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

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.

Management challenges of traumatic spondylolisthesis of the Axis with an unusual C2-C3 posterior subluxation in a paediatric patient: case report and literature review

Introduction

Paediatric cervical spine injuries are uncommon. Traumatic spondylolisthesis of the axis (TSA) is commonly encountered in the trauma setting. The management of TSA may be surgical or non-surgical. Decision making is quite challenging depending on patient presentation and nature of injury, and even more so in the paediatric age group.

Objectives

To present a case report highlighting the challenges in the management of TSA.

Methods

We present an 8 year old male, who sustained a bilateral C2 pars fracture with associated unusual C2-C3 posterior subluxation.

Results

Neuroradiological studies identified the fracture/subluxation of C2-C3 and revealed an intact but posteriorly displaced C2-C3 disc causing cord compression. An Extension Halter traction was initially commenced. This seemed to have worsened the patient's neck pains, and caused motor weakness and autonomic dysfunction. An anterior cervical discectomy and fusion was finally decided on and performed after evaluation and brainstorming by our spinal Unit. Intra-operative findings revealed separation of the C2-C3 disc from the C3 superior end plate which probably explains the unusual nature of the subluxation.

Conclusion

The case shows that surgical intervention as a primary management for TSA even in the paediatric age group is safe and also avoids risks inherent in conservative management.

Transoral Closed Reduction of Fixed Atlanto-Axial Rotatory-Subluxation (AARS) in Childhood and Adolescence

Atlanto-axial rotatory-subluxation (AARS) is the most common pediatric cervical spine injury. Patients usually present with contralateral rotation and inclination of the upper cervical spine after minor trauma, or associated with an infection of the upper respiratory tract. According to the authors, initial management of patients with acute and chronic AARS type I-II should comprise closed reduction and immobilization with a cervical collar or a Halo-Body-Jacket. Surgical options of open reduction or C1/2 fusion should be restricted to irreducible or recurrent subluxations. This paper reviews the detailed technique of transoral closed reduction of AARS, as well as the preoperative and postoperative considerations.

Epidemiology of spinal injury in childhood and adolescence in the United States: 1997-2012

OBJECTIVE There has been no successful study of trends in population-based incidences of pediatric spinal injury in the United States. The goal of the current study was to develop robust data to correct this deficiency in contemporary trauma epidemiology. METHODS Discharges coded for spinal injury were extracted from the Kids' Inpatient Database for 1997, 2000, 2003, 2006, 2009, and 2012 for patients younger than 18 years. Childhood was defined as ages 0 through 14 years and adolescence as ages 15, 16, and 17 years. Denominator population data were taken from the website of the US Census. Annual incidences were estimated for hospitalization for spinal injury, spinal cord injury (SCI), and hospital death with spinal injury. Mechanistic and anatomical patterns of injury were studied. RESULTS The annual population-based incidences of hospitalization for spinal injury, SCI, and death with spinal injury trended downward from 1997 to 2012 for children and adolescents in the United States. Rates of SCI and death fell faster than overall hospitalization rates, suggesting lower thresholds for admission or greater diagnostic sensitivity to minor injuries over time. The incidence of hospitalization for spinal injury was roughly 8 times greater for adolescents than for children, and the incidence of SCI was roughly 6 times greater. Motor vehicle crash predominated among mechanisms for both children and adolescents, but penetrating injuries and sport injuries were more commonly associated with SCI. Lumbosacral injuries predominated in both children and adolescents, but injuries of the cervical spine were more commonly associated with SCI. CONCLUSIONS Further research is needed to identify the cause or causes of the observed decline in injury rates. Epidemiological data can inform and support prevention efforts.

A geriatric patient with spinal cord injury without radiographic abnormality: outcomes and causes

Introduction

Although the prognosis of spinal cord injury without radiographic evidence of abnormality (SCIWORA) depends on the severity of the initial neurological damage, most patients with American Spinal Injury Association impairment scale grade D are expected to recover fully.

Case presentation

An 85-year-old patient with SCIWORA and urinary incontinence, who did not produce the expected response to rehabilitation, displayed the central, peripheral, and autonomic nervous system findings together. Conventional radiography, computed tomography, and even magnetic resonance imaging were unable to explain this complicated neurological condition thoroughly. More in-depth research into the patient's history revealed some sequelae left by urinary surgery and chemotherapy.

Discussion

Comorbidities in geriatric SCIWORA have severe effects on both etiology and prognosis. Furthermore, incontinence in SCIWORA is an essential condition that has not been addressed until now and may play a role in prognosis.

Acute management of cervical spine trauma

Traumatic cervical spine injuries represent a significant cause of morbidity and mortality in sports. Appropriate management of such injuries is critical to minimizing harm and facilitating optimal long-term recovery and outcome. Management strategies begin with emergency preparedness amongst sideline providers and extends to paramedic services and medical teams in the acute care setting. This chapter outlines the principles of treatment across the care continuum, with a primary focus on hospital-based care. Diagnostic imaging and equipment considerations are reviewed, with discussion of corticosteroid administration, therapeutic hypothermia, and traction of the cervical spine. Approaches to cervical spine stabilization and return to play are also detailed, with an emphasis on patient-centered care and individualized treatment approaches to the athlete.

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.

Triage tools for detecting cervical spine injury in pediatric trauma patients

BACKGROUND

Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population.

OBJECTIVES

To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma.

SEARCH METHODS

We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility.

SELECTION CRITERIA

We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy.

MAIN RESULTS

Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity.

AUTHORS' CONCLUSIONS

There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.

Trauma Arrest and Spinal Injury in a 3-Year-Old Girl

Management of an acutely injured pediatric patient with multiple traumas is a common challenge facing clinicians in pediatric emergency care. Blunt trauma is more common in the pediatric population with motor vehicle accidents being the most common cause of injury. Spinal injury, especially in young children, is only seen in 1% to 2% of cases and can be lethal. It is incumbent upon clinicians to be able to meet the challenges of patient management including airway management, providing hemodynamic support, and addressing potentially reversible causes of arrest while recognizing presenting symptoms of spinal injury. This case presents a child in trauma arrest after a motor vehicle crash requiring advanced interventions, diagnostics, and support. Her clinical course is described and reveals a complete distraction of the cervical and thoracic spine. This case illustrates pathology and management along with the importance of proper management and interventions by pediatric emergency clinicians to manage the patient and attempt to maximize the patient's outcome.

The Kids Are Alright: Pediatric Trauma Pearls

Pediatric patients with trauma pose unique challenges, both practical and cognitive, to front-line care providers. The combination of anatomic, physiologic, and metabolic factors leads to unique injury patterns with different approaches and responses to treatment compared with adults. A similar traumatic mechanism can lead to slightly different internal injuries with unique management and treatment strategies between the two groups. This article is intended for community, nonpediatric trauma centers, and emergency physicians who are frequently required to assess, resuscitate, and stabilize injured children before they can be safely transferred to a pediatric trauma center for ongoing definitive care and rehabilitation.

Imaging in paediatric spinal injury

Background

Paediatric spinal injury is rare and exhibits many unique features. Attending clinicians and radiologists often lack knowledge, expertise and experience in dealing with a potential injury to the paediatric spine. Within the paediatric age range itself there are different age-dependent mechanisms that can injure the paediatric spine. Moreover, the anatomical features and degree of osseous maturity of the developing paediatric spine determine the biomechanical characteristics which promote unique patterns of spinal injury in each paediatric age group.

Methods

An expert illustrated narrative review of the literature.

Results

Multiple factors make the imaging interpretation of the injured paediatric spine challenging. Each imaging modality has strengths and weaknesses in depicting spinal anatomy which vary with the type of spinal injury and age of the paediatric patient.

Conclusions

Attending doctors need to be familiar with the imaging appearances of the normal paediatric spine, its normal variants as well as the imaging features characteristics of paediatric spinal injury seen on radiographs, computed tomography and magnetic resonance imaging.

Fractures of the Bilateral C2 Neurocentral and Lateral Dental Synchondroses with Kyphotic C1-C2 Subluxation in a 3-Year-Old Girl: A Description of a Rare Fracture Pattern and Its Treatment: A Case Report

CASE

Spinal fractures are rare in young children. Because spinal anatomy and biomechanics differ in children and adults, knowledge of the deviations of the juvenile spine is necessary for adequate treatment. We present the case of a young girl with an unusual C2 fracture that included rupture of both of the neurocentral and lateral dental synchondroses, with an opening of the synchondroses and a caudal dislocation of both vertebral arches following a head-on motor vehicle collision. The whole body and apex of the dens was displaced anteriorly and cranially with a kyphotic angulation of 34°. We describe the treatment and clinical and radiographic outcome after 1 year.

CONCLUSION

Using passive hyperextension and distraction of the head, a closed open-mouth digital reduction was performed under continuous fluoroscopy. At the 1-year follow-up, the patient had full range of motion of the head without pain or neurologic dysfunction.

Changes in use of cervical spine magnetic resonance imaging for pediatric patients with nonaccidental trauma

OBJECTIVE Past studies have suggested correlations between abusive head trauma and concurrent cervical spine (c-spine) injury. Accordingly, c-spine MRI (cMRI) has been increasingly used in radiographic assessments. This study aimed to determine trends in cMRI use and treatment, and outcomes related to c-spine injury in children with nonaccidental trauma (NAT). METHODS A total of 503 patients with NAT who were treated between 2009 and 2014 at a single pediatric health care system were identified from a prospectively maintained database. Additional data on selected clinical events were retrospectively collected from electronic medical records. In 2012, a clinical pathway on cMRI usage for patients with NAT was implemented. The present study compared cMRI use and clinical outcomes between the prepathway (2009-2011) and postpathway (2012-2014) periods. RESULTS There were 249 patients in the prepathway and 254 in the postpathway groups. Incidences of cranial injury and Injury Severity Scores were not significantly different between the 2 groups. More patients underwent cMRI in the years after clinical pathway implementation than before (2.8% vs 33.1%, p < 0.0001). There was also a significant increase in cervical collar usage from 16.5% to 27.6% (p = 0.004), and more patients were discharged home with cervical collar immobilization. Surgical stabilization occurred in a single case in the postpathway group. CONCLUSIONS Heightened awareness of potential c-spine injury in this population increased the use of cMRI and cervical collar immobilization over a 6-year period. However, severe c-spine injury remains rare, and increased use of cMRI might not affect outcomes markedly.

Comparison of the GlideScope Cobalt® and Storz DCI® Video Laryngoscopes in Children Younger Than 2 Years of Age During Manual In-Line Stabilization: A Randomized Trainee Evaluation Study

OBJECTIVES

Video laryngoscopy facilitates tracheal intubation during manual in-line stabilization in adults, but it is not clear whether these findings translate to children. We compared trainee intubation times obtained using the GlideScope Cobalt® and Storz DCI® video laryngoscopes versus direct laryngoscopy in young children with immobilized cervical spines.

METHODS

Ninety-three children younger than 2 years underwent laryngoscopy with manual in-line stabilization using direct laryngoscopy, GlideScope Cobalt® video laryngoscopy, or Storz DCI® video laryngoscopy. Laryngoscopists were anesthesiology trainees in postgraduate training year of 3 or more. Total time to successful intubation (TTSI), best glottic view, and maximum degrees of neck deviation were recorded. An intubation time difference longer than 10 seconds was defined as clinically significant.

RESULTS

Data are reported as median; 95% confidence interval. The TTSI was similar among groups although Storz times were longer (median, 33.3 seconds; 95% confidence interval, 26.2-43.3 seconds) when compared to direct laryngoscopy (median, 23.3 seconds; 95% confidence interval, 20.7-26.5 seconds; P = 0.02). Obtaining a grade 1 Cormack-Lehane glottic view was less likely with direct laryngoscopy (P = 0.002). Maximum degrees of neck deviation were: Storz (median, 2.0; 95% confidence interval, 1.2-2.8), GlideScope (median, 2.0; 95% confidence interval, 1.4-2.6), and direct laryngoscopy (median, 1.9; 95% confidence interval, 1.2-2.1; P = 0.48).

CONCLUSIONS

Trainees were able to safely perform tracheal intubation in children younger than 2 years using any of the studied laryngoscopes, although Storz use resulted in a longer TTSI when compared to direct laryngoscopy. Video laryngoscopy may enhance best Cormack-Lehane glottic view during manual in-line cervical spine immobilization, but additional technical skills are needed to successfully complete tracheal intubation.

Cervical spine imaging for young children with inflicted trauma: Expanding the injury pattern

AIM

The purpose of this study was to document the incidence and pattern of cervical spine (c-spine) injuries in children below 36months with inflicted trauma.

METHODS

An IRB approved, prospective cohort study was performed between July 2011 and January 2016. Inclusion criteria were: age below 36months, loss of consciousness after inflicted trauma, and one initial head computed tomography finding: a subdural, intraventricular, intraparenchymal, subarachnoid hemorrhage, diffuse axonal injury, hypoxic injury, or cerebral edema. A protocol of brain and neck magnetic resonance imaging and angiography was obtained within 48h. Variables were compared by t-test and Fisher-exact test.

RESULTS

There were 53 children (median age: five months; range: 1-35months), 38 males (71.7%), of which seven died (13.2%). C-spine injury was identified in 8 (15.1%): ligamentous injury (2), vertebral artery shear injury (1), atlantooccipital dissociation (AOD) (1), cord injury with cord epidural hematoma (2), and isolated cord epidural hematoma (2). Retinal hemorrhages (p=0.02), shaking (p=0.04), lower Glasgow coma score (GCS) (p=0.01), brain infarcts (p=0.01), and hypoxic/ischemic injury (p=0.01) were associated with c-spine injury. One with AOD died. Six had significant disability.

CONCLUSION

For small children with inflicted trauma, the c-spine injury incidence is 15.1%. The injury pattern includes retinal hemorrhages, shaking, lower GCS, and brain injury. Evaluation of shaken infants should include c-spine imaging.

LEVEL OF EVIDENCE

Level 2 A- This is a prospective cohort study with complete follow-up to hospital discharge or death. In all cases, inflicted trauma was confirmed. Owing to the nature of child abuse, the precise time of injury is not known. All children underwent a strict imaging protocol on arrival to hospital that was supervised on a prospective basis.

Cervical facet dislocations in the adolescent population: a report of 21 cases at a Level 1 trauma center from 2004 to 2014

PURPOSE

The purpose of this study was to present a series of adolescent patients with cervical facet dislocations to identify the mechanism of injury, severity of neurological injury and rate of neurological recovery.

METHODS

Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with unilateral or bilateral dislocated facet(s). Demographic data, initial neurological exams, surgical data, radiographic findings, and follow-up records were reviewed.

RESULTS

Of the 21 adolescent facet dislocations, 7 were unilateral and 14 bilateral. Mean age was 14.9 years; (range 12-17). Male:female ratio was 15:6. All patients presented as a result of a high-energy injury. C6-7 was the most common level of dislocation. 1 of 18 (5.5%) patients had a cervical disc herniation on MRI. Nine (43%) patients had an associated facet fracture (8 unilateral, 1 bilateral). None of the 12 patients who presented as a complete spinal cord injury (SCI) (AISA A) had any neurological recovery. Only one of the three patients who presented as an incomplete SCI (ASIA B, C, D) had an ASIA grade improvement at final follow-up. Six patients who presented were neurologically intact (ASIA E).

CONCLUSION

Over half of children with this injury in our study had a complete SCI with no recovery. We believe that the adolescent spine is more resilient to injury, thus requiring a high-energy injury to cause a dislocation, but resulting in a high rate of SCI with a low rate of neurological recovery, and a low rate of cervical disc herniation.

Delayed diagnosis of fractured anterior arch of the atlas in a young child

A 2-year-old girl fell off a bunk bed onto a parquet floor. She immediately reported neck pain and presented with muscle spasm and limited motion of the cervical spine (C-spine). Plain X-rays of the C-spine showed no osseous lesion. Owing to persisting pain and limited motion in the neck, MRI of the C-spine was obtained which revealed intact ligaments and cervical spinal cord, as well as soft tissue swelling in front of the anterior arch of the atlas. Subsequent CT of the C-spine confirmed a complete, undisplaced fracture of the anterior arch of the atlas (Gehweiler type I fracture). A Minerva cast was applied for 2 months, followed by a soft cervical collar. Persistent neck pain and limited range of motion of the neck after a fall may be indicative of atlas fracture that should be ruled out by CT.

A comparison of McGrath MAC® and standard direct laryngoscopy in simulated immobilized cervical spine pediatric intubation: a manikin study

Emergency airway management in children is generally considered to be challenging, and endotracheal intubation requires a high level of personal skills and experience. Immobilization of the cervical spine is indicated in all patients with the risk of any cervical spine injury but significantly aggravates endotracheal intubation. The best airway device in this setting has not been established yet, although the use of videolaryngoscopes is generally promising. Seventy-five moderately experienced paramedics of the Emergency Medical Service of Poland performed endotracheal intubations in a pediatric manikin in three airway scenarios: (A) normal airway, (B) manual in-line cervical immobilization, and (C) cervical immobilization using a Patriot cervical extrication collar and using two airway techniques: (1) McGrath videolaryngoscope and (2) Macintosh blade in a randomized sequence. First-attempt intubation success rate, time to intubation, glottis visualization, and subjective ease of intubation were investigated in this study. Intubation of difficult airways, including manual in-line and cervical collar immobilization, using the McGrath was significantly faster, with a higher first-attempt intubation success rate, better glottic visualization, and ease of intubation, compared to Macintosh-guided intubation. In the normal airway, both airway techniques performed equal.

CONCLUSION

Our manikin study indicates that the McGrath may be a reasonable first intubation technique option for endotracheal intubation in difficult pediatric emergencies. Further clinical studies are therefore indicated. What is known : • Airway management in pediatrics is challenging and requires a high level of skills and experience. Cervical immobilization is indicated in all patients with any risk of cervical spine injury, but it significantly aggravates endotracheal intubation in these patients. Videolaryngoscopes have been reported to ease intubation and provide better airway visualization in the regular clinical setting. What is new: • The McGrath is an easy-to-use and clinically often used videolaryngoscope, but it has never been investigated in pediatrics with an immobilized cervical spine. In the normal airway, the McGrath provided better airway visualization compared to Macintosh laryngoscopy. However, better visualization did not lead to decreased time to intubation and a higher success rate of the first intubation attempt. In difficult airways, the McGrath provided better airway visualization and this led to faster intubation, a higher first-attempt intubation success rate, and better ease of intubation compared to Macintosh-guided intubation.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.

Sports injuries in children

Sports injuries in children affect both growing bone and soft tissues, and can result in damage of growth mechanisms with subsequent lifelong growth disturbance. During growth, there are significant changes in the biomechanical properties of bone. In young athletes, as bone stiffness increases and resistance to impact diminishes, sudden overload may cause bones to bow or buckle. Epiphyseal injuries are usually due to shearing and avulsion forces, although compression also plays a significant role. Given the remarkable healing potential of bone in childhood, fractures that initially united with some deformity can completely remodel, and the bone may appear totally normal in later life. Most injuries in children’s sports are minor and self-limiting, suggesting that children and youth sports are safe. However, as the risk of injuries sustained by young athletes can be significant, training programmes should take into account their physical and psychological immaturity, so that growing athletes can adjust to their own body’s changes.

Hospital Variation in Cervical Spine Imaging of Young Children With Traumatic Brain Injury

OBJECTIVE

Cervical imaging practices are poorly understood in young children with traumatic brain injury (TBI). We therefore sought to identify child-level and hospital-level factors associated with performance of cervical imaging of children with TBI from falls and abusive head trauma (AHT) and to describe across-hospital variation in cervical imaging performance. We hypothesized that imaging decisions would be influenced by hospital volume of young injured children.

METHODS

We performed a retrospective study of children younger than 2 years of age with TBI from 2009 to 2013 in the Premier Perspective Database. After adjustment for observed patient characteristics, we evaluated variation in advanced cervical imaging (computed tomography or magnetic resonance imaging) in children with AHT and TBI from falls.

RESULTS

Of 2347 children with TBI, 18.7% were from abuse and 57.1% were from falls. Fifteen percent of children with TBI underwent advanced cervical imaging. Moderate or severe head injuries were associated with increased odds of cervical imaging in AHT (odds ratio 7.10; 95% confidence interval 2.75, 18.35) and falls (odds ratio 2.25; 95% confidence interval 1.19, 4.27). There was no association between annual hospital volume of injured children and cervical imaging performance. The adjusted probability of imaging across hospitals ranged from 4.3% to 84.3% in AHT and 3.1 to 39.0% in TBI from falls (P < .001).

CONCLUSIONS

These results highlight variation across hospitals in adjusted probability of cervical imaging in AHT (nearly 20-fold) and TBI from falls (over 10-fold) not explained by observed patient characteristics. This variation suggests opportunities for further research to inform imaging practices.

Spinal Cord Injury without Radiological Abnormality in an 8 Months Old Female Child: A Case Report

Introduction:

Spinal cord injury in children frequently occurs without fracture or dislocation. SCIWORA is a syndrome occurring when the spinal cord sustains neural damage during a traumatic event without positive radiographic findings. The incidence of SCIWORA was found to be 8% to 32% in various studies with very few cases documented in children below the age of 1 year. We report such a case of spinal cord injury without radiological abnormality in an 8 months old female child.

Case Report:

An 8 months old female child was brought to the emergency room after a history of fall from the bed four days back. External spine examination revealed no abnormality. She had no upper or lower limb movements, both active and withdrawal movements with painful tactile stimuli, power was grade 0; are flexic; abdominal cremasteric and anal reflexes were absent, bladder was palpable and urine could be expressed on manual pressure. MRI of cervical spine with screening of whole spine: suggestive of non hemorrhagic cord edema at C4 level, with suspicious tear of anterior longitudinal ligament at that level. The child was immobilized in pediatric cervical collar and treatment was initiated with corticosteroids and the dose adjusted as per age of the patient. A paediatric physiotherapist started with physical therapy after four days of commencement of treatment.

Conclusion:

In present times with wide spread use of MRI, the definition of SCIWORA is slowly turning towards spinal cord injury without neuroimaging abnormality [4]. Traumatic spinal cord infarction is a special type of SCIWORA which presents with normal radiology with delayed neurological deterioration [1]. Corticosteroid usage has been useful in cases of SCIWORA as proved by NASCISII Trial.

Traumatic spinal injuries in children at a single level 1 pediatric trauma centre: report of a 23-year experience

BACKGROUND

With a reported incidence of up to 10% compared to all spinal trauma, spinal injuries in children are less common than in adults. Children can have spine fractures with or without myelopathy, or spinal cord injuries without radiological abnormalities (SCIWORA).

METHODS

We retrospectively reviewed the cases of children with spinal injuries treated at a level 1 pediatric trauma centre between 1990 and 2013.

RESULTS

A total of 275 children were treated during the study period. The mean age at admission was 12 ± 4.5 years, and the male:female ratio was 1.4:1. Spinal injuries were more common in children of ages 12-16 years, with most injuries among ages 15-16 years. The top 3 mechanisms of spinal injury were motor vehicle-related trauma (53%), sports (28%) and falls (13%). Myelopathy occurred in 12% and SCIWORA occurred in 6%. The most common spine levels injured were L2-sacrum, followed by O-C2. Associated injuries, including head injuries (29%), and fractures/dislocations (27%) occurred in 55% of children. Overall mortality was 3%. Surgical intervention was required in 14%.

CONCLUSION

The creation of a pediatric spinal injury database using this 23-year retrospective review helped identify important clinical concepts; we found that active adolescent boys had the highest risk of spine injury, that noncontiguous spine injuries occured at a rate higher than reported previously and that nonaccidental spine injuries in children are underreported. Our findings also emphasize the importance of maintaining a higher index of suspicion with trauma patients with multiple injuries and of conducting detailed clinical and radiographic examinations of the entire spine in children with a known spinal injury.

Prevalence of Unique Pediatric Pathologies Encountered by Paramedic Students Across Age Groups

Introduction Traditionally, Emergency Medical Services (EMS) educators have divided the pediatric population into age groups to assist in targeting their clinical and didactic curriculum. Currently, the accrediting body for paramedic training programs requires student exposure to pediatric patients based entirely on age without specifying exposure to specific pathologies within each age stratification. Identifying which pathologies are most common within the different pediatric age groups would allow educators to design curriculum targeting the most prevalent pathologies in each age group and incorporating the physiologic and psychological developmental milestones commonly seen at that age. Hypothesis It was hypothesized that there are unique clusterings of pathologies, represented by paramedic student primary impressions, that are found in different age groups which can be used to target provider education.

METHODS

This is a retrospective review of prospectively collected data documented by paramedic students in the Fisdap (Field Internship Student Data Acquisition Project; Saint Paul, Minnesota USA) database over a one-year period. For the purposes of this study, pediatric patients were defined arbitrarily as those between the ages of 0-16 years. All paramedic student primary impressions recorded in Fisdap for patients aged 0-16 years were abstracted. Primary impression by age was calculated and graphed. The frequency of primary impression was then assessed for significance of trend by age with an alpha ≤.05 considered significant.

RESULTS

The following primary impressions showed clinically and statistically significant variability in prevalence among different pediatric age groups: respiratory distress, medical-other, abdominal pain, seizure, overdose/poisoning, behavioral, and cardiac. In patients less than 13 years old, respiratory and other-medical were the most common two primary impressions and both decreased with age. In patients 5-16 years old, the prevalence of abdominal pain and behavioral/psych increased. Bimodal distributions for overdose were seen with one spike in the toddler and another in the adolescent population. Seizures were most common in the age group associated with febrile seizure. Sepsis was seen most often in the youngest patients and its prevalence decreased with age.

CONCLUSION

There are statistically significant variations in the frequency of paramedic student primary impressions as a function of age in the pediatric population. Emphasizing paramedic student exposure to the most common pathologies encountered in each age group, in the context of the psychological and physiological milestones of each age, may improve paramedic student pediatric practice. Ernest EV , Brazelton TB , Carhart ED , Studnek JR , Tritt PL , Philip GA , Burnett AM . Prevalence of unique pediatric pathologies encountered by paramedic students across age groups. Prehosp Disaster Med. 2016; 31(4):386-391.

Idiopathic Cervical Hematomyelia in an Infant: Spinal Cord Injury without Radiographic Abnormality Caused by a Trivial Trauma? Case Report and Review of the Literature

BACKGROUND

Spontaneous or idiopathic intramedullary bleeding is a very rare event in pediatric patients. This diagnosis requires an extended clinical, laboratory, and radiologic work-up to rule out all potential causes of hematomyelia. However, children may present with hematomyelia or spinal cord injury without radiographic abnormality even after a minor trauma.

CASE DESCRIPTION

A 15-month-old girl presented with a 24-hour history of progressive neurologic deficits. A trivial trauma had occurred a few days before the clinical onset. Head computed tomography scan and craniospinal magnetic resonance imaging revealed an isolated hemorrhagic central medullary lesion extending from the obex to C3 level. No underlying causes of intramedullary bleeding were identified. In the absence of obvious vascular abnormalities, the patient underwent an urgent occipitocervical decompression with hematoma evacuation. Postoperatively, the patient's motor symptoms rapidly resolved, and she was discharged with cervical collar immobilization.

CONCLUSIONS

We discuss the differential diagnosis of intramedullary bleeding in children, focusing on the diagnostic protocol and therapeutic options in this age group.

Management of subaxial cervical instability in very young or small-for-age children using a static single-screw anterior cervical plate: indications, results, and long-term follow-up

OBJECTIVE Subaxial cervical instability in very young or small-for-age children is uncommon and typically arises from trauma or skeletal dysplasia. Various operative techniques have been used to achieve stabilization in pediatric patients with evidence of instability, including anterior, posterior, and combined approaches. In this study, the authors report their results with subaxial cervical instability in this patient population treated using a static single-screw anterior cervical plate (ACP) system and allograft fusion. METHODS In a retrospective chart review, the authors identified all patients 6 years of age or younger who underwent an anterior cervical fusion procedure using a static single-screw ACP system either as a stand-alone construct or as part of an anterior-posterior stabilization procedure. Reasons for fusion included trauma, tumor, and congenital anomalies. RESULTS Five patients 6 years of age or younger underwent anterior cervical fusion using a static single-screw system during the 19-year study period. Follow-up ranged from 12 to 51 months (mean 26.8 months). Two patients underwent repeat surgery, one 7 days after and the other 21 months after their initial procedure. At last follow-up, a mean vertical growth of 22.8% was seen across the fused segments, with no evidence of kyphotic or lordotic abnormalities. CONCLUSIONS In very young or small-for-age children, the use of a static single-screw ACP system appears to be a safe and effective option to manage subaxial cervical instability. Bony fusion and continued longitudinal growth occur within the fused segments, with no evidence of long-term cervical malalignment.

Pediatric Cervical Spine Injuries: A Rare But Challenging Entity

BACKGROUND

Injuries to the cervical spine in pediatric patients are uncommon. A missed injury can have devastating consequences in this age group. Because of the lack of routine in diagnosis and management of pediatric cervical spine injuries (PCSI), each of these cases represents a logistic and personal challenge.

METHODS

By means of clinical cases, we demonstrate key points in diagnostics and treatment of pediatric spine injuries. We highlight typical pediatric injury patterns and more adult-like injuries.

RESULTS

The most common cause of injury is blunt trauma. There is an age-related pattern of injuries in pediatric patients. Children under the age of 8 frequently sustain ligamentous injuries in the upper cervical spine. After the age of 8, the biomechanics of the cervical spine are similar to adults, and therefore, bony injuries of the subaxial cervical spine are most likely to occur. Clinical presentation of PCSI is heterogeneous. Younger children can neither interpret nor communicate neurological abnormalities, which make timely and accurate diagnosis difficult. Plain radiographs are often misinterpreted. We find different types of injuries at different locations, because of different biomechanical properties of the immature spine. We outline that initial management is crucial for long-term outcome.

CONCLUSIONS

Knowledge of biomechanical properties and radiographic presentation of the immature spine can improve the awareness for PCSI. Diagnosis and management of pediatric patients after neck trauma can be demanding.

LEVEL OF EVIDENCE

Level IV.

Pediatric Cervical Spine and Spinal Cord Injury: A National Database Study

STUDY DESIGN

A retrospective administrative database analysis.

OBJECTIVE

The aim of this study was to investigate the incidence and characteristics of pediatric cervical spine injury (PCSI) utilizing the Kids' Inpatient Database (KID).

SUMMARY OF BACKGROUND DATA

PCSI is debilitating, but comprehensive analyses have been difficult due to its rarity. There have been a few database studies on PCSI; however, the studies employed databases that suffer from selection bias.

METHODS

The triennial KID was queried from years 2000 to 2012 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Pediatric admissions were divided into five age groups reflecting different developmental stages. PCSI was analyzed in terms of trend, demographics, injury characteristics, hospital characteristics, comorbidities, and outcomes variables. Multivariate logistic regression analyses were used to identify independent risk factors for PCSI among trauma admissions and to identify independent risk factors for mortality among PCSI admissions.

RESULTS

Over the past decade, the overall prevalence of traumatic PCSI was 2.07%, and the mortality rate was 4.87%. Most frequent cause of PCSI was transportation accidents, accounting for 57.51%. Upper cervical spine injury (C1-C4), cervical fracture with spinal cord injury, spinal cord injury without radiographic abnormality (SCIWORA), and dislocation showed a decreasing trend with age. Some comorbidities, including, but not limited to, fluid and electrolyte disorders, and paralysis were common across all age groups, while substance abuse showed a bimodal distribution. Independent risk factors for PCSI after trauma were older cohorts, non-Northeast region, and transportation accidents. For mortality after PCSI, independent risk factors were younger cohorts, transportation accidents, upper cervical spine injury, dislocation, and spinal cord injuries. Median length of stay and cost were 3.84 days and $14 742.

CONCLUSION

Pediatric patients are highly heterogeneous, constantly undergoing behavioral, environmental, and anatomical changes. PCSI after trauma is more common among older cohorts; however, mortality after sustaining PCSI is higher among younger patients.

LEVEL OF EVIDENCE

4.

The role of emergency radiology in spinal trauma

Spinal trauma is very frequent injury with different severity and prognosis varying from asymptomatic condition to temporary neurological dysfunction, focal deficit or fatal event. The major causes of spinal trauma are high- and low-energy fall, traffic accident, sport and blunt impact. The radiologist has a role of great responsibility to establish the presence or absence of lesions, to define the characteristics, to assess the prognostic influence and therefore treatment. Imaging has an important role in the management of spinal trauma. The aim of this paper was to describe: incidence and type of vertebral fracture; imaging indication and guidelines for cervical trauma; imaging indication and guidelines for thoracolumbar trauma; multidetector CT indication for trauma spine; MRI indication and protocol for trauma spine.

Peculiarities and Patterns of Cervical Spine Injuries in Children and Adolescents: A Retrospective Series of 84 Patients from a Single Institute

Cervical spine injuries occur infrequently in children but are associated with significant disability and mortality. A retrospective analysis was performed of 84 consecutive pediatric spine injuries treated at our institute from January 2002 to December 2011. The mean age was 14.7 years. There were 18 patients (21%) in group A (0-12 years) and 66 patients (79%) in group B (13-18 years). Overall, injury was more common in boys (ratio of 6:1). Trivial fall was the predominant cause in group A and fall from height in group B. There were 30 children (36%) with injuries of the upper cervical spine, 53 (63%) with injuries of the lower cervical spine and 1 patient (1%) with a combined injury of upper cervical spine and thoracic spine. Overall, 22% of the group A children and 67% of the group B patients had more severe injuries (Frankel grades A, B and C); 21% (18/84) were treated by surgical fusion. Where follow-up was available, 17 out of 22 children (77%) had good outcome (Frankel grade >C). In conclusion, mechanisms and patterns of injury in children are age related and the majority of the children had good outcome.

Successful delayed non-operative management of C2 neurosynchondrosis fractures in a pediatric patient: a case report and review of management strategies and considerations for treatment

Upper cervical synchondrosis fractures are the most common types of cervical fractures in the pediatric population less than 7 years of age (Blauth et al (Eur Spine J 5:63-70, 1996); Connolly et al (Pediatr Radiol 25(Suppl1):S129-133, 1995); Mandabach et al (Pediatr Neurosurg 19(5):225-232, 1993); Schippers et al (Acta Neurochir 138:524-530, 1990)) The vast majority occur through the dentocentral or basilar synchondrosis. We present the second reported case in recent literature of a unilateral neurosynchondrosis fracture. The patient, a 4-year-old male, was initially managed conservatively with a rigid cervical collar for a period of 3 months. Despite multiple counseling sessions with family, the patient remained poorly compliant with cervical immobilization. After 3 months, imaging demonstrated partial fusion with persistent anterolisthesis of C2 on C3. The decision was made to place the child in external halo fixation as an attempt to achieve fusion prior to committing to internal surgical fixation and the associated sequelae. Immobilization with a hard cervical collar is often first line treatment. In the case of failed fusion, debate exists regarding surgical fixation in children. Occipito-atlanto-axial fusion leads to permanent loss of a significant degree of flexion, extension, and rotatory movement. The pediatric population has a strong propensity to fuse; however, compliance is often a barrier to conservative treatment due to age-related behavioral practices. We demonstrate that even with initial failed fusion and progression of deformity while in a cervical collar, conservative management with external halo fixation can potentially obviate the need for internal fixation.

Identification of Risk Factors for Cervical Spine Injury from Pediatric Trauma Registry

BACKGROUND

Cervical spine injuries are rare in children. Our goal is to establish guidelines for cervical spine clearance that are practical for our pediatric population, and, in the process, to reduce the risk of radiation exposure from unnecessary advanced imaging.

METHODS

We retrospectively reviewed the records from the registries of two pediatric trauma centers from the past 11 years (January 2002 to June 2013). Patients aged 1 month to 17 years, who had a CT scan of the cervical spine due to trauma indication for possible cervical spine injury, were evaluated.

RESULTS

Three risk factors were identified as being significant for the presence of a cervical spine injury. Patients who sustained a cervical spine injury were more likely to be male (p = 0.0261), were more severely injured with a higher injury severity score (ISS 16.39 ± 15.79 injured vs. 8.7 ± 9.4 uninjured), and presented with neck tenderness (p = 0.0001).

CONCLUSION

In our study, significant cervical spine injury is related to male gender, higher ISS and neck tenderness.

Pediatric spinal injury in the US: epidemiology and disparities

OBJECT

In the US, race and economic status have pervasive associations with mechanisms of injury, severity of injury, management, and outcomes of trauma. The goal of the current study was to examine these relationships on a large scale in the setting of pediatric spinal injury.

METHODS

Admissions for spinal fracture without or with spinal cord injury (SCI), spinal dislocation, and SCI without radiographic abnormality were identified in the Kids' Inpatient Database (KID) and the National Trauma Data Bank (NTDB) registry for 2009. Patients ranged in age from birth up to 21 years. Data from the KID were used to estimate nationwide annual incidences. Data from the NTDB were used to describe patterns of injury in relation to age, race, and payor, with corroboration from the KID. Multiple logistic regression was used to model rates of mortality and spinal fusion.

RESULTS

In 2009, the estimated incidence of hospital admission for spinal injury in the US was 170 per 1 million in the population under 21 years of age. The incidence of SCI was 24 per 1 million. Incidences varied regionally. Adolescents predominated. Patterns of injury varied by age, race, and payor. Black patients were more severely injured than patients of other races as measured by Injury Severity Scale scores. Among black patients with spinal injury in the NTDB, 23.9% suffered firearm injuries; only 1% of white patients suffered firearm injuries. The overall mortality rate in the NTDB was 3.9%. In a multivariate analysis that included a large panel of clinical and nonclinical factors, black race retained significance as a predictor of mortality (p = 0.006; adjusted OR 1.571 [1.141-2.163]). Rates of spinal fusion were associated with race and payor in the NTDB data and with payor in the KID: patients with better insurance underwent spinal fusion at higher rates.

CONCLUSIONS

The epidemiology of pediatric spinal injury in the US cannot be understood apart from considerations of race and economic status.

Acquired pathology of the pediatric spine and spinal cord

Pediatric spine pathology poses a diagnostic challenge for radiologists. Acquired spine pathology often yields nonspecific signs and symptoms in children, especially in the younger age groups, and diagnostic delay can carry significant morbidity. This review is focused on some of the more common diagnostic dilemmas we face when attempting to evaluate and diagnose acquired pediatric spine anomalies in daily practice. An understanding of some of the key differentiating features of these disease processes in conjunction with pertinent history, physical exam, and advanced imaging techniques can indicate the correct diagnosis.

Pediatric Spinal Cord Injury: Recognition of Injury and Initial Resuscitation, in Hospital Management, and Coordination of Care

Spinal cord injury is uncommon in the pediatric population with a lifelong impact for the patient and family. Knowledge of spine embryology, mechanisms of injury that lead to specific injuries, appropriate utilization of radiographic imaging based on suspected injury, prehospital and hospital management of various spinal cord injuries is essential for providers attending to traumatically injured patients. In addition to patients who present with soft tissue and bony injuries diagnosed with clinical examination and confirmed with computed tomography or magnetic resonance imaging, it is important to note that the pediatric population is at a higher risk for spinal cord injury without radiographic abnormality than the adult population. Patients who survive the acute phase of injury face long-term rehabilitation and have an increased risk of depression and mortality. Understanding the long-term sequelae of spinal cord injuries is also an essential management component of traumatically injured children. A program that provides long-term rehabilitation, psychosocial and spiritual support, and adaptive environmental supports gives patients and their families the best opportunity for long-term recovery. A review of the current literature on the diagnosis, management, and follow-up of pediatric spinal cord injury is presented.

Cervical fractures with associated spinal cord injury in children and adolescents: epidemiology, costs, and in-hospital mortality rates in 4418 patients

BACKGROUND

Cervical spine fractures with spinal cord injury (CFSCI) can be devastating. We describe the epidemiology of children and adolescents with CFSCI.

METHODS

Using the Nationwide Inpatient Sample (NIS) database, we identified 4418 patients (≤18 years old) who had CFSCI from 2000 through 2010. Outcomes of interest were patient characteristics (age, sex), injury characteristics [fracture location, spinal cord injury (SCI) pattern], economic variables (duration of hospital stay, total hospital charges), and mortality.

RESULTS

Upper cervical fractures (UCFs) occurred half as often (31.4 %) as lower cervical fractures (LCFs; 68.8 %). Among patients <8 years old, 73.6 % had UCFs; among patients ≥8 years old, 72.3 % had LCFs. Overall, 68.7 % had incomplete SCI, 22.4 % had complete SCI, 6.6 % had central cord syndrome, and 2.3 % had anterior cord syndrome. Patients with complete SCI had the longest hospital stays and highest hospital charges. The overall in-hospital mortality rate was 7.3 %, with a sixfold higher rate in patients <8 (30.6 %) vs. those ≥8 (5.1 %) years old (p < 0.001). There was a threefold higher mortality rate in patients with upper (13.5 %) vs. lower (4.3 %) cervical fractures (p < 0.001). Patients with complete SCI had a 1.85-fold higher mortality rate than patients with other cord syndromes (p < 0.001).

CONCLUSIONS

Patients <8 years old were more likely than older patients to sustain UCFs. Patients with UCFs had a significantly higher mortality rate than those with LCFs. Patients with complete SCI had the longest duration of hospital stay and highest hospital charges and in-hospital mortality rate.

Association of injury mechanism with the risk of cervical spine fractures

Objective:

A full understanding of an injury event and the mechanical forces involved should be important for predicting specific anatomical patterns of injury. Yet, information on the mechanism of injury is often overlooked as a predictor for specific anatomical injury in clinical decision-making. We measured the relationship between mechanism of injury and risk for cervical spine fracture.

Methods:

Our case-control study is a secondary analysis of data collected from the Canadian C-Spine Rule (CCR) study. Data were collected from 1996 to 2002 and included patients presenting to the emergency departments of 9 tertiary care centres after sustaining acute blunt trauma to the head or neck. Cases are defined as patients who were categorized in the CCR study with a clinically important cervical spine fracture. Controls had no radiologic evidence of cervical spine injury. Bivariate and multivariate unconditional logistic regression models were used. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).

Results:

Among the 17 208 patients in the CCR study, 320 (2%) received a diagnosis of a cervical spine fracture. Axial loads, falls, diving incidents and nontraffic motorized vehicle collisions (e.g., collisions involving snowmobiles or all-terrain vehicles) were injury mechanisms that were significantly related to a higher risk of fracture. For motor vehicle collisions, the risk of cervical spine injury increased with the posted speed, being involved in a head-on collision or a rollover, or not wearing a seat belt (p&lt; 0.05). The occurrence of cervical spine fracture was negligible in simple rear-end collisions (1 in 3694 cases; OR 0.015, 95% CI 0.002–0.104]).

Conclusion:

Our study quantitatively demonstrates the relationship between specific mechanisms of injury and the risk of a cervical spine fracture. A full understanding of the injury mechanism would assist providers of emergency health care in assessing risk for injury in trauma patients.

Surgical treatment of cervical unilateral locked facet in a 9-year-old boy: A case report

Most of the cervical spine injuries in the pediatric population are typically seen in the upper cervical region. Unilateral cervical facet dislocation (UFD) in subaxial region is a rare injury in pediatric population. In this paper, a rare case of delayed locked UFD in a 9-year-old boy with rare injury mechanism treated surgically is reported. Clinical and radiological findings were described. The patient with C6-7 UFD without neurologic deficit was underwent open reduction and internal fixation via anterior and posterior combined approaches. Significant improvement of pain and free motion in cervical spine was obtained. There was no complication during the follow up. Only three case reports presented about the lower cervical spine injury with UFD under the age of 10 were found in the literature.

Cervical spine injury in children: a case report and literature review

Traumatic injuries of the cervical spine are less common in children than in adults. But may be associated with significant disability and mortality. Pediatric victims of blunt trauma have mechanisms of injury, developmental and anatomic characteristics different than the adults. The purpose of this observation is to highlight the differences between the adult and pediatric cervical spine. We report below the case of spinal cord cut occurs to a very young girl after a motor vehicle accident.

Subaxial cervical spine injuries in children and adolescents

BACKGROUND

Limited data exist on pediatric subaxial cervical spine injuries. The goal of this study was to characterize the injuries and initial treatment of a large consecutive series of patients with injuries from C3 to C7.

METHODS

Medical records and radiographs of consecutive patients admitted with cervical spine fractures and/or dislocations at a single level 1 pediatric trauma center from 2003 to 2013 were reviewed. Data abstracted included age, injury type and level, mechanism of injury, associated nonspine injuries, neurological status, length of hospitalization, and initial treatment.

RESULTS

Fifty-one patients were grouped into 3 age ranges: infant, 0 to 3 years (2); youth, 4 to 12 years (13); and adolescent, 13 to 16 years (36). Isolated fractures were identified in both infants and accounted for most of injuries in youths (85%) and adolescents (86%). Single vertebra or single vertebral level injuries were present in 65% of patients, most commonly at C7 (36%) or C6 (29%). No correlation existed between cervical level injured and patient age. Multiple cervical spine injuries occurred in 1 infant, 3 youths, and 14 adolescents. Other concomitant thoracic and/or lumbar spine injuries were found in 1 infant and 3 adolescents. The most common mechanisms of injury were motor vehicle accidents (53%) and sports (14%). High-energy trauma was associated with higher rates of noncontiguous spinal injuries and associated nonspinal injuries, with a longer length of hospitalization. Neurological deficits were observed in 8 patients: 1 infant, 2 youths, and 5 adolescents, of which 5 resulted from high-energy trauma. One infant and all youth patients were treated nonoperatively; 26 adolescents (73%) were treated in a cervical collar or with observation, 1 was treated with halo-vest immobilization, and 9 had surgical treatment.

CONCLUSIONS

Most subaxial cervical spine injuries in pediatric and adolescent patients are isolated fractures at C6 and C7. High-energy mechanisms are associated with noncontiguous spinal injuries and other nonspine injuries. Most patients can be treated in a cervical collar, but adolescent patients are more likely to require halo placement or surgical intervention.

LEVEL OF EVIDENCE

Level IV-retrospective, diagnostic.

Operative management of traumatic cervical spine distraction and complete cord transection in a 3-year-old patient

This report describes the presentation and operative treatment of a 3-year-old boy who survived a motor vehicle accident that resulted in a C6-7 distraction injury, complete avulsion of the spinal cord, and gross spinal instability. Only 5%-10% of all spinal cord and vertebral column injuries occur in children. Survival after such an injury is exceptionally rare in very young patients and is associated with severe neurological deficits. The authors discuss the substantial ethical challenges involved in the care of a patient with this injury. To their knowledge, only two other cases of survival have been reported in pediatric patients following motor vehicle trauma resulting in complete injury to the lower cervical spinal cord.