Cervical Spine Injuries in Children: Attention to … · Cervical Spine Injuries in Children: Attention to Radiographic Differences and Stability Compared to Those in the Adult Patient

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ervical Spine Injuries in Children:ttention to Radiographic Differencesnd Stability Compared to Those in the Adult Patient

ankaj A. Gore, MD, Steve Chang, MD, and Nicholas Theodore, MD

The relative rarity of pediatric cervical spine injuries can impede rapid response andefficient care of this patient population. An understanding of the unique anatomical,radiographic, and biomechanical characteristics of the pediatric cervical spine is essentialto the appropriate care of these challenging patients. Patterns of injury, diagnosis, andissues related to operative and nonoperative management are discussed with a focus onthe developing spine. Our aim is to improve the understanding of traumatic cervical spineinjuries in children for all practitioners involved with their care.Semin Pediatr Neurol 16:42–58 © 2009 Published by Elsevier Inc.

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ervical spine trauma accounts for approximately 1.5% ofpediatric trauma admissions.1 The medical, psycholog-

cal, and societal expenses of severe pediatric cervical spinerauma can be vastly disproportionate to this small percent-ge.2-5 An understanding of the unique anatomical, radio-raphic, and biomechanical characteristics of the pediatricervical spine is essential to the appropriate care of thesehallenging patients.

pidemiologyost pediatric cervical spine injuries are a result of blunt

rauma.1 In large series, males outnumber females (1.5:1-1.9:).1,6-8 Motor vehicle–related accidents, which account for8%-61% of all pediatric cervical spine injuries, are the mostommon mechanism of injury in children both older andounger than the age of 8 years.1,6,7 Of these, injuries tootor vehicle occupants (31%-42%) predominate over those

o pedestrians (11%-16%) and bicycle riders (5%-6%).1,6-8

Falls account for 18% to 30% of cervical spine injuries inhe younger age group (�8 years) and 11% in the older ageroup (�8 years).1,6 Sports injuries are more prevalent in thelder age group (20%-38%) and uncommon in the youngerge group (3%).1,6 Nonaccidental trauma and penetrating

rom the Division of Neurological Surgery, Barrow Neurological Institute,St. Joseph’s Hospital and Medical Center, Phoenix, AZ.

orrespondence Nicholas Theodore, MD, c/o Neuroscience Publications,Barrow Neurological Institute, 350 W. Thomas Road, Phoenix, AZ

f85013. E-mail: [email protected]

2 1071-9091/09/$-see front matter © 2009 Published by Elsevier Inc.doi:10.1016/j.spen.2009.03.003

njuries are also found in small numbers of very young chil-ren and adolescents, respectively.7,9

The largest reported series of pediatric cervical spine injuryatients (n � 1098) was gleaned from a 10-year interval ofhe National Pediatric Trauma Registry and probably repre-ents the best epidemiologic data from this patient popula-ion.1 Of these patients, 83% had bony cervical spine injuries.ractures were more common in all age groups, althoughislocations were more prevalent in younger children than inlder children. Upper cervical spine injuries (C1-C4) werelmost twice as common as lower cervical spine injuries (C5-7). Both upper and lower cervical spine injuries were seen

n 7% of patients. Spinal cord injury occurred in 35% of theediatric cervical spine injuries. About half of these injuriesemonstrated no radiographic evidence of bony injury. Sev-nty-five percent of spinal cord injuries were incomplete and5% were complete.1

mbryology and Developmentn understanding of the developmental anatomy of the pe-iatric cervical spine facilitates interpretation of its imagingnd conceptualization of its biomechanical properties. Theertebral bodies undergo chondrification around the fifth orixth week of gestation.10 By the fourth month, ossificationenters have appeared in all vertebral bodies. Ossificationontinues through adolescence. Most vertebrae originaterom 4 primary ossification centers: 1 in each hemi-arch and

within the centrum. The body of each vertebra develops
rom the fusion of the dorsal and ventral ossification centers
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Understanding pediatric cervical spine injuries 43

ithin the centrum, an event that occurs by the 24th week ofestation.11

he Atlasssification of the anterior arch of the atlas begins by 3onths in 33% of children and by 1 year in 81% of children

Fig. 1).12 Complete ossification of the posterior arch occursy the age of 3 years. The synchondroses between the bodynd the posterior elements fuse by age 7 years.13

igure 1 (A) Illustration showing the ossification centers and syn-hondroses of the atlas. The neural arch ossification centers formuring the seventh gestational week, whereas the ossification centerithin the body of C1 becomes visible during the first year of life.he posterior midline synchondrosis fuses at about the third year of

ife. The neurocentral synchondroses about the atlas body fuseround the age of 7 years. (B) Correlative axial computed tomogra-hy (CT) from a 24-week-old child. Reprinted with permission from

tarrow Neurological Institute.

he Axishe axis is unique in that there are 2 additional ossificationenters that fuse in the midline to form the odontoid processy the seventh gestational month. The body of C2 fuses to thedontoid between ages 3 and 6 years. The fusion line is oftenisible until the age of 11 years and is visible throughout theife in one-third of the population (Fig. 2).13 The secondaryssification center at the apex of the odontoid appears be-ween ages 6 and 8 years and fuses with the dens at aroundge 12 years.14 Failure of fusion at this location results inssiculum terminale, a condition that is usually benign butas been associated with atlantoaxial instability.15

The C2 posterior arches fuse in the midline by age 2 to 3ears and fuse with the body by age 3 to 6 years. The inferiorpiphyseal ring is a secondary ossification center that appearst the inferior end plate of C2 at puberty and fuses with theody by age 25 years.

he Subaxial Cervical Spinehe development of the subaxial cervical spine is highly con-erved from C3 through C7. Ossification of the centrum oc-urs by the fifth gestational month. The arches fuse in theidline by the second to third year and fuse to the body

etween the third and sixth year. Secondary ossification cen-ers develop at the anterior transverse processes, spinous pro-ess apices, and superior and inferior epiphyseal rings. Thenterior transverse process fuses with the vertebrae by theixth year. The latter 3 centers fuse by the 25th year (Fig. 3).13

maging Characteristicsf the Pediatric Cervical Spine

ncomplete ossification and physiologic hypermobility of theediatric cervical spine contribute to imaging findings thatan be confused with pathologic conditions. Lateral and an-eroposterior (AP) x-rays of the cervical spine are frequentlysed as a primary screening study. Imaging findings withinhe realm of normal variants in children include prevertebraloft-tissue thickening, increased atlantodens interval (ADI),verriding C1 anterior arch on the dens, pseudospread of the1 lateral masses on C2, pseudosubluxation of C2 on C3 andf C3 on C4, any radiolucent synchondrosis, wedging ofubaxial cervical vertebral bodies, and the absence of cervicalordosis.

Prevertebral soft-tissue swelling in adults can indicatedjacent cervical spine injury. In children, a thickenedrevertebral shadow on plain radiographs can result fromxpiration, especially if a child is crying.11 If repeat x-raysuring inspiration are infeasible, CT of the region is indi-ated.

In the adult population, the normal ADI is �3 mm. Onlain radiographs of the pediatric cervical spine, this distancehould be �5 mm.16 However, some authors report a moretringent distance of 4 mm.12,17 The exaggeration in ADI po-
entially reflects incomplete ossification of the dens and laxity

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44 P.A. Gore, S. Chang, and N. Theodore

f the transverse ligament. Overriding of the anterior arch of1 on the dens during extension also can be mistaken fortlantoaxial instability. This finding is normal in 20% of chil-ren �8 years old.18

C1 lateral mass displacement �6.9 mm on open-mouthiews is the classic radiographic indicator of transverse liga-ent disruption in adults,19 although magnetic resonance

maging (MRI) has demonstrated the low sensitivity of thisechnique.20 As much as 6 mm of C1 lateral mass displace-ent is common in children �4 years of age and may beresent until the age of 7 years.21,22

Pseudosubluxation of C2 on C3 is present in 22% to 24%f normal pediatric static cervical spine radiographs.18,23,24

lthough this finding diminishes with increasing age, it haseen noted in children as old as 14 years (Fig. 4).23 Onynamic films, as many as 46% of normal children aged �8ears have 3 mm of motion of C2 on C3. On lateral x-rays,4% of children have pseudosubluxation of C3 on C4.18

seudosubluxation does not correlate with intubation sta-us, injury severity score, or gender.23,24 Complete reduc-ion in displacement on extension suggests pseudosub-
uxation rather than true instability.11 a
Swischuk25 proposed a method to differentiate pseudosub-uxation of C2 on C3 from instability caused by a Hangman’sracture. A line is drawn from the anterior cortex of the pos-erior arch of C1 to the anterior cortex of the posterior arch of3. This line typically travels �1 mm anterior to the poste-

ior arch of C2. If this distance is �2 mm, a disconnection ofhe anteriorly displaced C2 body from the C2 posterior ele-ents is suggested. Pang and Sun26 proposed that �4.5 mm

f horizontal displacement at C2/C3 or C3/C4 should beonsidered unstable in children aged �8 years. In children8 years old, �3.5 mm of horizontal displacement at any

ervical level reflects instability.27

On both computed tomography (CT) and plain x-rays,ynchondroses can be mistaken for fracture lines. Con-ersely, fractures through synchondroses can be misinter-reted as within the realm of normal. The dens-C2 bodyynchondrosis is well corticated and lies below the level ofhe superior facets of C2, but it can be mistaken for a type IIens fracture. Fractures through the dens-C2 body synchon-rosis may be missed in pediatric patients.28 This is the mostommon injury involving the odontoid process in children

gure 2 (A) Illustration showing the ossification centers and syn-ondroses of the axis. Two ossification centers fuse in the midline torm the odontoid process by the seventh gestational month. The

ody of C2 fuses to the odontoid between ages 3 and 6 years. Theeurocentral synchondroses about the body also fuse between ages 3d 6 years. The secondary ossification center at the apex of the

dontoid appears between ages 6 and 8 years and fuses with the densound the age of 12 years. (B) Correlative coronal CT from a

-month-old child shows the synchondrosis between the odontoidd body of C2, the neurocentral synchondroses, and an early apical

ssification center for the odontoid. (C) Correlative sagittal CT from24-week-old child shows the synchondrosis between the odontoidd body of C2. Note the absence of an apical ossification center.

eprinted with permission from Barrow Neurological Institute.

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ged �7 years.29-31 Similarly, C1 synchondroses can be mis-

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nterpreted as fractures or abnormally separated.32 Epiphy-eal growth plates of vertebral bodies can be mistaken forractures. They also may be the sites of shearing injuries. Aorking knowledge of the location and evolution of syn-

hondroses is essential to the accurate interpretation of pedi-tric spine imaging.

In newborns, cervical vertebral bodies have an ovoid ap-earance with vertebral interspaces equivalent to the heightf the vertebral bodies. With the increasing age the vertebralodies assume a more rectangular shape. A wedge appear-nce of the anterior aspect is a common intermediate stage. Inarticular, mild C3 wedging can persist until the age of 12

igure 3 (A) Illustration showing the ossification centers and syn-hondroses of a subaxial vertebra. The development of the subaxialervical spine is highly conserved from C3 through C7. Ossificationf the centrum is present by the fifth gestational month. The archesuse in the midline by the age of 2 to 3 years. The neurocentralynchondroses fuse between the ages of 3 to 6 years. (B) Correlativeagittal CT from a 24-week-old infant. Discontinuity within bilateraleural arches is because of the plane of section. Reprinted with per-ission from Barrow Neurological Institute.

ears.33 e

Loss of cervical lordosis, which can indicate injury indults, is a normal finding in 14% of children.18

iomechanical Properties of theeveloping Cervical Spine

n comparison with the large number of published studies oniomechanics of the adult cervical spine, biomechanicaltudies of the pediatric cervical spine are rare. It is generallyccepted that the pediatric cervical spine demonstrates ange-dependent hypermobility resulting from underdevel-ped bony anatomy, ligaments, and musculature. Further-ore, forces applied to a proportionally larger head enable a

arger moment arm to act on the underdeveloped spine.In the age group of 0 to 8 years, large series have demon-

trated a tendency toward involvement of the occipitoatlan-oaxial complex1,69 and pure ligamentous injuries rather thanractures. The craniocervical junction is vulnerable in younghildren for several reasons: (1) The occipital condyles aremaller. (2) The articulation with the lateral masses of C1 isore planar than cup-like, and it is biased toward the axiallane.27,34 (3) The relatively large head size coupled with thepper cervical hypermobility places the fulcrum of flexion inhe craniocervical region.13,27 (4) The odontoid synchondro-is is susceptible to translational forces.

In children aged �8 years, injury patterns approach andult distribution. With increasing age the fulcrum movesaudally until it reaches the adult position at C5-C7.27 Inlder children, cervical spine injuries below the cranioverte-ral junction tend to be osseous although pure ligamentous

njuries still occur. Subaxial hypermobility arises for severaleasons: (1) The facet joints are biased toward the axiallane.35 (2) The anterior wedging of vertebral bodies permitsdded flexion. (3) The disk-annulus complex allows greaterongitudinal expansion and distraction.27,36 (4) In children

10 years old, undeveloped uncinate processes permitreater susceptibility to lateral and rotational forces.27 (5)inally, the joint capsules and ligaments are more elastic.7,13

arly Evaluationnd Managementrehospital Immobilizationstablishment of an airway, adequate ventilation, and cardio-ascular support are cardinal principles in the managementf any trauma patient. Apnea, cardiorespiratory arrest, orevere hypotension can result from injury to the high cervicalpinal cord.37 Immediate in-the-field spinal immobilizationf any patient with a suspicious mechanism of injury or withneurologic disability is likely essential to prevent repetitive

pinal cord or spinal column injury.As in adults, the goal of immobilization is to retain the

ediatric cervical spine in neutral position. In children aged8 years who are immobilized on a spine board, the rela-

ively large head compared to the shoulder girdle and torsolaces the cervical spine into flexion regardless of the pres-
nce of a collar.38 In one series, more than 20% of children

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ged �8 years immobilized on a backboard demonstratedore than 10° of cervical flexion (C2-C6 Cobb angle).39 Her-

enberg et al40 have recommended the use of an occipitalecess or thoracic elevation to eliminate the backboard-in-uced flexion. Nypaver and Treloar41 determined that chil-ren aged �8 years require a mean of 2.5 cm of thoraciclevation with respect to the occiput to achieve neutral posi-ion.

In a trauma setting, infants and young children are oftenncooperative and restless. Immobilization with a rigid collarlone may allow more than 15° of flexion and extension.42 Aigid collar combined with supplemental devices that par-ially enclose the head (eg, Kendrick Extrication Device) andape provides the best prehospital immobilization of the pe-iatric cervical spine.42 Cervical collars can lead to supra-hysiologic distraction and neurologic injury in the presencef occipitoatlantal dislocation.43 Sandbags and tape shoulde used in this situation instead.

linical Clearance of the Cervical Spinelinical clearance of the cervical spine can be undertaken insubset of pediatric trauma patients. Laham et al44 estab-

ished criteria for clinical clearance of the cervical spine in aetrospective series of 268 head-injured pediatric patients.atients with isolated head injuries who were able to com-unicate and who had no neck pain or neurologic deficitsere classified as low risk (n � 135). High-risk patients (n �33) were those aged �2 years, those incapable of verbalommunication, and those with neck pain. All patients un-erwent cervical spine x-rays. No injuries were found in the

ow-risk group, and 10 injuries were found in the high-risk

Figure 4 Normal flexion-extension views from a 12-yeaReprinted with permission from Barrow Neurological Institu

roup. Laham et al44 concluded that cervical spine x-rays are i

nnecessary in pediatric patients who fulfill the low-risk cri-eria.

Viccellio et al45 reported 3065 pediatric patients in a mul-icenter prospective trial that assessed the utility of cervicalpine imaging. Six hundred three patients met 5 low-riskriteria, which were defined as the absence of each of theollowing criteria: midline cervical tenderness, evidence ofntoxication, altered level of alertness or intubation, focaleurologic deficits, and painful distracting injury. All pa-ients underwent at least 3-view cervical spine imaging. Noatient who met all 5 low-risk criteria had a cervical spine

njury.At our institution, we use the 5 low-risk criteria studied by

iccellio et al,45 in combination with a sixth criterion, whichequires the ability for appropriate verbal communicationefore the cervical spine can be cleared.

magingll children who do not meet the above low-risk criteriahould undergo at least AP and lateral cervical spine radiog-aphy with swimmer’s views, as necessary. Swischuk et al46

ave questioned the utility of open-mouth views in childrenged �5 years. In a series of 51 pediatric patients with cervi-al spine injuries, Buhs et al47 concluded that open-mouthiews provided no additional information beyond that foundn AP and lateral views in children aged �9 years. Instead,he authors recommended eliminating the open-mouth viewnd obtaining a CT scan in this patient population.

The use of CT as a primary tool for cervical spine imagings controversial. Management guidelines from the Americanssociation of Neurological Surgeons\Congress of Neurolog-

oy. Note the persistent mild anterior wedging of C3.
r-old b
cal Surgeons24 suggest that “CT of the cervical spine should

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e used judiciously to define bony anatomy at specific levelsut is not recommended as a means to clear the entire cervicalpine in children.” In adults, a growing body of publishedrticles indicates a significantly higher sensitivity of CT com-ared to radiography for the evaluation of cervical spine in-

uries, especially in obtunded or intubated patients.48-51 Sim-lar studies in the pediatric population are lacking. CT-basedrotocols have replaced plain films in adults who cannot beleared clinically.52

Slack and Clancy53 have advocated CT imaging in ob-unded pediatric patients. Although the cervical spine inoung children is often easily visualized on plain x-rays,24

issed fractures on plain films alone have led to neurologicnjury in this population.54 Given the potentially devastatinglinical consequences of a missed pediatric cervical spinenjury, we recommend CT imaging in all patients who do notatisfy the low-risk criteria discussed in the previous section.urthermore, CT imaging can prove useful in preoperativelanning.MRI is far superior to CT in delineating nonosseous anat-

my. Flynn et al55 examined the use of MRI in the evaluationf pediatric cervical spine injury. By institutional protocol,RI was obtained if at least 1 of 4 criteria was met: (1) an

btunded or nonverbal child with a suspicious mechanism ofnjury, (2) equivocal plain films, (3) neurologic symptomsithout radiographic findings, or (4) an inability to clear the

ervical spine on the basis of clinical or radiographic evidenceithin 3 days of injury. MRI altered the diagnosis based onlain radiography in 34% of cases. Frank et al56 have reportedhat the use of MRI is associated with more rapid cervicalpine clearance and shorter stays in the intensive care unit inbtunded and intubated pediatric trauma patients. Of 52 pedi-tric trauma patients with normal plain radiographs and CTcans of the cervical spine, 31% demonstrated changes onRI.57 These findings ranged from soft-tissue or ligamentous

ignal changes to a bulging disc. The MRIs influenced surgicallanning in 4 patients. MRI is useful in the evaluation of spinalord injury without radiographic abnormality (SCIWORA),58

lthough findings may be normal in the pediatric populationith this injury.59

We use MRI whenever a neurologic deficit is presentnd to assess the extent of ligamentous involvement, par-icularly with craniovertebral junction injuries. We have aow threshold for obtaining MRIs of the cervical spine inbtunded young children with mechanisms of injury thatre at high risk for injury to the craniovertebral junction.owever, MRI is a static test and does not necessarilyredict cervical spine instability.60 The extent of injuryemonstrated on MRI can be used to guide managementFig. 5).57

Flexion-extension films enable the determination of dy-amic instability. Several authors have questioned theirse in the setting of adequate normal static films. Dweknd Chung61 reported a series of 247 pediatric traumaatients. No child with normal neutral x-rays demon-trated instability on flexion-extension views. Ralston etl62 similarly reported 129 pediatric trauma patients and
oncluded that flexion-extension radiography was un- s
ikely to be abnormal when isolated loss of lordosis or nocute abnormality was evident on AP and lateral cervicalpine radiographs. Woods et al63 concluded that flexion-xtension films were not useful in the setting of normaltatic cervical spine films.

ethylprednisolone Usehere are few data on the use of methylprednisolone specific

o pediatric patients. The Second National Acute Spinal Cordnjury Study included 13- to 19-year-old patients, but thisemographic group was composed of only 15% of the overalltudy population. Methylprednisolone is used at the discre-ion of the treating physician.

atterns of Pediatricervical Spine Injuryccipitoatlantal and Atlantoaxial Dislocationhen distraction injuries are considered, the occipitoatlan-

oaxial complex can be regarded as 1 unit. The O-C1 and1-C2 joint capsules and the atlantooccipital and atlantoax-

al membrane do not contribute significantly to the verticaltability of the craniocervical junction.16,64 The tectorial liga-ent, alar ligaments, and surrounding musculature appear toave the largest roles in stabilizing this segment.65-68

Although occipitoatlantal and atlantoaxial dislocation in-uries are uncommon, they are often seen in young childrennvolved in high-speed motor vehicle accidents, auto versusedestrian accidents, or in airbag-related injuries.69 Associ-ted neurologic deficits are partial or absent. Complete neu-ologic injury at this level usually results in rapid death. Inhis patient population, traction and a cervical collar can leado overdistraction and worsening neurologic injury andhould be avoided.43

Diagnosis of occipitoatlantoaxial dislocation (OAAD) re-uires a high index of suspicion, especially in victims ofedestrian–motor vehicle accidents and motor vehicle acci-ents with or without ejection. Reconstructed coronal andagittal CT images can demonstrate unilateral or bilateraloint widening at O-C1 and/or C1-C2. At C2 widening of theetropharyngeal space beyond 7 mm is a subtle sign of highervical injury. MRI can define abnormalities of joints, liga-ents, and soft tissues at O-C1 and C1-C2. Sun et al70 have

mphasized the integrity of the tectorial membrane on MRIs a critical factor in determining both occipitoatlantal andtlantoaxial stability against vertical distraction. Definitivereatment of occipitoatlantoaxial instability requires surgicalusion.

tlantoaxial Rotatory Fixationtlantoaxial rotatory fixation (AARF) is an alteration of theormal rotational relationship between the atlas and axis.his condition ranges from significant limitation of motion tobsolute fixation. Trauma, upper respiratory infections, andead and neck surgery are the main causes of this disorder.Fielding and Hawkins71 established a 4-tier classification

ystem (Fig. 6). Type I AARF is defined by an intact trans-


Figure 5 (A) Coronal CT from a 4-year-old girl who was an unrestrained passenger in a motor vehicle accident showswidening of the bilateral atlantoaxial joints. (B) Sagittal magnetic resonance imaging (MRI) short T1-weighted inversionrecovery (STIR) images show signal changes within the bilateral atlantoaxial joints and within the right occipitoatlantaljoint. MRI confirmed that the transverse ligament was intact (not shown). (C) Halo immobilization was unsuccessful asevidenced by persistent vertical translocation at C1/C2 between upright (left) and supine (right) films. (D) Surgicalstabilization was achieved with occiput-to-C4 titanium rod fixation and autograft fusion. Reprinted with permission from
Barrow Neurological Institute.


Figure 5 (Continued)

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erse ligament. Types II and III injuries are defined by theisruption of the transverse ligament alone and the transversend alar ligaments, respectively. These injuries are associatedith a progressively widened ADI corresponding to in-

reased displacement of the atlas on C2. Type IV AARF isefined as a posterior rotatory displacement of the atlas on2. This injury is very rare and can occur only in the settingf a hypoplastic odontoid process. Types II, III, and IV AARFre easily defined on CT and MRI and usually require surgicaltabilization of the atlantoaxial complex.

Type I AARF is most difficult to diagnose because theathologic C1-C2 fixation can appear within the range ofhysiologically normal on static imaging.72 In this largelyediatric disorder, patients have painful torticollis in thecock-robin” position with the head turned to one side andhe neck laterally flexed in the opposite direction. Ligamen-ous laxity and shallow C1-C2 lateral mass articulations pre-ispose children to initial over-rotation and subluxation.73

pasms of cervical musculature, synovial inflammation, orechanical obstruction of the C1-C2 articular surfaces have

Figure 6 Fielding and Hawkin classification scheme fofixation (AARF) is defined by an intact transverse ligametransverse ligament alone and the transverse and alarprogressively widened atlantodens interval (ADI). TypeC2, in the setting of odontoid hypoplasia. Reprinted with

ll been implicated in maintenance of the deformity.73 r

Conventionally, dynamic CT is used to evaluate AARF.74

n this protocol, fine-cut CT imaging is used to image thetlantoaxial span in the presenting position and at the limitsf rotation in either direction, as dictated by the patient’siscomfort. Limitation or absence of motion is used to diag-ose AARF, but the reliability of this technique has beenuestioned.16,75

Pang and Li72 have refined the conceptualization of Field-ng and Hawkins type I AARF from that of a locked angle ofotation of C1 on C2 to that of a “pathological stickiness”etween C1 and C2 that leads to abnormal motion on rota-ion. In normal individuals, axial rotation of the head resultsn 3 discrete phases of C1 motion on C2 (Fig. 7).72 From zeroegrees (defined by the head facing straight forward) to 23°f head rotation, C1 rotates independently, whereas C2 re-ains immobile. From 23° to 65°, C2 rotates with C1, albeitore slowly. At 65° of head rotation, the angle of C1-C2

otational separation reaches a maximum of 43°. Furtheread rotation from 65° to 90° is characterized by lock-stepotion of C1 with C2 and is entirely provided by subaxial

toaxial rotatory fixation. Type I atlantoaxial rotatoryes II and III injuries are defined by the disruption of thents, respectively. These injuries are associated with aF is as a posterior rotatory displacement of the atlas on

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On the basis of an analysis of 40 pediatric patients present-ng with torticollis, Pang and Li76 refined the dynamic CTrotocol and classified Fielding and Hawkins type I AARF

nto 3 subtypes corresponding to decreasing amounts ofpathological stickiness.” Atlantoaxial scans are obtained inhe presenting position, with the nose pointing directly for-ard and the head turned to the contralateral side to the

xtent that the patient can tolerate. The C1-C2 rotationalngle is assessed at each position. In subtype I AARF there iso motion between C1 and C2. In subtype II AARF, the1-C2 rotational angle will decrease but never approach zeroespite maximal contralateral neck rotation. In subtype IIIARF, the C1-C2 rotational angle will reduce to zero but onlyith rotation of the head greater than 20° past midline to the

ontralateral side. A fourth group of patients demonstratedndeterminate pathology between subtype III AARF andormal.Delays in treatment of AARF lead to worsening C1-C2

dherence. Severity and chronicity of AARF are both inde-endently associated with more difficult and longer treat-ent, a greater chance of recurrence, higher rates of irreduc-

bility, greater need for surgical stabilization, and higher ratesf complete C1-C2 motion segment loss.77 Chronic subtype IARF patients should undergo halo ring traction, followedy halo vest immobilization for 3 months. Chronic subtype IIatients should undergo halter or halo traction followed byalo vest immobilization for 3 months. Subtype III AARFhould undergo halter traction, followed by immobilizationn a cervicothoracic orthosis for 3 months. First recurrencesn the orthosis are treated with repeat traction and immobi-ization. During or after halo vest immobilization, irreducibleeformity or recurrence is treated with surgical fusion of

Figure 7 Superimposed C1-C2 motion curves from 18 nposition relative to body. Y-axis denotes rotational angstraight forward) to 23° head rotation, C1 rotates indepeC1, albeit more slowly. At 65° head rotation, a fixed anglrotation from 65° to 90° is characterized by lock-step momobility. Reprinted with permission from Lippincott W

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dontoid Injuriesn children aged �7 years, odontoid injuries are typicallyvulsions of the synchondrosis between the body of C2 andhe dens (Fig. 8).29-31,78 Falls and high-speed motor vehicleccidents, especially with children secured in forward-facingar seats, have been implicated in this injury pattern.79 Manyatients with odontoid synchondrosis are neurologically in-act because a high cervical spinal cord injury is otherwiseatal. Lateral x-rays often show an anteriorly displaced odon-oid peg.80 Reconstructed CT images may show widening ofhe synchondrosis.

Epiphyseal injuries appear to have a high likelihood ofealing with closed reduction and immobilization. Severaluthors have used halo or plaster cast immobilization as first-ine treatment, with most patients achieving stable fu-ions.78-80 This management strategy preserves the motionegment and avoids surgery in this very young population.1-C2 fusion may be necessary when nonoperative treat-ent fails.

ubaxial Ligamentous Injuriesnjuries to the subaxial cervical spine have been reported6,81

n children aged �8 years but are generally rare. As the pe-iatric spine matures toward adultlike biomechanics, sub-xial injuries become more common, with an increasing pro-ortion of bony rather than ligamentous injuries.The severity of subaxial soft tissue and ligamentous inju-

ies varies. Mild forms may present with neck pain but nobnormality on CT or dynamic plain films of the cervicalpine. More severe injuries may be associated with wideningf facet joints, widening or collapse of the disk space, andeparation of the spinous process. Short T1-weighted inver-

atients. X-axis denotes head position and therefore C1een C1 and C2. From 0° (defined by the head facing

ly of an immobile C2. From 23° to 65°, C2 rotates withof C1-C2 rotational separation is reached. Further headC1 with C2 and results wholly from subaxial rotationaland Wilkins.72

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ion recovery (STIR) MRI sequences delineate ligamentous,

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oft tissue, joint capsule, and epiphyseal end plate injury butay not correlate well with cervical stability.60 White and

anjabi81 have suggested that �11° angulation and/or 3.5m of subluxation between adjacent vertebrae imply signif-

cant ligamentous injury, with the likelihood of instability.n the basis of unpublished data from Pang, Ware et al27

igure 8 (A) Sagittal CT of a 3-year-old boy who was a restrainedassenger in a motor vehicle accident shows disruption of the syn-hondrosis between the odontoid process and body of C2. Note theidening of the posterior elements of C1 and C2. (B) Sagittal short1-weighted inversion-recovery (STIR) MRI confirms fracturecross the odontoid synchondrosis and posterior ligamentous in-ury at C1-C2. Reprinted with permission from Barrow Neurologicalnstitute.

ave suggested that �7° of kyphotic angulation between ad- b

acent vertebral bodies in the pediatric spine implies unstableigamentous injury. This poor tolerance for angulation re-ects the increased recoil forces within the intact pediatricervical spine.

Soft-tissue and ligamentous injury without radiographicbnormality on CT or dynamic x-rays is managed with anal-esics and a soft collar, as necessary. If neck pain limits suf-cient excursion on dynamic films, the patient is placed in aard cervical collar and re-evaluated with dynamic films after2-week interval.Patients with more substantial soft-tissue and ligamentous

njury with evidence of widened facet joints, disk spaces, orpinous processes need to be evaluated carefully. Pennecot etl82 reported that 8 of 11 patients with such injuries managedith reduction and a collar required surgical fusion for insta-ility. MRI may help to delineate the extent of injury and

nfluence management. If nonoperative management is un-ertaken, we recommend hard-collar immobilization andeticulous long-term follow-up with dynamic x-rays to eval-ate for late instability. Any neurologic deficits resulting frompinal column instability should be treated with operativetabilization.

Unilateral or bilateral facet dislocation is a relatively com-on injury pattern of the adolescent pediatric cervical spine.

t is caused by a flexion-distraction mechanism and completeisruption of facet capsules. In a patient with bilateral

umped facets and motor-complete spinal cord injury, we usemergent manual reduction followed by immediate MRI tovaluate for an epidural hematoma or herniated disk. In aeurologically intact patient with jumped facet(s), we firstbtain an MRI to evaluate for a herniated disk or hematomaithin the canal. In the absence of such a lesion, the patient islaced in tongs or halo traction for closed reduction of theeformity. In patients with motor-incomplete spinal cord

njury and jumped facet(s), we immediately obtain an MRI tovaluate for disk material or hematoma within the spinalanal. In their absence, manual or weighted traction can besed to reduce the deformity, based on the severity of motor

njury. In all cases anterior and/or posterior surgical stabili-ation at the level of injury is necessary. Surgery should bendertaken on an emergent basis to treat compressive pa-hology within the spinal canal.

pinal Cord Injuryithout Radiographic Abnormality

he syndrome of SCIWORA was described by Pang and Wil-erger in 1982.83 The incidence of SCIWORA in pediatricatients with spinal cord injury has been estimated to beetween 5% and 67%.84 A meta-analysis conducted by Panglaces this number at about 35%.84 In younger patients, fallsnd pedestrian–motor vehicle accidents are a common causef SCIWORA. In adolescents, sports injuries and motor ve-icle accidents are more common. In neonates, hyperflexionnd hyperextension resulting from child abuse can lead toevastating SCIWORA.The pathophysiologic basis for SCIWORA is the hypermo-

ility of the pediatric cervical spine. When subjected to trau-

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atic hyperflexion, hyperextension, or distraction, the spineecoils to its physiological state, while the spinal cord, withittle tolerance for deformation, sustains varying amounts ofnjury.84,85 Spinal cord ischemia from vertebral artery injuryas also been proposed as an underlying mechanism.49 Pa-ients present with a spectrum of neurologic manifestationsanging from mild transient sensory symptoms to quadriple-ia. Children aged �8 years are considerably more likely toave more rostral and severe SCIWORA than older chil-ren.49,86 In 8- to 16-year-olds, SCIWORA tends to occur at

ower levels and to be less severe than in younger chil-ren.49,86,87

Fundamental to the definition of SCIWORA is the absencef abnormality on static and dynamic flexion/extension films,T imaging, and x-ray or CT myelography. Also excluded are

njuries from penetrating trauma, obstetric complications,nd electric shock. MRI enables superior characterization ofoth the spinal cord and surrounding nonosseous supporttructures.

Pang84 reported the high prognostic utility of MRI in 50CIWORA patients. At presentation, MRI findings within thepinal cord were divided into major hemorrhage, minoremorrhage, edema, and no-abnormality categories. Patientsith major hemorrhage on MRI presented as Frankel gradesand C (severe deficits) and remained at this level of impair-ent for long term. Patients with minor spinal cord hemor-

hage also presented as Frankel grades B and C, but 40%mproved to grade D at 6 months. Of patients with edemanly, 44% presented as Frankel grade B and C and 56%resented as grade D (minor deficits). At 6 months, 75% ofatients who had presented with edema only were Frankelrade D and 25% were grade E (normal). There were no MRIndings in 23 patients with clinical SCIWORA. These pa-ients universally made a complete recovery.

MRI is useful in characterizing non-neural injury to theervical ligamentous and soft tissues in SCIWORA. Injurieso the anterior and posterior longitudinal ligaments, epiphy-eal growth plate, facet joints, tectorial membrane, and diskpaces have been documented on MRI.84 Pang84 proposedhe concept of “occult” instability of the spine in SCIWORAatients, even in the setting of normal dynamic films withufficient excursion. In occult instability, the ligamentousnd soft-tissue structures are injured but not destroyed. Theyre able to withstand moderate physiologic forces but areulnerable to significant stress. The published articles pro-ide scant direct evidence for this concept,86 but occult in-tability is proposed as a possible cause of the delayed neu-ologic deterioration that has been reported in SCIWORAatients.84,87,88 Occult instability has also been implicated inecurrent SCIWORA.89 In this entity, a minor trauma after annitial SCIWORA episode causes recurrent symptoms. Os-ensibly, the injured spinal cord is more vulnerable to recur-ent injury and the weakened non-neural structures may fa-ilitate the recurrence.

In the clinical setting of SCIWORA, MRI can be completelyormal.58,59 Pang reported that MRI was positive in 64% ofediatric SCIWORA patients with persistent motor deficits

asting more than 24 hours, in 27% of patients with deficits R

asting fewer than 24 hours, and in 6% of patients with onlyensory symptoms. Pang and coworkers89 advocate repeatingRI at 6 to 9 days after injury because edema may take 3 tohours to develop after the initial insult, and small foci of

emorrhage within the spinal cord may not manifest untilonverted to methemoglobin.

Cervical immobilization of patients with SCIWORA is con-roversial. If dynamic films sufficiently demonstrate stability ofhe cervical spine, the role of cervical immobilization is un-lear.90 Pang and Pollack85 advocated 12 weeks of immobiliza-ion in a Guilford brace to allow ligamentous injuries to heal ando prevent recurrent SCIWORA. Bosch et al91 reported that rigidraces, including the Guilford, Aspen, Miami J, and Minervaast, did not prevent recurrent SCIWORA. They questioned theheory of occult instability as a causative factor.91 In the setting ofnly extraneural MRI findings, neurologic recovery, and noeck pain, we recommend hard collar immobilization for 2eeks followed by dynamic films. With neural findings on MRI,2 weeks of immobilization followed by dynamic films are ap-ropriate.

ervical Cord Neurapraxiaervical cord neurapraxia, also known as spinal cord concus-

ion or a stinger, likely represents a mild form of SCIWORAhat occurs in athletes playing contact sports. Sensory andotor symptoms involving both arms, both legs, or all 4

xtremities can occur.92 The symptoms usually last 10 to 15inutes but can persist for as long as 48 hours.93 In adult

igure 9 Postoperative lateral radiograph of a 3-year-old girl withoth occipitoatlantal and atlantoaxial dislocation fixated via an oc-ipital keel screw, C1 lateral mass screws, and C2 pars screws.
eprinted with permission from Barrow Neurological Institute.

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thletes, cervical cord neurapraxia is often related to cervicaltenosis. The relative risk of an athlete sustaining cervicalord neurapraxia a second time increases exponentially com-ared to the risk of sustaining cervical cord neurapraxia therst time.94 Boockvar et al95 reported 13 children, aged 7 to5 years, with cervical cord neurapraxia, but with no evi-ence of spinal stenosis. In this population, cervical cordeurapraxia was attributed to cervical hypermobility. Mostatients were managed with 2 weeks of cervical immobiliza-ion in a hard cervical collar followed by dynamic films. At aean follow-up of 15 months after injury, all children had

eturned to sports without restriction, with no recurrence ofervical cord neurapraxia or neck pain.

eonatal Injurieshe incidence of birth-related spinal cord injuries is about 1

n 60 000.96 The upper cervical spine is most susceptible tonjury97 and is associated with cephalic presentation and these of forceps.97,98 Infants present with flaccidity and absencef spontaneous motion. Injured infants who do not makeespiratory efforts during the first day of life tend to remainependent on ventilators.24,96 Spinal immobilization with ahermoplastic-molded device spanning from the occiput tohe thorax has been used in the management of this difficultroblem.24

s Odontoideums odontoideum is a well-corticated odontoid process that lacks

ontinuity with the body of C2. Both traumatic and congenitalauses of os odontoideum have been documented.99,100 Twonatomic subsets of os odontoideum exist: orthotopic and dys-opic. An orthotopic os moves with C1, whereas a dystopic oss fixed to the basion. Patients can present with occipitocer-ical pain, myelopathy, or vertebrobasilar ischemia.101 Theatural history of os odontoideum has not been adequatelyefined, leading to significant controversy about its appro-riate management.The initial diagnosis can easily be made with lateral plain

lms. Multiple authors have reported that the degree of1-C2 instability on flexion-extension x-rays does not corre-

ate with the presence of myelopathy.102-104 However, theseuthors have also reported that a sagittal diameter of thepinal canal � 13 mm on plain x-rays is strongly associatedith myelopathy.102,104

Spierings and Braakman102 reported nonoperative man-gement of 16 patients with os odontoideum without my-lopathy. At a median follow-up of 7 years, no patient haduffered neurologic deterioration. As an option, the Guide-ines for the Management of Acute Cervical Spine and Spinalord Injuries suggest that patients without neurologic defi-its, but with instability at C1-C2 on flexion-extension stud-es, can be managed without surgical intervention.101 Givenhe potential for neurologic injury in children with os odon-oideum resulting from minor trauma,105 Brockmeyer be-ieves that the risks of untreated os odontoideum outweigh
he risks of C1-C2 fusion.106 s
perative and Nonoperativeanagement Considerations

any pediatric cervical spine injuries can be treated withalo or hard collar immobilization.87,107 Indications for sur-ical intervention include an unstable injury, irreducibleracture or dislocation, progressive neurologic deficit fromompression, and progressive deformity.6,107,108 Within theast decade, the percentage of pediatric cervical spine traumaatients managed surgically has increased because of ad-ances in fixation systems and techniques.6,108 Surgical sta-ilization of the spine, combined with early mobilization ofediatric patients with a spinal cord injury, likely reduces theisk of deep venous thrombosis, decubitus ulcers, and respi-atory infections.108,109

Historically, pediatric cervical spinal fusion was limited toosterior bone and wire techniques followed by halo or cer-icothoracic immobilization. These techniques have a higherate of failed fusion than contemporary rigid fixation tech-iques.108,110,111 However, the smaller anatomy and greaterroportion of cartilage in the young pediatric spine demandreat accuracy in the placement of any screw. Additionaloncerns in pediatric spine fusion are the development ofdjacent level disease and the “crankshaft” phenomenonharacterized by continued growth of bone at fixated levels,esulting in a deformity.

ccipitocervical Surgical Stabilizationccipitocervical fusion with threaded contoured rods andiring has proved effective in stabilizing the adult craniocer-ical junction.112 Schultz et al113 advocated this technique inhildren aged �12 months, suggesting that the rigidity af-orded by this method may eliminate the need for a halo. Weave successfully used this technique in children as young as1 months.114 Several authors have also used C1-C2 transartic-lar screws or C2 pedicle screws coupled with rigid loops andlate or rod constructs in pediatric patients, with excellent suc-ess.106,109,115 We have also used keel screws coupled with C1ateral mass screws and C2 pars screws for occipitoatlantoaxialtabilization in young pediatric patients (Fig. 9).

tlantoaxial Surgical Stabilizationonventionally, atlantoaxial fusion in the pediatric popula-

ion has been achieved by posterior wiring, using Sonntagnd Gallie-type constructs.116,117 Gluf and Brockmeyer109 re-orted 67 pediatric patients who underwent C1-C2 transar-icular screw fixation. Of these 67 patients, 65 developeduccessful fusion without application of a halo. Two unilat-ral vertebral artery injuries occurred without permanenteurologic deficit. There were 4 infections and 1 hardwareailure attributed to a novel fixation device. The authors suc-essfully placed transarticular screws in 13 patients aged �4ears, the youngest being 18 months old. Brockmeyer106 em-hasized the importance of obtaining preoperative multipla-ar reconstructions of thin-cut CT scans to determine theppropriate screw size, its entry point, and its trajectory. In a
eries of more than 50 patients who underwent C1-C2 trans-

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rticular fixation, growth was arrested at the fused atlantoax-al level and no craniovertebral deformities developed.106

ubaxial Surgical Stabilizationnterior and posterior subaxial instrumentation and tech-iques are increasingly being used for pediatric applications.o date, there has been little rigorous examination of the usef these techniques in children. Short stature and low-profilenterior plating systems have been placed in children asoung as 3 years of age.106 Small vertebral bodies and carti-aginous endplates provide little margin for error while plac-ng anterior screws in young children.106 Shacked et al118

uccessfully used the anterior cervical approach for autograftrthrodesis of cervical segments in 6 pediatric trauma pa-ients. No instrumentation was placed, but the patients un-erwent postoperative rigid immobilization in a halo or Min-rva cast. Posterior instrumentation is also limited by theonstraints of small anatomy. Brockmeyer106 reported thatedicle or lateral mass screws can be placed in children asoung as 4 years of age. In very young patients, posteriorone and wiring techniques followed by immobilization maytill represent the best treatment option.

one Graftsutograft has been shown to be superior to allograft for use inosterior cervical fusion constructs.119,120 Much of this workredates the current era of rigid internal fixation. Compositeone grafts, consisting of demineralized bone matrix andspirated bone marrow, may reduce morbidity and stillaintain the rates of fusion associated with iliac crest au-

ograft.121 Options for autograft harvest in pediatric patientsnclude the iliac crest, rib, and split-thickness and full-thick-ess calvarial grafts. In young children, iliac crest harvest mayot provide sufficient bone. Both iliac crest and rib harvestan cause severe postoperative pain, the latter potentiallyesulting in postoperative splinting. Chadduck and Boop122

ave advocated rostral extension of the posterior midlineervical incision and harvest of parietal bone. The lambdoiduture may not be ossified and should not be incorporated inhe graft.

raction and Immobilization Deviceshe use of traction in young children has not been well stud-

ed.24 The thin calvarium in this population increases the riskf skull penetration with pin placement. Low body weightecreases resistance to traction, and lax ligaments and under-eveloped musculature increase the risk of overdistraction.iparietal sets of bur holes with 22-gauge wire have beensed to achieve skull purchase in infants.123 For slightly olderhildren, the use of a halo ring with 8 to 10 pins may beppropriate. Weight should be administered judiciously,ith frequent neurologic examinations and radiographic im-

ging.Halo immobilization has been reported in children as

oung as 7 months old, with 10 pins placed to finger-tight-ess only.124 Children aged 16 and 24 months were also

mmobilized successfully in halos, with 2 foot-pounds of

orque applied at each of 10 pins.124 Minor complications,uch as pin site infections are common.125 Mandabach et al78

eported successful fusion of 8 of 10 odontoid epiphysealractures managed in a halo. This group recommends 1 foot-ounds of torque per year of age until 5 foot-pounds iseached. The thermoplastic Minerva body jacket is an alter-ative to halo immobilization in very young children. Thisevice permits 2.1° of flexion-extension compared to 1.3°ith a halo vest.78 No pins are used, and no artifact is createdn MRI or CT.

onclusionsppropriate management of cervical spine trauma in childrenequires an understanding of the unique anatomic, biomechani-al, radiographic, and pathophysiologic characteristics of pedi-tric patients. Almost all published articles on this subject arelass III standard. There are many areas for further study, in-luding the use of steroids in pediatric spinal cord injury, opti-ization of neck clearance in head-injured pediatric patients,

nd the appropriate management of SCIWORA. The relativearity of pediatric cervical spine injuries demands multicenternvolvement for well-designed studies.

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Cervical Spine Injuries in Children: Attention to … · Cervical Spine Injuries in Children: Attention to Radiographic Differences and Stability Compared to Those in the Adult Patient