1. Interesting Case Discussion and Imaging Approach in Pediatric Cervical Spine Trauma

2. Pediatric Versus Adult Cervical Spine
Pediatric Cervical Spine Injuries (CSIs) present differently when compared to adults.. Why?
Fulcrum of motion in the pediatric cervical spine –
Is at higher level (C2-C3 level)
as against C5-C6 in adults (1,2)
Hypermobile Spine in children(2-8) – Bony, Ligamentous and Muscular factors
Difference in proportion head vs rest of the body (9)
Huelke DF. An Overview of Anatomical Considerations of Infants and Children in the Adult World of Automobile Safety Design. Annual Proceedings / Association for the Advancement of Automotive Medicine. 1998;42:

3. Case 1: Is this a subluxation?
Diagnosis: Pseudosubluxation

4. Psudosubluxation Vs True Subluxation
Swischuk Line/ Spinolaminar/posterior cervical line: Line from the anterior aspect of C1-C3 spinous process. Anterior C2 spinous process should be within 2mm (10)

5. Case 2: Whats This?

6. Rt Para sag CT
Lt Para sag CT
Diagnosis: Bilateral Pars defect with mild subluxation of C6 over C7 vertebra

7. Do you think wedging is normal in 3 year old?
In early infancy cervical vertebrae have an oval appearance
Anterior wedging of 3 mm, should not be confused with compression fracture. Such wedging can be profound at C3 level

8. Case 3: Wedging in 8 year old?
Diagnosis : Burst fracture of C3

9. Imaging Approach to Pediatric Cervical Spine Trauma
Pediatric CSI are rare, therefore management principles are still mostly controversial(11)
According to a recent review article, diagnostic principles has been tabulated as follows (11)

10. Clinical Decision Rule
<3 years- Cleared if: GCS>13
No neurodeficit, cervical tenderness, distraction injury, hypotension, not intoxicated and No MVA/fall from height>10 feet
>3 years-Alert
No neurodeficit, cervical tenderness, distraction injuries, unexplained hypotension and not intoxicated
NEXUS (National Emergency X- ray utilization study and CCR ( Canadian cervical Spine Rule)
NEXUS criteria: Sensitivity and negative predictive value – 100% in 9-17 year old.
< 9 year old – No current evidence
CCR Criteria : No current evidence
Plain Radiograph
All
Initial radiographic modality of choice in patients who cannot be cleared using clinical decision rule < 9years- 2 view radiographs > or equal to 9 years – 3 view radiographs

11. CT
All
First investigation in obtunded child undergoing CT head <10 years: Less role in ruling out C-spine injuries (as ligamentous disruptions are common)
Greater radiation exposure,
Best investigation to identify upper cervical osseous injuries>10 years:
Indications(all ages), Inadequate X-rays, Fracture, dislocation,
Suspiscious injuries, High clinical suspicion
MRI
MRI- has an edge over CT in clearing C-spine in children <10 years. Indicated if any of the four criteria are met:
Obtunded, nonverbal child with suspicion,
Equivocal plain radiograph, Neurological findings in absence of radiological, Inability to clear cervical spine on other clinical and radiological basis within 3 days of injury

12. Summary: What you need to know
Summary: What you need to know? Normal Measurements of Upper Cervical Spine on Conventional Radiograph
Measurement
Value
Basion dens interval(mm)
Power ratio
Condylar gap(mm)
C1-C2 intraspinous distance(mm)
Predental space (interval)(mm)
<12
<1
<5
<5 in <8 year and <3 in >8year old.
According to American Journal of Roentgenology(12)

13. Summary: What you need to know Normal Measurements of Upper Cervical Spine on CT
Neasurement
Value
Basion dens interval
With ossification(mm)
Without ossification(mm)
Powers ratio
Atlantodental interval(mm)
Atlantooccipital interval(mm)
<9.5
<11.6
<0.9
<2.6
<2.5
According to American Journal of Roentgenology(12)

14. 1) Kokoska ER, Keller MS, Rallo MC, Weber TR
1) Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical spine injuries. J Pediatr Surg 2001; 36:100–105
2) Roche C, Carty H. Spinal trauma in children. Pediatr Radiol 2001; 31:677– 700
3) McGrory BJ, Klassen RA, Chao EY, Staeheli JW, Weaver AL. Acute fractures and dislocations of the cervical spine in children and adolescents. J Bone Joint Surg Am 1993; 75:988–995
4) Herman MJ, Pizzutillo PD. Cervical spine disorders in children. Orthop Clin North Am 1999; 30:457–466, ix
5) Harris JH Jr, Mirvis SE. The radiology of acute cervical spine trauma. In: Mitchell CW, ed. The normal cervical spine. 3rd ed. Baltimore, Md: Williams & Wilkins, 1996; 1–73

15. 6) Swischuk LE. Emergency imaging of the acutely ill or injured child
6) Swischuk LE. Emergency imaging of the acutely ill or injured child. In: The spine and the spinal cord. 4th ed. Philadelphia, Pa: Lippincott Williams &Wilkins, 2000; 532–587
7) Marx Rosen’s emergency medicine: concepts and clinical practice. 5th ed. St Louis, Mo: Mosby, 2002; 274–276
8) Reynolds R. Pediatric spinal injury. Curr Opin Pediatr 2000; 12:67–71
9) Huelke DF. An Overview of Anatomical Considerations of Infants and Children in the Adult World of Automobile Safety Design. Annual Proceedings / Association for the Advancement of Automotive Medicine. 1998;42:
10) Swischuk LE. Emergency imaging of the acutely ill or injured child. In: The spine and the spinal cord. 4th ed. Philadelphia, Pa: Lippincott Williams &Wilkins, 2000; 532–587
11) Gopinathan NR, Viswan athan VK, Crawford AH. Cervical spine evaluation in pediatric trauma: A review and an update of current concepts. Indian J Orthop 2018;52:
12) Timothy N Booth American Journal of Roentgenology. 2012;198: W417-W /AJR

16. Authors Name: Subramanian Surabhi Pierre Schmit Kathleen O’Brien Naeem Khan Affiliation: Department of Diagnostic Radiology, IWK Health Centre