• Epidemiology 
    • incidence
      • pediatric cervical spine injuries are uncommon
      • account for 60% of spinal injuries in the pediatric population
      • 3% of pediatric patients with cervical spine injury will present with neurologic deficits
    • location
      • at or above C3
        • 87% of injuries at C3 or above in children < 8 years
      • below C3
        • after 8 years of age, lower cervical injuries are more common (adult injury patterns)
  • Pathophysiology
    • mechanism
      • motor vehicle accidents
        • are most common mechanism
      • falls
        • may be cause of injury in toddlers and school aged patients
      • sports related injuries
        • may lead to cervical trauma in adolescents
    • pathoanatomy
      • in patients below 8 years of age the cervical spine is more susceptible  to injury due to
        • larger head size relative to the trunk
        • increased physiologic motion due to
          • horizontally oriented facet joints
          • elevated ligamentous laxity
          • weaker muscles
  • Associated conditions
    • neurologic injury
      • 33% of patients will present with neurologic deficits
    • solid organ involvement
      • other organs may be involved in ~40% of patients with spinal trauma
  • Prognosis
    • mortality
      • higher mortality rate at C3 or above
        • injuries at C1 lead to a mortality rate of 17%
        • injuries at C4 lead to a mortality rate of ~4%
    • neurologic injury
      • spinal cord injury is more common/lethal in patients younger than 8 years old
      • prognosis for recovery is better than patients older than 8 years old
  • Normal physiologic motion
    • the pediatric spinal column can stretch up to 5 cm without rupture
    • increased physiologic motion due to 
      • horizontally oriented facet joints
      • elevated ligamentous laxity
  • Physical exam
    • complete exam
      • is critical secondary to high incidence of associated injuries
      • always suspect cervical spine injuries when patients present with head trauma and facial fractures
    • careful neurologic exam
      • need to document sensation (including sacral sparing), motor function and presence of reflexes
      • repeat exams are warranted considering that 20% of patients with spinal fractures may have normal examinations
      • examinations can be difficult in unconscious patients
  • Radiographs
    • overview
      • pediatric cervical spine imaging interpretation complicated by
        • hypermobility
        • unique vertebral configurations
        • incomplete ossification
        • presence of apophyses
      • radiographic findings that could be considered abnormal in an adult, may be normal in a pediatric patient
    • mandatory trauma radiographs include
      • AP 
      • odontoid open mouth 
      • cross table lateral 
        • normal findings include
          • prevertebral swelling < 2/3 of adjacent vertebral width
          • smooth contour lines of 
            • anterior vertebral bodies
            • posterior vertebral bodies
            • spinolaminar line (inside lamina)
            • tips of spinous process
          • parallel facet joints
          • normal retropharyngeal space
            • < 6 mm at C2
            • < 22 mm at C6
          • retrotracheal space < 14 mm
          • atlanto-dens interval < 5 mm in children and < 3 mm adolescents
          • absent vertebral body wedging 
            • 7% of normal children have a wedge shaped C3 vertebral body
          • absence of  cervical lordosis
            • loss of cervical lordosis may be found in 14% of normal children
          • C2-3 or C3-4 pseudosubluxation < 4mm
            • considered normal as long as the posterior laminar line is contiguous
    • additional xrays (optional)
      • oblique
        • can help visualize facet disruption
      • flexion-extension
        • problematic and should only be performed under physician supervision
  • CT scan
    • useful to identify
      • fractures of upper cervical spine
      • atlantoaxial rotatory subluxation
    • can help to assess the degree of spinal canal compromise
  • MRI
    • indications
      • useful in obtunded patients or patients with closed head injuries
    • findings
      • can help to assess the degree of spinal canal compromise
  • Nonoperative
    • initial Immobilization
      • indications
        • all pediatric cervical spine trauma
      • modalities
        • on pediatric spine board with head "cutout" to compensate for large head size
        • commercial collars often do not fit properly, may use sandbags
        • using an adult backboard for pediatric patients creates a dangerous level of cervical flexion   
          • transporting patients less than 8 years of age requires a spine board with occipital depression or enough thoracic elevation to align the cervical and thoracic segments of the spine  
    • observation
      • indications
        • pseudosubluxation C2-3
    • collar immobilization
      • some common indications include
        • stable odontoid fractures
        • atlantoaxial instability
        • acute atlantoaxial rotatory displacement (AARD)
        • stable subaxial cervical spine trauma
      • modalities
        • rigid collar vs. soft collar (depends on injury, often controversial)
    • halo immobilization 
      • some common indications include
        • unstable odontoid fractures
        • occipitocervical instability
        • atlantoaxial instability
        • subacute atlantoaxial rotatory displacement (AARD)
        • C1 fractures (Jefferson fractures)
        • unstable subaxial cervical spine trauma
    • surgical stabilization
      • some common indications
        • unstable cervical spine with spinal cord injury
        • atlantoaxial instability
        • chronic atlantoaxial rotatory displacement (AARD)

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