Paed C Spine Injuries Simon.ppt

Pediatric C-Spine Injuries
Harold K. Simon, MD, MBA
Professor, Emory Department of Pediatrics & Emergency Medicine

Objectives
• Epidemiology
• Anatomy: Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreting the cervical spine radiograph
– Cases

Epidemiology : Age
• Mean age is 8-9 years old, 2:1 male to female
• < 8 years old mainly, ligamentous injuries
• > 8 years old mainly fractures
• Infants under 1 year old with Cervical Spine
Injuries are rare

Epidemiology : Mechanism
• 67% occur with motor vehicle collision
– 33% occupant
– 23% bicyclist vs. auto
– 11% pedestrian vs. auto
• 30% occur with falls and sports injuries
• < 3% occur with gunshot wounds

Epidemiology :
Associated Injuries
Of 45 children with Cervical Spine Injuries
Pulmonary Contusion 10
Femur Fracture 8
Hemoperitoneum 6
Tibial Fracture 5
Arm Fracture 4
Rib Fracture 3
Splenic Laceration 3
Ruptured Kidney 2
Pelvis Fracture 2
Clavicle fracture, pneumothorax, 1 each
hemothorax, flail chest, liver laceration,
bowel wall edema, limb amputation
Note: 40% of children with cervical spine injury have no trauma to an other body part
Orestein et al.

Anatomy : Pediatric
versus Adult
• Proportionally larger and heavier head
• Weaker and underdeveloped neck musculature
• Higher center of gravity
– Pediatric : C2-C3
– Adult: lower cervical vertebrae
• Greater elasticity and laxity of ligaments in
children
• More horizontal orientation of facet joints

Anatomy : Pediatric
versus Adult
• Relatively wedged anterior vertebral bodies
• Biomechanical and anatomic difference begin to
disappear around 8-10 years old, but are not
fully gone until 15-17 years old

Anatomy : Implications
• Ligamentous laxity
– Allows the spine to absorb and cushion traumatic
forces, thus protecting the bones and spinal cord
– More cervical distraction injuries, as well as
hyperflexion-extension injuries in rapid deceleration
accidents (high energy injuries)
– Children may have spinal cord injury in the absence
of radiographic abnormality (SCIWORA)

Question
• 28 month old male
• Fell from shopping cart, landed on head
• Arrives in C-collar
• Primary survey is normal
• Patient is crying and uncooperative
• How would you clear his cervical spine?

Which Trauma Patients
Should Be Immobilized
Severe or high risk mechanism of injury,
instability, or inability to assess
Altered level of consciousness, altered
alertness, or inebriated
No
Neurologic abnormality at any time post-
injury
No
Complaints of neck pain
No
Cervical spine tenderness (or other painful
injuries which might mask neck pain
No
Limited or painful neck motion
No
Clinical evaluation without radiographs
No
Immobilize, radiographic evaluation
Yes
Yes
Yes
Yes
Yes
Yes

Immobilization Techniques
• Epidemiology
– Cases

 Cervical collars - soft foam, firm foam, and rigid plastic
 Sandbags/foam cushions/towels/tape
 Backboards/Kendricks extrication device/Extriboard
 Combinations usually used in the pre-hospital setting

Pediatric patients have disproportionally large
heads that actually cause neck flexion on a rigid
backboard. Padding under the shoulders and back,
or a recessed area for the head is recommended to
keep the patient in the neutral position.

 Pediatric backboards with recessed head areas
 Pre-hospital: Use a rigid or firm foam collar in
combination with other padding, on a rigid
backboard, with tape to provide the best initial
immobilization

 Never attempt to straighten a cervical deformity when
immobilizing a child!
Cervical collar alone DOES NOT provide full
immobilization if moving about uncontrollably!
It may however be an option for a totally cooperative
patient not moving about and for lower risk situations.
Only mobilization necessary for most in-hospital
situations

Flexion Extension Rotation Lateral
Pediatric Control 35° 45° 80° 16°
Infant Control 35° 38° >90° 40°
Range of neck motion in mannequins

Degrees of Motion Allowed From Neutral Position in Mannequin Models
Collar Flexion Extension Rotation Lateral Summed Score* (%) ±
Infant
Infant car seat, padding, tape
With foam collar 8 12 2° 3° 25 (64)
Head Brace 35 38 4 ° 1 ° 78 (205)
With Foam Collar 11 19 2 ° 2 ° 34 (87)
Half-Spine board, tape 1 1 4 ° 6 ° 12 (23)
With Foam Collar 1 1 2 ° 4 ° 8 (17)
Kendrick Extriction 12 10 19 ° 9 ° 50 (92)
With Foam Collar 1 1 4 ° 1 ° 7 (11)
Pitfalls of Pediatric Immobilization:

Pitfalls of Pediatric
Immobilization:
Child Control
Head Immobilizer
Foam cushions to spine board 11 18 26 ° 3 ° 58 (122)
With Vertebrace 10 14 1 ° 1 ° 26 (66)
Head Brace 16 12 2 ° 1 ° 31 (82)
With Flex-Support 7 9 5 ° 2 ° 23 (58)
Kendricks Extrication 6 8 4 ° 2 ° 20 (53)
With Flex-Support 4 3 1 ° 2 ° 10 (31)
Extriboard Disposable
Extrication device 9 7 5 ° 4 ° 24 (73)
With Vertebrace 3 2 2 ° 1 ° 8 (20)
Half-Spine board & tape 10 1 4 ° 7 ° 22 (79)
With Flex-Support & Tape 2 3 1 ° 2 ° 8 (26)
Full-Spine board & Tape 4 12 5 ° 3 ° 24 (63)
Tape, Beanbag & Flex-Sup 10 9 3 ° 2 ° 24 (66)
Tape, Beanbag5 5 0 ° 1 ° 11 (31)
* Summed score, arithmatic sum of degrees of motion in each direction. Degrees of motion allowed
±Summed of score, arithmatic sum of percentage of control motion. Control
In each direction

• National Emergency Medicine X-ray Utilization Study
• 23 Center National Cooperative Study
• Viccellio P, Simon HK, Pressman B, Shah M, Mower W,
Hoffman J, for the NEXUS Group. A Prospective
Multicenter Study of Cervical Spine Injury in Children.
Pediatrics August 2001;108: e20
NEXUS

NEXUS : Study Definitions
Low Risk Patient
Those with none of the following criteria:
– Midline cervical tenderness
– Focal neurologic deficits
– Altered level of alertness
– Evidence of intoxication
– Distracting painful injury

NEXUS : Study Results
• 34,069 patients enrolled
– 3,065 Pediatric Patients
• (9%) were < 18 yrs
• 603 (19.7%) were “Low-risk”

Age distribution in years - All Nexus Patients
102
96
90
84
78
72
66
60
54
48
42
36
30
24
18
12
6
0
Number
1000
800
600
400
200
0

Age distribution in years - All Nexus Patients
102
96
90
84
78
72
66
60
54
48
42
36
30
24
18
12
6
0
Number
1000
800
600
400
200
0
n = 3,065 n = 31,004
N = 34,069

600
Age distribution in years
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
#
of
patients
500
400
300
200
100
0
Age Distribution of Pediatric Patients
N = 3,065

600
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
#
of
patients
500
400
300
200
100
0
N = 3,065
<2 y.o.,
n = 88

600
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
#
of
patients
500
400
300
200
100
0
N = 3,065
2-8 y.o.,
n = 817
<2 y.o.,
n = 88

600
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
#
of
patients
500
400
300
200
100
0
N = 3,065
9-17 y.o.,
n = 2160
2-8 y.o.,
n = 817
<2 y.o.,
n = 88

• Of 3,065 children enrolled, 30 had c-spine injuries
(0.98%)
• All children with c-spine injuries were prospectively
classified as being in the “high-risk” group
• No child from the “low-risk” group had a c-spine
injury

Clinical Features + - N/A
Tenderness 21 4 5
Neuro deficits 8 19 3
Altered LOC 6 21 3
Intoxication 0 27 3
Distracting injury 11 17 2
Of the 30 children with c-spine injuries

Clinical Features + - N/A
Tenderness 1179 1333 523
Neuro deficits 176 2611 248
Altered LOC 520 2326 189
Intoxication 110 2730 195
Distracting injury 878 1915 242
Of the 3,035 children without c-spine injuries

Age Sex Fracture type
2 F C2 type III odontoid fracture
3 M Occipital condyle fracture
6 M Cranio-cervical dissociation
8 M C1 & C2, fractures
9 M C4 flexion tear drop fracture
11 M Cranio-cervical dissociation
11 F C7 burst fracture
11 M C5 body fracture
11 M C1 lateral mass fracture
12 F C2 spinous process fracture
13 M C6 spinous process fracture
14 M C7 wedge compression
14 F C4 - C5 subluxation, C5 - C6 subluxation, C5 body and,posterior element fractures, C4-6 cord contusion
16 F C7 compression fracture
16 F C6 - C7 fracture
16 M C6 burst fracture and bilateral laminar fractures, C7 body fractures
16 M C5 burst fracture and bilateral laminar fractures; C5 – C6 subluxation
16 M C5 body fracture; C5-6 sublux
16 M C5 & C6 trabecular fractures, C3 - C7 interspinous ligament injury
16 M C6 facet fracture; C6 compression fracture; C5 – C6 interfacetal dislocation; C5 – C6 cord contusion
16 M C1 posterior arch fracture
16 M C4 compression fracture; C3 – C4 subluxation; C3 – C4 cord contusion
16 F C4 burst fracture; C4-C5 subluxation; C4-C5 cord contusion
17 M C7 spinous process fracture
17 F C7 body fracture
17 M C6 - C7 facet and capsular injury
17 M C5 laminar fracture, C6 body fracture, C5 – C6 nterfacetal dislocation, C5 – C6 cord contusion

Item of interest Age <18yrs Age ≥18yrs
Total # of cases 3,065 31,004
# with c-spine injury 30 788
Injury Rate 0.98% 2.54%
“Missed injuries” 0 8
(all negative criteria)
# of cases with all (-) criteria 20% 12%
Pediatric versus Adult

Take Home
–No c-spine injuries occurred in children
prospectively identified at “low-risk”
–NEXUS decision instrument could have safely
reduced c-spine imaging by nearly 20%
–Limited data on under 2 years old

• Advantages
– CT is more sensitive for detecting C-Spine Injuries
than plain film
– Depending on age may save time
• Disadvantages
– Radiation
– Cost
– May increase time if sedation required
Helical CT vs Plain
Films

Helical CT vs Plain
Films
• Randomized trial
• 136 children 0-14yr
• Increased radiation in HCT group
• No reduction in the amount of sedation or LOS in the
HCT group
• 34% crossover from assigned group secondary to
perceived advantages
Adelgais KM, Grossman D, et al. Academic Emerg Med
March 2004

Helical CT vs Plain
Films
Outcome Helical CT (n=97) Plain Film (n=39)
Mean ED time (min) 243 (CI 143, 343) 174 (CI 154,194)
Mean Radiation time (min) 89 (CI 60, 118) 88 (CI 76, 99)
Radiographic cost
total RVU 17.3 (CI 15, 19) 10.7 (CI 8.5, 12.9)
Total $ 657 (CI 570, 737) 407 (CI 323, 494)
C-Spine RVU 5.9 (CI 5.8, 6.1) 1.8 (CI 1.4, 2.2)
C-Spine $ 224 (CI 220, 232) 68 (CI 53, 84)
Rad dose (nRem) 432 (CI 340, 465) 127 (CI 117, 138)

Objectives
• Epidemiology
– NEXUS Study
– Canadian Rules
– Cases

C-Spine Radiograph
• Lateral film
• Anteroposterior film
• Open-mouth odontoid view

• Lateral Film
– Most injuries picked up with lateral film >80%
– Odontoid view utility questionable in small children
• Basic Information
– Jefferson Fracture – axial compression
• Burst of C1 ring
– Hangman Fracture – hyperextension, then flexion
• C2 pedicle fracture
– Physiologic dislocation
• Usually under 16 years of age
• Anteriorly displacement of C2 on C3
C-Spine Radiograph

C-Spine Radiograph
Focus on the lateral neck
1. Film adequacy
2. C-spine alignment and curves
3. Inter-vertebral spaces: discs and joints
4. Pre-vertebral space
5. Pre-dental space

C1
“Atlas”
C2
“Axis”
C4 C5 C6 C7
C3
Brief anatomic review
Bodies
Dens

Adequacy
– Visualize entire cervical
spine
– Count 7 cervical bodies
and 1 thoracic body
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Adequacy
– Visualize entire cervical
spine
– Count 7 cervical bodies,
and 1 thoracic body

Alignment
• C-Spine Curves

Alignment
• C-Spine Curves
– Anterior Vertebral Bodies

Alignment
• C-Spine Curves
– Anterior Spinal Canal

Alignment
• C-Spine Curves
– Posterior Spinal Canal

Alignment
• C-Spine Curves
– Posterior Spinal Canal
– Spinous Process Tips

Inter-vertebral spaces
– Disc spaces
– Cartiledge
– Apophyseal joints

Pre-vertebral space

Pre-vertebral space
– Space between vertebral
bodies and air column

Pre-vertebral space
– Space between vertebral
bodies and air column
– Must measure space
above the glottis
– Normal size
• ~1/2 to 2/3 of adjacent
vertebral body
– Can be abnormal if
• non-inspiratory film
• Intubated
– Often normal in C-Spine
injuries

Pre-Dental Space

Pre-Dental Space
– Space between Dens
of C2 and anterior,
interior side of C1 ring

Pre-Dental Space
of C2 and anterior,

Pre-Dental Space
of C2 and anterior,
– Must be less than or
equal to 5 mm
– Cause of increased
space
• transverse ligament injury
• burst fracture of C1

Case 1
4 year old female, restrained, back seat
High speed, head on, car versus tree
Eye witnesses noted the passengers’ heads violently
snapped forward
The driver died at the scene
C-spine immobilized
Minimally responsive
Intubated
Ng-tube placed

Fracture at base of dens with anterior displacement

Case 1
• The greater elasticity and laxity of ligaments in
children allow for more hyper flexion and
extension injuries
• Children with hypoplasia of dens, ie: Trisomy 21
• Children with rheumatoid arthritis, are at higher risk for
atlanto-axial dislocation

Case 2
18 month old female, unrestrained, front seat
Sitting in babysitter’s lap, babysitter died at scene
C-spine ‘immobilized’ by gauze strapped with tape over
child’s head
Alert and awake
Severe respiratory distress, with decreased breath
sounds on right chest
No movement of lower extremities

Distraction injury

Case 2
• C-spine injuries in children are rare
• Up to 40% of children with c-spine injury have
trauma to another body part
• Must learn to properly immobilize the c-spine

Case 3
A 4 year old child, fell from shopping cart, no loc
Fever, sore throat, strep positive yesterday
Not tolerating liquids or solid food
Temperature=104
Alert, awake and talking with hoarse voice
Drooling, mild increased work of breathing
He complains of neck pain

Glottis
Abscess

Case 3
• The pre-vertebral space can be enlarged with a
hematoma post c-spine trauma or general
edema

Case 4
5 year old male, sitting in seatbelt, front seat
Airbag deployed
C-spine immobilized
Alert and awake
Numerous abrasions to face, neck and left shoulder and
arm
Left arm limp and without sensation

Ruptured Transverse Ligament

C2 - Axis

v
C1 - Atlas

ANTERIOR
POSTERIOR
ANTERIOR

ANTERIOR
ANTERIOR
POSTERIOR

Case 4
• The safest place for any aged child is the back
seat
– Air bags can be lethal to children
– AAP Recommends: Children ages 12 and younger
should ride in the back seat
• Must wear seat belts

Summary
• Epidemiology
• Interpreted the cervical spine radiograph

Paed C Spine Injuries Simon.ppt

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