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Whitney Minnock, MD, Clinical Faculty, Department of Emergency Medicine, OUWB (Oakland University William Beaumont) School of Medicine, Rochester, MI
Aaron Leetch, MD, Assistant Professor, Departments of Emergency Medicine and Pediatrics; Program Director, Combined Emergency Medicine & Pediatrics Residency, University of Arizona, Tucson, AZ
Steven M. Winograd, MD, FACEP, Mt. Sinai Queens Hospital Center, Jamaica Queens, NY; Assistant Clinical Professor of Emergency Medicine, Mt. Sinai Medical School, New York City; Assistant Clinical Professor of Emergency Medicine, NYiTCOM, Old Westbury, NY
Although spinal injuries are uncommon, they should be considered when children have sustained head or neck trauma or multiple severe injuries. The cervical spine is the area most commonly affected. The upper cervical vertebrae (C1-C4) is injured more commonly in children younger than 8 years of age, whereas adolescents and adults are more likely to suffer injury to the lower cervical vertebrae (C5-T1). Children with severe or multisystem trauma are more likely to suffer a spinal injury. Thus, emergency department (ED) providers should have a lower threshold to immobilize and image such patients to prevent morbidity and mortality. These authors review the most common pediatric spinal fractures and injuries and optimal management practices.
— Ann M. Dietrich, MD, FAAP, FACEP
Despite trauma being the leading cause of morbidity and mortality in children, cervical spinal injury (CSI) is relatively uncommon.1 When present, it can carry tremendous clinical sequelae if not recognized early and managed appropriately. Spinal injuries should be considered in all children presenting to the ED who have sustained head or neck trauma or multiple severe injuries. The risk of CSI increases with age, with a 10-fold increase after age 11.2 Nearly three-fourths of spinal injuries in young children occur in the cervical spine. Upper cervical vertebral injuries (C1-C4) are more common in children younger than 8 years of age, whereas adolescents and adults are more likely to suffer lower cervical vertebral (C5-T1) trauma.3 Spinal injuries are more common in males than females.4 Motor vehicle accidents in which the victim was unrestrained or improperly restrained are the most common mechanism of CSI in children.5 Falls are the second most common mechanism in patients younger than 8 years of age, and sports injuries are the second most common mechanism in older children.
Mortality rates for CSI range from 4% to 41%.6 Higher cervical vertebral injuries, including atlanto-occipital dislocation, are associated with the highest mortality rate. (See Figure 1.) Children with severe or multi-system trauma are more likely to suffer a spinal injury. Therefore, providers should have a lower threshold to immobilize and image such patients to prevent morbidity and mortality. Even after proper care, nearly one-third of children with CSI will require surgical intervention.7
Children with underlying structural abnormalities or genetic predisposition to ligamentous laxity are more vulnerable to injury. Such patients include those with Down syndrome (atlanto-occipital instability), a history of previous CSI or cervical spine arthritis, Klippel-Feil syndrome (congenital fusion of cervical spine), Morquio syndrome (hypoplasia of odontoid), Larsen syndrome (cervical vertebrae hypoplasia, multiple joint dislocations), and any other syndromes associated with spinal abnormalities.8,9 In addition, chin trauma, fractures of the posterior teeth, and mandibular condyles may be associated with CSI.
Nonaccidental trauma (NAT) contributes to about 1% of spinal injuries in children.10 In those with intracranial injury from NAT, the incidence rises to more than 15%. These generally occur in patients younger than 2 years of age, generally are in the cervical spine, and nearly always are part of a multisystem trauma. Most often, these children will have focal neurologic findings, although occasionally they will present with a normal exam initially.11 Cervical spinal imaging should be considered in patients with NAT to evaluate for occult injuries in this vulnerable population.
The cervical spine can be thought of as having three columns: an anterior, a posterior, and a middle column. Together, all three columns provide stability to the spine; if one column is injured, the other two can continue to compensate for a short time. Two- and three-column injuries generally are considered unstable. These injuries can be grouped by mechanism and are described in Table 1. There are several important structural differences between the pediatric and the adult spine:
Younger children are susceptible to growth plate and ligamentous injuries. Children have immature growth centers that are susceptible to shear forces during rapid deceleration or hyperflexion/extension, particularly at the synchondrosis between the odontoid and vertebral body of C2. In young children, a more elastic spinal column can tolerate more distraction before rupture, thus leading to spinal cord injury without obvious bony spinal column injury or ligamentous disruption. Injuries to the spinal cord itself are listed in Table 2.
Four injury patterns are common in children 8 years of age and younger:6
Between the ages of 8-10 years is a transition point in anatomic development.2,12,13 Epidemiologic studies show that children older than 8 years of age more commonly have injuries in a pattern similar to adults (i.e., C7-T1 region in contrast to the upper vertebral injuries sustained in younger children).13 These studies show an independent correlation not only to age but also to mechanism. This makes sense given that children’s activities change as they mature and develop.
Jefferson fractures refer to burst fractures of C1 and may involve both the anterior and posterior arches. (See Figure 2.) The mechanism usually is from an axial load (i.e., diving). The fracture is seen on an odontoid view, but this view is difficult to obtain in children younger than 3 years of age. (See Figure 3.) Typically, there will be a lateral offset of the lateral mass of C1 of > 1 mm from the vertebral body of C2. A pseudo-Jefferson fracture can be seen between 2-6 years of age secondary to the increased growth of the atlas compared to the axis.
Hangman fracture is a traumatic spondylolisthesis of C2, fracture of the pars interarticularis of the axis, horizontal tearing of the C2-C3 disk, and anterior subluxation of C2 on C3. Hangman fractures often result from hyperextension forces. If hyperflexion occurs after hyperextension, C2 may sublux onto C3 and cause spinal cord damage. The subluxation can be mistaken for pseudosubluxation.
Pseudosubluxation is seen in the C2-C3 or C3-C4 region in 25% of children younger than 8 years of age but can persist to age 16 years. On radiographs, evaluate the spinolaminar line or Swischuk line, which is drawn from the posterior arches of C1-C4. (See Figure 4.) This should pass within 1-2 mm of the anterior cortex of the posterior arch of C2 in children with pseudosubluxation. Distances greater than 1-2 mm usually are abnormal.
Atlanto-axial subluxation occurs as a result of movement between C1 and C2 secondary to transverse ligament rupture or a fractured dens.14 On lateral spine radiographs, there will be a widened predental soft tissue space (normal < 5 mm). Patients often present after falls with symptoms such as neck pain and torticollis, although sometimes only torticollis is present.15 Presentation can be delayed in more minor trauma. Rotary subluxation involves facet fracture or dislocation. These injuries present with muscle spasm on the sternocleidomastoid on the same side to which the chin points. These injuries usually are associated with a ligamentous injury. Management is variable, although the decision between conservative treatment with a soft collar or surgical fixation with halo placement generally is based on the presence or absence of neurologic symptoms.
Odontoid fractures are the most common cervical spine injuries in children. These fractures may be confused with normal anatomic variations due to synchondrosis between the body and the axis. Type 1 odontoid fractures involve the apex of the dens. Type 2 fractures are through the waist of the dens, and Type 3 extend into the body of C2. Type 2 and 3 are considered unstable and require emergent consultation.
Distraction injuries occur with a longitudinal stress on the cervical column. The most serious type is the atlanto-occipital dislocation. On radiographs, there is an increased distance between the occiput and C1 or widening of intervertebral disk space without adjacent compression. (See Figure 1.) These injuries are associated with high cervical spinal cord injuries and commonly are incompatible with long-term survival. This injury often is fatal on impact, causing an internal decapitation.
Spinal cord injury without radiographic abnormality (SCIWORA) is a clinical-radiological condition that mostly affects children.16-19 Patients present with neurologic symptoms and deficits consistent with cord injury but without radiographic abnormalities on plain radiography and computed tomography (CT). These injuries can occur through many mechanisms, including hyperextension, hyperflexion, and distraction. In hyperextension injuries, the posterior interlaminar ligaments impinge the spinal cord, whereas, in hyperflexion injuries, the anterior interlaminar ligaments impinge on the cord. Distraction injuries occur when the longitudinal distraction stretches the spinal column beyond the tolerance of the spinal cord. This is seen with rapid acceleration/deceleration forces. Hematomyelia may occur with these injuries, causing hemorrhage into the spinal cord and severe neurologic injury.
SCIWORA lesions are found mainly in the cervical spine but also can be seen, although much less frequently, in the thoracic or lumbar spine. The level of spinal cord injury corresponds to the location of these changes. Thoracic SCIWORA has been described, but is less common because of the splinting protection of the rib cage.
The prognosis for children with SCIWORA alone is better than for children with vertebral fractures and neurologic symptoms. Some will have only transient neurologic symptoms and completely recover after 24 hours. Some may not have any neurologic symptoms immediately after the injury, but may develop them up to four days post-injury.
Magnetic resonance imaging (MRI) is the diagnostic study of choice. A recent systematic review emphasizes the prognostic value of spinal MRI for children with SCIWORA and highlights the role of the MRI classification system in improving the comparability and interpretability. With recent advances in neuroimaging techniques and increasing availability of MRI, the overall detection rate of SCIWORA has improved significantly and the term has become more ambiguous.20 Children with true SCIWORA should have a neurologic deficit with normal imaging, including MRI. Consequently, these children have substantially more favorable clinical outcomes than those with cervical cord abnormalities on MRI. In the ED setting, providers should remember the previous application of SCIWORA to those children with normal radiography and CT and be vigilant to re-examine patients for signs of neurologic stigmata.
Children with suspected CSI must be evaluated efficiently and their injury recognized promptly. Initial assessment includes the primary and secondary survey with attention to the airway, breathing, and circulation according to Advanced Trauma Life Support Guidelines.21 Hypotension, bradycardia, and temperature instability may be signs of spinal shock, which results from disruption of the sympathetic chain and unopposed parasympathetic innervation. Apnea/hypoventilation may be a result of diaphragmatic paralysis (C3-C5).
A thorough neurologic examination should be performed. (See Table 3.) Children with fractures typically have pain, muscle spasm, and decreased range of motion. They may complain of transient or persistent paresthesia, paralysis, or weakness. The distribution may vary based on the injury. Some children are unable to express their symptoms, and others may have distracting injuries. Transient burning of the upper extremities may be indicative of a hyperextension injury with central cord contusion. For unconscious children, maintain spinal immobilization, log roll the patient, and quickly feel down the back for step-off deformities.
Spinal immobilization should be maintained and rapid radiologic evaluation should be performed.21 The cervical spine should be maintained in midline position with the airway open. Children are very good at protecting their injuries and are unlikely to move an injured neck spontaneously. Most children only require pain control, distraction, or parental presence to maintain spinal immobilization.22 The use of cervical collars has become synonymous with spinal immobilization; however, the evidence to support this recommendation is sparse.23 Although cervical collars are known to cause complications with prolonged use, they still are the mainstay of trauma management in the ED setting.24
Given the overall low prevalence of CSI in children, clinical clearance is most likely to be employed in awake patients.25 The majority of children with CSI will have some conspicuous findings, and providers with an attentive eye are unlikely to miss them.26 Still, decision algorithms for cervical spine imaging have been extrapolated from the adult literature to aid providers.27 (See Figure 5.) The Canadian C-Spine Decision Rule excluded patients younger than 16 years of age and, therefore, cannot be used readily for cervical spine clearance in children.28 However, the NEXUS study included children and has been validated for use in pediatric patients.29 (See Table 4.) However, only 2.5% of patients younger than 8 years of age and no children younger than 2 years of age were included.30 The authors stress caution in applying these rules to younger children, especially infants and toddlers. A multicenter study determined four high-risk factors for CSI in patients younger than 3 years of age:31
When applied to a cohort of infant and toddler trauma patients from a trauma registry, no CSIs were missed and authors suggest that these criteria can be used to screen effectively for CSI.
Unconscious, obtunded, or intubated children presenting after trauma should be presumed to have a CSI until effectively evaluated by imaging. In obtunded adults, there is literature suggesting that collars can be removed after a normal CT.32,33 However, the relatively higher rate of SCIWORA precludes the use of this literature in children. Currently, there is no methodology for clearing these patients after normal imaging, although collars generally can be cleared after a normal MRI.34
In patients with high-risk features for cervical spinal injury, imaging is recommended. (See Table 5.) Available modalities include plain radiography, CT, and MRI, each of which carries its own risks and benefits. Plain radiographs are readily available and quickly obtainable in all EDs with a minimal amount of ionizing radiation. Although CT long has been recognized as the gold standard for adults,36 plain radiographs still are the first-line recommendation for suspected cervical spinal injury in children because of the risk of ionizing radiation delivered to the thyroid by CT.37-39 Plain radiograph cervical spine series should include at least three views of the cervical spine (lateral, anterior-posterior, and, if possible, open-mouth odontoid). Cross-table lateral views identify most fractures, dislocations, and subluxations but are not sufficient to exclude injury without anterior-posterior views. Odontoid views increase the sensitivity of identifying injuries although they can be omitted in an uncooperative or preverbal child. This series has been shown to be > 90% sensitive in identifying CSI in pediatric patients.40,41
Still, the interpretation of cervical spinal radiographs in children is difficult and requires an experienced radiologist or provider to interpret the anatomic variations. (See Table 6.)
CT is recommended for any patient with inconclusive initial films or continued high clinical suspicion for CSI. CT is an excellent modality for identifying bony abnormalities, although it still will miss ligamentous injury unless there is a bony malalignment. Some patients with high-risk features as described earlier may benefit from immediate CT, such as those who are unconscious, intubated, or show focal neurologic deficit.
MRI is preferred for visualizing soft tissues, ligamentous injuries, spinal cord edema, hemorrhage, compression, and transection. However, MRI is not readily available in all ED settings, and younger children may not tolerate the duration of scanning while awake. MRI should be obtained in all children with focal neurologic findings with or without injury identified on plain radiograph or CT. In areas where this is unavailable, transfer should be initiated.
Children with clinical findings suggestive of spinal cord injury should be treated conservatively with immobilization, even in the absence of radiographic abnormalities. Immediate consultation or referral to a regional trauma center for pediatric neurosurgical and pediatric orthopedic evaluation is crucial for definitive management. All patients with CSI and neurologic deficit should be admitted to the pediatric intensive care unit.
Steroid therapy is debated, and randomized, controlled trials are needed in the pediatric population to assess the advantages of steroid use after SCI in children.42-44 The use of steroids in patients is associated with increased infectious risks and no neurological improvements, with some literature suggesting an increased incidence of complications in children.13 Current expert opinion-based guidelines recommend against steroids for pediatric spinal cord injury.
Some patients may meet criteria for discharge from the ED with a padded hard cervical collar despite persistent neck pain.45 Consider discharge if any of the following are present:
Pediatric CSI can be a complicated issue in the ED. It is not diagnosed often but is considered quite often. Higher frequency of adult CSI leads to more uncertainty in children. Because of these concerns, adult clinical decision rules can be inappropriately used in children. A good understanding of both low-and high-risk factors for pediatric CSI, coupled with a thorough and repeated physical exam, generally can alleviate these concerns while still maintaining a high sensitivity for injury. The use of plain radiography as a first-line imaging modality can help further with diagnostic uncertainty without the considerable ionizing radiation of CT. The relative increased incidence of SCIWORA in children highlights the importance of serial exams over reliance on imaging. A structured, evidence-based approach to pediatric CSI evaluation is an invaluable tool for the ED provider to ensure quality patient care and minimize radiation exposure.
To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, we disclose that Dr. Hocum (pharmacist reviewer) reports he is an employee of Braeburn Pharmaceuticals. Dr. Dietrich (editor), Dr. Skrainka (CME question reviewer), Dr. Minnock (author), Dr. Leetch (author), Dr. Winograd (peer reviewer), Ms. Wurster (nurse reviewer), Ms. Coplin (executive editor), Ms. Mark (executive editor), and Ms. Hatcher (editorial group manager) report no relationships with companies related to the field of study covered by this CME activity.