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

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

Inspiration Yet Reality

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

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

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

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

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

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 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

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

Immobilization Techniques 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

Immobilization Techniques 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

Immobilization Techniques 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.

Immobilization Techniques 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

Immobilization Techniques 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

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

Pitfalls of Pediatric Immobilization: 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: 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, Beanbag 5 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

Pitfalls of Pediatric Immobilization: Degrees of Motion Allowed From Neutral Position in Mannequin Models Collar Flexion Extension Rotation Lateral Summed Score* (%) ± Infant Control (no collar) 35 38 180 40 293 (400) Prosplints Cervical Collar 11 19 12 20 62 (138) Child Control (no collar) 35 45 80 16 176 (400) Foam Extrication 35 45 16 11 107 (289) Disposable Foam 24 32 7 5 68 (180) Ferno-Fit 36 31 8 6 81 (217) Standard 21 23 10 3 57 (142) Hare 35 45 12 6 98 (253) Thomas 24 21 6 7 58 (168) Flex-Support 3” 4-way 17 19 4 6 46 (134) Flex-Support 2” 4-way 23 23 7 5 58 (157) Vertebrace 20 18 9 7 54 (152) Stiff Neck 20 18 6 8 52 (155) Philadelphia 23 15 5 12 55 (180)

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

NEXUS 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 : Study objectives Examine the spectrum of cervical spine (c-spine) injuries in children Evaluate the efficacy of a decision instrument designed to identify which patients are at “low risk” for radiographic c-spine injury

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 Definitions High Risk Patient Those with any of the following criteria: Midline cervical tenderness Focal neurologic deficits Altered level of alertness Evidence of intoxication Distracting painful injury Instability or inability to assess

NEXUS: Study Definitions Distracting Injury Significant, painful injury Examples Skin Large lacerations or heavy bleeding Soft tissue Crush injuries Muscle Bone Any long bone fracture Vascular structures Viscera Injury requiring surgical consultation **Any injury causing acute functional impairment

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

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

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

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

Age Distribution of Pediatric Patients NEXUS : Study Results Age Distribution of Pediatric Patients 600 Age distribution in years 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 # of patients 500 400 300 200 100 N = 3,065 <2 y.o., n = 88

Age Distribution of Pediatric Patients NEXUS : Study Results Age Distribution of Pediatric Patients 600 Age distribution in years 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 # of patients 500 400 300 200 100 N = 3,065 <2 y.o., n = 88 2-8 y.o., n = 817

Age Distribution of Pediatric Patients NEXUS : Study Results Age Distribution of Pediatric Patients 600 Age distribution in years 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 # of patients 500 400 300 200 100 N = 3,065 <2 y.o., n = 88 2-8 y.o., n = 817 9-17 y.o., n = 2160

NEXUS : Study Results 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

Of the 30 children with c-spine injuries NEXUS : Study Results Of the 30 children with c-spine injuries 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 NEXUS : Study Results Of the 30 children with c-spine injuries 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 NEXUS : Study Results Of the 30 children with c-spine injuries 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 NEXUS : Study Results Of the 30 children with c-spine injuries 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 NEXUS : Study Results Of the 30 children with c-spine injuries 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 NEXUS : Study Results Of the 30 children with c-spine injuries 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 3,035 children without c-spine injuries NEXUS : Study Results Of the 3,035 children without c-spine injuries Clinical Features + - N/A Tenderness 1179 1333 523 Neuro deficits 176 2611 248 Altered LOC 520 2326 189 Intoxication 110 2730 195 Distracting injury 878 1915 242

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

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

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

NEXUS : Study Results Value (95% CI) Sensitivity 100% (87.8 – 100%) Negative Predictive Value 100% (99.2 – 100%)

NEXUS : Study Results Value (95% CI) Sensitivity 100% (87.8 – 100%) Negative Predictive Value 100% (99.2 – 100%)

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

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

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

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

NEXUS : Study Results 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 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

Helical CT vs Plain Films 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

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

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

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

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

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

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

Objectives Epidemiology 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

C-Spine Radiograph Lateral Film Basic Information 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

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

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

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

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

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

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

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

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

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

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

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

Alignment C-Spine Curves Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Alignment C-Spine Curves

Alignment C-Spine Curves Anterior Vertebral Bodies Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Alignment C-Spine Curves Anterior Vertebral Bodies

Alignment C-Spine Curves Anterior Vertebral Bodies Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Alignment C-Spine Curves Anterior Vertebral Bodies Anterior Spinal Canal

Alignment C-Spine Curves Anterior Vertebral Bodies Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Alignment C-Spine Curves Anterior Vertebral Bodies Anterior Spinal Canal Posterior Spinal Canal

Alignment C-Spine Curves Anterior Vertebral Bodies Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Alignment C-Spine Curves Anterior Vertebral Bodies Anterior Spinal Canal Posterior Spinal Canal Spinous Process Tips

Inter-vertebral spaces Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Inter-vertebral spaces Disc spaces Cartiledge Apophyseal joints

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Pre-vertebral space

Pre-vertebral space Space between vertebral bodies and air column Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Pre-vertebral space Space between vertebral bodies and air column

Pre-vertebral space Space between vertebral bodies and air column Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Pre-vertebral space Space between vertebral bodies and air column

Pre-vertebral space Space between vertebral bodies and air column Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Pre-Dental Space

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Pre-Dental Space Space between Dens of C2 and anterior, interior side of C1 ring

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Pre-Dental Space Space between Dens of C2 and anterior, interior side of C1 ring

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Fracture at base of dens with anterior displacement

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Distraction injury

C-spine injuries in children are rare Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Case 2 C-spine injuries in children are rare Up to 40% of children with c-spine injury have trauma to another body part Must learn to properly immobilize the c-spine

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

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Abscess Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Glottis Abscess

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Ruptured Transverse Ligament Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental Ruptured Transverse Ligament

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental C2 - Axis

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental C1 - Atlas

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental ANTERIOR ANTERIOR POSTERIOR

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental ANTERIOR ANTERIOR POSTERIOR

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental ANTERIOR ANTERIOR POSTERIOR

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental ANTERIOR ANTERIOR POSTERIOR

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental ANTERIOR ANTERIOR POSTERIOR

The safest place for any aged child is the back seat Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 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