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

Pediatric C-Spine InjuriesPediatric 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

Inspiration Yet Reality

Objectives


– 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 10Femur Fracture 8Hemoperitoneum 6Tibial Fracture 5Arm Fracture 4Rib Fracture 3Splenic Laceration 3Ruptured Kidney 2Pelvis Fracture 2Clavicle 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 partOrestein et al.

Objectives


– Cases

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)

Objectives


– Cases

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 evaluationYes






Immobilization Techniques


– 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

Objectives


– Cases

• 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

10296

9084

7872

6660

5448

4236

3024

1812

60

Num

ber

1000

800

600

400

200

0


Age distribution in years - All Nexus Patients

10296

9084

7872

6660

5448

4236

3024

1812

60

Num

ber

1000

800

600

400

200

0


n = 3,065 n = 31,004

N = 34,069

600

Age distribution in years

17161514131211109876543210

# of

pat

ient

s

500

400

300

200

100

0


Age Distribution of Pediatric Patients

N = 3,065

600


17161514131211109876543210

# of

pat

ient

s

500

400

300

200

100

0



N = 3,065

<2 y.o., n = 88

600


17161514131211109876543210

# of

pat

ient

s

500

400

300

200

100

0



N = 3,065

2-8 y.o., n = 817

<2 y.o., n = 88

600


17161514131211109876543210

# of

pat

ient

s

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



Tenderness 21 4 5


Altered LOC 6 21 3

Intoxication 0 27 3





Tenderness 21 4 5


Altered LOC 6 21 3

Intoxication 0 27 3





Tenderness 21 4 5


Altered LOC 6 21 3

Intoxication 0 27 3





Tenderness 21 4 5


Altered LOC 6 21 3

Intoxication 0 27 3





Tenderness 21 4 5


Altered LOC 6 21 3

Intoxication 0 27 3





Tenderness 1179 1333 523


Altered LOC 520 2326 189

Intoxication 110 2730 195


Of the 3,035 children without c-spine injuries


NEXUS : Study ResultsAge Sex Fracture type2 F C2 type III odontoid fracture3 M Occipital condyle fracture6 M Cranio-cervical dissociation8 M C1 & C2, fractures9 M C4 flexion tear drop fracture11 M Cranio-cervical dissociation11 F C7 burst fracture11 M C5 body fracture11 M C1 lateral mass fracture12 F C2 spinous process fracture13 M C6 spinous process fracture14 M C7 wedge compression 14 F C4 - C5 subluxation, C5 - C6 subluxation, C5 body and,posterior element fractures, C4-6 cord contusion16 F C7 compression fracture16 F C6 - C7 fracture 16 M C6 burst fracture and bilateral laminar fractures, C7 body fractures16 M C5 burst fracture and bilateral laminar fractures; C5 – C6 subluxation16 M C5 body fracture; C5-6 sublux16 M C5 & C6 trabecular fractures, C3 - C7 interspinous ligament injury16 M C6 facet fracture; C6 compression fracture; C5 – C6 interfacetal dislocation; C5 – C6 cord contusion16 M C1 posterior arch fracture16 M C4 compression fracture; C3 – C4 subluxation; C3 – C4 cord contusion16 F C4 burst fracture; C4-C5 subluxation; C4-C5 cord contusion17 M C7 spinous process fracture17 F C7 body fracture17 M C6 - C7 facet and capsular injury17 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 788Injury 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

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

Canadian c-spine algorithm

Objectives


– Cases

• 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


• 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


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)




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)





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)





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)





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)





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)


Objectives

• Epidemiology• Anatomy: Pediatric versus Adult• Who should be immobilized• Clinical versus radiograph clearance

– NEXUS Study– Canadian Rules

• CT versus Plain Films• Interpreting the cervical spine radiograph

– 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 neck1. 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


spine– Count 7 cervical bodies,

and 1 thoracic body




and 1 thoracic body




and 1 thoracic body




and 1 thoracic body




and 1 thoracic body




and 1 thoracic body




and 1 thoracic body




and 1 thoracic body


Alignment• C-Spine Curves



– Anterior Vertebral Bodies



– Anterior Vertebral Bodies– Anterior Spinal Canal



– Anterior Vertebral Bodies– Anterior Spinal Canal – Posterior Spinal Canal



– Anterior Vertebral Bodies– Anterior Spinal Canal – 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







– 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– Space between Dens

of C2 and anterior, interior side of C1 ring

Pre-Dental Space– Space between Dens of

C2 and anterior, interior side of C1 ring

– Must be less than or equal to 5 mm

– Cause of increased space

• transverse ligament injury • burst fracture of C1


Objectives

• Epidemiology• Anatomy: Pediatric versus Adult• Who should be immobilized• Clinical versus radiograph clearance

– NEXUS Study– Canadian Rules

• CT versus Plain Films• Interpreting the cervical spine radiograph

– Cases

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 locFever, sore throat, strep positive yesterdayNot tolerating liquids or solid food

Temperature=104Alert, awake and talking with hoarse voiceDrooling, mild increased work of breathingHe 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

POSTERIORANTERIOR


ANTERIOR

POSTERIORANTERIOR


ANTERIOR

POSTERIORANTERIOR


ANTERIOR

POSTERIORANTERIOR


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

• Anatomy: Pediatric versus Adult

• Who should be immobilized

• Immobilization Techniques

• Clinical versus radiograph clearance

• CT versus Plain Films

• Interpreted the cervical spine radiograph

Documents

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