Pediatric C-Spine Injury Joshua Rocker, MD Schneider Children’s Hospital LIJ Medical Center.

Pediatric C-Spine Injury

Joshua Rocker, MD

Schneider Children’s Hospital

LIJ Medical Center

• Anatomical Considerations• Embryology• Risk Factors• Causes of Injury• Immobilization• Symptoms and Physical Exam• Radiography• Prediction Rules

Anatomical Considerations

Children <8 years old

• Relatively larger heads than body– Head circumference 50% adult by 2 yrs

vs chest circumference, 8 yrs

Children <8 years old

• Cervical spine fulcrum– Moves caudally

• C2-C3 at birth• C5-6 at 8 yr and older

Children <8 years old

• Weaker cervical musculature and increased laxity of ligaments

• Immature vertebral joints

• Horizontally inclined articulating facets

– Facilitate sliding of upper c-spine

Children’s C-spine Injuries

• More susceptible to:– fractures through growth plates – ligamentous injuries

• Why– Growth centers fragile to sheer forces

during rapid decel or flex/ext

(particularly at the synchondrosis b/n odontoid and body of C2)

SCIWORA

• “Spinal Cord Injury without Radiological Abnormality”– Theoretical increase risk in children– Young spinal column more elastic than

spinal cord- can handle more distraction before rupture

• 5cm vs 5-6mm

Children 8yrs and older

• Equivalent to adult

• Most injuries to vertebral bodies and arch

• Lower C-spine

Embryology and why pediatric C-spines are

difficult to interpret

Embryological Considerations

• C1 (Atlas) formed by 3 ossification sites– Anterior arch and 2 neural arches

Embryology: C1

• Anterior arch fuses with neural arches by 7 yrs. Before this non-fusion can be mistaken as fracture

Embryology: C2

• C2 (Axis) has four ossification centers– 2 neural arches– 1 for the body– 1 odontoid

Embryology: C2

• Body fuses with dens at 3-6 yrs

• The fusion line or remnant of cartilagenous synchondrosis can be seen till 11 yrs

Embryology: C3-C7

• Same developmental pattern

• 3 ossification centers

• Neural arches fuse posteriorly 2-3 yrs

• Body fuses with arches 3-6 yrs

Embryology

• Coronal view: Notice synchondroses

Predisposing risk factors

Congenital abnormalities

• Downs Syndrome– 15% with atlantoaxial instability

Congenital abnormalities

• Klippel-Feil– Fusion of cervical vertebrae

Congenital abnormalities• Morquio (MPS IV)

– No galctose 6-sulfatase– Hypoplasia of odontoid

Congenital abnormalities

• Larsen’s Syndrome– skeletal dysplasia with multiple joint

dislocations, short stature, abnormal facial features

At Risk by History

• Spinal Cord surgery

• C-spine arthritis

Causes of Injuries

Causes of Injuries: By age

• Infants– Birth Trauma

• 1-8 yrs– MVAs and falls

• > 8 yrs – Sports Injuries and MVAs

Causes of Injuries:

• Direct severe force to neck

• Diving

• Acceleration-deceleration

Causes of Injuries: Mechanism

• Hyperflexion

• Hyperextension

• Axial Load

• Roatational

• Blow to Chin

Causes of Injuries:Hyperflexion

• Most common

• Cause wedge fracture of anterior vertebral bodies

• Disruption of posterior elements

• Ex: – Clay-shoveler’s, – anterior teardrop fracture

Hyperflexion: Clay-shoveler’s

Hyperflexion: Teardrop fracture of anteroinferior portion of vertebral body

Causes of Injuries: Hyperextension

• Compression of posterior elements

• Disruption of anterior longitudinal ligament

• Ex: – Hangman’s

Hyperextension: Hangman’s Fracture

Causes of injuries: Axial Load

• Direct load on top of head

• May cause burst or comminuted fracture of C1.

• May also cause injury caudal to C-spine

• Ex:– Jefferson fracture

Axial Load: Jefferson fracture

•

Causes of Injuries

• Rotational– Usually associated with additional injuries

• Chin Trauma– Fractures of posterior teeth and mandibular

condyles seen as a single injury pattern

Immobilization

Indications

• Mechanism– Severe force– Diving– Accel-dec

• PE– AMS– Neuro deficits– Multi-system trauma– Neck pain/tenderness– Distracting injuries

Ouch!!!!

• 3-25% of patients with SC injury develop neurological deficits caused by manipulation during resuscitation or transport

Immobilize

• Neck- in collar– Stif-Neck– Philadelphia– ProSplint

• Body- on long backboard

Neutral Position

• Not well defined– “anatomical position of the head and torso

that one assumes when standing and looking straight ahead”

– External auditory meatus is in line with the shoulder in the coronal plane

– “Supine without rotating or bending the spinal column” ATLS

Neutral Position

• Adults (>8 yrs)– Require occiput elevation (1.3-9.5, 2cm)

• Children– Special allowance b/c relatively large

heads• Special peds boards with depressed area for

head• Elevate back with padding (2.5cm)

Protocols

• Do not reduce obvious deformities

• Keep helmets in place unless need airway

• Log roll onto board with support of head/neck and torso

• Place wedges beside head to limit lateral movement

Protocols: Airway

• Jaw-thrust maneuver with in-line traction

Protocol: Surgical Airway

• Nasotracheal intubation– Contraindicated: apnea, facial injuries (?fx

of cribiform plate)

• Orotracheal intubation with in-line stabilization

• Surgical airway– Maxillofacial or laryngotracheal trauma

Symptoms and Physical Exam

Symptoms

• Classic Triad– Local pain, muscle spasm and decreased

ROM

• Transient or persistent parasthesias or weakness– SCIWORA

Symptoms

• “Burning hands”– Seen with football players– Transient burning in hands/fingers– Hyperextension of C-spine with SC

contusion

• Asymptomatic– Significant mechanism or distracting injury

Physical Exam

• Essentials

– Vital Signs

– Neuro

– Neck

Physical Exam

• Vitals– Apnea or hypoventilation

• Injuries to C3-C5

– Spinal Shock• Hypotension, bradycardia, temperature

instability

Physical Exam

• Neuro exam

– Tone, strength, sensation and reflexes

– Up to 50% of children with C-spine injuries have neuro deficits

Tone

• Loss of spontaneous breathing if injury above C4

• Hypotonia– Lower motor neuron deficit– Spinal shock

Tone

• Rectal tone– Absence- poor prognostic sign– Bulbocavernous reflex (S3-S4)

• Squeezing glans, tapping on mons pubis, pulling on foley

– Stimulate trigone of the bladder reflex contraction of anal sphincter

Strength

• Dorsiflexion of the wrist– C6

• Extension of the elbow– C7

• Extension of the knee– L2-L4

• Dorsiflexion of the great toe– L5

Sensory

• Most common deficit with SC injuries

• Level of sensory impairment localizes level of injury

Reflexes

• Areflexia indicates spinal shock – Usually lasts less than 24 hours

Specific Injuries

• Anterior Cord Syndrome– Hyperflexion and anterior cord

compression– Paralysis and loss of pain WITHOUT loss

of light touch or proprioception

Specific Injuries

• Central Cord Syndrome– Hyperextension Injuries– Weakness greater in upper vs lower

extremities

Specific Injuries

• Brown-Sequard syndrome– Cord Hemisection

– Ipsilateral • Paralysis, Loss of proprioception and light

touch

– Contralateral• Loss of pain and temperature

• Horner’s Syndrome– Disruption of cervical sympathetic chain– Ptosis, miosis and anhidrosis

Specific Inuries

Neck Exam

Maintain in-line stabilization

• Palpate spinous processes

• Assess muscle spasm

• Assess for deformities

Radiography

What to do?

• If your suspicion of injury is high– get CT!!! (>98% sensitive)

• If low to moderate– get 3 view radiographs

• AP, cross table lateral, odontoid (open mouth)

• Lateral view identifies approx. 80-90% of fx, dislocations and subluxations

Plain Radiographs

• Lateral– Must visualize all 7 cervical vertebrae – Include C7-T1 junction

– If difficult visualizing• Gentle traction on arms (?)• Transaxillary (swimmer’s) view

Lateral view: 4 curvilineal contour lines

• Anterior vert body

• Posterior vert body

• Spinolaminar line

• Tips of spinous

processes

•

Psuedosubluxation

• C2 on C3– 20-40% of children

• C3 on C4– 14%

Swischuk line

• line from the anterior

aspect of C1-C3

spinous processes

• anterior C2

spinous process

within 2 mm

Soft tissue spaces

• Prevertebral space/

Retropharngeal– C2- <6mm– C6- <22mm

– C3/C4• <8 yrs < ½-2/3 diameter

of AP vertebral body• >8 yrs < 7mm

Soft tissue spaces

• Predental space – <8 yrs < 4-5mm– >8 yrs < 3mm

• Represents:– Atlantoaxial instability or rotational sublux or Jefferson fx

AP View

• Height of vertebral

bodies similar

• Spinous processess

aligned

Odontoid

• Equal amounts of space

on each side of the dens

• Lateral aspects of C1

should line up with the

lateral aspects of C2

Odontoid fractures

• Types– 1

• Apex of dens

– 2• Base of dens

– 3• Extends into body of C2

Odontoid Fracture types

Flexion-Extension View

• May identify cervical instability, atlantoaxial joint instability or ligamentous injury

• If suspicion still present with negative films

• Adds little to evaluation

Oblique View

• Better visualization of pedicules, facet alignment and posterior lamina or articular mass fractures

• Usually add nothing

Prediction Rules

Prediction Rules

• In alert and stable trauma patients establish rule to avoid irradiating low risk patients

Canadian C-Spine Rule

• Stiell, et al JAMA, 2001• Prospective, but Canadian…• 8924

– Blunt trauma– GCS- 15– Stable vitals

• SCI in 151 (1.7%)– Rule 100% sensitive

Canadian Rule

• High risk– > 65 yrs– Dangerous mechanism

• Fall >1m/5 stairs• Axial load• MVA >100km/hr• Motorized recreational vehicle• Bicycle vs immobile object

– Paresthesias in extremities

Canadian Rule

• Low risk if :– Simple rear end MVA– Sitting position in ER– Ambulatory at scene– No neck pain at scene– Absence of mid-line tenderness

• If low risk…

Voluntarily and actively rotate neck 45 degrees both left and right

• If able- no Xray

Canadian Rule

Canadian Rule

• Validated study

• 8923 enrolled

• 169 with SCI (2%)

• Sensitivity = 99.4%

• Specificity = 45.1%

• But…

Canadian C-Spine Rule

• In adults!!!!!!!!

NEXUS: National Emergency X-Radiography Utilization

Study

• Hoffman, et al, NEJM, 2000

• Prospective

• 34,069 enrolled

• Blunt trauma

NEXUS Rule

• Get radiography unless all are met:– No midline tenderness– Not intoxicated– No AMS– No focal neuro deficits– No distracting injuries

NEXUS Rule

• SCI- 818 (2.4%)

• Sensitivity = 99.6%

• Specificity = 12.9%

Comparing Canadian and NEXUS

• Canadian rule more sensitive and more specific

• Neither have been validated in settings other than where they were established

NEXUS- Children

• Viccellio, et al, Pediatrics, 2001

• NEXUS data, extract pediatric info

• 3065 pts (9% of total)– <18 yrs

• SCI- 30 (0.98%)

Viccellio, et al

• SCIWORA- 0%

• SCI– Only 4/30= 13.3% were younger then 9 yrs

(said population made up 29.5% of total)– 0/30= 0% younger than 2 yrs (2.9% of

total)

Viccellio, et al

• NEXUS decision rule 100% sensitive

• Low risk- 603 of 3065– Reduction of Xrays in 19.7%

Viccellio, et al

• Conclusion:– NEXUS is sensitive for peds– Need a prospective study of 80,000 cases

to improve CI and even more for youngest peds

– Can only be generalized for the adolescent population

– SCIWORA more common in adults

Viccellio, et al

• Discussion:– Rarity of SCI in infants

• Doesn’t occur or lethal because of anatomy (damage to higher C-spine)

Jaffe, et al

• Ann Emerg Med, 1987• Retrospective review of 206 children

<16• 8 variables: neck pain, neck

tenderness, limited ROM, hx of trauma to neck, abnl reflexes/sensation or MS.

• 98% sensitive if 1 positive• Avoided radiation in 38%

SO……..

Remember

• Anatomy

• Risk factors

• Mechanism

• Symptoms

• If Radiography– Ossification centers

Thank you!!!

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