Utility of the cervical spine radiograph in pediatric trauma

Distinguishing Pseudosubluxation From True Injury: A Case of C2-3 and C3-4 Subluxation in a Pediatric Patient

A 6-year-old girl presented with a one-week history of neck pain after a trampoline accident. Cervical radiographs interpreted as pseudosubluxation of C2 on C3. CT demonstrated the reversal of lordosis with anterolisthesis of C2-C3 and C3-C4. Ten weeks after two months of halo traction, radiographs demonstrated anatomic alignment and maintained disk heights. This case highlights the similarities of pseudosubluxation and true injury, emphasizing the need for high index of suspicion in this population and a successful treatment of subluxation using a halo construct.

Safer Roads to School

Any and all advances made by medical science cannot solve the problem of road traffic injuries (RTIs) in school-going children, especially if the only concerned people are those of the medical fraternity. Children are a vulnerable part of the traveling population and thus have been persistent due to the callous nature of the citizens and policy makers toward road safety and injury prevention. In our multicultural and multilingual country, there is a need for multistakeholder initiative with a countrywide presence if we are to stem the rise of mortality and morbidity due to these accidents. The first question we need to ask is how to prevent road traffic accidents and improve the condition of our roads. Pediatric RTIs are eternal problem of industrial revolution with complications and effects that may affect individual and society with increase in the number of motorized communications. Dedicated capacity building is urgently need who should be able to provide the necessary care to the injured children at the road crash spot as well as should be informed where to take the injured child and whom to contact in the dedicated injury care center while transporting the victims of situations.

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.

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.

Pediatric spine injuries

Pediatric spine injuries are rare, not only due to the plasticity of the pediatric spine, but also due to the difficulty of diagnosis and the usually severe, if not fatal, associated injuries. Mechanisms of injury, transportation, initial management, diagnostic exams, and management of such lesions are different from those of the adult, and an individualized approach to each case, looking for specific injury patterns, avoids misdiagnosis. The goal of this manuscripts is to summarize the specific spinal injury patterns of the pediatric population, as well as the present literature regarding their diagnosis and treatment.

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.

Clinical Predictors for the Selective Use of Chest Radiographs in Pediatric Blunt Trauma Evaluations

BACKGROUND

Chest radiographs continue to be a routine part of the evaluation of children sustaining blunt trauma. This study sought to determine those clinical markers associated with an abnormal chest radiograph in nonintubated, pediatric, blunt trauma victims.

METHODS

A retrospective case-control study was performed for severely injured pediatric trauma patients presenting to our emergency department between January 1, 1996, and December 31, 1997. Abnormal chest radiographs were identified through the trauma registry and four controls were matched to each case. Radiographs were reevaluated by our study radiologist. Variables associated with an abnormal chest radiograph were grouped to develop a set of clinical markers that could predict an abnormal chest radiograph with a high degree of sensitivity.

RESULTS

An initial chest radiograph was obtained in 457 of 587 trauma patients. Thirty study patients with an abnormal radiograph that met inclusion criteria were analyzed with 133 controls. The presence of either an abnormal respiratory rate for age, chest tenderness, or back abrasions had a sensitivity of 1.0 (95% confidence interval, 0.86-1.0) and a specificity of 0.38 (95% confidence interval, 0.30-0.47).

CONCLUSION

In pediatric trauma patients, the presence of chest tenderness, back abrasions, or an abnormal respiratory rate identified all abnormal chest radiographs.

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.

Using CT of the cervical spine for early evaluation of pediatric patients with head trauma

OBJECTIVE

The purpose of this study was to assess the effectiveness of CT of the cervical spine in addition to radiography in pediatric patients with suspected head trauma at the time of the CT head examination.

MATERIALS AND METHODS

We identified 63 pediatric patients admitted to the emergency department who had head trauma and who underwent both head CT and neck radiography. Those who underwent CT of the cervical spine at the time of the head CT examination during their initial evaluation were compared for demographics, clinical status, mechanism of injury, and number of excess radiographs (number required by protocol minus number of films obtained) required to evaluate the cervical spine with those patients who did not undergo early CT of the cervical spine.

RESULTS

Twenty-one patients (33%) underwent cervical spine CT at the time of the head CT examination. The number of excess radiographs differed significantly between these patients (2.1 +/- 2.6 vs 3.6 +/- 2.7, p = 0.04) and the comparison group. Patients who did not undergo early CT for whom excess radiographs were obtained had the following characteristics: they were older than 8 years (p = 0.03), were unrestrained in a motor vehicle crash (p = 0.04), had a Glasgow coma score of 13-15 (p = 0.01), and were intubated (p = 0.02).

CONCLUSION

The number of repeated radiographs required to ascertain that the cervical spine is free of injury after suspected head trauma is significantly fewer when initial CT of the neck is performed at the time of head CT examination. Including cervical spine CT in trauma protocols for subgroups of children with head injuries may lead to more effective clearance of the pediatric cervical spine.

Pediatric trauma. Anesthesia management

Prevention of childhood injury remains the cornerstone of reducing the number of children who present for post-traumatic surgical intervention. Beyond prevention, the next best step is the accurate diagnosis and treatment of traumatic injury. Anesthesiologists contribute to this step by providing timely resuscitation and optimal care to avoid secondary injury. This article classifies trauma in children into different categories depending on the location of the injury. Trauma, of course, is rarely focal, and is often a multisystem entity. With knowledge in management for each subset of trauma, one may be efficient in prioritizing injury and have a good understanding of the appropriate management of the pediatric patient with multiple traumatic injuries.

Pediatric cervical spine injuries: defining the disease

BACKGROUND/PURPOSE

Pediatric cervical spine injuries are uncommon. Most previous studies have been hampered by the small number of patients available for evaluation. The purpose of this study is to determine the incidence and characteristics of pediatric cervical spine injury utilizing a multiinstitutional pediatric trauma database, and to assess the impact of age and level of spine injury on mortality rate.

METHODS

All children with cervical spine injury entered into the National Pediatric Trauma Registry over a consecutive 10-year period were identified. Patients were stratified by age, mortality, presence or absence of bony injury, level of cervical spine injury, and presence of neurologic deficit. Data were analyzed utilizing Student's t test for continuous variables and chi(2) analysis for categorical variables. Statistical significance was accepted at the P less than .05 level.

RESULTS

From a database of 75,172 injured children, 1,098 were identified with cervical spine injury, overall incidence 1.5%. The mean age of the study group was 11 +/- 5 years, and 61% were boys. Nine hundred eight children (83%) had bony spine injury. Distribution of bony injury among upper cervical spine, lower cervical spine, or both was 52%, 28%, and 7%, respectively. The remaining 13% comprised unspecified levels of injury. Upper cervical spine injuries were prevalent among all age groups (42%, age < or = 8; 58%, age > 8), whereas lower spine injuries predominated in older children (85%, age > 8). One third of children in the study group had neurologic injury, and half of these had no radiographic evidence of bony injury. Ninety-four children (24%) had a complete cord injury, and the remaining 76% had an incomplete spinal cord injury. One hundred eleven children (23%) with upper spine injury died compared with 11 children (4%) with lower spine injury. Mortality rate was highest (48%) in those with atlanto-occipital dislocation.

CONCLUSIONS

From this, the largest experience with pediatric cervical spine injury, several conclusions can be drawn. (1) Cervical spine injury occurs in 1.5% of injured children. (2) Upper cervical spine injuries are not limited to younger children but are equally prevalent in both age groups. (3) Associated mortality rate is nearly 6-fold higher in patients with upper cervical injury. (4) Seventeen percent of children with cervical spine trauma show no radiologic anomaly, yet 50% of children with cervical spinal cord injury have no initial radiologic abnormalities. (5) Of those in whom cervical spine injury is associated with a neurologic deficit, the deficit is complete in 24% of children.

Cervical spine trauma in the injured child: a tragic injury with potential for salvageable functional outcome,

BACKGROUND/PURPOSE

Cervical spine injuries are uncommon in children, and, therefore, presumptive immobilization and diagnosis remain controversial. The purpose of this study was to review the author's experience with cervical spine injuries in children to determine the incidence, injury mechanism, pattern of injury, and subsequent functional outcome.

METHODS

Fifty-two children over a 6-year period (1994 to 1999) with a cervical spine injury secondary to blunt trauma were identified (1.3% incidence). The functional independent measure (FIM) was assessed at the time of discharge in each of 3 categories: communication, feeding, and locomotion.

RESULTS

Mean age of the study children was 10.7 +/- 0.7 years. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanism of injury included motor vehicle crash (52%), falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents (8%), and motorcycle crashes (4%). Seven patients died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlanto-occipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries. FIM scores were recorded for 18 patients. Seventeen communicated independently, 14 fed themselves independently, and 12 had independent locomotive function.

CONCLUSIONS

Cervical spine injuries occur in children across a spectrum of ages. Although atlanto-occipital dislocation is a highly lethal event, children with C1 to C7 injuries have a high likelihood of reasonable independent functioning.

Upper cervical spine fusion in the pediatric population

The outcomes of 25 pediatric patients who underwent upper cervical or occipitocervical fusion at the authors' institution since 1983 were reviewed. At a mean age of 9 years, the patients presented with spinal instability that was associated with os odontoideum in 11 cases, rotatory subluxation in five cases, odontoid fracture in two cases, atlantooccipital dislocation in two cases, and congenital atlantoaxial instability in five patients, four of whom had Down's syndrome (trisomy 21). Ten children had abnormal findings on neurological examination preoperatively; however, nine experienced improvement or resolution of deficits as of their latest follow-up evaluation (mean 17 months). Fusion was achieved with the first operation in 21 of 25 patients; eventually it was attained in all but one. Four patients exhibited persistent spinal instability after an initial procedure. This was caused by erosion of a multistranded cable through the intact arch of C-2 in two cases, by pin site infection necessitating early halo removal in one case, and by slippage in a halo following a Gallie procedure, which was revised with a Brooks fusion in one case. This series, the largest yet published, shows that with appropriate surgical management, posterior upper cervical fusion in the pediatric population is highly successful. Careful attention to halo pin site care and caution in using multistranded cable in young patients may improve results.

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.

Predictive factors of the outcome of traumatic cervical spine fracture in children

The uncommon traumatic cervical spine fractures and dislocations were studied in 227 consecutively treated children (1 to 17 years of age). Lower cervical spine injuries (C-3 to C-7) affected 73% of our patients. However, among the 38 patients younger than 8 years of age, 87% had an injury at the C-3 level or higher (P < .0001). There were 19 fatalities (8.4%), all of which were associated with injuries at the C-4 level or higher. Of the 11 patients with atlanto-axial fracture or dislocation, all died soon after the injury. All had an unstable fracture and cord transection that resulted in cardiorespiratory collapse. Injuries at the vertebral levels C-1, C-2, C-3, and C-4 were associated with fatality rates of 17%, 9%, 4.3%, and 3.7%, respectively. No fatalities were encountered among patients with lesions lower than C-4. The authors conclude that the younger the age, the higher the cervical spine injury, and that the fatality rate correlates directly with the level of cervical spine fracture.

Cervical spine injuries in blunt trauma patients requiring emergent endotracheal intubation

Airway management in the blunt trauma patient is complicated by the potential for causing or exacerbating an injury to the cervical cord if an unstable cervical fracture is present. The records of 987 blunt trauma patients who required emergent endotracheal intubation over a 5-year period were retrospectively reviewed to determine the incidence and type of cervical spine injury and the incidence of injury based on airway management. Sixty of the patients (6.1%) had a cervical fracture; 53 were potentially unstable injuries by radiographic criteria. Twenty patients had neurologic deficits prior to intubation. Twenty-six patients with unstable injuries were intubated orally, 25 nasally, and two by cricothyrotomy. One patient developed a neurologic deficit after nasotracheal intubation. Because of a possible selection bias in which severely injured patients were preferentially referred to this trauma center, the true incidence of cervical spine injuries may be lower than the 6.1% we found. The authors conclude that the incidence of serious cervical spine injury in a very severely injured population of blunt trauma patients is relatively low, and that commonly used methods of precautionary airway management rarely lead to neurologic deterioration.