Updated: 6/23/2021

Pediatric Cervical Trauma Overview

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  • 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
        • 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
Flashcards (2)
Cards
1 of 2
Questions (3)

(OBQ18.8) With regard to automobile safety in children, which of the following is a consistent recommendation among the United States National Highway Traffic Safety Administration, Transport Canada, and the American Academy of Pediatrics?

QID: 212904
1

A 15 lbs (6.8kg) 6-month-old boy should ride in a forward-facing car seat in the rear center seat

4%

(65/1798)

2

A 30 lbs (13.6kg) 3-year-old boy should ride in a booster seat in the rear center seat

12%

(208/1798)

3

A 55 lbs (24.9kg) 7-year-old girl should ride with a seat belt only directly behind the driver

6%

(105/1798)

4

A 75 lbs (34.0kg) 13-year-old girl riding in the front passenger seat should have the airbag turned on

29%

(516/1798)

5

A 75 lbs (34.0kg) 13-year-old girl riding in the front passenger seat should have the airbag turned off

49%

(879/1798)

L 4 A

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(OBQ04.4) An 8-year-old child falls from a 15-foot retaining wall and is found unconscious by emergency personnel. Which of the following is the most appropriate form of cervical stabilization in the acute setting?

QID: 115
1

Utilize adult spine board with modification of a one inch sandbag under the patient's head

2%

(78/3446)

2

Maintaining in-line cervical stabilization with the external auditory meatus posterior to the shoulders

12%

(420/3446)

3

Maintaining in-line cervical stabilization with the external auditory meatus anterior to the shoulders

7%

(251/3446)

4

Halo immobilization with 8 to 12 low insertion torque pins

0%

(11/3446)

5

Maintaining in-line cervical stabilization with the external auditory meatus in-line with the shoulders

77%

(2669/3446)

L 2 C

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Evidence (3)
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EXPERT COMMENTS (7)
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