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

2. 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

3. Inspiration Yet Reality

5. 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

6. 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

7. 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

8. Epidemiology : Associated Injuries
Of 45 children with Cervical Spine Injuries
Pulmonary Contusion
Femur Fracture
Hemoperitoneum
Tibial Fracture
Arm Fracture
Rib Fracture
Splenic Laceration 3
Ruptured Kidney
Pelvis Fracture
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.

9. 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

10. 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

11. 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 years old

12. 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)

13. 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

14. 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?

15. 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

16. 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

18. 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

19. 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.

20. 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

21. 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

22. Immobilization Techniques
Flexion Extension Rotation Lateral
Pediatric Control ° ° ° °
Infant Control ° ° >90° °
Range of neck motion in mannequins

23. 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 ° 3° (64)
Head Brace ° 1 ° (205)
With Foam Collar ° 2 ° 34 (87)
Half-Spine board, tape ° 6 ° 12 (23)
With Foam Collar ° 4 ° (17)
Kendrick Extriction ° 9 ° (92)
With Foam Collar ° 1 ° (11)

24. Pitfalls of Pediatric Immobilization:
Child Control Head Immobilizer
Foam cushions to spine board ° 3 ° 58 (122) With Vertebrace ° 1 ° 26 (66)
Head Brace ° 1 ° 31 (82) With Flex-Support ° 2 ° 23 (58)
Kendricks Extrication ° 2 ° 20 (53) With Flex-Support ° 2 ° 10 (31)
Extriboard Disposable Extrication device ° 4 ° (73) With Vertebrace ° 1 ° 8 (20)
Half-Spine board & tape ° 7 ° (79) With Flex-Support & Tape ° 2 ° 8 (26)
Full-Spine board & Tape ° 3 ° (63) Tape, Beanbag & Flex-Sup ° ° 24 (66)
Tape, Beanbag ° ° (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

25. 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) (400)
Prosplints Cervical Collar (138)
Child Control
(no collar) (400)
Foam Extrication (289)
Disposable Foam (180)
Ferno-Fit (217)
Standard (142)
Hare (253)
Thomas (168)
Flex-Support 3” 4-way (134)
Flex-Support 2” 4-way (157)
Vertebrace (152)
Stiff Neck (155)
Philadelphia (180)

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Of the 30 children with c-spine injuries
NEXUS : Study Results
Of the 30 children with c-spine injuries
Clinical Features N/A
Tenderness
Neuro deficits
Altered LOC
Intoxication
Distracting injury

41. Of the 30 children with c-spine injuries
NEXUS : Study Results
Of the 30 children with c-spine injuries
Clinical Features N/A
Tenderness
Neuro deficits
Altered LOC
Intoxication
Distracting injury

42. Of the 30 children with c-spine injuries
NEXUS : Study Results
Of the 30 children with c-spine injuries
Clinical Features N/A
Tenderness
Neuro deficits
Altered LOC
Intoxication
Distracting injury

43. Of the 30 children with c-spine injuries
NEXUS : Study Results
Of the 30 children with c-spine injuries
Clinical Features N/A
Tenderness
Neuro deficits
Altered LOC
Intoxication
Distracting injury

44. Of the 30 children with c-spine injuries
NEXUS : Study Results
Of the 30 children with c-spine injuries
Clinical Features N/A
Tenderness
Neuro deficits
Altered LOC
Intoxication
Distracting injury

45. Of the 30 children with c-spine injuries
NEXUS : Study Results
Of the 30 children with c-spine injuries
Clinical Features N/A
Tenderness
Neuro deficits
Altered LOC
Intoxication
Distracting injury

46. 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
Neuro deficits
Altered LOC
Intoxication
Distracting injury

47. 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

48. 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

49. 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

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

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

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

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

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

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

56. 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

57. 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

58. Canadian c-spine algorithm

59. 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

60. 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

61. 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

62. 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 (CI 15, 19) (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)

63. 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 (CI 15, 19) (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)

64. 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 (CI 15, 19) (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)

65. 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 (CI 15, 19) (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)

66. 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 (CI 15, 19) (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)

67. 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 (CI 15, 19) (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)

68. 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

69. C-Spine Radiograph
Lateral film
Anteroposterior film
Open-mouth odontoid view

70. 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

71. 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

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

73. 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

74. 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

75. 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

76. 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

77. 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

78. 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

79. 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

80. 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

81. 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

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

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

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

85. 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

86. 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

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

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

89. 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

90. 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

91. 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

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

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

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

95. 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

96. 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

97. 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

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

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

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

101. 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

102. 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

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

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

106. 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

107. 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

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

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

110. 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

111. 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

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

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

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

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

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

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

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

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

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

121. 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

122. 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