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Updated: Jun 23 2021

Pediatric Cervical Trauma Overview

  • 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
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