Developing a clinical algorithm for early management of cervical spine injury in child trauma victims

Clearing the pediatric cervical spine following injury

Injury to the pediatric cervical spine is uncommon; however, a missed or delayed diagnosis can lead to disastrous consequences. Thus, following trauma, clearance of the pediatric cervical spine is important. Problematic issues include child compliance with examination, the complex anatomy of the pediatric cervical spine, lack of agreement on definitive imaging modalities, and the coordination of multiple medical specialties. Expediting clearance of the pediatric cervical spine requires an organized, multidisciplinary approach. In addition to systematic procedures within the emergency department, preventing missed and delayed diagnoses of cervical spine injury can be facilitated by applying a clear methodology for reviewing radiographs in conjunction with the child's clinical examination. This algorithm considers the adequacy of the images, alignment of the bony and soft-tissue elements, assessment of the cervical intervals, and the presence of abnormal angulation. Together with standard treatment, this protocol facilitates effective and expeditious clearance of the cervical spine.

Cervical spine clearance after trauma in children

Object

Currently, no diagnostic or procedural standards exist for clearing the cervical spine in children after trauma. The purpose of this study was to determine if reeducation of nonneurosurgical personnel and initiation of a new protocol based on the National Emergency X-Radiography Utilization Study criteria could safely increase the number of pediatric cervical spines cleared of suspected injury without a neurosurgical consultation.

Methods

Data regarding cervical spine clearance in children (ages 0–18 years) after trauma protocol activation at Primary Children's Medical Center between 2001 and 2005 were collected and reviewed. Radiographic and clinical methods of clearing the cervical spine as well as the type and management of injuries were determined for two time frames: Period I (January 2001–December 2003) and Period II (January 2004–July 2005).

Between 2001 and 2003, 95% of 936 cervical spines were cleared of suspected injury by the neurosurgical service. Twenty-one ligamentous injuries (2.2%) and 12 fracture–dislocations (1.3%) were detected, with five patients requiring surgical stabilization (0.5%). Between January 2004 and July 2005, 507 (68%) of 746 cervical spines were cleared by nonneurosurgical personnel. Six ligamentous injuries (0.8%) and 10 fracture–dislocations (1.3%) were identified, with three patients (0.4%) requiring surgical stabilization. No late injuries were detected in either period.

Conclusions

The protocol used has been effective in enabling detection of cervical spine injuries in children after trauma, with the new protocol increasing by more than 60% the number of cervical spines cleared by nonneurosurgical personnel. Reeducation with establishment of the new protocols can safely facilitate clearance of the cervical spine by nonneurosurgical personnel after trauma.

Clearing the cervical spine of paediatric trauma patients

OBJECTIVES

To review the evidence available for clearance of the cervical spine in children under 16 years of age after trauma, and to provide guidance to enable this to be practised safely.

METHODS

A comprehensive literature review was carried out, and combined with a review of standard texts and liaison with experts.

RESULTS

241 papers were identified, of which 71 papers were thought possibly relevant. These were obtained and appraised. Children in whom there is concern about possible cervical spine injury may be divided into three groups. Alert, asymptomatic children with a normal examination may be clinically cleared without need for radiology. Children with cervical spine symptoms or signs require plain radiology in the first instance. Those areas that are poorly visualised or suspicious should be discussed with a paediatric radiologist and are likely to undergo computed tomography. Children with impaired conscious level require careful evaluation. Plain radiology, if normal, can be usefully complemented by early magnetic resonance imaging to exclude ligamentous and spinal cord damage.

CONCLUSIONS

There is limited evidence to guide clinicians on how to clear the paediatric cervical spine. The approach suggested is similar to adult recommendations made elsewhere, and the differences are highlighted.

Acute evaluation and management of pediatric spinal cord injury

BACKGROUND/OBJECTIVE

Of new spinal cord injuries (SCIs) throughout North America, up to 14% occur in children younger than 15 years of age. The purpose of this paper is to present several aspects unique to the evaluation and treatment of a child with SCI.

EVALUATION

Vital signs may be absent along with minimal blood loss, indicating upper cervical spine injury that is common in children. Lap belt injuries are more prevalent in children, especially since 1984, when seat belt laws were enacted, and more children began using a lap belt but no shoulder harness. Of children with lap belt injuries, 4% to 39% have significant neurologic injuries, and 30% to 50% have associated retroperitoneal injuries. Radiographic evaluation is more challenging in children because of the presence of normal variants such as C2-C3 pseudosubluxation, which occurs in 9% of children younger than 7 years. SCI without radiographic abnormality (SCIWORA) is common in children under 10 years of age and is associated with more complete neurologic injuries than in cases where the injuries can be seen on radiograph.

MANAGEMENT

For transportation of children and infants younger than 6 years of age, the cervical spine needs to be in a neutral position, and spine boards need to be modified to allow for the larger head-to-torso ratio that is present in children. Cervical traction with Crutchfield tongs in children <12 years of age is associated with dural leaks, and therefore, the use of halo traction with modified pin placements is recommended. Indications for surgery are generally the same as those for adults in regard to decompression and alignment. The length of a spinal fusion for stabilization should be minimized in the thoracolumbar spine because of the potential for premature arrest of spinal growth.

SUMMARY

The differences between children and adults with acute SCI are significant enough that caregivers cannot evaluate and treat a child with SCI as they would a small adult.

The usefulness of a modified adult protocol for the clearance of paediatric cervical spine injury in the emergency department

OBJECTIVE

To determine if the use of a modified adult protocol that uses cervical spine imaging on presentation for the assessment of cervical spine injury in children improves clinical outcome.

METHODS

This is a case series study on all consecutive trauma patients presenting from April to July 2000 inclusive to the ED of a major paediatric trauma hospital. Children presenting to the ED with potential cervical spine injury (CSI) were identified using standard selection criteria. Patient demographics, mechanism of injury, method and time of presentation, associated injuries, radiological investigation and clinical outcome were recorded. The major outcome measures for this study were: time to clearance of the cervical spine, length of stay in the ED and admission to an in-hospital bed. Data were analysed for compliance to the protocol, this being the standard assessment pathway of cervical spine clearance used by our trauma service.

RESULTS

The trauma registry identified 1721 trauma presentations during the 4-month study period; 208 presentations representing 200 children with potential CSI were entered into the study. Males represented 72.5% of the study population, having a mean age of 8.32 years, although 29% were less than 5 years of age. The majority of presentations (69%) occurred outside of normal working hours. In 17.8% of cases the cervical spine was cleared based on clinical assessment alone, half less than 5 years of age. Compliance to the protocol occurred in 78% of presentations. However, when examined by age group, children 5 years of age or above were 1.5 times more likely to comply with the protocol as compared with younger children. Adequate plain imaging was not obtained in 18% of presentations, this group almost exclusively less than 5 years of age. There were no missed injuries and no short or long-term neurological sequelae reported during this study. There were no differences in time to clearance, length of stay and admission rate between compliant and non-compliant groups.

CONCLUSIONS

Modified adult protocols for cervical spine clearance offer guidance in managing the majority of children suffering blunt trauma. However, we recommend caution in rigidly applying such protocols, especially to children of young age.

A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results

BACKGROUND/PURPOSE

Assessment of potential spine injuries is inconsistent and controversial. Subsequent morbidity includes prolonged immobilization and missed injuries. To address these issues, a multidisciplinary team was organized to design a cervical spine management/clearance pathway. The process, algorithm, and initial results are described.

METHODS

Team members consisted of pediatric surgeons, orthopedic surgeons, neurosurgeons, emergency room physicians, and trauma nurse practitioners. Nationwide standards, guidelines, and experiences across disciplines were reviewed, and a consensus pathway evolved for cervical spine clearance in children 8 years and younger. A short-term retrospective review (5 months) was performed to assess initial performance. Time required for clearance, number and type of imaging studies, and number of missed injuries were compared between a group of patients before (n = 71) and after (n = 56) the implementation of the pathway.

RESULTS

Strict guidelines for cervical spine immobilization and clearance criteria were defined. After implementation of this pathway, time required for cervical clearance in nonintubated children decreased (before, 12.3 +/- 1.5 v after, 7.5 +/- 0.9 hours; P =.014). A clear trend toward earlier clearance in intubated patients existed (before [n = 6], 40.0 +/- 16.8 v after [n = 6], 19.4 +/- 8.1 hours; P =.10); there need to be larger numbers to determine statistical significance. The 2 study groups were similar in age; mechanism of injury; Glasgow coma scale score; and number of plain x-rays, computed tomography scans, and magnetic resonance imaging studies obtained. Neither group had missed injuries.

CONCLUSIONS

standards for cervical spine immobilization, assessment, and clearance. Implementation of such guidelines decreased time for cervical spine clearance, and ongoing analysis of sensitivity is encouraging.

Spinal injuries

The pre-hospital care of patients with suspected spinal injuries involves early immobilisation of the whole spine and the institution of measures to prevent secondary injury from hypoxia, hypoperfusion or further mechanical disruption. Early ventilation and differentiation of haemorrhagic from neurogenic shock are the key elements of pre-hospital resuscitation specific to spinal injuries. Falls from a significant height, high-impact speed road accidents, blast injuries, direct blunt or penetrating injuries near the spine and other high energy injuries should all be regarded as high risk for spinal injury but clinical examination should determine whether the patient requires full, limited or no spinal immobilisation. Although there is little conclusive evidence in the literature that supports pre-hospital clinical clearance of the spine, the similarities between pre-hospital immobilisation decisions and in-hospital radiography decisions are such that it is likely that clinical clearance will be effective for selected patients. This decision can be made at the scene provided the patient has no evidence of: Altered level of consciousness or mental status Intoxication Neurological symptoms or signs A distracting painful injury (e.g. chest injuries, long bone fracture) Midline spinal pain or tenderness. Where there is evidence to support spinal immobilisation, then the full range of devices and techniques should be considered. In the remote or operational environment where pre-hospital times are prolonged, full immobilisation, analgesia and re-assessment may allow localisation of the injury and a reduction in the degree of immobilisation. Common reasons for missing significant spinal injuries include failing to consider the possibility of spinal injuries in patients who are either unconscious, intoxicated or uncooperative (54,55). The application of the decision rule discussed here will ensure that no clinically significant spinal injuries are missed in pre-hospital care.

Spinal injury: optimising the imaging options

There have been numerous documented attempts in formulating risk-based guidelines for the exclusion of spinal injury using conventional radiography. Although the advent of computed tomography (CT) (including spiral and multi-slice) and magnetic resonance imaging (MRI) confirmed the known limitations of conventional radiography, there is still a requirement to define optional use of these modalities in a trauma setting. This chapter addresses these issues by reviewing the literature and provides a synopsis of the current thinking in the appropriate sections (adult, paediatric, symptomatic, asymptomatic, etc.) in the quest of finding out the correct answers on how best to exclude/confirm spinal trauma.

Cervical spine injuries among submersion victims

BACKGROUND

Submersion victims are frequently considered at high risk for cervical spine (C-spine) injury regardless of whether they sustain a traumatic injury. We hypothesized that C-spine injury is unlikely in submersion victims who do not sustain high-impact injuries.

METHODS

The study was a cohort study of all people who submerged between January 1974 and July 1996 and received medical care or were seen by the medical examiner in King, Pierce, and Snohomish counties in Washington State.

RESULTS

Eleven (0.5%) of 2,244 submersion victims had C-spine injuries. All 11 had submerged in open bodies of water; had clinical signs of serious injury; and had a history of diving, motorized vehicle crash, or fall from height. No C-spine injuries occurred in 880 low-impact submersions.

CONCLUSION

Submersion victims are at risk for C-spine injury only if they have also sustained a traumatic injury. Routine C-spine immobilization does not appear to be warranted solely on the basis of a history of submersion.

A prospective multicenter study of cervical spine injury in children

OBJECTIVE

Pediatric victims of blunt trauma have developmental and anatomic characteristics that can make it difficult to assess their risk of cervical spine injury (CSI). Previous reports, all retrospective in nature, have not identified any cases of CSI in either children or adults in the absence of neck pain, neurologic symptoms, distracting injury, or altered mental status. The objective of this study was to examine the incidence and spectrum of spine injury in patients who are younger than 18 years and to evaluate the efficacy of the National Emergency X-Radiography Utilization Study (NEXUS) decision instrument for obtaining cervical spine radiography in pediatric trauma victims.

METHODS

We performed a prospective, multicenter study to evaluate pediatric blunt trauma victims. All patients who presented to participating emergency departments underwent clinical evaluation before radiographic imaging. The presence or absence of the following criteria was noted: midline cervical tenderness, altered level of alertness, evidence of intoxication, neurologic abnormality, and presence of painful distracting injury. Presence or absence of each individual criterion was documented for each patient before radiographic imaging, unless the patient was judged to be too unstable to complete the clinical evaluation before radiographs. The decision to radiograph a patient was entirely at the physician's discretion and not driven by the NEXUS questionnaire. The presence or absence of CSI was based on the final interpretation of all radiographic studies. Data on all patients who were younger than 18 years were sequestered from the main database for separate analysis.

RESULTS

There were 3065 patients (9.0% of all NEXUS patients) who were younger than 18 years in this cohort, 30 of whom (0.98%) sustained a CSI. Included in the study were 88 children who were younger than 2, 817 who were between 2 and 8, and 2160 who were 8 to 17. Fractures of the lower cervical vertebrae (C5-C7) accounted for 45.9% of pediatric CSIs. No case of spinal cord injury without radiographic abnormality was reported in any child in this study, although 22 cases were reported in adults. Only 4 of the 30 injured children were younger than 9 years, and none was younger than 2 years. Tenderness and distracting injury were the 2 most common abnormalities noted in patients with and without CSI. The decision rule correctly identified all pediatric CSI victims (sensitivity: 100.0%; 95% confidence interval: 87.8%-100.0%) and correctly designated 603 patients as low risk for CSI (negative predictive value: 100.0%; 95% confidence interval: 99.4%-100.0%).

CONCLUSIONS

The lower cervical spine is the most common site of CSI in children, and fractures are the most common type of injury. CSI is rare among patients aged 8 years or younger. The NEXUS decision instrument performed well in children, and its use could reduce pediatric cervical spine imaging by nearly 20%. However, the small number of infants and toddlers in the study suggests caution in applying the NEXUS criteria to this particular age group.

Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center

PURPOSE

Cervical spine (C-spine) injuries occur infrequently in children but may be associated with significant disability and mortality. The purpose of this study was to review the experience of a level 1 pediatric trauma center to determine the epidemiology, risk factors, mechanisms, levels, types of injury, comorbid factors, and outcomes associated with these potentially devastating injuries.

METHODS

A retrospective analysis of 103 consecutive C-spine injuries treated at a level 1 pediatric trauma center over a 9(1/2)-year period (January 1991 through August 2000) was performed.

RESULTS

The mean age was 10.3 +/- 5.2 years, and the male-to-female ratio was 1.6:1. The most common mechanism of injury was motor vehicle related (52%), followed by sporting injuries (27%). Football injuries accounted for 29% of all sports-related injuries. Sixty-eight percent of all children sustained injuries to C1 to C4; 25% to C5 to C7; and 7% to both. Spinal cord injury without radiographic abnormality (SCIWORA) occurred in 38%. Five patients had complete cord lesions involving the lower C-spine (C4 to C7); 4 of these were motor vehicle related, and all 4 patients died. Isolated C-spine injuries occurred in 43%, whereas 38% had associated closed head injuries (CHI). The overall mortality rate was 18.5%, most commonly motor vehicle related (95%), occurring in younger children (mean and median age 5 years) and associated with upper C-spine injuries (74%) and CHI (89%). C1 dislocations occurred in younger children (mean age, 6.6 years), most often as a result of motor vehicle-related trauma (especially pedestrians) and were associated with the highest injury severity score (ISS), longest length of stay (LOS), most CHIs, and the highest mortality rate (50%). C-spine fractures with or without SCI occurred most commonly as a result of falls and dives. Sporting injuries occurred almost exclusively in adolescent boys (mean age, 13.8 years) and were isolated injuries associated with a relatively low ISS and shorter LOS. Interestingly, 75% of sporting injuries showed SCIWORA, and all infants suffering from child abuse had SCIWORA.

CONCLUSIONS

Mechanisms of injury are age related, with younger children sustaining C-spine injuries as a result of motor vehicle-related trauma and older adolescents commonly injured during sporting activities. C-spine injuries in children most commonly involve the upper C-spine, but complete lesions of the cord are associated more frequently with lower C-spine injuries. The type of C-spine injury is related to the mechanism of injury: SCIWORA is associated with sporting activities and child abuse, C-spine dislocations most commonly result from motor vehicle-related trauma (especially among pedestrians), and C-spine fractures occur most commonly as a result of falls and dives. Predictors of mortality include younger age, motor vehicle-related mechanism, C1 dislocations, high ISS greater than 25, and associated CHI. A high index of suspicion for SCIWORA is essential when evaluating adolescents with neck trauma associated with sporting injuries or victims of child abuse.

Rate of abnormal osteoarticular radiographic findings in pediatric patients

OBJECTIVE

The objective of our study was to assess the rate of abnormal radiographic findings in the most frequent osteoarticular locations of traumatic injury in a pediatric population.

SUBJECTS AND METHODS

During two periods of 12 weeks each, all patients admitted to the pediatric emergency department for osteoarticular trauma who underwent radiography were prospectively included in this study. A connection was drawn between the rate of abnormal radiographic findings for the seven most frequently radiographed locations and the clinical findings.

RESULTS

Of 3128 locations of trauma in 2470 children, only 22% of the radiographic examinations were considered to reveal abnormal findings. In decreasing order, the hand and fingers, the ankle, the wrist, the knee, the elbow, the foot and toes, and the forearm were the most frequently examined locations. The rate of abnormal findings was 25.7% for the hand and fingers, 9.0% for the ankle, 42.5% for the wrist, 9.5% for the knee, 33.3% for the elbow, 18.3% for the foot, and 43.2% for the forearm. When only the direct sign of fracture was taken into account, these rates decreased for the ankle and knee to 2.6% and 1.9%, respectively. There was always a significant link between the degree of clinical suspicion and the rate of abnormal radiographic findings. However, fewer than 50% of the cases with high clinical suspicion of fracture were radiographically confirmed.

CONCLUSION

It appears necessary, especially in cases of lower limb trauma, to evaluate clinical tests, including the implementation of the Ottawa ankle rules, to reduce the number of unnecessary radiographic examinations. This reduction will improve some parameters of children's quality of life and will significantly decrease the cost of emergency care.

Accuracy of visual determination of neutral position of the immobilized pediatric cervical spine

BACKGROUND

The definition of neutral position for the immobilized pediatric cervical spine is not well standardized. In this study, we attempted to determine whether 1) physicians and/or paramedics could accurately assess visually if the cervical spine was in a neutral position, 2) the visual assessments of the observers were in agreement, and 3) a radiographic Cobb angle would correlate with the visual determination.

METHODS

Children presenting to a pediatric emergency department (ED) in full spinal immobilization were randomly selected (convenience sample) for this prospective study. The emergency physician and transporting paramedic independently determined positioning of the cervical spine. A radiologist, blinded to clinical information, determined Cobb angles from radiographs of the immobilized cervical spines.

RESULTS

Of the 59 children studied, the evaluation of cervical spine position by the physician and paramedic correlated in 88% of the cases. For the 22 children with non-neutral Cobb angles (definition of neutral: between 5 degrees flexion and 5 degrees extension), observers agreed in 100% of the cases. However, in 21 of these cases (95%) the position was observed as neutral.

CONCLUSIONS

Although visual determinations of neutral position of the cervical spine by two observers may correlate, radiographic studies demonstrate that neutral position was not achieved in 37% of the cases.

Emergency department evaluation and treatment of pediatric orthopedic injuries

Orthopedic injuries in children are unique in terms of the mechanisms of injury, pathophysiology, and healing. This article reviews the pediatric fracture patterns and common pediatric injuries or complaints seen in the emergency department, with an emphasis on management in the emergency department. Additionally, the approach to pediatric cervical spine injuries and child abuse will be described as it pertains to the emergency physician.

Evaluation of pediatric cervical spine injuries

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.

Pediatric cervical spine injury sustained in falls from low heights

STUDY OBJECTIVE

To determine whether history and clinical examination findings can identify young children who have sustained cervical injury after falling short distances.

METHODS

We conducted a retrospective review of the medical records of children younger than 6 years old with the diagnosis of cervical vertebral fracture or cervical spinal cord injury after a fall of less than 5 feet. Data from medical records over an average time span of 11 years at four large children's hospitals were compiled.

RESULTS

We identified eight children who sustained cervical spine injury after a fall of less than 5 feet. These children ranged in age from 9 to 68 months. Three had rotary subluxation of C1, and three had subluxation of C1-C2. One of the children in the latter group also had an odontoid fracture. Two children had a fracture of C2. All the children had limited range of motion of the neck or neck pain.

CONCLUSION

All children in this study with the diagnosis of cervical spine injury had clinical evidence of that injury on history or physical examination. Clinicians treating asymptomatic young children who sustain short falls may not need to perform radiographic evaluation of the cervical spine.

Cervical spine injuries in children

While cervical spine injuries are unusual in children, when they occur they frequently cause death or life-long disability. The primary care practitioner should be familiar with the signs and symptoms of cervical spine injuries, know the proper techniques of initial management, and engage in anticipatory guidance to prevent these injuries.

Infant involved in a motor vehicle accident

The authors present and discuss the differential diagnosis for a 7-month-old infant who was seen in the ED after having been involved in a motor vehicle accident. The infant was subsequently found to have an odontoid fracture. Strict attention to the mechanism of injury is emphasized for appropriate evaluation of this patient's condition. An infant who becomes airborne in a car that is extensively damaged deserves an aggressive workup. In a child of this age, examination for subtle or even quite significant injury is difficult. Therefore the focus should be on the potential for injury. This article addresses the rarity of this injury pattern and discusses factors involved in treatment of cervical spine injuries in pediatric patients. The development of the axis and radiography of the cervical spine in pediatric patients are reviewed also. Neurosurgical treatment options are presented. This case also reminds us to ensure parents understand the proper use of a car seat.

Intracranial hemorrhage as a predictor of occult cervical-spine fracture

STUDY OBJECTIVE

To determine whether intracranial hemorrhage is a predictor of occult cervical-spine fracture.

DESIGN

A prospective, cross-sectional study.

SETTING

University-affiliated Level I trauma center.

PARTICIPANTS

Ninety-three blunt trauma victims with a Glasgow Coma Scale score of 12 or less. Exclusion criteria were incomplete radiographic evaluation caused by hemodynamic instability, death, or other reasons.

INTERVENTIONS

The study protocol required that all patients undergo a five-view cervical-spine trauma series, head computed tomography (CT), and upper cervical-spine CT. Cervical-spine radiographs and CT scans were read by two radiologists blinded to each other's interpretations. The results were compared with each patient's head CT diagnosis. Medical records were reviewed for demographic information and mechanism of injury.

RESULTS

Of the 93 patients, 54 had intracranial hemorrhage noted on CT scan; two of these patients had an upper cervical-spine fracture, but only one was an occult cervical-spine fracture. Thirty-nine patients had no intracranial hemorrhage; two patients had an upper cervical-spine fracture, but only one had an occult cervical-spine fracture. Fisher's exact test showed no significant difference between the rate of occult cervical-spine fracture between patients with and without hemorrhage.

CONCLUSION

Despite a high percentage of patients with traumatic intracranial hemorrhage, our study failed to demonstrate that intracranial hemorrhage is predictor of occult cervical-spine fracture.

Pediatric cervical spine fractures: predominantly subtle presentation

Previous description of cervical spine fractures in children have emphasized high mortality injuries to the upper cervical vertebra. Our experience suggests a much wider spectrum of injury. The medical records of all children with cervical spine fractures admitted to Children's Hospital between January 1, 1985 and December 31, 1989 were reviewed. The average age of the 50 patients was 11 years (range, 2.7 to 18.8 years) and 62% were boys. Motor vehicle-related accidents (54%), sports injuries (18%), and falls (12%) accounted for the majority of the fractures. Twenty-nine patients (58%) had an associated head injury. Fifty percent of the patients were transported from the accident scene and 44% were interhospital transfers. All patients receiving medical care prior to referral had appropriate cervical spine stabilization. On admission 30% of the patients were unresponsive. Thirty-one children were alert and verbal at the time of evaluation and 30 complained of neck pain and tenderness (97%). Twenty-five of the 31 patients (83%) had no demonstrable neurological deficit on initial physical examination. Lateral cervical spine radiographs were diagnostic in 49 children (98%). A relatively even distribution of fractures occurred at all levels of the cervical spine. The anatomic site of the injury did not correlate with age. Sixteen patients (32%) died. Of the 34 who survived, only 6 had a persistent neurological deficit. Children with cervical spine fractures have two distinct patterns of presentation: lethal or intact. The majority of children with cervical spine fractures presented with no complaints of neck pain and/or tenderness need a complete radiographic evaluation of their cervical spine.

Cervical spine fractures and maxillofacial trauma

Cervical spine fractures are a serious complication of maxillofacial trauma because of the high potential for mortality and neurologic morbidity. This study reviewed 563 patients with facial fractures treated by the Division of Oral and Maxillofacial Surgery at a level I trauma center and identified 11 concomitant cervical spine fractures (2.0%). These patients were almost exclusively male (91%), white (100%), between 20 and 35 years of age (64%), involved in a motor vehicle accident (91%), with a concomitant mandibular fracture (91%). The examination, diagnosis, and management of patients with cervical spine injuries are discussed.

Emergency management of blunt trauma in children

Apart from the trend to nonoperative treatment of blunt abdominal injuries, based on accurate CT diagnosis, most of the recent and anticipated changes in pediatric trauma are organizational. They include resuscitation and triage before hospitalization, the use of designated trauma centers, resuscitation by trauma teams, noninvasive diagnosis and monitoring, comprehensive pediatric intensive care, the use of objective measures of outcome, and improved rehabilitation programs (Templeton JM: personal communication). The treatment of individual cases is based on simple but well-established principles. The key steps in management are to recognize children with life-threatening injuries (on the basis of the mechanism of injury or a Pediatric Trauma Score less than or equal to 8 or a Revised Trauma Score less than or equal to 11), to support the function of vital organs by establishing and maintaining adequate respiratory gas exchange and circulation, and to identify all important injuries by thorough and ongoing assessment.

Hangman's fracture in a 7-week-old infant

The "hangman's fracture" in infancy and childhood is a bilateral avulsion of the pedicles or their synchondroses from the C-2 vertebral body, frequently with anterior dislocation of C-2 or C-3. We present the case of the youngest infant in the medical literature with a hangman's fracture and discuss anatomy, kinematics of injury, radiographic diagnosis, and treatment.

Utility of the cervical spine radiograph in pediatric trauma

To determine the utility of the routine cervical spine radiograph, we reviewed all cervical spine radiographs obtained in pediatric trauma patients over a 2 1/2-year period at the Childrens Hospital of Los Angeles. Records of patients admitted with a documented cervical spine injury over a 20-year period were also reviewed. One hundred eighty-seven children had at least one cervical spine radiograph. Forty-six patients (25 percent) required at least one repeat study in an attempt to see all 7 vertebrae. Thirty-eight children (20 percent) had a second radiograph and 8 patients had a third study, all of which showed no injury. There was only one fracture seen during the 2 1/2-year time period. Of the 16 children admitted over the 20-year period, only 3 sustained an injury below the fourth cervical vertebra (C4), and all were over 8 years of age. All patients with cervical spine injury were either comatose or had symptoms referable to the neck. We conclude that the routine cervical spine radiograph in pediatric trauma is a very low-yield test.

Pediatric spinal injury: the very young

Maturity of the spine and spine-supporting structures is an important variable distinguishing spinal cord injuries in children from those in adults. Clinical data are presented from 71 children aged 12 years or younger who constituted 2.7% of 2598 spinal cord-injured patients admitted to the authors' institutions from June, 1972, to June, 1986. The 47 children with traumatic spinal cord injury averaged 6.9 years of age and included 20 girls (43%). The etiology of the pediatric injuries differed from that of adult injuries in that falls were the most common causative factor (38%) followed by automobile-related injuries (20%). Ten children (21.3%) had spinal cord injury without radiographic abnormality (SCIWORA), whereas 27 (57%) had evidence of neurological injury. Complete neurological injury was seen in 19% of all traumatic pediatric spinal cord injuries and in 40% of those with SCIWORA. The most frequent level of spinal injury was C-2 (27%, 15 cases) followed by T-10 (13%, seven cases). Upon statistical examination of the data, a subpopulation of children aged 3 years or younger emerged. These very young children had a significant difference in level of injury, requirement for surgical stability, and sex distribution compared to 4- to 12-year-old children.