Odontoid

by 3-6 Years• Inferior Epiphyseal

Ring at Puberty

Gary R. Strange, MD

Factors Complicating Radiographic Factors Complicating Radiographic Interpretation -- AxisInterpretation -- 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

Gary R. Strange, MD

Factors Complicating Radiographic Factors Complicating Radiographic Interpretation – C3 to C7Interpretation – C3 to C7

• Ossification Centers• Secondary Centers

for Bifid Spinous Processes appear at Puberty

• Superior and Inferior Epiphyseal Rings appear at Puberty

Gary R. Strange, MD

Factors Complicating Radiographic Factors Complicating Radiographic Interpretation – C3 to C7Interpretation – 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

Gary R. Strange, MD

Factors Complicating Radiographic Factors Complicating Radiographic Interpretation -- HypermobilityInterpretation -- Hypermobility

• Ligamentous Laxity

• Horizontal Articulations• Facet joints at 300 for Age < 8; 600 in Adults

• Large Head

• Underdeveloped Muscles

Gary R. Strange, MD

Radiographic InterpretationRadiographic InterpretationHypermobilityHypermobility

• 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%)

Gary R. Strange, MD

Radiographic InterpretationRadiographic InterpretationHypermobilityHypermobility

• Widening of Atlanto-Dens Interval (20%)• > 3 mm is abnormal

• Over-Riding of Anterior Arch of C1 on the Odontoid with Extension (20%)

Gary R. Strange, MD

Radiographic InterpretationRadiographic InterpretationHypermobilityHypermobility

• 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

Gary R. Strange, MD

Radiographic InterpretationRadiographic InterpretationAnterior WedgingAnterior Wedging

• Present at Multiple Levels

• Simulates Wedge Compression Fracture

• < 3 mm ▲in Anterior and Posterior Body Height is Normal

Gary R. Strange, MD

Progressive Maturation of Vertebral BodiesProgressive Maturation of Vertebral Bodies

• Oval (immature)• Anterior wedging• Rounded upper

corner• Rectangular (mature)

Gary R. Strange, MD

Pre-Vertebral Soft Tissue SpacePre-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

Gary R. Strange, MD

Pediatric Vertebral FracturesPediatric Vertebral FracturesLevel of Fracture by AgeLevel of Fracture by Age

AGE (years) PERCENT @ C1-C2

> 12 30

8-12 70

< 8 90

Gary R. Strange, MD

Pediatric Vertebral FracturesPediatric Vertebral FracturesMortality by Level of FractureMortality by Level of Fracture

LEVEL OF FRACTURE MORTALITY (%)

C1 17

C2 9

C3 4.3

C4 3.7

C5-C7 0

Gary R. Strange, MD

Common Pediatric Cervical Spine InjuriesCommon 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%)

Gary R. Strange, MD

Odontoid FractureOdontoid 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

Gary R. Strange, MD

Hangman’s FractureHangman’s Fracture

• Fracture through the Pedicles of the Axis (C2)

• Subluxation of the Body of C2

Gary R. Strange, MD

Hangman’s FractureHangman’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

Gary R. Strange, MD

Atlanto-Axial Rotatory SubluxationAtlanto-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

Gary R. Strange, MD

Occipito-Atlantal DislocationOccipito-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

Gary R. Strange, MD

Jefferson FractureJefferson 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

Gary R. Strange, MD

Physeal InjuriesPhyseal 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

Gary R. Strange, MD

SummarySummary

• 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.

Gary R. Strange, MD

SummarySummary• 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

Gary R. Strange, MD

SummarySummary

• 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

Questions???Questions???

FERNE www.ferne.org

GStrange@uic.edu