Pediatric Cervical Spine Injury

Oh, once again, Homer is correct! Physics does matter. As does Anatomy and Physiology with respect to caring for children. We’ve previously discussed how these aspects have significance when evaluating ill and injured children (ex, Thoracic Trauma, Abdominal Trauma), but a recent post on the hazards of children sitting in the front seat of cars has brought to mind another condition that warrants specific consideration Pediatric Cervical Spine Injury. With adults it is relatively straight forward; apply your favorite validated screening tool and if your patient needs imaging, obtain a CT. With children, it isn’t as “simple.” Fortunately, my friend and colleague, Dr. Emily MacNeill has spent some time pondering this and can help us decipher the issue of Pediatric Cervical Spine Injury:

Cervical Spine Injury: Basics

  • Fortunately, cervical spine trauma is rare in children! [Gopinathan, 2018; Leonard, 2014]
    • Accounts for only 1-10% of all spinal injuries.
    • Of pediatric spinal injuries, however, the cervical spine is involved in 60-80% of the time.
  • The majority of c-spine injuries in children occur between the Skull and C4! [Gopinathan, 2018]
    • Many involve C1 and C2.
    • Atlanto-Axial injuries are more common in children than adults
  • Age-related Mechanisms
    • Young infants and Toddlers (Can’t protect themselves)
    • School age children and Adolescents (Put themselves in harm’s way)
      • Motor Vehicle Collisions
      • Sport-Related Injuries become very prevalent [Babcock, 2018]
        • Higher Risk Sports:
        • Non-organized “Rough Play” around the house is also found to be a risk factor.
    • Non-accidental trauma is also, sadly, a well known mechanism.

Cervical Spine Injury: Anatomy Matters

  • Young Child Anatomy & Injury Predisposing Characteristics: [Gopinathan, 2018; Baumann, 2015; Leonard, 2014]
    • Relatively larger head size to body
      • Leads to Higher fulcrum
      • Leads to Higher cervical spine level of injury
    • Elastic / Flexible spinal column
      • The spinal column can be distracted by 5cm without structural injury.
      • Unfortunately, the Spinal Cord cannot!
      • Leads to Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) – so imaging the bones may not be good enough.
    • Poor Musculature – less protection
    • Open Ossification Centers
      • Can make interpretation of images more challenging (just like that elbow film)
        • The Atlas vertebrae has 3 ossification centers that don’t fuse until 7 years of age.
        • The Dens has 2 ossification centers that don’t unite until 5-7 years of age.
      • Can have growth plate injuries!
    • Horizontally oriented vertebral facet joints and Physiologic Wedging of the vertebral bodies – greater incidence of dislocation!
  • As a child matures, the above factors alter changing of the Fulcrum position over time. [Gopinathan, 2018; Baumann, 2015]
    • Infant: ~C2-C3
    • 5 yo: ~C3-C4
    • 10 yo: ~C4-C5
    • Adult: ~C5-C6
  • Pediatric patients are often characterized in studies as belonging to one of 3 groups with respect to cervical spine evaluation:
    • < 3 year olds
    • 3 – 8 year olds
    • 9 – 17 year olds

Cervical Spine Injury: Conundrum

  • Evaluation of pediatric c-spine is challenging!!
    • Spinal cord injury is rare in children overall.
    • Young children cannot communicate effectively.
    • It is known that children with C-spine injury can, occasionally, be asymptomatic initially. [Gopinathan, 2018; Hale, 2015]
    • Mechanisms and Anatomy change with age.
    • C-Spine clearance “Rules” for Adults do NOT fit all children well. [Gopinathan, 2018; Slaar, 2017; Baumann, 2015]
      • NEXUS – only 1.3% of spine injuries in study were in kids 8 years or younger, but does perform well in 9-17 year olds!
      • Canadian C-Spine Rule – included NO patients <16 years
      • Both have been studied retrospectively and can perform reasonably well for older children.
    • PECARN C-spine Injury Risk Factors have not yet been validated.
      • 8 Risk Factors (when ALL absent, 98% sensitive). [Leonard, 2011]
        • Altered Mental Status
        • Focal Neurologic Findings
        • Substantial Torso Injury
        • Neck Pain
        • Torticollis
        • Conditions Predisposing to Cervical Injury
        • Diving
        • High-Risk Motor Vehicle Crash
    • Plain Films are decently sensitive for young children. [Cui, 2016; Nigrovic, 2012]
    • CT imaging images the bones better, but injury in children is often not bony so they add unnecessary radiation to the equation.
    • SCIWORA exists!
    • MRI is costly and often requires sedation.
  • Simply put… we are not going to be 100% sensitive… but let’s not be defeatist.
    • Consider High Risk Mechanisms: [Gopinathan, 2018; Baumann, 2015]
      • High Risk Motor Vehicle Collision (fatality, rollover, speed >55mph, ejection, head-on collision)
      • Diving (or axial load) injury
      • Fall > 10 feet
      • Non-Accidental Trauma
    • Consider Patient Specific Risk Factors (ex, Down’s Syndrome and other Musculoskeletal disorders) [Gopinathan, 2018]

Cervical Spine Injury: Proposed Evaluation

  • Children < 3 years of age
    • Obtunded? – Obtain CT +/- MRI
    • Alert?
      • If Normal Exam and Low Mechanism
        • Do a thorough exam!
        • Discuss low risk with family.
        • Consider clearing clinically or with plain films [Cui, 2016; Nigrovic, 2012]
      • If Neurologic abnormality – Obtain MRI
      • Obtain CT if: Torticollis, Substantial Torso Injury, High Risk Mechanism, Not Properly Restrained, Predisposing Patient Factors (ex, Down’s Syndrome), or obtaining head CT.
  • Children 3 – 8 years of age
    • Obtunded? – Obtain CT +/- MRI
    • Alert?
      • Apply NEXUS (or PECARN).
        • If negative, remove collar.
        • If positive, Neuro symptoms (ex, hands “burning”) or findings? Then MRI!
        • If positive, but no Neuro symptoms / findings, consider Plain Films or LIMITED CT (from skull to C3). [Hannon, 2015; Nigrovic, 2012]
  • Children 9 years and older
    • Obtunded? – Obtain CT +/- MRI
    • Alert?
      • Apply NEXUS or Canadian. [Slaar, 2017; Baumann, 2015]
      • If positive, Neuro symptoms (ex, hands “burning”) or findings? Then MRI!
      • If positive, but no Neuro symptoms / findings, consider Plain Films or CT.

Moral of the Morsel

  • Anatomy Matters! The spinal column is more flexible than the spinal cord! Don’t overlook SCIWORA and those subtle neurologic symptoms.
  • Physics Matters! That fulcrum is really high for the very young, and gradually moves caudally… consider limited CT (skull to C3) for 3-8 year olds who you want to CT.
  • Plain films are still en vogue! You can use them to screen low risk patients.
  • CTs are of less value in the very young!
  • Have a plan! Since there is no validated strategy for clearing children’s c-spine, it is good to have an institutional plan!

References

Babcock L, Olsen CS1, Jaffe DM2, Leonard JC3; Cervical Spine Study Group for the Pediatric Emergency Care Applied Research Network (PECARN). Cervical Spine Injuries in Children Associated With Sports and Recreational Activities. Pediatr Emerg Care. 2018 Oct;34(10):677-686. PMID: 27749628. [PubMed] [Read by QxMD]
Fisher JD, Thorpe EL1. Bilateral Upper Extremity Hyperesthesia and Absence of Neck Tenderness in Four Adolescent Athletes With Cervical Spine Injuries. Pediatr Emerg Care. 2018 Oct;34(10):e178-e180. PMID: 28121977. [PubMed] [Read by QxMD]
Gopinathan NR1, Viswanathan VK2, Crawford AH3. Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts. Indian J Orthop. 2018 Sep-Oct;52(5):489-500. PMID: 30237606. [PubMed] [Read by QxMD]
Slaar A1, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NW, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database Syst Rev. 2017 Dec 7;12:CD011686. PMID: 29215711. [PubMed] [Read by QxMD]
Cui LW1, Probst MA2, Hoffman JR3, Mower WR4. Sensitivity of plain radiography for pediatric cervical spine injury. Emerg Radiol. 2016 Oct;23(5):443-8. PMID: 27321014. [PubMed] [Read by QxMD]
Hale DF1, Fitzpatrick CM, Doski JJ, Stewart RM, Mueller DL. Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger. J Trauma Acute Care Surg. 2015 May;78(5):943-8. PMID: 25909413. [PubMed] [Read by QxMD]
Leonard JC1, Jaffe DM, Olsen CS, Kuppermann N. Age-related differences in factors associated with cervical spine injuries in children. Acad Emerg Med. 2015 Apr;22(4):441-6. PMID: 25779934. [PubMed] [Read by QxMD]
Hannon M1, Mannix R2, Dorney K2, Mooney D3, Hennelly K2. Pediatric cervical spine injury evaluation after blunt trauma: a clinical decision analysis. Ann Emerg Med. 2015 Mar;65(3):239-47. PMID: 25441248. [PubMed] [Read by QxMD]
Baumann F1, Ernstberger T, Neumann C, Nerlich M, Schroeder GD, Vaccaro AR, Loibl M. Pediatric Cervical Spine Injuries: A Rare But Challenging Entity. J Spinal Disord Tech. 2015 Aug;28(7):E377-84. PMID: 26165728. [PubMed] [Read by QxMD]
Leonard JR1, Jaffe DM2, Kuppermann N3, Olsen CS4, Leonard JC5; Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Cervical spine injury patterns in children. Pediatrics. 2014 May;133(5):e1179-88. PMID: 24777222. [PubMed] [Read by QxMD]
Solin LJ1, Fowble BL, Schultz DJ, Goodman RL. Bilateral breast carcinoma treated with definitive irradiation. Int J Radiat Oncol Biol Phys. 1989 Aug;17(2):263-71. PMID: 2546905. [PubMed] [Read by QxMD]
Henry M1, Riesenburger RI, Kryzanski J, Jea A, Hwang SW. A retrospective comparison of CT and MRI in detecting pediatric cervical spine injury. Childs Nerv Syst. 2013 Aug;29(8):1333-8. PMID: 23584614. [PubMed] [Read by QxMD]
Nigrovic LE1, Rogers AJ, Adelgais KM, Olsen CS, Leonard JR, Jaffe DM, Leonard JC; Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children. Pediatr Emerg Care. 2012 May;28(5):426-32. PMID: 22531194. [PubMed] [Read by QxMD]
Leonard JC1, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, Adelgais KM, Anders J, Borgialli D, Donoghue A, Hoyle JD Jr, Kim E, Leonard JR, Lillis KA, Nigrovic LE, Powell EC, Rebella G, Reeves SD, Rogers AJ, Stankovic C, Teshome G, Jaffe DM; Pediatric Emergency Care Applied Research Network. Factors associated with cervical spine injury in children after blunt trauma. Ann Emerg Med. 2011 Aug;58(2):145-55. PMID: 21035905. [PubMed] [Read by QxMD]
Easter JS1, Barkin R, Rosen CL, Ban K. Cervical spine injuries in children, part I: mechanism of injury, clinical presentation, and imaging. J Emerg Med. 2011 Aug;41(2):142-50. PMID: 20493655. [PubMed] [Read by QxMD]
Easter JS1, Barkin R, Rosen CL, Ban K. Cervical spine injuries in children, part II: management and special considerations. J Emerg Med. 2011 Sep;41(3):252-6. PMID: 20493656. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. Jonathan Cohen says:

    Thank you Dr. Fox for your winderful morsels! I did have a interesting case several months ago. I want to remind folks to not forget about vertebral artery dissection with neck trauma. Although much more common in adults. I did have a case several months ago with a 1 yr that fell down 3 steps. Fortunately the patient is doing well today.

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