Severe spinal cord injury in craniocervical dislocation. Case-based update

Craniocervical Dissociation in Pediatric Patients: Pearls and Pitfalls of Diagnosis and Management

AIMS

The aims of this study were to document the injury pattern in pediatric traumatic craniocervical dissociation (CCD) and identify features of survivors.

METHODS

Pediatric traumatic CCDs, diagnosed between January 2004 and July 2016, were reviewed. Survivors and nonsurvivors were compared. Categorical and continuous variables were analyzed with Fisher exact and t tests, respectively.

RESULTS

Twenty-seven children were identified; 10 died (37%). The median age was 60 months (ranges, 6-109 months [survivors], 2-98 months [nonsurvivors]). For survivors, the median follow-up was 13.4 months (range, 1-109 months). The median time to mortality was 1.5 days (range, 1-7 days). The injury modality was motor vehicle collision in 18 (67%), pedestrian struck in 8 (30%), and 1 shaken infant (3%). For nonsurvivors, CCD was equally diagnosed by plain radiograph and head/cervical spine computed tomography scan. For survivors, CCD was diagnosed by computed tomography in 7 (41%), magnetic resonance imaging in 10 (59%), and none by radiograph. Seven diagnosed by magnetic resonance imaging (41%) had nondiagnostic initial imaging but persistent neck pain. Magnetic resonance imaging was obtained and was diagnostic of CCD in all 7 (P < 0.01). Survivors required significantly less cardiopulmonary resuscitation (P < 0.01), had lower Injury Severity Scores (P < 0.01), higher Glasgow Coma Scale scores (P < 0.01), and shorter transport times (P < 0.01). Significantly more involved in motor vehicle collisions survived (P = 0.04). Nine (53%) had no disability at follow-up evaluation.

CONCLUSIONS

In pediatric CCD, high-velocity mechanism, cardiac arrest, high Injury Severity Score, and low Glasgow Coma Scale score are associated with mortality. If CCD is correctly managed in the absence of cardiac arrest or traumatic brain or spinal cord injury, children may survive intact.

Traumatic atlanto-occipital dislocation: do children and adolescents have better or worse outcomes than adults? A narrative review

BACKGROUND

Traumatic atlanto-occipital dislocation is an uncommon, severely unstable pathology, which can lead to detrimental or even fatal neurological impairment. Specifically, children have consistently been reported to be more susceptible to this type of injury because of their disproportionately larger head, ligament laxity, and injury mechanisms. However, to date, rates of missed injury and outcomes including neurologic recovery of pediatric and adult populations following this insult have not been comparatively evaluated.

METHODS

Standard search engines were used to investigate outcomes of traumatic atlanto-occipital dislocation in children and adolescents compared to adults.

CONCLUSIONS

Based on case reports and small series from the literature, it seems that children and adolescents tend to have a better likelihood of survival with the possibility of long-term neurological complications. Comparatively, adults who suffer traumatic atlanto-occipital dislocation either succumb to their injuries or survive with very little if any neurological complications.

Pediatric spinal trauma

Pediatric spinal trauma is unique. The developing pediatric spinal column and spinal cord deal with direct impact and indirect acceleration/deceleration or shear forces very different compared to adult patients. In addition children are exposed to different kind of traumas. Moreover, each age group has its unique patterns of injury. Familiarity with the normal developing spinal anatomy and kind of traumas is essential to correctly diagnose injury. Various imaging modalities can be used. Ultrasound is limited to the neonatal time period; plain radiography and computer tomography are typically used in the acute work-up and give highly detailed information about the osseous lesions. Magnetic resonance imaging is more sensitive for disco-ligamentous and spinal cord injuries. Depending on the clinical presentation and timing of trauma the various imaging modalities will be employed. In the current review article, a summary of the epidemiology and distribution of posttraumatic lesions is discussed in the context of the normal anatomical variations due to progressing development of the child.