Pediatric C-Spine Injury

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Pediatric C-Spine Injury

• Joshua Rocker, MD
• Schneider Childrens Hospital
• LIJ Medical Center

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• Anatomical Considerations
• Embryology
• Risk Factors
• Causes of Injury
• Immobilization
• Symptoms and Physical Exam
• Radiography
• Prediction Rules

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Anatomical Considerations
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Children lt8 years old

• Relatively larger heads than body
• Head circumference 50 adult by 2 yrs vs
  chest circumference, 8 yrs

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Children lt8 years old

• Cervical spine fulcrum
• Moves caudally
• C2-C3 at birth
• C5-6 at 8 yr and older

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Children lt8 years old

• Weaker cervical musculature and increased laxity
  of ligaments
• Immature vertebral joints
• Horizontally inclined articulating facets
• Facilitate sliding of upper c-spine

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Childrens C-spine Injuries

• More susceptible to
• fractures through growth plates
• ligamentous injuries
• Why
• Growth centers fragile to sheer forces during
  rapid decel or flex/ext
• (particularly at the synchondrosis b/n odontoid
  and body of C2)

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SCIWORA

• Spinal Cord Injury without Radiological
  Abnormality
• Theoretical increase risk in children
• Young spinal column more elastic than spinal
  cord- can handle more distraction before rupture
• 5cm vs 5-6mm

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Children 8yrs and older

• Equivalent to adult
• Most injuries to vertebral bodies and arch
• Lower C-spine

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Embryology and why pediatric C-spines are
difficult to interpret
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Embryological Considerations

• C1 (Atlas) formed by 3 ossification sites
• Anterior arch and 2 neural arches

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Embryology C1

• Anterior arch fuses with neural arches by 7 yrs.
  Before this non-fusion can be mistaken as fracture

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Embryology C2

• C2 (Axis) has four ossification centers
• 2 neural arches
• 1 for the body
• 1 odontoid

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Embryology C2

• Body fuses with dens at 3-6 yrs
• The fusion line or remnant of cartilagenous
  synchondrosis can be seen till 11 yrs

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Embryology C3-C7

• Same developmental pattern
• 3 ossification centers
• Neural arches fuse posteriorly 2-3 yrs
• Body fuses with arches 3-6 yrs

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Embryology

• Coronal view Notice synchondroses

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Predisposing risk factors
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Congenital abnormalities

• Downs Syndrome
• 15 with atlantoaxial instability

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Congenital abnormalities

• Klippel-Feil
• Fusion of cervical vertebrae

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Congenital abnormalities

• Morquio (MPS IV)
• No galctose 6-sulfatase
• Hypoplasia of odontoid

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Congenital abnormalities

• Larsens Syndrome
• skeletal dysplasia with multiple joint
  dislocations, short stature, abnormal facial
  features

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At Risk by History

• Spinal Cord surgery
• C-spine arthritis

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Causes of Injuries
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Causes of Injuries By age

• Infants
• Birth Trauma
• 1-8 yrs
• MVAs and falls
• gt 8 yrs
• Sports Injuries and MVAs

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Causes of Injuries

• Direct severe force to neck
• Diving
• Acceleration-deceleration

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Causes of Injuries Mechanism

• Hyperflexion
• Hyperextension
• Axial Load
• Roatational
• Blow to Chin

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Causes of InjuriesHyperflexion

• Most common
• Cause wedge fracture of anterior vertebral bodies
• Disruption of posterior elements
• Ex
• Clay-shovelers,
• anterior teardrop fracture

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Hyperflexion Clay-shovelers

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Hyperflexion Teardrop fracture of anteroinferior
portion of vertebral body

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Causes of Injuries Hyperextension

• Compression of posterior elements
• Disruption of anterior longitudinal ligament
• Ex
• Hangmans

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Hyperextension Hangmans Fracture
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Causes of injuries Axial Load

• Direct load on top of head
• May cause burst or comminuted fracture of C1.
• May also cause injury caudal to C-spine
• Ex
• Jefferson fracture

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Axial Load Jefferson fracture

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Causes of Injuries

• Rotational
• Usually associated with additional injuries
• Chin Trauma
• Fractures of posterior teeth and mandibular
  condyles seen as a single injury pattern

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Immobilization

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Indications

• Mechanism
• Severe force
• Diving
• Accel-dec

• PE
• AMS
• Neuro deficits
• Multi-system trauma
• Neck pain/tenderness
• Distracting injuries

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Ouch!!!!

• 3-25 of patients with SC injury develop
  neurological deficits caused by manipulation
  during resuscitation or transport

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Immobilize

• Neck- in collar
• Stif-Neck
• Philadelphia
• ProSplint
• Body- on long backboard

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Neutral Position

• Not well defined
• anatomical position of the head and torso that
  one assumes when standing and looking straight
  ahead
• External auditory meatus is in line with the
  shoulder in the coronal plane
• Supine without rotating or bending the spinal
  column ATLS

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Neutral Position

• Adults (gt8 yrs)
• Require occiput elevation (1.3-9.5, 2cm)
• Children
• Special allowance b/c relatively large heads
• Special peds boards with depressed area for head
• Elevate back with padding (2.5cm)

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Protocols

• Do not reduce obvious deformities
• Keep helmets in place unless need airway
• Log roll onto board with support of head/neck and
  torso
• Place wedges beside head to limit lateral movement

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Protocols Airway

• Jaw-thrust maneuver with in-line traction

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Protocol Surgical Airway

• Nasotracheal intubation
• Contraindicated apnea, facial injuries (?fx of
  cribiform plate)
• Orotracheal intubation with in-line stabilization
• Surgical airway
• Maxillofacial or laryngotracheal trauma

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Symptoms and Physical Exam
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Symptoms

• Classic Triad
• Local pain, muscle spasm and decreased ROM
• Transient or persistent parasthesias or weakness
• SCIWORA

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Symptoms

• Burning hands
• Seen with football players
• Transient burning in hands/fingers
• Hyperextension of C-spine with SC contusion
• Asymptomatic
• Significant mechanism or distracting injury

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Physical Exam

• Essentials
• Vital Signs
• Neuro
• Neck

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Physical Exam

• Vitals
• Apnea or hypoventilation
• Injuries to C3-C5
• Spinal Shock
• Hypotension, bradycardia, temperature instability

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Physical Exam

• Neuro exam
• Tone, strength, sensation and reflexes
• Up to 50 of children with C-spine injuries have
  neuro deficits

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Tone

• Loss of spontaneous breathing if injury above C4
• Hypotonia
• Lower motor neuron deficit
• Spinal shock

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Tone

• Rectal tone
• Absence- poor prognostic sign
• Bulbocavernous reflex (S3-S4)
• Squeezing glans, tapping on mons pubis, pulling
  on foley
• Stimulate trigone of the bladder ? reflex
  contraction of anal sphincter

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Strength

• Dorsiflexion of the wrist
• C6
• Extension of the elbow
• C7
• Extension of the knee
• L2-L4
• Dorsiflexion of the great toe
• L5

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Sensory

• Most common deficit with SC injuries
• Level of sensory impairment localizes level of
  injury

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Reflexes

• Areflexia indicates spinal shock
• Usually lasts less than 24 hours

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Specific Injuries

• Anterior Cord Syndrome
• Hyperflexion and anterior cord compression
• Paralysis and loss of pain WITHOUT loss of light
  touch or proprioception

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Specific Injuries

• Central Cord Syndrome
• Hyperextension Injuries
• Weakness greater in upper vs lower extremities

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Specific Injuries

• Brown-Sequard syndrome
• Cord Hemisection
• Ipsilateral
• Paralysis, Loss of proprioception and light touch
  
• Contralateral
• Loss of pain and temperature

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Specific Inuries

• Horners Syndrome
• Disruption of cervical sympathetic chain
• Ptosis, miosis and anhidrosis

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Neck Exam

• Maintain in-line stabilization
• Palpate spinous processes
• Assess muscle spasm
• Assess for deformities

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Radiography
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What to do?

• If your suspicion of injury is high
• get CT!!! (gt98 sensitive)
• If low to moderate
• get 3 view radiographs
• AP, cross table lateral, odontoid (open mouth)
• Lateral view identifies approx. 80-90 of fx,
  dislocations and subluxations

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Plain Radiographs

• Lateral
• Must visualize all 7 cervical vertebrae
• Include C7-T1 junction
• If difficult visualizing
• Gentle traction on arms (?)
• Transaxillary (swimmers) view

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Lateral view 4 curvilineal contour lines

• Anterior vert body
• Posterior vert body
• Spinolaminar line
• Tips of spinous
• processes

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Psuedosubluxation

• C2 on C3
• 20-40 of children
• C3 on C4
• 14

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Swischuk line

• line from the anterior
• aspect of C1-C3
• spinous processes
• anterior C2
• spinous process
• within 2 mm

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Soft tissue spaces

• Prevertebral space/
• Retropharngeal
• C2- lt6mm
• C6- lt22mm
• C3/C4
• lt8 yrs lt ½-2/3 diameter
• of AP vertebral body
• gt8 yrs lt 7mm

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Soft tissue spaces

• Predental space
• lt8 yrs lt 4-5mm
• gt8 yrs lt 3mm
• Represents
• Atlantoaxial instability or
• rotational sublux or Jefferson fx

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AP View

• Height of vertebral
• bodies similar
• Spinous processess
• aligned

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Odontoid

• Equal amounts of space
• on each side of the dens
• Lateral aspects of C1
• should line up with the
• lateral aspects of C2

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Odontoid fractures

• Types
• 1
• Apex of dens
• 2
• Base of dens
• 3
• Extends into body of C2

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Odontoid Fracture types
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Flexion-Extension View

• May identify cervical instability, atlantoaxial
  joint instability or ligamentous injury
• If suspicion still present with negative films
• Adds little to evaluation

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Oblique View

• Better visualization of pedicules, facet
  alignment and posterior lamina or articular mass
  fractures
• Usually add nothing

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Prediction Rules
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Prediction Rules

• In alert and stable trauma patients establish
  rule to avoid irradiating low risk patients

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Canadian C-Spine Rule

• Stiell, et al JAMA, 2001
• Prospective, but Canadian
• 8924
• Blunt trauma
• GCS- 15
• Stable vitals
• SCI in 151 (1.7)
• Rule 100 sensitive

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Canadian Rule

• High risk
• gt 65 yrs
• Dangerous mechanism
• Fall gt1m/5 stairs
• Axial load
• MVA gt100km/hr
• Motorized recreational vehicle
• Bicycle vs immobile object
• Paresthesias in extremities

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Canadian Rule

• Low risk if
• Simple rear end MVA
• Sitting position in ER
• Ambulatory at scene
• No neck pain at scene
• Absence of mid-line tenderness

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Canadian Rule

• If low risk
• Voluntarily and actively rotate neck 45 degrees
  both left and right
• If able- no Xray

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Canadian Rule

• Validated study
• 8923 enrolled
• 169 with SCI (2)
• Sensitivity 99.4
• Specificity 45.1
• But

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Canadian C-Spine Rule

• In adults!!!!!!!!

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NEXUS National Emergency X-Radiography
Utilization Study

• Hoffman, et al, NEJM, 2000
• Prospective
• 34,069 enrolled
• Blunt trauma

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NEXUS Rule

• Get radiography unless all are met
• No midline tenderness
• Not intoxicated
• No AMS
• No focal neuro deficits
• No distracting injuries

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NEXUS Rule

• SCI- 818 (2.4)
• Sensitivity 99.6
• Specificity 12.9

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Comparing Canadian and NEXUS

• Canadian rule more sensitive and more specific
• Neither have been validated in settings other
  than where they were established

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NEXUS- Children

• Viccellio, et al, Pediatrics, 2001
• NEXUS data, extract pediatric info
• 3065 pts (9 of total)
• lt18 yrs
• SCI- 30 (0.98)

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Viccellio, et al

• SCIWORA- 0
• SCI
• Only 4/30 13.3 were younger then 9 yrs (said
  population made up 29.5 of total)
• 0/30 0 younger than 2 yrs (2.9 of total)

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Viccellio, et al

• NEXUS decision rule 100 sensitive
• Low risk- 603 of 3065
• Reduction of Xrays in 19.7

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Viccellio, et al

• Conclusion
• NEXUS is sensitive for peds
• Need a prospective study of 80,000 cases to
  improve CI and even more for youngest peds
• Can only be generalized for the adolescent
  population
• SCIWORA more common in adults

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Viccellio, et al

• Discussion
• Rarity of SCI in infants
• Doesnt occur or lethal because of anatomy
  (damage to higher C-spine)

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Jaffe, et al

• Ann Emerg Med, 1987
• Retrospective review of 206 children lt16
• 8 variables neck pain, neck tenderness, limited
  ROM, hx of trauma to neck, abnl
  reflexes/sensation or MS.
• 98 sensitive if 1 positive
• Avoided radiation in 38

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SO..
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Remember

• Anatomy
• Risk factors
• Mechanism
• Symptoms
• If Radiography
• Ossification centers

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Thank you!!!