Cervical injury (peds)

Background

• C-spine injury uncommon in children but large head in age <8 creates system for upper cervical injury
• Injuries most feared include atlanto-occipital dissociation (AOD) and atlantoaxial rotatory subluxation or fixation (AARF).

SCIWORA

• Spinal cord injury without radiographic abnormality
• Exam findings of myelopathy without abnormalities on XR or CT

Clinical Features

• Blunt trauma in pediatric population.
• AARF- may occur spontaneously or in trauma- exam shows head rotated, tilted or unable to turn past midline
• AOD- can be devastating injury or even fatal

Differential Diagnosis

Cervical Spine Fractures and Dislocations

• Atlanto-occipital dissociation
• C1
  • Jefferson fracture
  • C1 isolated anterior arch fracture
  • C1 isolated posterior arch fracture
• C2
  • Odontoid fracture
  • Hangman's fracture
• C3-C7
  • Cervical burst fracture
  • Cervical spinous process fracture
  • Extension cervical teardrop fracture
  • Flexion cervical teardrop fracture
  • Anterior cervical wedge fracture
• Cervical facet dislocation

Evaluation

Algorithm for the evaluation of pediatric cervical spine injuries

C-Spine Clearance Without Imaging

<3 years old

• GCS>13
• no neurological deficit
• no midline cervical tenderness to palpation
• no painful distracting injury
• no unexplained hypotension
• not intoxicated
• mechanism-image if: MVC, fall >10 feet, non-accidental trauma known or suspected

>3 years old

• alert
• no neurological deficit
• no midline cervical ttp
• no painful distracting injury
• no unexplained hypotension
• not intoxicated

Imaging

No imaging if above criteria met based upon age

• CT c-spine for concern of Atlanto-occipital dislocation(AOD) or atlantoaxial rotatory subluxation or fixation (AARF)

1. AOD- CT to look for condyle-C1 interval (CCI)
2. AARF- C1-C2 motion analysis to characterize injury(3 position CT)
3. Plain films otherwise acceptable

• SCIWORA- full spinal column radiographic imaging
  • MRI of suspected area of spinal damage
  • Assess spinal stability acutely and in follow-up with flex/ex films

Management

• Immobilization must account for relatively larger occiput using occipital recess or thoracic elevation to maintain c-spine neutrality.
• Neurosurgery consult for abnormalities

See Also

General/Adult

• Head Trauma (Main)
• Concussion
• Skull Fracture
• Maxillofacial Trauma
• C-spine (NEXUS)

Pediatric

• C-spine (peds)
• Abuse (Nonaccidental Trauma)
• GCS (Peds)
• EBQ:PECARN Pediatric Head CT Rule

References

• EB Medicine- EM Practice Guideline Update- Sept 2014- Updated Guidelines For Management Of Acute Cervical Spine And Spinal Cord Injury In Pediatric Patients
• American Association of Neurological Surgeons and Congress of Neurological Surgeons in 2013.

Authors

Ross Donaldson