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 Anatomic 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) Etiology Pathophysiology mechanism motor vehicle accidents are most common mechanism airbags should be turned off in children riding in the front passenger seat and weighing less than 80lbs 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 Anatomy 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 Presentation 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 Imaging 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 Treatment 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) 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