Pediatric Spinal trauma - AIM Group · Pediatric Spinal trauma Prof. Pia C Sundgren MD, PhD Diagnostic Centre for Imaging and Functional Medicine, University of Lund, UMAS, Malmoe,

Pediatric Spinal trauma

Prof. Pia C Sundgren MD, PhDDiagnostic Centre for Imaging and Functional Medicine, University of Lund, UMAS, Malmoe, Sweden

Department of Radiology, University of Michigan Health Systems, Ann Arbor, USA

injury to the spinal column and spinal cord is a major cause of disability affecting predominatelyyoung healthy individuals

costs of life time care and rehabilitation are extremely high, often over $1,000,000 per individual

spinal cord injuries are rare in infants and children (1-2% of pediatric trauma victims)

Introduction

PC Sundgren Pediatric Spine Trauma Spineradiology´09

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Note di presentazione�

läs text slide With the frame of one 30 minutes lecutre it is impossible to present the complete panorama of spinal injury. Insteed I will focus on the three following aspects the technical aspects of imaging and the importance of preset protocols, the possibility of multi-level and complex or combined injuries and finally. I will emphasize to actively search for ligamentous injuries and the possiblity of instability.that might not be obvious at first glance.�

Cause < 3 years2 1-20 years1 overall

Motor vehicle 66% 44% 47.7%

Fall 15% 14% 20.8%

Pedestrian 11%

Bicycle 6%

Violence 14.6%

Sports 16% 14.2%

Spinal trauma and spinal cord injury

1Kokoska E et al. Characteristics of pediatric… J. Ped. Surg. 2001:36;100-105 (408 cases (+))2Polk-Williams A et al. Cervical spine injury…. J. Ped. Surg. 2008:43;1718-1721 (1523 cases (+))


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The majority of injuries are caused by MVA followed by fall as violence and different sport activities may result in trauma to the spinal colum and cord injury�


<10 years of age 50% in C1-C2 (-C4) region

incidence of dislocations

incidence of cord injuries

> 10 years of age shift towards C5 and below

C-spine fractures

Mortality rates 17% (overall) higher in small children

1Kokoska E et al. Characteristics of pediatric… J. Ped. Surg. 2001:36;100-105 (408 cases (+))PC Sundgren Pediatric Spine Trauma Spineradiology´09


2Polk-Williams A et al. Cervical spine injury…. J. Ped. Surg. 2008:43;1718-1721 (1523 cases (+))

Children < 3years of age

• injury to upper cervical spine C1-C4

47% cord injuries and 53.4% spine fractures

• injury to lower cervical spine C5-C7

53% cord injuries and 46.6% fractures

• most common sites:C2 (26.5%) followed by C7 (18.5%)


Misdiagnosis of acute cervical spine injuries

< 8 years of age 24%> 9 years of age 15%

Most common site of diagnostic errorocciput to C2 region

Predisposing factors for misdiagnosis:• unfamiliarity with pediatric cervical spine anatomy• not recognizing normal variants• suboptimal technique

Avellino AM et al The misdiagnosis of acute cervical spine injuries.. Childs Nerv system2005;21;122-127. (37 cases) PC Sundgren Pediatric Spine Trauma Spineradiology´09

Fracture?


Pitfall

Motion artefacts


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Fallgrop Översta rörelseartefakter, fraktur?? Nedre: Omkörd CT: Ingen fraktur�

3 year old girl in high speed MVA


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Flicka som varit passagerare i en bil som voltat i känd hastighet. Smärtor i buken som ömmar diffust samt fluktuerande medvetande fraktur på vänster sida med isärsprängning av fysen upp till leden mellan massa lateralis till C1 resp C2. �


6 month FU the fracture has healed


ventral dislocationand

luxation C1-C2

after reposition


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Falltrauma 2 år gammalt barn Fraktur genom synkondrosen av C2 med volar bockning.Luxation mellan C1 och C2 på bild 2. Bild 3 efter reposition i narkos.�

Burst fracture

C7


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CT 17 årig man efter trafikolycka visar två pelarfraktur av burst typ genom C7 MR ung tjej som i berusat tillstånd dykt i en bassäng med grunt vatten Frakturer C4,5,6.�

CT parametersyour choice depends on

• technical specification of the scannersingle slice, helical, multislice

• anatomic regionC1-C2 1-2 mm*C-spine 2-3 mm*T+L-spine <4 mm*

• required detail information• 2D multiplanar reformatting (3D)

* Reconstructed slices, acquisition with sub-millimeter slices (0.6, 0.75…)


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The choice of CT parameters depends on the technial specification of the scanner The anatomic region and and the required detail information The multislice CT (spiral) in high resolution mode with aquiered with submillimeter slices and reconstructed 1.25-2mm thin slices in the C1-C2 region, 3mm thin slices in the rest of the cervical spine and 4mm thin slices in the thoracolumbar spine with 1.5 mm reconstruction interval, for sagittal and coronal reconstructions with bone and soft tissue algorithm is suggested I would like to emphizie the need to have these protocol already preset in the scanner to save time at the ime of examination of these often multitrauma patients �

MR parameters

• sagittal T2 STIR, T2-w, T1-w

• axial T1SE, T2 fast SE,

• axial fat sat T2-w (soft tissue injury)

• axial and sagittal T2* GRE (hemorrhage)

• 3D – ( eg. T2 space (Siemens)


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several of the following imaging fat saturated images are suggested for the MRI trauma proticol again I would like to emphisize the importance of having preset trauma protocol programmed in the scanner. sagittal T2 STIR, T2-w and T1 w images pre and post contrast, axial T1SE, axial T2 fast SE, fat-saturated T2W images for ligamentous and soft tissue injuries, and T2* GRE to evaluate for small hemorrhage or blood products in the spinal cord. 3D faster STIR to see signal abnormaliies in the spine�

Atlanto-occipital disassociation

occipital condyle is small, almost horizontal and lacks inherent stability

severe hyperextension with distraction

• anterior translation (hyperflextion)• posterior translation (hyperextension)• longitudinal

complete – dislocationincomplete – subluxation

atlanto-occipital condyle distance < 5mmPC Sundgren Pediatric Spine Trauma Spineradiology´09

Harris Criteria: The basion should lie within 12 mm of the posterior-axial line. The distance between the basion and the tip of the odontoid < 12 mm.

Power's Ratio: A = the anterior tubercle of the atlas. B.= the basion. C = the spinolaminar line of the atlas. O = the opisthion. The value BC/AO should be less than 1.

The Wackenheim's Clivus Line: a line drawn along the clivus should intersect or be tangential to the odontoid.

Roche CJ, Carty H. Spinal trauma in children. Pediatr Radiol 2001;31:677-700.

2 ½ year-old girl, strapped into a car seat withshoulder harness, facing forward after MVA.

Clinical neurological examination upon admission: child is wide awake,with flaccid tetraparesis

The next day ventilatory assistance is needed

Courtesy Dr P Parizel et al, Antwerp, Belgium PC Sundgren Pediatric Spine Trauma Spineradiology´09

Craniocervical distraction injury

CT sag CT sag CT corCT upon admission


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C1-C2 distraction trauma with spinal cord disruption and intramedullary hematoma Motorvehicle accident (frontal collision with another car) The patient is a 2 ½ year-old girl, strapped into a car seat with shoulder harness, facing forward Clinical neurological examination upon admission: child is wide awake, with flaccid tetraparesis The next day ventilatory assistance is needed The child is kept in an artificial coma, on a ventilator �

Craniocervical distraction injuryMRI upon admission

T1 sag T2 corT2 sag


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Mechanism of injury and findings: Upon impact the head was accelerated anteriorly CT scan upon admission: distraction injury of C1-2, fracture of the ring apophysis of C2, prevertebral hematoma, intra-and perimedullary hemorrhage, rupture of the interspinous ligament posterior to the spinal canal MRI day of admission: cord edema and rupture, …. etc. etc. MRI 1 week later shows an additional distraction injury through the upper endplate of Th1 DTI with fiber trcking: complete cord transsection Supposedly due to this deceleration injury, the craniocervical junction was distracted at C1_C2, with a second axis of rotation through the cervico-thoracic junction, causing a second distraction injury involving the ring apophysis Th1 �

Craniocervical distraction injuryMRI 6 days later

T1 sag T2 corT2 sag


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Mechanism of injury and findings: Upon impact the head was accelerated anteriorly CT scan upon admission: distraction injury of C1-2, fracture of the ring apophysis of C2, prevertebral hematoma, intra-and perimedullary hemorrhage, rupture of the interspinous ligament posterior to the spinal canal MRI day of admission: cord edema and rupture, …. etc. etc. MRI 1 week later shows an additional distraction injury through the upper endplate of Th1 DTI with fiber trcking: complete cord transsection Supposedly due to this deceleration injury, the craniocervical junction was distracted at C1_C2, with a second axis of rotation through the cervico-thoracic junction, causing a second distraction injury involving the ring apophysis Th1 �

Craniocervical distraction injury

T2 stirMRI 6 days later


Relatore�


Mechanism of injury and findings: Upon impact the head was accelerated anteriorly CT scan upon admission: distraction injury of C1-2, fracture of the ring apophysis of C2, prevertebral hematoma, intra-and perimedullary hemorrhage, rupture of the interspinous ligament posterior to the spinal canal MRI day of admission: cord edema and rupture, …. etc. etc. MRI 1 week later shows an additional distraction injury through the upper endplate of Th1 DTI with fiber trcking: complete cord transsection Supposedly due to this deceleration injury, the craniocervical junction was distracted at C1_C2, with a second axis of rotation through the cervico-thoracic junction, causing a second distraction injury involving the ring apophysis Th1 References: Chang W, Alexander MT, Mirvis SE. AJR Am J Roentgenol. 2009; 192(1): 52-58 Deliganis AV, Baxter AB, Hanson JA, Fisher DJ, Cohen WA, Wilson AJ, Mann FA. Radiographics. 2000; 20 Spec No: S237-250. �

Atlanto-occipital dislocation

Courtsey Dr E Hoeffner, Ann Arbor, USA PC Sundgren Pediatric Spine Trauma Spineradiology´09

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Atlanto-occiptal dislocation�

Courtsey Dr E Hoeffner, Ann Arbor, USA

Atlanto-occipital dislocation



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End ellen hoeffner�

Spinal cord injury without radiographic abnormality- SCIWORA -

Incidence: 19-34% of all spinal cord injuries in children

More common in younger children < 8 years of age

Specific to children and extremely rare in adults


Spinal cord injury without radiographic abnormality- SCIWORA -

• immature and elastic pediatric spine• vulnerable to external forces• allows for significant inter-segmental movement• transient disc protrusion

compression and stretching of the spinal cord

cord injuryPC Sundgren Pediatric Spine Trauma Spineradiology´09

Normal spine in infants and children

Courtesy Dr M Galluchi, Italy PC Sundgren Pediatric Spine Trauma Spineradiology´09

The elasticity of neonatal bony spine is eight times that the cord

Biomechanics in children

5 cm

6/7 mm

Leventhal H. J. Pediatr 56:447 1969


8 year old boy bound with seat belt, therefore had aflexion trauma in the upper thoracic spine while thelower was immobilized. He became paraplegic


SCIWORA


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Car accident. 8 yrs old boy, bound with seat belt, therefore had a flexion trauma in the upper thoracic spine while the lower was immobilized. He became paraplegic�

SCIWORA

Courtesy Dr M Galluchi, Italy

Same case 4 month laterPC Sundgren Pediatric Spine Trauma Spineradiology´09

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Same case after 4 months. I’m sorry for the quality but it is a quite old case.�

2 year old boy in high speedMVA

Courtsey Dr M Castillo, Chapel Hill,USA

SCIWORA


14 year old female fell on her head while performing a backward flip at cheer leading

try-out.

Unable to move or breath herself at time of the accident


CT reformatted images, bone windowscoronal sagittal axial


Sagittal T1-w T2-w PDAxial T2-w


Ligamentous injurytransverse lig.


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Finaly I would like to emphize the nessecitty of actively looking for ligamentous injury that is easy to overlook. The signs are meny ranging from displacement to tears of ligamneous attachments. In particular MRI is very good to both discover and to confirm the supicion made from plain films and CT�

Tectorial membrane injury

hematoma


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I would like to demonstrate this infrequent entity the tectorial membrane injury most commonly seen in children. It can be suspected from careful reading of the CT where we see a unusal hematoma in the low clivus reagion extending to C2 in a 3 year old boy after MVA�

clivus

dens

tectorial membrane

hematoma

hematoma


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Reformatting of these images shows the detached tectorial memebrane and underlying hematoma.�

T2T2

clivus

dens

tectorial membrane

hematoma

hematoma


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MR confirms the diagnosis and shows even better the hemorrhage. CPI #: 32637531 Name: HEANEY, LIAM 3-year-old male, motor vehicle accident, with multiple injuries. Oral and maxillofacial surgery is called to evaluate an intraoral laceration of the upper lip. 3-year-old male, a restrained passenger in the back seat of a van versus other motor vehicle that was hit head-on at approximately 60 miles per hour. The patient was extricated by EMS in full backboard and C spine precautions, and per EMS had decreased level of consciousness en route to this facility. See: Brther Conor with similar AO injury and sister L with normal C-spineThis patient had two new problems which developed today. The first is a very complicated cervical spinal lesion in the C1 region, which may be due to some type of distractive process ligamentous disruption with a hematoma around his spinal cord. Neurosurgery and orthopaedics are carefully involved with this and are following and treating this. A halo device has been placed today for cervical spine stabilization. In addition, a repeat CT scan was done today, which showed free air in the peritoneal cavity and the patient was urgently taken to surgery after the halo was placed, before the patient was extubated, and an exploration of the abdomen was done with sewing of a perforation of his midsmall bowel. The patient was placed on a ventilator postoperatively with excellent saturation and ventilation findings being shown.�

Thank you very much for your attention


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What has this nice image from the backyard of our family summerhouse to do with the severe traumas that I have presented?�

Plexus injury

methemoglobin

Day 4

Day 14

pseudomeningocele


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15 årig pojke efter skidolycka sökt med tecken på plexusskada med engagemang av flera dermatom höger arm. Första raden 4 dagar efter olyckan methemoglobin 10 dagar senare pseudomeningocele�

16 year old male with axial trauma towards the spine a monthearlier with decreased sensibility in fingers bilaterally and disturbance in sensibility below Th 7.

Traumatic disc herniation


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våld mot kotpelaren, därefter torticoliis. Rtg �

Pediatric Spinal trauma - AIM Group · Pediatric Spinal trauma Prof. Pia C Sundgren MD, PhD Diagnostic Centre for Imaging and Functional Medicine, University of Lund, UMAS, Malmoe,

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