An Approach to Paediatric Cervical Spine Injury (doc)

An approach to Paediatric Cervical spine injury

Browne GJ, Cheng, NG, McCaskill ME, Phin S and Cree A

Department of Emergency Medicine, Orthopaedics and Spinal Surgery

The Children's Hospital at Westmead

An approach to cervical spine injury in children

The difficulties in predicting a paediatric cervical spine injury (CSI) are considerable.

Unrecognised CSI can produce catastrophic neurological disability1. Alternatively,

fear of failing to diagnose such injuries may lead to unnecessary imaging and a

reluctance to pass the spine as normal2,3. The unfortunate consequence of this can be

prolonged immobilisation of the child in the emergency department (ED) while

waiting for a final decision to clear the spine, often resulting in complications such as

pressure areas4. The challenge to the emergency physician therefore is the timely

assessment and appropriate management of the child with a possible CSI.

Paediatric CSI is uncommon. On best available evidence, the prevalence of paediatric

CSI is 1-2% of major trauma. Prevalence data are highly variable and depend upon

patient census within the reporting ED. Even in tertiary paediatric trauma centres, CSI

reports vary depending on geoanthropological factors5,6,7,8,9.

1 Demetriades D. Charalambides K. Chahwan S. Hanpeter D. Alo K. Velmahos G. Murray J. Asensio J. Nonskeletal cervical spine injuries: epidemiology and diagnostic pitfalls. Journal of Trauma-Injury Infection & Critical Care. 2000. 48(4):724-7.

2 Orenstein JB. Delayed diagnosis of pediatric cervical spine injury. Pediatrics 1992; 89: 1185–8.

3 Furnival RA, Woodward GA, Schunk JE. Delayed diagnosis of injury in pediatric trauma. Pediatrics 1996; 98: 56–62.

4 Webber-Jones JE. Thomas CA. Bordeaux RE Jr. The management and prevention of rigid cervical collar complications. Orthopaedic Nursing. 2002. 21(4):19-25.

5 Viccellio P, Simon H, Pressman BD et al. A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics 2001: 108: 1–6.

6 Hadley MN, Zabramski JM, Browner CM, Rekate H, Sonntag VK. Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg 1988;68:18-24.

7. Finch GD. Barnes MJ. Major cervical spine injuries in children and adolescents. Journal of Pediatric Orthopedics. 1998 18(6): 811-4.

8 Givens TG, Polley KA, Smith GF et al. Pediatric cervical spine injury: a three-year experience. J. Trauma 1996; 41: 310–4.

2

Adult studies have reported the effectiveness of various algorithms and have

suggested ways of risk stratification of adult patients with possible CSI10, 11, 12, 13. Few

studies have addressed these issues in children14,15,16. Large prospective studies have

been performed but they mostly evaluate adult CSI with small numbers of children

included5. In particular they have reported few children with CSI under nine years of

age, making clinical recommendations in this age group difficult. The study findings

were extrapolated into clinical practice for younger children. Despite this short fall in

best practice evidence, reports have suggested that in the case of younger children

with a potential CSI, significant modifications in approach may be prudent14,17.

Children of all ages present to EDs every day for assessment of possible CSI

following trauma. We present our approach, based on current evidence and joint

consensus between the ED, our trauma committee and the spinal unit.

9 Patel JC. Tepas JJ 3rd. Mollitt DL. Pieper P. Pediatric cervical spine injuries: defining the disease. Journal of Pediatric Surgery. 2001. 36(2):373-6.

10 Touger M. Gennis P. Nathanson N. Lowery DW. Pollack CV Jr. Hoffman JR. Mower WR. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Annals of Emergency Medicine. 2002. 40(3): 287-93.

11 Krochmal P. Clinical criteria to rule out cervical-spine injury. New England Journal of Medicine. 2000. 343(18): 1338-9.

12 Hoffman JR. Mower WR. Wolfson AB. Todd KH. Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. New England Journal of Medicine. 2000. 343(2):94-9.

13 Banit DM. Grau G. Fisher JR. Evaluation of the acute cervical spine: a management algorithm. Journal of Trauma-Injury Infection & Critical Care. 2000. 49(3): 450-6.

14 Jaffe DM. Binns H. Radkowski MA. Barthel MJ. Engelhard HH 3rd. Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Annals of Emergency Medicine. 1987. 16(3):270-6.

15 Baker C. Kadish H. Schunk JE. Evaluation of pediatric cervical spine injuries. American Journal of Emergency Medicine. 1999. 17(3):230-4.

16 Browne, GJ, Lam, LT and Barker, RA. The usefulness of a modified adult protocol for the clearance of paediatric cervical spine injury in the emergency department. Emergency Medicine. 2002. 14; 287-296.

17 Ruge JR. Paediatric Spinal Injury: the very young. J. Neurosurg. 1988; 68: 25–30.

3

Unique factors in children with potential cervical spine injury

The majority of paediatric CSIs are due to blunt trauma related to high-speed motor

vehicle or pedestrian accidents7, 8, 16. Gunshot wounds and non-accidental injuries are

less common causes7, 8, 18. Of those children with potential CSI, most have multi-

trauma8; associated head injury may occur in up to 67% of these cases19, 20, 21.

Despite the low prevalence, a number of biomechanical factors may predispose

children to CSI17, 22, 23. Children have a relatively large, heavy head and

underdeveloped cervical musculature, allowing the head to move around in an

uncontrolled fashion during trauma. The ligaments and joint capsules in children are

relatively hyper-mobile with considerable laxity, thus allowing for considerable

movement of one cervical vertebra on the other. The natural fulcrum for flexion of the

neck in children is at a higher level, C2/3 and C3/4, rather than at C5/6 as occurs in

adults. The articular surfaces of the vertebral bodies, facet joints and uncinate

processes lie more horizontally than in adults and this allows for greater movement in

the cervical region, even during a minor fall or accident.

CSIs fall into four distinct patterns: fracture only, fracture with subluxation,

subluxation only and spinal cord injury without radiological abnormality

(SCIWORA) 1, 5, 24. It should be noted that in the years since it was first described

SCIWORA has become a misnomer. A combination of plain films, CT scans and

MRI scans will eventually display spinal lesions in almost all patients (see “Other

imaging modalities” below).

In most cases reported in retrospective studies CSI involves the upper cervical spine

(C4 or above) of younger children (below nine years of age), with the lower cervical

spine more vulnerable to injury in older children4, 6, 7, 8, 25. A recent prospective study,

though lacking in numbers, has also shown this, with all patients nine years old or less

having lesions above C4, whilst 13/17 subjects between 10 and 16 years of age had

injuries below C45. Mortality in all studies remains high with lesions above C3, 24 Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children--the SCIWORA syndrome. J Trauma 1989; 29:654-64.

4

increasing exponentially with higher lesions, with C1 lesions having a reported 30%

mortality26, 27, 28.

There are reports of delayed diagnosis of CSI in children1, 2. Several factors contribute

to this delay. Cervical spine clearance in paediatric patients can be problematic

particularly in young children of variable developmental age. The young child’s

verbal skills and their poor ability to localise pain limit clinical assessment.

Developmental issues also impair the child’s ability to cooperate with spinal

immobilisation. SCIWORA may not become evident until several days have

elapsed29.

The process of cervical spine assessment

The most time-consuming process in trauma for the emergency physician may well be

the assessment of a child with a potential CSI. However, no published data exists that

quantifies the proportion of time devoted to this task. In our trauma centre, assessment

alone accounts for the majority of the activity in the ED devoted to these patients. The

treatment of defined injuries is a minor component of our paediatric ED and spinal

surgical work. Of those patients with potential CSI treated in our centre, further

management is required in approximately 10% of cases. Our management therefore

mainly consists of close observation and expectant recovery.

Most CSI patients are multi-trauma cases 8, 18, 19, 20, 21, 30, 31 and are often admitted to high

dependency wards or the PICU. Very few patients who present to our institution (less

than 1%) with a potential CSI will have a serious injury needing specific surgical

intervention. Of these cases around two to three present annually with an unstable

injury that will require urgent operative intervention or fixation. Even in a large

institution such as ours the rate of presentations of SCIWORA remains unclear, being

estimated at around three to four per annum 1, 9, 31.

Interpretation of paediatric cervical spine x-rays present a number of difficulties that

may make assessment in the ED challenging17, 22, 23, 32. These include:

5

Incomplete ossification of vertebrae; unfused synchondroses have the

appearance of a fracture

Increased pre-odontoid space is common due to laxity of the transverse

ligament

When the head is held in mild flexion in infants and young children there may

be an anterior pseudo-subluxation between adjacent vertebrae at C2/3

Widening of pre-vertebral space with dynamic soft tissues

Hence, considerable expertise and experience is required in correct interpretation of

even basic x-rays. A further confounding factor is the presence of congenital

anomalies, which adds further anxiety and difficulty in assessment of paediatric CSI23.

These congenital issues are beyond the scope of this paper and the reader should

consult the comprehensive reviews available.

The remainder of this paper will focus on an approach to the child with a potential

CSI in the ED and will refer to the algorithm presented in figure 1 (see figure 1).

History and examination of the potential paediatric CSI patient

History

The history is the key to the evaluation of CSIs. In patients who have had recent

trauma, subsequent symptoms of pain or neurological change at any stage should

arouse suspicion of CSI.

If pain is the presenting symptom, the physician must ask about the location, radiation

and duration of the pain. It is also important to inquire about factors that exacerbate or

relieve pain and other symptoms. Radicular pain may direct the evaluation to a

specific nerve root level.

Elicit any history of paraesthesia, numbness or weakness. Evaluate muscle weakness

urgently, especially if it is progressive. Specific inquiry for neurological symptoms

with sacral sparing is important, as it is a characteristic feature of some CSIs.

6

Several elements in the patient's history, if elicited, are “red flags” (see Table 1)2, 33 .

In situations in which it may be extremely difficult to interpret non-classic signs and

symptoms, the examining doctor exercises best judgment to determine an indication

for diagnostic testing or referral to a spine specialist16.

Table 1 : Historical indicators of C-spine injury

Mechanism of injury Pedestrian / cyclist hit > 30km/hr Motor vehicle passenger – collision > 60km/hr Fall – more than 3 meters (in smaller children a fall from a proportionally lower

height is an indication) Kicked by or fall from a horse Backed over by a car Thrown from vehicle Thrown over handlebars of bike Severe electric shock

Serious injury of other occupants in a vehicle accident

Multiple trauma

Neck trauma

Neck pain or neurological deficit at any time since injury (even if resolved)

Significant injury above the clavicles, eg, the head, face or mandible

Physical Examination of the injured child

The physical examination of children is challenging, particularly in a high acuity

setting such as trauma. Developmental immaturity is a major factor, as exemplified in

a preverbal frightened child. Keen observational skills are required in these situations,

where subtle signs of pain, such as limitation of neck movement, may be a vital clue.

Examination

Any child presenting with the symptoms or signs in Table 2 after an injury is at risk of

cervical spinal injury2, 33. Irritability in an infant in the context of trauma is also a

suspicious finding and necessitates careful examination for cervical pain.

7

Table 2 : Indicators on examination of C-spine injury

Neck tenderness, particularly midline tenderness

Limitations of neck movement due to pain

Any signs of spinal cord injury below the cervical spine

Acute peripheral neurological deficit

Infant with acute torticollis

Significant injury above clavicles

Trauma with unexplained hypotension or bradycardia

Other major injuries (eg, fractured limbs, abdominal injury)

Chest injury with another body system injured

The examining doctor should perform a systematic, thorough motor and sensory

examination of the patient's extremities. Progressive neurological signs demand

urgent attention. An important aspect of the physical examination is a rectal

examination to assess sphincter tone, especially if the patient mentions bowel or

bladder dysfunction.

The Babinski sign and hyperreflexia are widely understood to be cardinal signs of the

upper motor neuron syndrome that typically occurs in spinal cord compression. The

examining doctor should be aware that a positive (abnormal/upwards) Babinski sign

is helpful, but a negative or absent sign does not exclude severe disease, especially

since the Babinski sign is typically absent in the acute phase of trauma. One ED study

found that patients who presented with severe myelopathy had a low incidence of

extensor plantar responses and hyperreflexia. This study had small numbers (nine

patients) Additionally, the Babinski sign is highly unreliable in young infants, with

either an upward or downward response being normal at this age34, 35.

34 Hogan GR. Milligan JE. The plantar reflex of the newborn. New England Journal of Medicine. 1971. 285(9):502-3.

35 Ross ED. Velez-Bprras J. Rosman NP. The significance of the Babinski sign in the newborn-a reappraisal. Pediatrics. 1976. 57(1):13-5.

8

If positive findings are noted on neurological assessment consideration should be

given as to whether they may represent a complete spinal cord lesion36 or incomplete

lesion such as central cord, anterior cord, posterior Cord or Brown-Sequard syndrome.

Examination of the cervical spine for pain on voluntary movement

This examination is the final step in clearing a cervical spine if history, initial

examination and imaging appear normal. Remove the hard collar (with cervical spine

control) and palpate the cervical spine for midline tenderness again. If this is absent,

active flexion, extension, lateral flexion and rotation is encouraged so long as it does

not cause the patient pain or neurological symptoms. Cease this examination and

reapply the hard collar if any neurological symptoms or pain occurs.

Case 1

LC was a three-year, six-month old girl who was the front seat passenger of a

stationary car that was hit by a bus at high speed. Her seven-year old brother, the back

seat passenger, was rendered unconscious possibly sustaining a serious head injury.

Her father, the driver, received abrasions only.

As LC was considered stable she was transferred to a district level ED for assessment.

LC was a difficult child to assess. No major injuries were apparent and she was

haemodynamically stable. Abrasions were noted over her neck and pelvis. Neck pain

was documented but her GCS was 15 and she was neurologically normal. A single

lateral X-ray of the cervical spine showed no abnormality and she was discharged

home.

LC represented three days later to our institution complaining of neck pain. On

examination her GCS was 15 and she was neurologically normal. Traumatic torticollis

was diagnosed. A hard collar was applied. A three film cervical spine series showed

an abnormality of C2. Focused CT scan confirmed this abnormality.

Immobilisation of the Cervical Spine in children

Paediatric patients with suspected or possible CSI must have their cervical spine and

the rest of the spinal column properly immobilised if possible. Suspicion of a CSI is

raised by the mechanism of injury, the energy involved or by historical or

examination findings (see history and examination of the potential paediatric CSI

9

patient)12, 33. Immobilisation takes place as soon as trained carers are on hand either at

the scene or in hospital. Current techniques do not stop all movement of the cervical

region but do reduce it when used appropriately37, 38. In children the age, size and

cooperation of the child and the child’s level of consciousness all impact on the

decision to immobilise and the techniques used16.

The need for continued immobilisation is reviewed after the history and examination

are completed and again after imaging. In the absence of midline neck tenderness,

peripheral neurological signs and distracting injuries the cooperative child can

proceed to an examination for pain voluntary movement (see above)14. Immobilisation

may cease if this is clear.

How to immobilise the cervical spine 37, 38, 39:

Explain to child and parents that they need to remain still.

Place a hard collar of the appropriate size for the child (a one-piece hard collar is

used in the initial stages). For the Stiffneck collar measure the distance from the

top of the patient’s shoulder to the angle of the jaw with your hand. This should

correspond to the distance from the bottom of the rigid plastic rim of the collar to

the "measuring post".

Lie child flat on their back on a bed with a thin mattress that will maintain the

alignment of the whole spine.

If needed, use manual immobilisation to reduce movement of head and torso of

the child to immobilise the whole spine. One person places their hands on either

side of the child’s head to reduce movement at the neck. Another person holds the

shoulders and a third person holds the pelvis to reduce thoracic and lumbar spinal

movement respectively.

Use a head immobiliser or sandbags to limit lateral movement.

If continued restraint is needed place child on an age-appropriate spinal board. If

the child is less than eight years old use a board allowing for the occipital

prominence, if possible. If no such board is available, a towel folded several times

39 Huerta C. Griffith R. Joyce SM. Cervical spine stabilization in pediatric patients: evaluation of current techniques. Annals of Emergency Medicine. 1987. 16(10):1121-6.

10

and placed under the shoulders will help maintain spinal alignment in young

children 40, 41, 42.

If a spinal board is used then strap the child’s head to the head immobilisers or

sandbags and the spine board. Strap the torso at the level of the shoulders and the

pelvis as well. Significant deformity can occur in the cervical spine of an agitated

child if the rest of the body is moving freely.

If the child’s head is strapped, be particularly aware of vomiting and risk of

aspiration. Someone must be with the patient at all times. Avoid fixing the patient

to the trolley or bed, otherwise turning the patient to the side is impossible if

vomiting occurs.

Spinal immobilisation in children less than three years old is especially

challenging. Rigid cervical collars do not usually fit these patients. They should be

immobilised with staff holding the head and body, or with sandbags or towels.

Strap the head and torso to a spinal board.

Children with pain or anxiety need to be evaluated on a case-by-case basis. Where

required adequate intravenous analgesia and/or conscious sedation must be

carefully titrated. If sedation/analgesia is given, the patient should undergo full

imaging and consideration given to a CT scan. Sedation to the extent of needing

intubation to aid cervical spine immobilisation is rarely needed.

If a hard collar has been in place for more than four hours, change to a fitted collar

such as Philadelphia or Aspen collar4, 43. This may improve tolerance of

immobilisation.

Patients with an altered level of consciousness

Any paediatric trauma patients with an altered level of consciousness should be

appropriately immobilised as if a CSI is present. These children need imaging of their

spine and cannot comply with active examination. Prolonged immobilisation may be

necessary so hard collars should be changed to a fitted collar and the patient taken off

hard spinal boards as soon as practical to reduce pressure areas.

43 Cosan TE. Tel E. Arslantas A. Vural M. Guner AI. Indications of Philadelphia collar in the treatment of upper cervical injuries. European Journal of Emergency Medicine. 2001. 8(1):33-7.

11

The uncooperative child

This is problematic as immobilisation techniques may agitate and distress the patient,

thus increasing movement of the cervical spine. It is important to be gentle but firm

and institute manual restraint first. Some children settle when held firmly. The

presence of parents and close relatives is vital as it can reassure and calm the child44.

If immobilisation attempts appear to cause more movement of the cervical spine than

if they are not applied, they should be abandoned. Further history, examination and in

particular active examination will be necessary once the child has calmed.

The cooperative child

In a cooperative child with a suspected CSI, institute immobilisation until a full

history and examination is obtained. If on history and examination there is no

evidence of neck pain or tenderness, acute peripheral neurological deficit at any time

after the injury or the presence of another major injury then examine the neck

actively. However, if any of these features are present continue immobilisation and

obtain imaging. If imaging is normal and the neck pain or tenderness settles examine

the cervical spine actively. If prolonged immobilisation is likely, change to a fitted

collar43.

Case 2

LJ is a 2-year-old boy who was kicked in the face while chasing a horse.

He did not lose consciousness. Ambulance personnel reported his GCS was 15. His

only obvious injuries were a fractured left zygoma and fractured left clavicle. His

cervical spine was adequately immobilised using a hard collar.

LJ was transported to hospital. During transport, he became “unstable”. The hard

collar caused pain at the fracture sites with restlessness and desaturation on oximetry,

He developed an irritable cry and had considerable torso and neck movement. The

ambulance personnel’s concerns of a serious head injury were communicated to the

hospital.

Upon arrival, the trauma team assessed him as clinically normal. X-ray films were

reviewed and reported as normal. The hard collar was removed and the child’s

condition rapidly improved.

12

Imaging

Selection of patients to x-ray

Not all trauma patients must have cervical spine radiographs, even if they arrive in the

ED wearing a cervical collar and immobilised on a spinal board45, 46, 47. Clinical

clearance without radiographs may be possible depending on the level of expertise of

the clinician.

Low-risk criteria do exist for adults to exclude CSI, based on the patient's history and

physical examination. Patients who meet these criteria do not require x-rays to rule out

CSI. However, there is limited applicability of these studies to children, even those

able to verbalise their injuries. Preverbal children, who cannot communicate

symptoms, respond to the examination, nor cooperate as well as older patients are a

separate, even more difficult group to manage.

In spite of the limited evidence to guide evaluation of paediatric CSI, a set of criteria

that identify patients with a low risk of CSI can be established (see Table 3). Patients

who fulfil these criteria do not need to have a cervical spine x-ray12, 16.

Table 3: Features that obviate the need for cervical spine x-rays. The presence of any of these factors should prompt consideration of cervical spine imaging

No mechanism of injury suggesting increased risk of CSI (see table 1)

No history of loss of consciousness

No neck pain

No neck tenderness on palpation

No neurological signs or symptoms referable to the neck eg, paraesthesia or weakness in extremities (includes transient symptoms now resolved)

No mental status changes resulting from trauma, alcohol, drugs etc

No distracting painful injuries eg fractured ankle, fractured ribs etc

13

Selection of x-rays to order

Once deciding to proceed with a x-ray evaluation, proper views are required. A single

lateral cervical spine x-ray is insufficient to exclude a cervical spine fracture, having

only 70% sensitivity16. Immobilise the patient's neck until a full cervical spine series

is performed in the radiology department. In children two years or older, this is a three

view series including lateral, anteroposterior (AP) and open mouth odontoid views,

which will pick up the injury in the majority of cases. The lateral view must include

all seven cervical vertebrae as well as the C7-T1 junction. If no arm injury is present,

traction on the arms may facilitate visualisation of all seven cervical vertebrae. If all

seven vertebrae and the C7-T1 junction are still not visible, a swimmer's view, taken

with one arm extended over the head, may allow full visualisation. The importance of

obtaining adequate x-rays cannot be overemphasised48. While some missed cervical

fractures, subluxations and dislocations are the result of misinterpretation; the most

frequent cause of overlooked injury is an inadequate film series2.

There has been recent discussion about whether it is necessary to obtain the open-

mouth odontoid view in infants and young children. Dens fractures in infants and

young are usually visible on the lateral x-ray, as most fractures in this age group are

through the dens synchondrosis and/or due to a flexion injury causing anterior

displacement of the dens. In addition it is often extremely difficult to obtain good

quality open mouth odontoid views in this age group. A retrospective study by

Swischuk et al showed that there was an extremely low miss rate of dens fractures on

a single lateral cervical spine view. They therefore suggest not performing routine

open mouth odontoid views for children under the age of five years49. As our

radiologists feel capable of reading open mouth odontoid views of children over two

years of age, we do perform all three views from the age of two years onwards.

Some authors recommend flexion/extension views to help identify ligamentous

injuries. However, in the acute setting, ligamentous injury often causes muscle spasm,

limiting the usefulness of these views. Moreover, children are often too young to

understand what is happening or too scared or anxious to be able to rely on them to

cooperate fully with this potentially dangerous task. Therefore, we do not include

flexion/extension views in the acute setting of our pathway50, 51, 52.

14

Cervical spine x-rays do have limitations. There is a small but substantial miss rate in

cervical bony injury2. Further, x-rays do not reveal cases of SCIWORA (by

definition). Other forms of imaging of the cervical spine may therefore be required

under certain circumstances.

Other imaging modalities

The role of spiral CT scan in the intubated, unconscious child in order to clear their

cervical spine is controversial. The CT scan has excellent sensitivity for detecting

fractures, but not for ligamentous injuries48, 53, 54, 55.

Table 4: Indications for focused CT scan

Any question of an abnormality on plain radiographs

18 Eleraky MA. Theodore N. Adams M. Rekate HL. Sonntag VK. Pediatric cervical spine injuries: report of 102 cases and review of the literature. Journal of Neurosurgery. 2000. 92(1 Suppl):12-7.

19 Iida H. Tachibana S. Kitahara T. Horiike S. Ohwada T. Fujii K. Association of head trauma with cervical spine injury, spinal cord injury, or both. Journal of Trauma-Injury Infection & Critical Care. 1999. 46(3):450-2.

20 Michael DB. Guyot DR. Darmody WR. Coincidence of head and cervical spine injury. Journal of Neurotrauma. 1989. 6(3): 177-89.

21 Vavilala MS. Lam AM. Perioperative considerations in pediatric traumatic brain injury. International Anesthesiology Clinics. 2002. 40(3):69-87.

22 Fesmire FM. Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. Journal of Emergency Medicine. 1989. 7(2):133-42.

23 Reynolds R. Pediatric spinal injury. Current Opinion in Pediatrics. 2000. 12(1):67-71.

25 Orenstein JB, Klein BL, Gotschall CS et al. Age and outcome in pediatric cervical

spine injury: 11-year experience. Pediatr. Emerg. Care 1994; 10: 132–7.

26 Nitecki S, Moir CR. Predictive factors of the outcome of traumatic cervical spine fracture in children. J. Pediatr. Surg. 1994; 29: 1409–11.

15

Patient has neck pain that seems disproportionate to the findings on plain

radiographs

Detailed assessment of a recognised abnormality on plain radiographs

Some studies have used magnetic resonance imaging (MRI) as an adjunct to plain

films and CT scanning. It is superior to CT scanning in the detection of ligamentous

injuries and soft tissue injuries such as epidural haematomas and traumatic disc

27 Lui TN, Lee ST, Wong CW et al. C1–C2 fracture-dislocations in children and adolescents. J. Trauma 1996; 40: 408–11.

28 Bohn D. Cervical Spine Injuries in Children. J. Trauma 1990; 30: 463–9.

29 Pang D. Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. Journal of Neurosurgery. 1982. 57(1):114-29.

30 Michael DB. Guyot DR. Darmody WR. Coincidence of head and cervical spine injury. Journal of Neurotrauma. 1989. 6(3): 177-89.

31 Brown RL. Brunn MA. Garcia VF. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. Journal of Pediatric Surgery. 2001. 36(8):1107-14.

32 Dormans J. Evaluation of children with suspected cervical spine injury. J. Bone Joint Surg. 2002; 84: 124–32.

33 Rachesky I, Boyce WT, Duncan B, Bjelland J, Sibley B. Clinical prediction of cervical spine injuries in children. Radiographic abnormalities. Am J Dis Child 1987;141:199-201.

36 Nockels RP. Nonoperative management of acute spinal cord injury. Spine. 2001. 26(24 Suppl): S31-7.

37 Hauswald, M and Braude, D. Spinal immobilisation in trauma patients: is it really necessary? Current opinion in critical care. 2002. 8: 566-570.

38 Skellett S. Tibby SM. Durward A. Murdoch IA. Lesson of the week: Immobilisation of the cervical spine in children. British Medical Journal. 2002. 324(7337):591-3.

40 Nypaver M. Treloar D. Neutral cervical spine positioning in children. Annals of Emergency Medicine. 1994. 23(2):208-11.

41 Herzenberg JE. Hensinger RN. Dedrick DK. Phillips WA. Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. Journal of Bone & Joint Surgery - American Volume. 1989. 71(1):15-22.

16

protrusions56, 57, 58. However, the lack of wide availability and the relatively prolonged

time required for MRI scanning limits its usefulness in the acute setting.

Clearing the cervical spine of injury

Who can clear the c-spine?

In our institution, if the patient is to be discharged from the ED, a consultant from the

following units may clear the cervical spine (the clearing doctor):

Emergency (paediatric or emergency training streams)

Intensive Care

42 Curran C. Dietrich AM. Bowman MJ. Ginn-Pease ME. King DR. Kosnik E. Pediatric cervical-spine immobilization: achieving neutral position? Journal of Trauma-Injury Infection & Critical Care. 1995. 39(4):729-32.

44 Browne GJ. Cocks AJ. McCaskill ME. Current trends in the management of major paediatric trauma. Emergency Medicine. 2001. 13(4):418-25.

45 Edwards MJ. Frankema SP. Kruit MC. Bode PJ. Breslau PJ. van Vugt AB. Routine cervical spine radiography for trauma victims: Does everybody need it? Journal of Trauma-Injury Infection & Critical Care. 2001. 50(3):529-34.

46 Anonymous. Radiographic assessment of the cervical spine in asymptomatic trauma patients. Neurosurgery. 2002. 50(3 Suppl):S30-5.

47 McCormick, P. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery. 2002. 50(3 Suppl):S85-99.

48 Proctor MR. Spinal cord injury. Critical Care Medicine. 2002. 30(11 Suppl):S489-99.

49 Swischuk LE. John SD. Hendrick EP. Is the open-mouth odontoid view necessary in children under 5 years?. Pediatric Radiology. 2000. 30(3):186-9.

50 Ralston ME. Chung K. Barnes PD. Emans JB. Schutzman SA. Role of flexion-extension radiographs in blunt pediatric cervical spine injury. Academic Emergency Medicine. 2001. 8(3):237-45.

51 Dwek JR. Chung CB. Radiography of cervical spine injury in children: are flexion-extension radiographs useful for acute trauma? American Journal of Roentgenology. 2000. 174(6):1617-9.

52 Pollack CV Jr. Hendey GW. Martin DR. Hoffman JR. Mower WR. NEXUS Group. Use of flexion-extension radiographs of the cervical spine in blunt trauma. Annals of Emergency Medicine. 2001. 38(1):8-11.

17

Orthopaedic

Neurosurgery

General Surgery

Registrars from the same units may also clear the cervical spine after discussion with

the ED consultant on duty. EMST/APLS (or equivalent) certification is a prerequisite.

Cervical spine clearance for an inpatient or potential an inpatient may only occur after

consultation with the neurosurgical consultant, orthopaedic consultant or the

emergency consultant (if the patient is still in the ED).

How to clear the c-spine

It is imperative that the clearing doctor has both examined the patient and viewed the

x-rays.

1. Examination: Perform a comprehensive focused neurological and cervical

examination.

2. View the films: Seek a second opinion if there is any doubt about the

‘normality’ of the films.

3. Re-examine the patient: While a trained staff member maintains the head

alignment the collar is removed and the clearing doctor checks for the

following:

Inadequacy of the examination for pain and tenderness

The presence of other (distracting) pain/injuries

Neck pain, especially tenderness over the cervical spine

Motor or sensory abnormalities

Limitation of active neck movement

Limitation of head control

If any of the above are present, the cervical collar should remain in situ. Consultation

by the orthopaedic and neurosurgical service should be requested.

Documenting clearance of the cervical spine:

The clearing doctor must document explicitly in the patient’s records whether or not

the cervical spine is clear and hence the feasibility of removing the collar. If the

cervical spine is not cleared a plan for further cervical spine assessment must also be

18

documented. The hard collar should be changed to a fitted collar. A timely decision is

mandatory.

Pitfalls in the Emergency Department

SCIWORA, Spinal Cord Injury Without Radiological Abnormality

SCIWORA occurs when the elastic ligaments of a child's neck stretch during trauma.

Therefore, the spinal cord also undergoes stretching, leading to neuronal injury or, in

extreme cases, complete severing of the cord24, 29, 59, 60. The incidence of this condition

is uncertain; reports vary widely from 1.3 to 75 percent, with most retrospective series

reporting 20 to 30 percent of paediatric CSI29, 59. Initial reports suggest that

SCIWORA is most common in children younger than eight years24, 29, but firmer

evidence is not available. A recent prospective study did not have sufficient numbers

to clarify either the incidence or demographics of SCIWORA in children5. Symptoms

and/or signs may be present on the patient's arrival in the ED. However, up to 30

percent of patients have a delayed onset of neurological signs, which may not occur

until up to four days after the injury29, 59. Many of these patients have transient

neurological symptoms at the time of injury that resolve24. It is important to inform

the parents of young patients with neck trauma about this possibility so that they will

be alert for any developing symptoms or signs.

MRI can evaluate SCIWORA-type injuries and thus aid prognostication58.

Fortunately, most children with partial or delayed onset SCIWORA have a complete

recovery. In those children with a major defect and a definite MRI finding the

prognosis, as with other major spinal cord injuries, is poor.

No adequate studies of the treatment of SCIWORA exist48, 59. In a child who has

sustained significant trauma but recovered completely, restriction from physical

activities for several weeks is prudent. In definite lesions, steroids are of possible

benefit but currently controversy surrounds their use (see below).

Case 3

An 8-year-old boy was performing handstands at the Sydney Olympic Superdome

during a school conference. He lost balance and fell onto his head. He complained of

19

decreased strength in right arm and neck pain. Cervical spine x-rays were normal.

Subsequent MRI showed an incomplete cervical cord lesion.

Steroids in Paediatric Cervical Spine injury

There is controversy surrounding the use of steroids in CSI. The most recent National

Acute Spinal Cord Injury Study (NASCIS) of steroid therapy in acute CSI has, as

with its predecessors, been widely criticised61, 62, 63, 64 both in terms of outcome and

adverse effects. A recent Cochrane review indicates suggested possible benefit from

steroids administered within eight hours of injury and weak evidence of possible

further benefit from later doses in certain situations65. However, adverse effects from

using high dose steroids in CSI are significant. In the NASCIS studies high dose

methylprednisolone increased the incidence of pneumonia62 and other sepsis64. It also

increased the duration of ventilation and intensive care admission64. They should be

only used if indicated by orthopaedic and/or neurosurgical opinion. Therefore, the

discovery of a CSI mandates urgent orthopaedic or neurosurgical consultation.

Juvenile cervical spine injury and atlanto-occipital dissociation

In 1990, Bohn et al described a syndrome they called “juvenile cervical spine

injury”66. The syndrome occurs in the context of high speed motor vehicle accidents.

The patients they described presented with multiple injuries and either absent vital

signs or profound hypotension not secondary to exsanguination. X-ray or autopsy

findings showed CSI. None of the 19 patients studied survived. The authors

postulated a distinct paediatric pattern of high CSI representing a previously

unrecognised cause of cardiorespiratory arrest/profound hypotension.

Atlanto-occipital dissociation is a closely related catastrophic injury where the upper

cervical spine undergoes a severe hyperextension injury48, 67. The condition is usually

fatal due to disruption of the brainstem respiratory centres. Some children,

particularly those with partial dissociation, may survive the initial injury48, 68.

Difficulty in diagnosing this condition may occur especially if reduction occurs after

the subluxating injury in an incomplete lesion27, 69. A high index of suspicion is

required and in all cases there must be immobilisation of the cervical spine without

traction.

20

Case 4

A nine year old female pedestrian was hit by a car at high speed and thrown a

considerable distance along the road. Bystanders provided cardiopulmonary

resuscitation. Paramedics transferred her to hospital. Pulses were present but she had a

profoundly depressed GCS of five.

On arrival in ED, severe head injury, right haemothorax, fractured right

femur, fractured iliac crest, fractured right clavicle, multiple bruises and abrasions

were documented. The lateral cervical spine x-ray was normal. MRI showed complete

craniocervical disjunction with complete transection of the cord. Initial

cardiopulmonary resuscitation was successful and she went to PICU but subsequently

died. Post-mortem confirmed the MRI findings.

Summary

The evidence for assessment and clearance of potential and actual paediatric CSI is

far from complete. Considerable variations in protocols exist between tertiary

paediatric centres. Our protocol utilises the best available evidence for spinal

clearance with modifications to allow for local factors. If any of part of or the entire

protocol is considered for use in another institution, these modifications should be

noted and any adjustments necessary should be made.

Paediatric CSI is primarily a preventable condition. The permanent sequelae that

can occur as an outcome to CSI causes very significant morbidity. Therefore, further

efforts at improving prevention eg, enhanced motor vehicle safety, would have

significant effects in terms of reducing the burden of illness for this modern disease.

21

53 Berne JD. Velmahos GC. El-Tawil Q. Demetriades D. Asensio JA. Murray JA. Cornwell EE. Belzberg H. Berne TV. Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study. Journal of Trauma-Injury Infection & Critical Care. 1999. 47(5):896-902; discussion 902-3.

54 McDonald JW. Sadowsky C. Spinal-cord injury. Lancet. 2002. 359(9304): 417-25.

55 Acheson MB. Livingston RR. Richardson ML. Stimac GK. High-resolution CT scanning in the evaluation of cervical spine fractures: comparison with plain film examinations. AJR. American Journal of Roentgenology. 1987. 148(6):1179-85. 56 Frank JB. Lim CK. Flynn JM. Dormans JP. The efficacy of magnetic resonance imaging in pediatric cervical spine clearance. Spine. 2002. 27(11):1176-9.

57 Flynn JM. Closkey RF. Mahboubi S. Dormans JP. Role of magnetic resonance imaging in the assessment of pediatric cervical spine injuries. Journal of Pediatric Orthopedics. 2002. 22(5):573-7.

58 Grabb PA. Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children. Neurosurgery. 1994. 35(3): 406-14.

22

References

59 Labelle, H and Mercier, C. The SCIWORA Syndrome. In: Management of Pediatric Fractures. Ed: Letts, RM. 1st Edition. Churchill Livingston, New York.

60 Committee on the Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2002. 50(3 Suppl): S100-4.

61 Bracken MB, Holford TR. Effects of timing of methylprednisolone or naloxone on recovery of segmental and long-tract neurological function in NASCIS 2. Journal of Neurosurgery. 1993. 79: 500-507.

62 Gerndt SJ. Rodriguez JL. Pawlik JW. Taheri PA. Wahl WL. Micheals AJ. Papadopoulos SM. Consequences of high-dose steroid therapy for acute spinal cord injury. Journal of Trauma-Injury Infection & Critical Care. 1997. 42(2):279-84.

63 Molano MR. Broton JG. Bean JA. Calancie B. Complications associated with the prophylactic use of methylprednisolone during surgical stabilization after spinal cord injury. Journal of Neurosurgery. 2002. 96(3 Suppl):267-72.

64 Bracken MB. Shepard MJ. Holford TR. Leo-Summers L. Aldrich EF. Fazl M. Fehlings M. Herr DL. Hitchon PW. Marshall LF. Nockels RP. Pascale V. Perot PL Jr. Piepmeier J. Sonntag VK. Wagner F. Wilberger JE. Winn HR. Young W. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA. 1997. 277(20):1597-604.

65 Bracken, MB. Steroids for acute spinal cord injury. (Cochrane Review). In: Cochrane Database of Systematic Reviews. Issue 4, 2002. Oxford. Update Software.

66 Bohn D. Armstrong D. Becker L. Humphreys R. Cervical spine injuries in children. Journal of Trauma-Injury Infection & Critical Care. 1990. 30(4):463-9.

67 Matsumoto M. Toyama Y. Chiba K. Fujimura Y. Fukui Y. Kobayashi K. Traumatic subluxation of the axis after hyperflexion injury of the cervical spine in children. Journal of Spinal Disorders. 2001. 14(2):172-9.

23

68 Kenter K. Worley G. Griffin T. Fitch RD. Pediatric traumatic atlanto-occipital dislocation: five cases and a review. Journal of Pediatric Orthopedics. 2001. 21(5):585-9.

69 Bayar MA. Erdem Y. Ozturk K. Buharali Z. Isolated anterior arch fracture of the atlas: child case report. 2002 Spine. 27(2):E47-9.

24