Pediatric C-Spine Injury Joshua Rocker, MD Schneider Children’s Hospital LIJ Medical Center

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

Anatomical Considerations

Children <8 years old Relatively larger heads than body Head circumference 50% adult by 2 yrs vs chest circumference, 8 yrs

Children <8 years old Cervical spine fulcrum Moves caudally C2-C3 at birth C5-6 at 8 yr and older

Children <8 years old Weaker cervical musculature and increased laxity of ligaments Immature vertebral joints Horizontally inclined articulating facets Facilitate sliding of upper c-spine

Children’s 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)

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

Children 8yrs and older Equivalent to adult Most injuries to vertebral bodies and arch Lower C-spine

Embryology and why pediatric C-spines are difficult to interpret

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

Embryology: C1 Anterior arch fuses with neural arches by 7 yrs. Before this non-fusion can be mistaken as fracture

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

Embryology: C2 Body fuses with dens at 3-6 yrs The fusion line or remnant of cartilagenous synchondrosis can be seen till 11 yrs

Embryology: C3-C7 Same developmental pattern 3 ossification centers Neural arches fuse posteriorly 2-3 yrs Body fuses with arches 3-6 yrs

Embryology Coronal view: Notice synchondroses

Predisposing risk factors

Congenital abnormalities Downs Syndrome 15% with atlantoaxial instability

Congenital abnormalities Klippel-Feil Fusion of cervical vertebrae

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

Congenital abnormalities Larsen’s Syndrome skeletal dysplasia with multiple joint dislocations, short stature, abnormal facial features

At Risk by History Spinal Cord surgery C-spine arthritis

Causes of Injuries

Causes of Injuries: By age Infants Birth Trauma 1-8 yrs MVAs and falls > 8 yrs Sports Injuries and MVAs

Causes of Injuries: Direct severe force to neck Diving Acceleration-deceleration

Causes of Injuries: Mechanism Hyperflexion Hyperextension Axial Load Roatational Blow to Chin

Causes of Injuries: Hyperflexion Most common Cause wedge fracture of anterior vertebral bodies Disruption of posterior elements Ex: Clay-shoveler’s, anterior teardrop fracture

Hyperflexion: Clay-shoveler’s Sudden load on a flexed spine, avulsion at C7 or T1

Hyperflexion: Teardrop fracture of anteroinferior portion of vertebral body

Causes of Injuries: Hyperextension Compression of posterior elements Disruption of anterior longitudinal ligament Ex: Hangman’s

Hyperextension: Hangman’s Fracture anterior subluxation of C2 on C3 and bilateral pedicle fractures of C2

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

Axial Load: Jefferson fracture

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

Immobilization

Indications Mechanism PE Severe force Diving Accel-dec AMS Neuro deficits Multi-system trauma Neck pain/tenderness Distracting injuries

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

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

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

Neutral Position Adults (>8 yrs) Children 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)

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

Protocols: Airway Jaw-thrust maneuver with in-line traction

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

Symptoms and Physical Exam

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

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

Physical Exam Essentials Vital Signs Neuro Neck

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

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

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

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

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

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

Reflexes Areflexia indicates spinal shock Usually lasts less than 24 hours

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

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

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

Specific Inuries Horner’s Syndrome Disruption of cervical sympathetic chain Ptosis, miosis and anhidrosis

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

Radiography

What to do? If your suspicion of injury is high If low to moderate get CT!!! (>98% 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

Plain Radiographs Lateral Must visualize all 7 cervical vertebrae Include C7-T1 junction If difficult visualizing Gentle traction on arms (?) Transaxillary (swimmer’s) view

Lateral view: 4 curvilineal contour lines Anterior vert body Posterior vert body Spinolaminar line Tips of spinous processes

Psuedosubluxation C2 on C3 20-40% of children C3 on C4 14%

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

Soft tissue spaces Prevertebral space/ Retropharngeal C2- <6mm C3/C4 <8 yrs < ½-2/3 diameter of AP vertebral body >8 yrs < 7mm Hematoma, abscess, bony injury

Soft tissue spaces Predental space Represents: <8 yrs < 4-5mm Atlantoaxial instability or rotational sublux or Jefferson fx

AP View Height of vertebral bodies similar Spinous processess aligned

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

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

Odontoid Fracture types

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

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

Prediction Rules

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

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

Canadian Rule High risk > 65 yrs Dangerous mechanism Fall >1m/5 stairs Axial load MVA >100km/hr Motorized recreational vehicle Bicycle vs immobile object Paresthesias in extremities

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

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

Canadian Rule Validated study 8923 enrolled 169 with SCI (2%) Sensitivity = 99.4% Specificity = 45.1% But…

Canadian C-Spine Rule In adults!!!!!!!!

NEXUS: National Emergency X-Radiography Utilization Study Hoffman, et al, NEJM, 2000 Prospective 34,069 enrolled Blunt trauma

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

NEXUS Rule SCI- 818 (2.4%) Sensitivity = 99.6% Specificity = 12.9%

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

NEXUS- Children Viccellio, et al, Pediatrics, 2001 NEXUS data, extract pediatric info 3065 pts (9% of total) <18 yrs SCI- 30 (0.98%)

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)

Viccellio, et al NEXUS decision rule 100% sensitive Low risk- 603 of 3065 Reduction of Xrays in 19.7%

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

Viccellio, et al Discussion: Rarity of SCI in infants Doesn’t occur or lethal because of anatomy (damage to higher C-spine)

Jaffe, et al Ann Emerg Med, 1987 Retrospective review of 206 children <16 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%

SO……..

Remember Anatomy Risk factors Mechanism Symptoms If Radiography Ossification centers

Thank you!!!