Pediatric cervical spine clearance: A review
and understanding of the concepts
Review Article
Pediatric cervical spine clearance: A review
and understanding of the concepts
Pankaj Kumar
Consultant Orth...
3. Anatomical considerations
There are several features peculiar to the pediatrics cervical
spine, when compared to that o...
8. Radiological assessment
There is still insufficient evidence to support diagnostic
standards. The lateral view alone is ...
16. Bledsoe BE, Porter RS, Cherry RA. Pediatrics. In: . Paramedic
Care: Principles and Practice, vol. 4. Upper Saddle Rive...
Apollohospitals:http://www.apollohospitals.com/
Twitter:https://twitter.com/HospitalsApollo
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Pediatric cervical spine clearance: A review and understanding of the concepts

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Cervical spine injuries are uncommon in pediatric trauma
patients. Delayed or missed diagnosis is usually attributed to failure to suspect an injury to the cervical spine, or to inadequate cervical spine radiology and incorrect interpretation of radiographs. New imaging techniques have become available, but did not solve the problem, adding their own ‘baggage’, such as cost, availability, logistic difficulties, radiation dosage, lack of specificity and evidence of effectiveness or safety.

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Pediatric cervical spine clearance: A review and understanding of the concepts

  1. 1. Pediatric cervical spine clearance: A review and understanding of the concepts
  2. 2. Review Article Pediatric cervical spine clearance: A review and understanding of the concepts Pankaj Kumar Consultant Orthopaedic and Spine Surgeon, Apollo Reach Hospital, Karimnagar 505001, India a r t i c l e i n f o Article history: Received 16 August 2012 Accepted 2 February 2013 Available online xxx Keywords: Spine Cervical spine injury Cervical spine clearance Pediatric cervical spine a b s t r a c t Spinal injuries to children account for somewhere between 1% and 10% of all spinal trauma. Evaluations of cervical spine injuries required multidisciplinary approach for definitive management. Knowing which patients are at highest risk for injuries will un- doubtedly influence decisions on how aggressively to pursue a potential cervical spine injury. This can be achieved by establishing a multidisciplinary team that provides stan- dards for cervical spine immobilization, assessment, and clearance. Implementation of such guidelines will decrease time for cervical spine clearance and incidence of missed injuries. In this article different aspect of cervical spine injuries and cervical spine clear- ance protocols are reviewed. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction Cervical spine injuries are uncommon in pediatric trauma patients. Delayed or missed diagnosis is usually attributed to failure to suspect an injury to the cervical spine, or to inade- quate cervical spine radiology and incorrect interpretation of radiographs. New imaging techniques have become available, but did not solve the problem, adding their own ‘baggage’, such as cost, availability, logistic difficulties, radiation dosage, lack of specificity and evidence of effectiveness or safety.1 2. Epidemiology Spinal injuries to children account for somewhere between 1% and 10% of all spinal trauma.2 The most common cause of spinal trauma in children is motor vehicle crashes and failure to recognize a cervical spine injury can produce catastrophic neurologic disability.3,4 The incidence of traumatic spinal injury increases with age, and the leading mechanism of injury often varies with age.2,5 Children under 1 year of age, motor vehicle crashes were the leading mechanism, but for children aged between 2 and 9 years of age, falls accounted for the majority of injuries.6 In children aged 10e14 years injuries were sports related 6 and 60e80% of all pediatrics vertebral column injuries are located in the cervical region while in adults, injury to the cervical region usually accounts for about 30e40% of vertebral injuries.7 Atlanto-occipital dislocation is a rare injury, however it has been reported to occur 2.5 times more frequently in children than in adults, particularly in younger children.8 The reported incidence of spinal cord injury without radiographic abnormality (SCIWORA) in chil- dren has varied enormously, with some authors suggesting they occur in 5% of spinal injuries while others have estimated the incidence to be as high as 65%.8 However, it appears that SCIWORA is more common among younger children.2 Some studies of spinal trauma have recorded a missed injury rate as high as 33%.2 E-mail addresses: drpankaj06@yahoo.co.in, drpankaj06@gmail.com. Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e4 Please cite this article in press as: Kumar P, Pediatric cervical spine clearance: A review and understanding of the concepts, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.003 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.02.003
  3. 3. 3. Anatomical considerations There are several features peculiar to the pediatrics cervical spine, when compared to that of adults.8,9 A relatively large head leading to a fulcrum of flexion at C2/3 rather than at C5/6, as compared to adults. There are horizontally aligned facet joints as compared to oblique orientation in adults. This is the most noticeable in upper cervical vertebrae. Underdeveloped uncinate processes of C3eC7, leads to flatter articular surfaces. There is anterior “wedging” of the vertebral bodies. Synchondrosis at the junction of the odontoid peg and C2 vertebral body, allows physeal injuries to occur. Less rigid ligamentous support and weaker supportive muscles, allows greater displacement for a given force. These anatomical differences can be expected to lead to different patterns of injuries in children. Horizontal facet joints, increased ligamentous laxity and weaker musculature make the child’s bony cervical spine more mobile, with a lower expectation of bony injury. The higher fulcrum of flexion would be expected to lead to injuries occurring at a higher level than those seen in adults. Although there is inevitably some indi- vidual variation, the cervical spine is believed to take on a more adult structure and behavior at around the age of 8e9 years.10,11 4. Clinical evaluation Evaluation of the stability of the cervical spine in pediatric pa- tients has been inconsistent and controversial. Pediatric sur- geons as well as emergency room physicians and trauma, orthopedic spine surgeon and neurosurgeons often are asked to rule out cervical spine injuries.12e14 When to contact subspecia lists, when to obtain computed tomography (CT) and magnetic resonance imaging (MRI) scans, and how to show the absence of a ligamentous injury in comatosed patients.1 The solution often is the overuse of cervical spine radiographs. However, guidelines as to which patients require imaging as well as what constitutes “routine screening” are variable and still evolving.13,14 Pediatric patients with the following risk factors for cervi- cal spine injury undergo cervical immobilization and radio- graphic evaluation1 : Unconscious patient or patient with abnormal neurologic examination findings Mechanism of injury potentially associated with cervical spine injury (high-speed motor vehicle collisions, falls greater than body height, bicycle or diving accidents, forced hyper- extension injuries, accelerationedeceleration injuries involving the head) Neck pain Focal neck tenderness or inability to assess secondary to distracting injury Abnormal neurologic examination findings (complete testing of motor, sensory, and reflex functions of all extremities is required) History of transient neurologic symptoms suggestive of SCIWORA (weakness, paresthesias, or lightning/burning sensation down the spine/extremity or related to neck movement) Physical signs of neck trauma (ecchymosis, abrasion, deformity, swelling, or tenderness) Unreliable examination secondary to substance abuse Significant trauma to the head or face Although the issue of radiographic assessment of children with suspected cervical injury has been addressed in several studies, there is still insufficient evidence to support diag- nostic standards. To date, the Nexus criteria absence of: (1) midline cervical tenderness, (2) altered alertness, (3) intoxication, (4) neuro- logical deficit, and (5) painful distracting injury provide the most reliable instrument for assessing the need. Absence of all 5 of these had a negative predictive value of 99.9% (95% confidence interval 99.8e100%).15 5. Prehospital Manual spinal protection should be instituted immediately. If there is any pain, neurological deterioration or resistance to movement the procedure should be abandoned and the neck splinted in the current position. Patients may also be trans- ferred on a scoop stretcher and/or vacuum mattress. Children less than four years of age required greater elevation than those four years of age or older (P 0.05). Because of these findings it was recommended that when immobilizing chil- dren less than eight years of age that either the torso is elevated or an occipital recess be created to achieve a more neutral position for immobilization of the cervical spine. 6. In-hospital Full immobilization should be maintained. This slight degree of flexion is rarely a problem, though it can give rise to diffi- culties in X-ray interpretation.2 This can be corrected by placing a folded towel or sheet under the patient’s shoulders can better position the head and airway.16e19 There is little literature available that documents the methods used for immobilizing young children. We chose to immobilize them flat on a spine board in a semi rigid one-piece cervical collar and a head immobilizer, and for children less than 2 year of age we use towels and staff or parents holding the head. The log-roll is the standard maneuver to allow examination of the back and transfer on and off back boards. Anesthesia may be necessary to allow adequate diagnosis and therapy. 7. Transfer to secondary units Patients may require transfer to other units for definitive care of other injuries such as head or pelvic trauma. The spine should be immobilized and protected for the transfer. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e42 Please cite this article in press as: Kumar P, Pediatric cervical spine clearance: A review and understanding of the concepts, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.003
  4. 4. 8. Radiological assessment There is still insufficient evidence to support diagnostic standards. The lateral view alone is inadequate and will miss upto 15% of cervical spine injuries. According to Hoffman et al19 if the lower cervical spine is not visualized in X-ray a CT scan of the region is indicated. With technically adequate studies and experienced interpretation, the combination of plain radiology and directed CT scanning provides a false negative rate of less than 0.1%. In intubated patient CT scan from the occiput to C2 is mandatory. 9. Magnetic resonance imaging All patients with an abnormal neurological examination should be evaluated in a specialist unit and have an MRI scan of the spine. Patients who report transient neurological symp- toms (the ‘stinger’ or ‘burner’) but who have a normal exam should also undergo an MRI assessment of their spinal cord. 10. Who If the patient is to be discharged from the emergency depart- ment, the Registrar from the following units may clear the cervicalspine after discussionwith theemergencydepartment: Intensive care Orthopedic Neurosurgery General surgery If the patient is an inpatient the cervical spine can only be cleared after consultation with the Neurosurgical or Ortho- pedic Consultant, or the Emergency Consultant if the patient is still in the emergency department. 11. How Several questions need to be asked when attempting to clear the cervical spine. These are: Can pain and tenderness be assessed? Are there other distracting (painful) injuries? Is there neck pain? Is there tenderness over the cervical spine? Are there any motor or sensory abnormalities? Is there limitation of active neck movement? Emergency Is there limitation to head control? 12. Conclusions There is insufficient evidence to support treatment standards and insufficient evidence to support treatment guideline. Establishing a multidisciplinary team provides standards for cervical spine immobilization, assessment, and clearance. Implementation of such guidelines will decrease time for cervical spine clearance, and ongoing analysis of sensitivity is encouraging. Team members consisted of pediatric sur- geons, orthopedic surgeons, neurosurgeons, emergency room physicians, and trauma nurse practitioners. Cervical spine injuries in children are uncommon, but present many po- tential pitfalls in management. Knowledge of current practice is essential to future development of guideline for managing pediatric trauma patients for whom cervical spine injury is a consideration. Conflicts of interest The author has none to declare. r e f e r e n c e s 1. Lee SL, Sena M, Greenholz SK, Sacramento MF. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatr Surg. 2003;38:358e362. 2. Carreon LY, Glassman SD, Campbell MJ. Pediatric spine fractures: a review of 137 hospital admission. J Spinal Disord Tech. 2004;17:477e482. 3. O’Connor P. Injury to the spinal cord in motor vehicle traffic crashes. Accid Anal Prev. 2002;34:477e485. 4. Osenbach RK, Menezes AH. Pediatric spinal cord and vertebral column injury. Neurosurgery. 1992;30:385e390. 5. Anderson PA, Rivara FP, Maier RV, Drake C. The epidemiology of seatbelt-associated injuries. J Trauma. 1991;31:60e67. 6. Cirak B, Ziegfeld S, Knight VM, Chang D, Avellino AM, Paidas CN. Spinal injuries in children. J Pediatr Surg. 2004;39:607e612. 7. Akbarnia BA. Pediatric spine fractures. Orthop Clin North Am. 1999;30:521e536. 8. Roche C, Carty H. Spinal trauma in children. Pediatr Radiol. 2001;31:677e700. 9. Bonadio WA. Cervical spine trauma in children. Part I. General concepts, normal anatomy, radiographic evaluation. Am J Emerg Med. 1993;11(2):158e165. 10. Dickman CA, Rekate HL, Sonntag VKH, Zabramski JM. Pediatric spinal trauma: vertebral column and spinal cord injuries in children. Pediatr Neurosci. 1989;15(5):237e256. 11. Hill S, Miller C, Kosnick E. Pediatric neck injuries: a clinical study. J Neurosurg. 1984;60(4):700. 12. Pasquale M, Fabian TC. Practice management guidelines for trauma from the Eastern Association for the Surgery of Trauma. J Trauma. 1998;44:941e957. 13. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108:E20. 14. 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. J Pediatr Surg. 2001;36:1107e1114. 15. Goldberg W, Mueller C, Panacek E, Tigges S, Hoffman JR, Mover WRNEXUS Group. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38(1):17e21. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e4 3 Please cite this article in press as: Kumar P, Pediatric cervical spine clearance: A review and understanding of the concepts, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.003
  5. 5. 16. Bledsoe BE, Porter RS, Cherry RA. Pediatrics. In: . Paramedic Care: Principles and Practice, vol. 4. Upper Saddle River (NJ): Prentice-Hall; 2001:38e135. 17. Emergency Nurses Association. Pediatric trauma. In: Emergency Nursing Pediatric Course. 2nd ed. Park Ridge (IL): ENA; 2000:131e176. 18. Trauma. In: Dieckmann R, ed. Pediatric Education for Prehospital Professionals. Sudbury (MA): Jones Bartlett; 2000:129e155. 19. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94e99. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e44 Please cite this article in press as: Kumar P, Pediatric cervical spine clearance: A review and understanding of the concepts, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.003
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