Subaxial cervical spine injuries in children and adolescents

Pediatric neck pain of a 10-year-old child with cervical spinal tumor evaluated and managed in direct access physical therapy: a case report

INTRODUCTION

Differential diagnosis of pediatric neck pain requires age-appropriate communication and assessment tools. Recognizing these age-related nuances is critical, emphasizing the role of physical therapists in assessing and managing pediatric patients while ruling out severe pathologies.

CASE DESCRIPTION

A 10-year-old male presented to physical therapy with a five-week history of increasing neck pain. A thorough history and segmental cervical examination considering the patient's age and development, led to patient referral to the emergency department. This case underscores the significance of comprehensive evaluation in pediatric neck pain management.

OUTCOMES

The patient was diagnosed with Langerhans Cell Histiocytosis (LCH). LCH primarily affects children and is treated with chemotherapy. Chemotherapy reduced the tumor, revealing C2 vertebral body damage. The patient underwent C1-C3 fusion surgery, a standard procedure for atlanto-occipital region stabilization in children. The patient was advised to restrict motion for 6 months while monitoring for tumor growth.

DISCUSSION-CONCLUSION

Pediatric neck cancer presents diagnostic challenges due to varied symptoms, but research highlights specific indicators to assist with differential diagnosis. This case emphasizes the need to recognize the complexities of pediatric neck pain and perform a thorough age-appropriate evaluation.

Cervicothoracic dislocation due to congenital and bone-dysplasia-related vertebral malformations

PURPOSE

To evaluate the approaches to treatment of congenital and bone-dysplasia-related pediatric cervicothoracic dislocations and define the optimal treatment method.

METHODS

The publications available in PubMed and Google Scholar data bases were selected following such criteria as the disease in question, pediatric age, the treatment description, and follow-up results. The paper also includes the descriptions of our own six cases of the cervicothoracic dislocations detected in children with different vertebral malformations.

RESULTS

Only eight patients meeting the abovementioned selection criteria were found in the publications: three of them had the Klippel-Feil syndrome (KFS), two had one-level vertebral anomaly, one had neurofibromatosis (NF type 1), one had the Larsen syndrome, and one had a variation of VACTERL association. Their treatment was long term, multi stage, and complicated. Among six our own cases, four patients also had KFS, one had a variation of VACTERL association, and one had NF type 1. All the patients suffered from preoperative neurological disorders. Posterior instrumental fixation with posterior vertebral body resection was performed in four cases and one patient underwent a combined surgery. The parents of one of the patients refused the operation, so he was observed while receiving bracing treatment. Since the treatment was long term and complicated by reoperations, the average follow-up period comprised 5 years.

CONCLUSION

Congenital cervicothoracic dislocations are an extremely rare pathology that manifests itself in early age and requires an early surgical treatment. Failure to provide the treatment leads to the patient's disability. The surgical tactics for such patients is determined individually, but the published data and our own experience demonstrate that early multi-stage combined treatment has been the best option available so far. The cervicothoracic dislocations due to NF 1 manifest later and have a more favorable forecast.

A case report on a child with fracture and dislocation of the upper cervical spine accompanied by spinal cord injury

RATIONALE

This study describes an 8-year-old boy with a C2 fracture and dislocation with a left C2-C3 articular process interlocking and spinal cord injury who underwent open reduction and internal fixation using the posterior cervical approach and achieved satisfactory results.

PATIENT CONCERNS

An 8-year-old boy underwent an emergency transfer from a previous hospital after a car accident.

DIAGNOSES

Axial fracture and dislocation with spinal cord injury (American Spinal Injury Association grade C), traumatic shock, brain contusion, intracranial hemorrhage, mandibular fracture, pulmonary contusion and hemorrhage, left vertebral artery stenosis, and multiple fractures throughout the body. Radiological examination revealed a fracture of the lower edge of the C2 vertebral body, fourth-degree anterior spondylolisthesis of the C2 vertebral body, interlocking of the left C2-C3 articular processes, widening of the C2-C3 vertebral space, and occlusion of the V1 and 2 segments of the left vertebral artery.

INTERVENTIONS

The boy was immediately intubated and transferred to the pediatric intensive care unit for rescue treatment. However, the reduction was unsuccessful with 2 weeks of cranial traction. Thus, an open reduction was performed under general anesthesia. One month after the surgery, the boy was discharged from the hospital on foot after rehabilitation treatment.

OUTCOMES

The boy was discharged from the hospital 1 month after surgery. At the 8-month follow-up, a radiological examination showed that the corrected C2 vertebral body fracture and dislocation were satisfactorily reduced, and the spinal cord was adequately decompressed. The internal fixation position was also good, and the spinal sequence had recovered well. In summary, except for the muscle strength of the right upper limb, which was slightly worse, the other clinical symptoms were significantly improved.

LESSONS

In treating cervical fracture and dislocation with unilateral facet lock, the posterior open reduction of pedicle screw and lateral mass screw internal fixation achieved satisfactory results. Consequently, treating complex cervical spine injuries in children requires an accurate diagnosis and careful treatment strategy.

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.

Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations

Cervical trauma in children have variations from the adults mainly due to anatomic differences. An optimal diagnostic and treatment strategy is critical, particularly when there is a lack of standardized protocols for the management of such cases. This review paper examines the diagnostic and treatment options of pediatric cervical trauma and Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). A literature search for the last 10 years were conducted using key words. Case reports, experimental studies, papers other than English language were excluded. Up-to-date information on pediatric cervical trauma and SCIWORA were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. This review reflects different aspects of contemporary pediatric cervical trauma decision-making and treatment, and SCIWORA. The mainstay of SCIWORA treatment is nonsurgical with immobilization, avoidance of risky activities. Prognosis generally depends on the initial neurological status and magnetic resonance imaging. Due to a significant discrepancy in the literature on diagnostic and management, future randomized controlled trials are needed to aid in generating standardized protocols.

Cervical spine evaluation in pediatric trauma: A cost-effectiveness analysis

OBJECTIVE

The emergent evaluation of children with suspected traumatic cervical spine injuries (CSI) remains a challenge. Pediatric clinical pathways have been developed to stratify the risk of CSI and guide computed tomography (CT) utilization. The cost-effectiveness of their application has not been evaluated. Our objective was to examine the cost-effectiveness of three common strategies for the evaluation of children with suspected CSI after blunt injury.

METHODS

We developed a decision analytic model comparing these strategies to estimate clinical outcomes and costs for a hypothetical population of 0-17 year old patients with blunt neck trauma. Strategies included: 1) clinical pathway to stratify risk using NEXUS criteria and determine need for diagnostic testing; 2) screening radiographs as a first diagnostic; and 3) immediate CT scanning for all patients. We measured effectiveness with quality-adjusted life years (QALYs), and costs with 2018 U.S. dollars. Costs and effectiveness were discounted at 3% per year.

RESULTS

The use of the clinical pathway results in a gain of 0.04 QALYs and a cost saving of $2800 compared with immediate CT scanning of all patients. Use of the clinical pathway was less costly and more effective than immediate CT scan as long as the sensitivity of the clinical prediction rule was greater than 87% and when the sensitivity of x-ray was greater than 84%.

CONCLUSION

A strategy using a clinical pathway to first stratify risk before further diagnostic testing was less costly and more effective than either performing CT scanning or screening cervical radiographs on all patients.

Management of cervical spine trauma in children

PURPOSE

Paediatric cervical spine injuries are fortunately a rare entity. However, they do have the potential for devastating neurological sequelae with lifelong impact on the patient and their family. Thus, management ought to be exceptional from the initial evaluation at the scene of the injury, through to definitive management and rehabilitation.

METHODS

We set out to review cervical spine injuries in children and advise on current best practice with regards to management.

RESULTS

Epidemiology, initial management at the scene of injury, radiological findings and pitfalls of cervical spine trauma are outlined. Strategies for conservative and surgical management are detailed depending on the pattern of injury. The management of spinal cord injuries without radiological abnormality (SCIWORA) and cranio-cervical arterial injuries is also reviewed.

CONCLUSIONS

Due to a paucity of evidence in these rare conditions, expert opinion is necessary to guide best practice management and to ensure the best chance of a good outcome for the injured child.

Nonmetallic posterior monosegmental cervical fusion of a dislocated C6/7 fracture in a 4-year-old girl : A case report

PURPOSE

Pediatric cervical spine injuries constitute approximately 1-2% of all pediatric trauma cases. Usually pediatric vertebral injuries appear as stable A type fractures, whereas B and C type injuries are relatively uncommon. In contrast to adults, the appropriate treatment strategy in children is still controversial and places spine surgeons in complex situations. This article reports the case of a 4-year-old girl with an unstable B type injury at the C6/7 level (AOSpine C6-7: B2 [F4 BL, C7:A1]) with bilateral locked fractures of the facet joints after falling down a flight of stairs.

PATIENT AND METHODS

Magnetic resonance imaging (MRI) and computed tomography (CT) were initially performed. The 4‑year-old girl was treated under intraoperative neurophysiological monitoring via open reduction after partial resection of both C7 upper articular processes and nonmetallic monosegmental posterior interlaminar fusion (FiberWire®) at the C6/7 level with temporary immobilization in a halo brace.

RESULTS

Clinical and radiological follow-up was carried out after 9 months. The patient suffered no pain or neurological deficits. Plain radiographs revealed a correct cervical alignment with anatomical correction of the initial dislocation.

CONCLUSION

The treatment of highly unstable pediatric B type injuries of the lower cervical spine via open reduction and nonmetallic monosegmental posterior interlaminar fusion results in good clinical and radiological outcomes. A temporary immobilization in a halo brace provides stability until osseous fusion occurs.

Surgical treatment for old subaxial cervical dislocation with bilateral locked facets in a 3-year-old girl: A case report

RATIONALE

This study aimed to describe the case of a 3-year-old girl with old bilateral facet dislocation on cervical vertebrae 6 and 7, who had spinal cord transection, received surgical treatment, and achieved a relative satisfactory therapeutic effect.

PATIENT CONCERNS

A 3-year-old girl was urgently transferred to the hospital after a car accident. DIAGNOSES:: she was diagnosed with splenic rupture, intracranial hemorrhage, cervical dislocation, spinal transection, and Monteggia fracture of the left upper limb.

INTERVENTIONS

The girl underwent emergency splenectomy and was transferred to the intensive care unit of the hospital 15 days later. One-stage anterior-posterior approach surgery (anterior discectomy, posterior laminectomy, and pedicle screw fixation) was performed when the patient stabilized after 45-day symptomatic treatment. The operation was uneventful.

OUTCOMES

The reduction of lower cervical dislocation was satisfactory, with sufficient spinal cord decompression. The internal fixation position was good, and the spinal sequence was well restored. The girl was discharged 2 weeks later after the operation and followed up for 2 years. The major nerve function of both upper limbs was recovered, with no obvious retardation of the growth of immature spine.

LESSONS

A satisfactory therapeutic effect was achieved for a pediatric old subaxial cervical dislocation with bilateral locked facets using anterior discectomy, posterior laminectomy, and pedicle screw fixation. The posterior pedicle screw fixation provided a good three-dimensional stability of the spine, with reduced risk and complications caused by anterior internal fixation. The growth of immature spine was not obviously affected during the 2-year follow-up.

Epidemiology of vertebral fractures in pediatric and adolescent patients

Spinal injuries in children and adolescents are rare injuries, but consequences for the growing skeleton can be devastating. Knowledge of accident causes, clinical symptoms and diagnostics should be part of every trauma department treating these patients. We retrospectively analyzed patients with radiographically proven vertebral fractures of the spine. After clinical examination and tentative diagnosis the fractures and injuries were proven with conventional X-ray, computed tomography (CT) scans or magnetic resonance imaging (MRI). The study included 890 fractures in 546 patients with an average age of 12.8±6.2 (6.6-19.4) years. Females had an average age of 13.7±6.3 (7.4-20.0) years, whereas males were on average 12.0 (6.0-18.0) years old. Fall from height (58%) was the main cause of accident and the most common region of fracture was the thoracolumbar spine with a shift towards the thoracic spine the more fractures occurred. Merely 3.7% of all patients required operative treatment. If a vertebral fracture is found in children and adolescents, it is highly recommended to exclude synchronous additional spine fractures in other levels; prevention should concentrate on fall and traffic accidents.

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.

Congenital subaxial cervical subluxation presenting as a bilateral Erb's palsy: surgical management, rehabilitation, and outcome

INTRODUCTION

Subaxial spine injuries during infancy are uncommon.

CASE REPORT

We present the case of an infant referred to our brachial plexus clinic with proximal weakness of both arms noted immediately following a complicated breech delivery. Nerve conduction studies were consistent with bilateral proximal upper plexus injury; however, radiological evaluation revealed a C4-C5 subluxation and MRI features of bilateral C5 root avulsions. He was immobilized in a cervical-body orthosis and underwent open reduction and posterior C4-C5-C6 fixation at 10 weeks age using luque rods, sublaminar wires, and rib graft. The spine was immobilized in a custom molded cervicothoracic brace for a total of 3 months, and a home exercise program prescribed. Follow-up radiographic evaluation showed good posterior bony fusion by 2 months but persistent bilateral proximal upper limb weakness with reduced compound motor action potential (CMAP) amplitudes of the axillary and musculocutaneous nerves. Bilateral supraclavicular exploration and C5 root neurotization using the ipsilateral C7 nerve roots were performed at 7 months of age. Voluntary biceps activity followed by voluntary external rotation with gravity eliminated was noted within the next 2-3 months. He progressed to develop near normal motor control of bilateral upper limbs within 1 year.

CONCLUSIONS

We wish to report this rare entity and our favorable outcome using a strategy of early spinal stabilization and neurotization repair to restore function following proximal nerve root injury.

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.

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.

Management of a 3-year-old with an unstable C6-C7 diastasis without quadriplegia

BACKGROUND

Caring for pediatric spine trauma patients places spine surgeons in situations that require unique solutions for complex problems. Recent case reports have highlighted a specific injury pattern to the lower cervical spine in very young children that is frequently associated with complete spinal cord injury.

METHODS

This report describes the presentation and treatment of a C6-C7 dislocation in a 3-year-old patient with an incomplete spinal cord injury. The highly unstable cervical injury and the need to prevent neurologic decline added complexity to the case.

RESULTS

A multi-surgeon team allowed for ample manpower to position the patient; with individuals with the requisite training and experience to safely move a patient with a highly unstable cervical spine. Initial closed reduction under close neurophysiologic monitoring, posterior fusion and immediate anterior stabilization lead to a successful patient outcome with preserved neurologic function. A traumatic cerebrospinal fluid leak, while a concern early on during the procedure, resolved without direct dural repair and did not complicate the patient's fusion healing. Additional anterior stabilization and fusion allowed long-term stability with bone healing that may not be achievable with posterior fixation and/or soft tissue healing alone.

CONCLUSIONS

Familiarity with the challenges and solutions presented in the case may be useful to surgeons who could face a similar challenge in the future.