Pediatric cervical spine: normal anatomy, variants, and trauma

A systematic review and meta-analysis of the global epidemiology of pediatric traumatic spinal cord injuries

Despite being relatively rare, pediatric traumatic spinal cord injury (TSCI) is a debilitating event with high morbidity and long-term damage and dependency. This study aims to provide insight on the epidemiological characteristics of pediatric TSCI worldwide. The studies were included if they provided data for the pediatric population with the diagnosis of TSCI. Information sources included PubMed, Embase, Web of Science, and Scopus. All databases were searched from 1990 to April 2023. The quality of included studies was evaluated by Joanna Briggs Institute Critical Appraisal Tools. The results of the meta-analysis were presented as forest plots. PROSPERO Registration code: CRD42020189757. We identified 87 studies from 18 developed and 11 developing countries. Of the 87 studies evaluated, 52 studies were considered medium quality, 27 studies were considered high quality, and 8 studies were considered low quality. In developed countries, the proportion of TSCIs occurring in patients aged 0-15 years was 3% (95% CI: 2.2%; 3.9%), while in developing countries, it was 4.5% (95% CI: 2.8%; 6.4%). In developed countries, the pooled incidence of pediatric TSCI was 4.3/millions of children aged 0-15/year (95% CI: 3.1; 6.0/millions children aged 0-15/year) and boys comprised 67% (95% CI: 63%; 70%) of cases. The most prevalent level of injury was cervical (50% [95% CI: 41%; 58%]). The frequency of SCI Without Obvious Radiological Abnormality (SCIWORA) was 35% (95% CI: 18%; 54%) among children 0-17 years. The most common etiology in developed countries was transport injuries (50% [95% CI: 42%; 57%]), while in developing countries falls were the leading cause (31% [95% CI: 20%; 42%]). The most important limitation of our study was the heterogeneity of studies in reporting age subgroups that hindered us from age-specific analyses.   Conclusion: Our study provided accurate estimates for the epidemiology of pediatric TSCI. We observed a higher proportion of pediatric TSCI cases in developing countries compared to developed countries. Furthermore, we identified distinct epidemiological characteristics of pediatric TSCI when compared to adult cases and variations between developing and developed countries. Recognizing these unique features allows for the implementation of cost-effective preventive strategies aimed at reducing the incidence and burden of TSCI in children. What is Known: • Pediatric Traumatic Spinal Cord Injury (TSCI) can have profound physical and social consequences for affected children, their families, and society as a whole. • Epidemiological insights are vital for they provide the data and understanding needed to the identification of vulnerable populations, aiding in the development of targeted prevention strategies and effective resource allocation. What is New: • The estimated incidence of pediatric TSCI in developed countries is 4.3 cases per million children aged 0-15. The proportion of pediatric TSCI cases in relation to all-age TSCI cases is 3% in developed countries and 4.5% in developing countries. • The etiology of TSCI in pediatric cases differs between developing and developed countries. In developed countries, transport injuries are the most prevalent cause of pediatric TSCI, while falls are the least common cause. Conversely, in developing countries, falls are the leading cause of pediatric TSCI.

C2 Synchondrosal Injuries: A Case Report and Anatomic Review

Developmental succession in the pediatric patient requires special consideration in post-traumatic assessment. An understanding of the sequential development of this region and common patterns of injury can provide an accurate initial assessment before proceeding to further management and prognostic evaluation. Primarily, this article focuses on the synchondrosal development of C2 and its role in the craniocervical junction, as well as its common patterns of injury. This article presents two sample cases and offers a review of treatment options with added prognostic factors.

Imaging of the Craniocervical Junction: A Pictorial Review

The craniocervical junction (CCJ) is a complex anatomical structure comprising the occiput, the atlas, and the axis. The CCJ plays an important role in maintaining stability, providing protection, and supporting neurovascular structures. The CCJ can be affected by a wide range of congenital variants and traumatic, degenerative, inflammatory, and tumoral pathologies. This pictorial review the normal anatomy of the CCJ and presents the most common anatomical variants and pathologic conditions affecting the CCJ.

C1-C2 subluxation in enthesitis-related arthritis: two case reports and literature review of ten cases

BACKGROUND

C1-C2 subluxation is a rare complication of enthesitis-related arthritis (ERA). If left untreated, it may lead to functional impairment or cervical spinal cord compression. This study aims to highlight key points regarding the management of C1-C2 subluxation in ERA.

CASE PRESENTATION

We present two cases of C1-C2 subluxation: an 8-year-old boy with ERA and 16-year-old boy with ERA with bilateral sacroiliitis. Ten cases of ERA in the literature were reviewed. The diagnosis of C1-C2 subluxation is mostly based on radiographs and cervical spine computed tomography. All patients were treated with non-steroidal anti-inflammatory drugs. Six ERA patients were treated surgically for cervical fusion. Most ERA patients with sacroiliitis had cervical collar protection. Neurologic abnormalities after treatment were not reported. Despite the use of cervical collar, cervical fusion and persisting ankylosis were found in two ERA patients with sacroiliitis without surgical treatment.

CONCLUSIONS

Cervical spine protection and ruling out spinal cord compression should be prioritized, in addition to controlling the underlying inflammation in ERA. Cervical halter traction may be applied after severe cervical inflammation is excluded. To reduce the risk of complications, early recognition and appropriate treatments of C1-C2 subluxation in ERA are essential.

A Pediatric Cervical Spine Clearance Guideline Leads to Fewer Unnecessary Computed Tomography Scans and Decreased Radiation Exposure

OBJECTIVES

Physical examination and computed tomography (CT) are useful to rule out cervical spine injury (CSI). Computed tomography scans increase lifetime cancer risk in children from radiation exposure. Most CSI in children occur between the occiput and C4. We developed a cervical spine (C-spine) clearance guideline to reduce unnecessary CTs and radiation exposure in pediatric trauma patients.

METHODS

A pediatric C-spine clearance guideline was implemented in September 2018 at our Level 2 Pediatric Trauma Center. Guidance included CT of C1 to C4 to scan only high-yield regions versus the entire C-spine and decrease radiation dose. A retrospective cohort study was conducted comparing preguideline and postguideline of all pediatric trauma patients younger than 8 years screened for CSI from July 2017 to December 2020. Primary endpoints included the following: number of full C-spine and C1 to C4 CT scans and radiation dose. Secondary endpoints were CSI rate and missed CSI. Results were compared using χ 2 and Wilcoxon rank-sum test with P < 0.05 significant.

RESULTS

The review identified 726 patients: 273 preguideline and 453 postguideline. A similar rate of total C-spine CTs were done in both groups (23.1% vs 23.4%, P = 0.92). Full C-spine CTs were more common preguideline (22.7% vs 11.9%, P < 0.001), whereas C1 to C4 CT scans were more common post-guideline (11.5% vs 0.4%, P < 0.001). Magnetic resonance imaging utilization and CSIs identified were similar in both groups. The average radiation dose was lower postguideline (114 vs 265 mGy·cm -1 ; P < 0.001). There were no missed CSI.

CONCLUSIONS

A pediatric C-spine clearance guideline led to increasing CT of C1 to C4 over full C-spine imaging, reducing the radiation dose in children.

LEVEL OF EVIDENCE

Level IV, therapeutic.

Surgical Treatment for Displaced Odontoid Synchondrosis Fracture: A Retrospective Case Series Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Odontoid synchondrosis fracture is rare, and there is a paucity of literature on its surgical treatments. This case series study analyzed patients treated with C1 to C2 internal fixation with or without anterior atlantoaxial release and discussed the clinical effectiveness of the procedure.

METHODS

Data were retrospectively collected from a single-center cohort of patients who had undergone surgical treatments for displaced odontoid synchondrosis fracture. The operation time and blood loss volume were recorded. Neurological function was assessed and classified using the Frankel grades. The odontoid process tilting angle (OPTA) was used to evaluate fracture reduction. Fusion duration and complications were also analyzed.

RESULTS

Seven patients (1 boy and 6 girls) were included in the analysis. Three patients underwent anterior release and posterior fixation surgery, and the other 4 underwent posterior-only surgery. The fixation segment was C1 to C2. The average follow-up period was 34.7 ± 8.5 months. The average operation time was 145.7 ± 45.3 min, with an average blood loss volume of 95.7 ± 33.3 mL. The OPTA was corrected from 41.9° ± 11.1° preoperative to 2.4° ± 3.2° at the final follow-up (P < .05). The preoperative Frankel grade of 1 patient was grade C, of 2 patients was grade D, and of 4 patients was grade E. The neurological function of the patients in grade C and grade D recovered to grade E at the final follow-up. None of the patients developed a complication. All the patients achieved odontoid fracture healing.

CONCLUSIONS

Posterior C1 to C2 internal fixation with or without anterior atlantoaxial release is a safe and effective method for treating young children with displaced odontoid synchondrosis fracture.

The cervical spine in paediatric radiology

Accurate radiological assessment of the cervical spine is vital in the management of the child presenting with trauma. Compared to an adult's spine, the significant differences in the developmental anatomy (variants or synchondrosis), biomechanics and fracture patterns in the paediatric cervical spine makes assessment difficult, even for experienced radiologists. This review discusses the unique biomechanical factors, developmental anatomy, patterns of injury and imaging strategy in the paediatric population.

Appropriateness of Cervical Magnetic Resonance Imaging in the Evaluation and Management of C1 Jefferson Fractures

BACKGROUND

Traditionally, C1 fractures have been designated as stable or unstable based on the inherent integrity of the transverse altantal ligament. The purpose of our study was to identify adult trauma patients with C1 fractures on cervical computed tomography and evaluate whether C1-C2 alignment differed in patients with and without an associated transverse atlantal ligament injury on follow-up cervical magnetic resonance imaging.

METHODS

Adult trauma patients who suffered a C1 fracture were identified retrospectively. The cervical computed tomography examinations for these patients were reviewed for the following: C1 fracture classification, anterior atlantodens interval (ADI) widening, asymmetry in the lateral atlantodens interval, C1 lateral mass offset, and atlantoaxial rotation.

RESULTS

Acute C1 fractures were grouped into those with an unequivocal transverse atlantal ligament injury (n = 12), and patients with an unequivocally intact transverse atlantal ligament (n = 20). Three patients were classified as indeterminate for transverse atlantal ligament injury. Statistically significant increases in lateral ADI asymmetry and combined C1 lateral mass offset were identified in patients with transverse atlantal ligament tears.

CONCLUSIONS

Lateral ADI asymmetry (using a cutoff of >3 mm), combined C1 lateral mass offset, and anterior ADI demonstrate robust specificity to "rule in" transverse atlantal ligament injury. Atlantoaxial alignment was overall relatively insensitive as a screening test although sensitivity can be improved using a cutoff of >2 mm for lateral ADI asymmetry. Our findings reinforce the role of cervical magnetic resonance imaging in the diagnostic workup and clinical management of trauma patients with an acute burst fracture of the C1 vertebra.

Update on imaging of the cervical spine in rheumatoid arthritis

Rheumatoid arthritis is a multisystem, autoimmune, inflammatory disorder with numerous musculoskeletal manifestations. Involvement of the cervical spine is common and may result in severe complications due to synovitis, erosions, pannus formation, spinal instability and ankylosis. The purpose of this article is to review the current role of imaging in the rheumatoid spine, with emphasis on radiographs and MRI.

How to interpret spinal imaging in paediatric trauma

Spinal injuries in children are fortunately rare; however, it is important that they are assessed and managed in a timely manner. A systematic approach to traumatic spinal injuries should be used, by following recent evidence and national protocols, in order to avoid misinterpretation and potentially, inappropriate discharge. The aim of this article is to highlight the concepts of spinal imaging in paediatric trauma with regards to indications, interpretation and limitations.

Sex-specific differences in ossification patterns of the atlas and axis: a computed tomography study

BACKGROUND

We investigated the sex-specific differences in ossification patterns of the first two cervical vertebrae in Chinese children.

METHODS

A retrospective computed tomography (CT) study was performed between June 2016 and December 2020. Patients younger than 16 years with cervical CT images acquired ≤ 1.5 mm slice thickness were included. All eligible patients were stratified into 2 sex groups and 16 age groups based on 1-year intervals. The ossification status of each synchondrosis and ossification variants were evaluated.

RESULTS

A total of 910 subjects (518 males and 392 females) were included in the study. For the C1 vertebra, the neurocentral synchondroses closed at a median age of 8 years in males and 6.3 years in females, and the posterior synchondrosis fused at 5.4 years in males and at 4.4 years in females. Multifocal anterior arch ossification centers were present in 74 of 411 (18%) subjects, whereas posterior arch variants were observed in 18 of 258 (7%) subjects. For the C2 vertebra, the sequence of complete fusion was as follows: posterior synchondrosis, neurocentral synchondroses, and dentoneural synchondrosis. Uniquely, a fusion line was observed in the dentocentral synchondrosis through adolescence. Anterior arch variants of the C2 vertebra occurred in 17 of 248 (6.9%) subjects. There was no significant difference between the sexes in ossification variants.

CONCLUSIONS

All synchondroses of the first two cervical vertebrae fuse slightly earlier in females. The sequence of fusion follows a posterior-to-anterior and caudal-to-cephalad pattern in both sexes. Congenital variants are not rare and should not be confused with trauma.

Evaluation of cervical spine pathology in children with Loeys-Dietz syndrome

Background:

Loeys-Dietz syndrome (LDS) is a genetic connective tissue disorder associated with multiple musculoskeletal anomalies, including cervical spine instability. We sought to examine the nature of imaging for cervical spine instability in children with LDS due to likely pathogenic or pathogenic variants in TGFBR1, TGFBR2, TGFB2, SMAD3, or TGFB3.

Methods:

A retrospective chart review was conducted, examining relevant data for all children with LDS screened at our institution from 2004 through 2021. Cervical spine X-rays were used to assess cervical instability, cervical lordosis, and basilar impression.

Results:

A total of 39 patients were identified; 16 underwent cervical spine screening (56.25% male). Median age at initial screening was 7 years (Q1-Q3: 3.75–14, range: 0.1–19). Six of 16 patients evaluated (37.5%) had radiographical evidence of cervical instability. Mean angles of cervical lordosis were 20° (SD = 14.1°, range = 4°–33°) and 17.3° (SD = 16.4°, range = 2°–41°), respectively. Three patients demonstrated radiographical basilar impression. Radiographic progression of cervical instability was seen in one case. All but two were managed conservatively with observation, one patient underwent surgical fixation and fusion of C1-2, the other underwent complex cervical reconstruction anterior and posterior instrumentation.

Conclusion:

Cervical spine evaluation is important in this cohort; we identified 37.5% had evidence of cervical spine instability, and many had concurrent spinal pathology. From our experience, we agree with the recent advisement for screening at diagnosis and for those previously diagnosed that have not undergone screening. Future study may outline more specific screening practices.

Three Column Cervical Fracture-Dislocation in a 3-Year-Old Boy

Complete traumatic cervical fracture-dislocation with spinal cord transection in children is a rare entity with no evidence-based guidelines on management. The authors reviewed the literature for pediatric spinal cord injury and present the case of a 3-year-old with traumatic cervical fracture-dislocation and spinal cord transection who presented as a cervical-6 complete spinal cord injury (ASIA A). His other organ systems injured included liver, spleen, bowel, and abdominal aortic injury. The patient underwent halo placement for preoperative reduction followed by open reduction and internal fixation with posterior segmental instrumented fusion. Intraoperatively, the patient had motor evoked potential signals present below the level of his injury. Early postoperative follow-up demonstrated that, although his leg function did not improve, he did demonstrate improvement in upper extremities. This is a rare case of complete cervical spinal cord transection in a pediatric patient. We elected to manage this challenging case with initial external reduction and orthosis with a halo vest followed by acute posterior cervical fusion. Despite a cervical-6 injury level on clinical exam, there was electrographic evidence of function below that level on intraoperative neuromonitoring. Postoperatively the patient has recovered some lost function.

Asymmetry of the C2 pars interarticularis: a clinical anatomical study with relevance to screw placement

PURPOSE

Potential asymmetries of the C2 posterior elements pose a problem for the spine surgeon seeking to make the best choice for spinal stabilization while reducing morbidity.

METHODS

A digital caliper was used to measure the pars interarticularis height and length on left and right sides of 25 adult C2 vertebrae. The pars interarticularis was defined as the bone between the posterior most aspect of the superior articular process and the anterior most aspect of the inferior articular process of C2. Also, the C2 vertebrae from 49 patients were scanned by CT. Parasagittal images were reviewed and using the same definitions as were used for the skeletal specimens, the length and the height of the C2 pars interarticularis from both the left and right sides were measured using CT. The image slices were acquired at 3 mm intervals. The pars interarticularis height was determined on sagittal CT reconstruction, while the pars interarticularis length was calculated on the basis of the axial images.

RESULTS

The lengths and the heights of the left and right pars interarticularis were compared using CTs of patients and skeletal specimens. No significant differences were found in the length and height measurements of the CT images on both sides. However, in the skeletal specimens, the left and right pars interarticularis did not differ significantly in length but differed significantly in height (p = 0.003). The mean height of the left pars interarticularis was approximately two times larger than the right in the skeletal specimens. Absolute differences were calculated between the side with the greater length and height and the side with the lesser length and height irrespective of their left-right orientations. For CT measurements, most differences in length and height between the greater pars interarticularis and lesser pars interarticularis occurred between 0 and 1 mm with each successive disparity interval yielding lower numbers. Skeletal measurements revealed a similar length disparity distribution to the CT measurements. However, height measurements in the skeletal specimens varied widely. Eight pars interarticularis specimens demonstrated a height difference between 0 and 1 mm. No dry bone pars interarticularis specimens demonstrated a height difference between 1 and 2 mm. The pars interarticularis of nine specimens demonstrated a height difference between 2 and 3 mm. Two demonstrated a height difference between 3 and 4 mm. Four demonstrated a height difference between 4 and 5 mm and two demonstrated a height difference greater than 5 mm. The greater pars interarticularis lengths and heights were combined and compared to their lesser counterparts on CT and skeletal measurements. In all measurements of this type, significant differences were found in the pars interarticularis length and height, whether measured through CT or via digital calipers.

CONCLUSION

Asymmetry between the left and right C2 pars interarticularis as shown in the present study can alter surgical planning. Therefore, knowledge of this anatomical finding might be useful to spine surgeons.

Occult craniocervical dissociation on cervical CT: an under-appreciated presentation of craniocervical trauma requiring occipital cervical fusion

BACKGROUND AND PURPOSE

Craniocervical dissociation is a rare and life-threatening injury that results from a significant hyperflexion-hyperextension force. Occult craniocervical dissociation is defined as an unstable craniocervical injury in the absence of atlanto-occipital joint space widening or other skull base line abnormality. The early and accurate diagnosis of craniocervical dissociation is crucial since the early diagnosis and subsequent stabilization with occipital-cervical fusion has been shown to reduce neurologic morbidity and mortality. Several normative skull base lines have been developed to predict craniocervical dissociation. The purpose of our study was to measure the atlanto-occipital joint space and four other common skull base lines in patients who underwent occipital-cervical fusion for post-traumatic craniocervical instability.

MATERIALS AND METHODS

Patients who underwent occipital-cervical fusion for craniocervical injury were identified retrospectively using a keyword search of radiology reports using Nuance mPower software. The cervical CT and MRI exams for these patients were reviewed and the atlanto-occipital joint space, Powers ratio, Wackenheim line, posterior axial line, and basion dens interval were measured. Detailed descriptions of craniocervical ligament injuries on MRI were recorded along with patient demographic information, clinical history, management, and outcome.

RESULTS

Nine adult patients who underwent occipital-cervical fusion for an acute craniocervical injury were identified. Six patients demonstrated an atlanto-occipital joint space measuring 2 mm or less on cervical spine CT with no additional abnormality in the Powers ratio, Wackenheim line, posterior axial line, or basion-dens interval. Three patients demonstrated widening of the atlanto-occipital joint space with two patients demonstrating an abnormality in at least two additional skull base lines. Clinical outcomes were variable with nearly half of the patients demonstrating persistent neurologic deficits, including one quadriplegic patient.

CONCLUSIONS

A normal atlanto-occipital joint space and skull base line measurements on cervical CT demonstrated a low predictive value for detecting unstable craniocervical injuries. Occult craniocervical dissociation was present in two-thirds of patients who underwent occipital cervical fusion for acute, craniocervical trauma. A high clinical and radiologic index of suspicion for craniocervical trauma with subsequent follow-up cervical MRI to directly evaluate ligamentous integrity is necessary to accurately diagnose and triage patients with high velocity trauma.

Pediatric Upper Cervical Spine Trauma: A 10-Year Retrospective Review at a Pediatric Trauma Center

Background

Traumatic upper cervical spine injuries (tUCSI) are generally caused by high-impact injuries to the C1-C2 vertebral level. The current literature is limited with regards to comparing epidemiological trends, treatment options, and overall outcomes for tUCSI within the pediatric cohort. The purpose of this study was to analyze pediatric tUCSI epidemiological data, potential variations in treatment and patient outcomes, and to evaluate any specific trends that may be clinically relevant.

Methodology

We conducted a retrospective cohort study on pediatric patients ages 1 day to 16 years old, admitted for tUCSI over the past 10 years (1/2011 to 1/2021) at a Midwest level 1 trauma center. Retrospective data was queried using ICD-9 and ICD-10 diagnosis codes for tUCSI. Children were stratified into three age groups: Group 1 - Infants and Toddlers (children under three years of age); Group 2 - Young Children (children between three and seven years of age); Group 3 - Juveniles and Adolescents (children between the ages of seven and 16). Numerical data and categorical variables were summarized and the normality of the distribution of data was evaluated using the Anderson-Darling normality test. Differences between the age groups were examined using either an unpaired, independent Two-Sample t-test or Unpaired Mann-Whitney U test. Pearson’s chi-squared or Fisher’s exact tests were used to compare categorical data between groups.

Results

Forty total patients were included in the final analysis, 23 female (57.5%) and 17 male (42.5%). The mean age was 11 ± 4 (range 2-16). Overall, the most common mechanism of injury was a motor vehicle collision (n=16, 40%), followed by sports injury (n=13, 32.5%), falls (n=6, 15%), and unknown mechanism (n=5, 12.5%). The most common mechanism of injury in young children was a fall (n=4, 57.5%, p<0.001). Adolescents and Juveniles significantly suffer from sports injuries compared to young children (n=13, 39.4%, p=0.043). Mechanisms of injuries presented with unique associated concomitant injuries. The most common associated sites of injuries were lower cervical spine (n=31, 77.5%), and skull injury (n=4, 10%). The vast majority of these cases were managed nonoperatively (pain medication and non-operative cervical orthosis) (n=36, 90%). Mortality and morbidity rates from tUCSI were rare in our cohort (n=1, 2.5%).

Conclusion

This study found that the majority of pediatric tUCSI patients can be managed nonoperatively, with dislocations and spinal instability being the most common indications for operative management. Commonly used non-operative external fixation methods include cervical collars and Minerva jackets. Our cohort showed very low mortality and morbidity rates, however, these preliminary results will require validation by future prospective multicenter studies.

An audit of computed tomography request practices for suspected cervical spine injury post‐guideline change in a tertiary referral paediatric hospital

BACKGROUND

Paediatric neck injuries are a common presenting complaint to emergency departments (EDs). Medical imaging can assist diagnosis, however previous research suggests computed tomography (CT) scan results do not alter management in this patient group and therefore expose children to unnecessary radiation. Following an audit by the hospital Trauma Service that identified unnecessary cervical spine CTs in patients at Women's and Children's Hospital (WCH), Adelaide, the Clinical Procedure for imaging and clearance of the cervical spine in conscious patients was modified to include CT scan only at the request of the orthopaedic service. The aim of this study was to evaluate whether a change in hospital guideline resulted in a change in practice and radiation exposure.

METHODS

A retrospective review was performed for patients that presented to the WCH ED with a suspected cervical spine injury during two defined time periods pre- and post-guideline change. Mechanism of injury, imaging requested, radiation exposure and final diagnosis were compared.

RESULTS

Three hundred seventy-nine patients were included, with 164 (43.3%) post-guideline changes. Radiograph use was similar between groups, 132/215 (61.4%) versus 101/164 (61.6%) (p = 0.97). CT scan use was lower post-guideline modification 19/215 (8.8%) versus 12/164 (7.3%), however was not statistically significant (p = 0.59), with an absolute reduction of 17%.

CONCLUSION

Guideline modification at our hospital did not significantly reduce CT scan use or eliminate unnecessary CTs. Unnecessary CT scans followed lack of knowledge of and therefore compliance with guidelines. Individual hospitals should consider strategies to reduce unnecessary CTs, given the association with cancer risk in children.

A retrospective study of incidental findings occurring in a consecutive case series of lateral cephalograms of 12- to 20-year-old patients referred for routine orthodontic treatment

Purpose

Lateral cephalograms of orthodontic patients may contain incidental findings that could potentially lead to harm.

Materials and Methods

The lateral cephalograms of 1765 consecutive 12- to 20-year-old patients, being considered for routine orthodontic treatment, were retrospectively reviewed. These patients were considered normal, because no abnormalities were found either in their medical history or on their clinical examination.

Results

The overall prevalence of incidental findings was 18.8%, of which 10.3% were ponticulus posticus and 4.2% were bridging of the sella turcica. Although occipital spurs and ponticulus posticus were more prevalent in males, the size of the sella turcicas did not differ between sexes. Of the 1156 patients completing treatment about 2 years later, only one lateral cephalogram displayed progression of the ponticulus posticus in that time.

Conclusion

The prevalence of incidental findings on lateral cephalograms of otherwise normal orthodontic 12- to 20-year-old patients was almost a fifth, of which ponticulus posticus, vertebral fusion, and enlarged parietal foramina were clinically significant.

Radiographs and MRI of the Cervical Spine in Juvenile Idiopathic Arthritis: A Cross-Sectional Retrospective Study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease among children. In some patients, cervical spine arthritis remains a serious and chronic manifestation of JIA. The aim of this study was to assess the frequency of cervical spine lesions on radiographs and MRI in JIA patients with clinical signs of cervical spine involvement and to verify if with the addition of MRI, the use of radiographs could be abandoned.

METHODS

This retrospective study evaluated consecutive 34 children (25 girls; aged 6-18 years, median 15.5 years) with JIA and with clinical involvement of cervical spine. In each patient, both radiographs and MRI of the cervical spine were performed. Imaging findings were correlated with clinical and laboratory data.

RESULTS

The cervical spine was affected in 35% of patients. The most frequent lesions were subaxial subluxations (SAS; 24%), apophyseal joint ankylosis (9%), and C1/C2 joint lesions (9%). Anterior atlanto-axial subluxation (AAS) was diagnosed only by radiography, and most of the SAS were seen on radiography, whereas only a few on MRI. Reversely, C1/C2 soft tissue involvement were seen on MRI only. Cervical spine involvement was associated with raised ESR (p = 0.012) and CRP (p = 0.014).

CONCLUSIONS

The cervical spine lesions are still frequent complication of JIA affecting up to 35% of JIA patients. Most of them develop serious complications, such as AAS and ankylosis. Despite advantages of MRI in terms of the imaging of the atlanto-axial region radiography shows superiority in diagnosis of AAS and SAS.

Temporary Internal Bracing for Pediatric Odontoid Synchondrosis Fracture

Children are predisposed to injuries of the upper cervical spine given their relatively immature osteology, ligamentous laxity, underdeveloped musculature, and larger ratios of head to body mass. Odontoid process fractures involving the synchondroses are among the most common of these injuries. Though many of these fractures can be treated conservatively with external bracing, fractures with significant displacement that are unable to be reduced require operative management. In these cases, most patients undergo C1-2 posterior fusion with arthrodesis with permanent limitation to atlantoaxial range of motion (ROM). Here, we present a novel operative approach to manage odontoid synchondrosis fractures with temporary internal bracing via C1-2 posterior instrumentation without arthrodesis. We saw a three-year-old female who presented after a motor vehicle collision with a displaced odontoid synchondrosis fracture that was unable to be adequately reduced in a closed fashion. In an attempt to preserve maximal atlantoaxial ROM, temporary internal bracing was carried out with excellent results.

Contributions of anatomy to forensic sex estimation: focus on head and neck bones

This study sought to provide an up-to-date review of the importance of anatomy to human identification, focusing on the usefulness of anatomical knowledge about the head and neck bones and teeth to sex estimation in routine forensic anthropology methods. A detailed search of osteology applications in forensic sex estimation was conducted through the electronic databases for the 10 years prior to July 2020. Relevant articles and classic literature on the subject were gathered and are outlined in this review. Among the available literature, several metric analyses showed accuracy superior to 80% in sexual diagnosis. Angles measured from the inclination of glabellae and analysis of the external frontal bone surface through three-dimensional computer-aided design emerge as reliable cranial indexes for sex estimation. In the mandible, the condylar and coronoid height, bigonial width, and coronion–gonion distance express significant sexual dimorphism. Measurements of the canine are the best option for sex estimation using teeth, as well as the thickness of the dentine or enamel of incisors. The axis vertebra surpasses other neck bones for sex estimation due to its atypical shape and the presence of the odontoid process. Metric analyses based on anatomy can provide reliable accuracy in sexual diagnosis. Adequate training and anatomical knowledge can reduce bias and interobserver differences, and the use of three-dimensional models and computed tomography images can enhance the accuracy of these methods for sex estimation. However, every method should be validated before being applied to a different population.

Key Points

• Anatomy-based metric analyses can provide reliable accuracy in forensic sex estimation.

• Glabellae inclination, external frontal bone surface, mandible, and canine teeth measurements can reach accuracies superior to 80% in sexual diagnosis.

• The use of three-dimensional models and computed tomography images can enhance accuracy in sex estimation.

• Every method should be validated before being applied to a different population.

Diagnostic Benefit of MRI for Exclusion of Ligamentous Injury in Patients with Lateral Atlantodental Interval Asymmetry at Initial Trauma CT

Background Cervical spine CT is regularly performed to exclude cervical spine injury during the initial evaluation of trauma patients. Patients with asymmetry of the lateral atlantodental interval (LADI) often undergo subsequent MRI to rule out ligamentous injuries. The clinical relevance of an asymmetric LADI and the benefit of additional MRI remain unclear. Purpose To evaluate the diagnostic benefit of additional MRI in patients with blunt trauma who have asymmetry of the LADI and no other cervical injuries. Materials and Methods Patients who underwent cervical spine CT during initial trauma evaluation between March 2017 and August 2019 were retrospectively evaluated. Those who underwent subsequent MRI because of LADI asymmetry of 1 mm or greater with no other signs of cervical injury were identified and reevaluated by two readers blinded to clinical data and initial study reports regarding possible ligamentous injuries. Results Among 1553 patients, 146 (9%) had LADI asymmetry of 1 mm or greater. Of these, 46 patients (mean age ± standard deviation, 39 years ± 22; 28 men; median LADI asymmetry, 2.4 mm [interquartile range, 1.8-3.1 mm]) underwent supplementary MRI with no other signs of cervical injury at initial CT. Ten of the 46 patients (22%) showed cervical tenderness at clinical examination, and 36 patients (78%) were asymptomatic. In two of the 46 patients (4%), MRI revealed alar ligament injury; both of these patients showed LADI asymmetry greater than 3 mm, along with cervical tenderness at clinical examination, and underwent treatment for ligamentous injury. In 13 of the 46 patients (28%), signal intensity alterations of alar ligaments without signs of rupture were observed. Four of these 13 patients (31%) were subsequently treated for ligamentous injury despite being asymptomatic. Conclusion Subsequent MRI following CT of the cervical spine in trauma patients with lateral atlantodental interval asymmetry may have diagnostic benefit only in symptomatic patients. In asymptomatic patients without proven cervical injuries, subsequent MRI showed no diagnostic benefit and may even lead to overtreatment. © RSNA, 2021 Online supplemental material is available for this article.

Anterior Odontoid Screw Fixation for Pediatric and Adolescent Odontoid Fractures: Single-Center Experience Over a Decade

OBJECTIVE

Management of pediatric odontoid fractures is tricky and controversial. This study will enrich world literature with intricacies of anterior odontoid screw (OS) fixation in the pediatric population learned over the last decade.

METHODS

In this retrospective study, all patients with pediatric odontoid fracture who underwent anterior odontoid screw fixation from January 2010 to December 2019 were included and evaluated for surgical outcome.

RESULTS

Thirteen patients were included in this study (mean age, 15 years; range, 6-18 years; male/female, 11:2; type II, 10; type IIA, 1; type III, 2). Common causes of injury were motor vehicle accidents (61.5%) followed by fall from height (38.5%) and all were acute fractures (2-30 days). Five patients had neurologic deficits. Accurate placement of screw was achieved in 92.3% of patients, including all 9 patients who used intraoperative O-arm. K wire migration during bicortical drilling resulted in neurovascular injury, with 1 mortality (7.7%). The remaining 12 patients were available for follow-up (mean, 36 months; range, 20-72 months) and all had preservation of neck movements. Successful OS fixation was achieved in 84.6% of patients, including 1 patient (7.7%) who had a fibrous union. One patient (8.3%) had nonunion because of migration of the screw head in the C2 body.

CONCLUSIONS

Anterior odontoid screw fixation in the pediatric population provides good functional outcomes with instant fixation by direct osteosynthesis. However, the surgeon should be meticulous in the surgical approach and should achieve a lag effect. The surgeon should stop after engaging the outer cortex of the odontoid peg with K wire to avoid cranial migration. Intraoperative O-arm guidance is useful.

Pediatric cervical spine fracture case report: Best practice to delay transition to rear-facing restraint

Pediatric physicians and motor vehicle safety experts have been advocating for change in child passenger restraint practices for decades. As professional recommendations evolve to support extended rear-facing restraint, actual practices remain disparate. We report a case of pediatric cervical spine fracture due to motor vehicle collision, an uncommon, yet predictable, pattern of injury for which prevention education is undoubtedly preferable to managing the consequences of premature forward-facing in vulnerable pediatric patients. Currently, 9 kg is a minimum legal standard for forward-facing child restraint system use in Ontario, rather than a recommended transition time. We advise that parents should be counselled on the benefits of rear-facing as long as possible and discuss realistic transition times using their child restraint system manual as a reference, with the goal of approaching, but not exceeding, the maximum weight, height and fit requirements for optimal safety.

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A case of pediatric cervical spine fracture due to a motor vehicle collision

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Prevention education is crucial to reduce risk of pediatric cervical spine injury.

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9 kg is a minimum legal standard for FFCRS rather than recommended transition time.

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Counsel parents on benefits of extended rear-facing and realistic transition times

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Aim to approach but not exceed maximum requirements of child restraint systems

Estimation of a statistical geometric model for the cervical vertebrae of children aged 10-18 years

Child neck injuries in motor vehicle crashes (MVCs) result in high morbidity and mortality rates. Estimating a statistical cervical vertebrae geometric model and quantifying the variations of the size and shape with age are very important for investigating the dynamic response and injury risk to a child's cervical spine, as well as for providing a geometric basis for developing child anthropomorphic test devices (ATDs) and finite element models (FEMs) of different ages. In this study, spatial geometric points were automatically extracted from the cervical vertebrae computed tomography (CT) scans of 30 children aged 10 to 18 years old (YO), and a statistical geometric model was estimated for the cervical vertebrae as a function of age and neck circumference/neck length according to the method of principal component analysis and regression (PCA&R). Based on this statistical model, geometric point sets representing cervical vertebrae geometries at different ages and percentiles were generated and formed to envelope surfaces. Meanwhile, the size changes of the cervical vertebrae with child growth from 10 to 18 YO were quantified. In general, the anteroposterior length (APL), transverse process width (TPW), vertebral body height (VBH), and vertebral body depth (VBD) of the cervical vertebrae increase with age; the VBH and VBD increase faster than the APL and TPW. Compared with other vertebrae, the APL of C7 is larger, and the rate of increase of C1 with age is evidently slower. The TPWs of C1 and C7 are greater than those of C2 to C6. C7 has higher average values for the VBH and VBD than C3 to C6.

Traumatic cervical spine fracture patterns on CT: a retrospective analysis at a level 1 trauma center

PURPOSE

The purpose of our study was to determine common acute traumatic cervical spine fracture patterns on CT cervical spine (CTCS).

METHODS

We retrospectively reviewed 1091 CTCS positive for traumatic fractures performed over a 10-year period at a level 1 trauma center. Fractures were classified by vertebral level, laterality, and anatomic location (anterior/posterior arch, body, odontoid, pedicle, facet, lateral mass, lamina, spinous process, transverse foramina, and transverse processes).

RESULTS

C2 was the most commonly fractured vertebra (38% of all studies), followed by C7 (32.4%). 48.7% of studies had upper cervical spine (C1 and/or C2) fractures. 39.7% of positive studies involved > 1 vertebral level. Conditioned on fractures at one cervical level, the probability of fracture was greatest at adjacent levels with a 50% chance of sustaining a C7 fracture with C6 fracture. However, 31.3% (136) of studies with multi-level fractures had non-contiguous fractures. The most common isolated vertebral process fracture was of the transverse process, seen in 89 (8.2%) studies at a single level, 27 (2.5%) studies at multiple levels. Subaxial spine vertebral process fractures outnumbered body fractures with progressive dominance of vertebral process fracture down the spine.

CONCLUSION

C2 was the most commonly fractured vertebral level. Multi-level traumatic cervical spine fractures constituted 40% of our cohort, most commonly at C6/C7 and C1/C2. Although the conditional probability of concurrent fracture in studies with multi-level fractures was greatest in contiguous levels, nearly one-third of multi-level fractures involved non-contiguous fractures.

Prevalence of Cervical Spondylolisthesis in the Sagittal Plane Using Radiographic Imaging in a Pediatric Population: A Cross Sectional Analysis of Vertebral Subluxation

INTRODUCTION

Cervical Spondylolisthesis (CS) in children is under-studied. This cross-sectional study reports the CS prevalence in children.

MATERIALS & METHODS

Subjects were selected from a private practice. Inclusion criteria: 0-17 years of age; documented demographics and health complaints; neutral lateral cervical (NLC) radiographs; and CS. Exclusion criteria: pseudosubluxation.

RESULTS

342 NLC radiographs were analyzed. 73 (21.3%) had CS greater than 2.0 mm. 42 (57.5%) had no musculoskeletal complaints. 8 (2.3%) had the presence of a CS greater than 3.5 mm. 5 (62.5%) had no musculoskeletal complaints.

DISCUSSION

Pediatric populations endure various traumas. Pediatric cervical spine biomechanics has an increased risk of upper cervical spine injury. Regular spinal radiographic exams may help identify serious spinal conditions in their pre-symptomatic state.

CONCLUSION

CS in pediatric populations is under-studied. CS is present in children and adolescents with and without symptoms.

Identification of clinical and radiographic predictors of central nervous system injury in genetic skeletal disorders

Some studies report neurological lesions in patients with genetic skeletal disorders (GSDs). However, none of them describe the frequency of neurological lesions in a large sample of patients or investigate the associations between clinical and/or radiological central nervous system (CNS) injury and clinical, anthropometric and imaging parameters. The project was approved by the institution’s ethics committee (CAAE 49433215.5.0000.0022). In this cross-sectional observational analysis study, 272 patients aged four or more years with clinically and radiologically confirmed GSDs were prospectively included. Genetic testing confirmed the diagnosis in the FGFR3 chondrodysplasias group. All patients underwent blinded and independent clinical, anthropometric and neuroaxis imaging evaluations. Information on the presence of headache, neuropsychomotor development (NPMD), low back pain, joint deformity, ligament laxity and lower limb discrepancy was collected. Imaging abnormalities of the axial skeleton and CNS were investigated by whole spine digital radiography, craniocervical junction CT and brain and spine MRI. The diagnostic criteria for CNS injury were abnormal clinical and/or radiographic examination of the CNS. Brain injury included malacia, encephalopathies and malformation. Spinal cord injury included malacia, hydrosyringomyelia and spinal cord injury without radiographic abnormalities. CNS injury was diagnosed in more than 25% of GSD patients. Spinal cord injury was found in 21.7% of patients, and brain injury was found in 5.9%. The presence of low back pain, os odontoideum and abnormal NPMD remained independently associated with CNS injury in the multivariable analysis. Early identification of these abnormalities may have some role in preventing compressive CNS injury, which is a priority in GSD patients.

The Pediatric Spine

The spine, a frequently investigated site in children, has a complex development in relation to both nervous and bone/cartilaginous structures and shows several particular features in children compared with adults. We report the main normal variants and pathologies of the pediatric spine, from the prenatal period to adolescence, focusing on a multimodality imaging approach.

Axis spinous process malformations are commonly identified in a sample of English Bull Terriers without associated clinical signs

Congenital cervical vertebral malformations (CCVM) have been infrequently reported in veterinary medicine, with limited examples of axis spinous process malformations. The objective of this retrospective cross-sectional study was to describe the radiological characteristics, prevalence, and clinical relevance of a characteristic axis vertebral malformation in a sample of English Bull Terriers (EBTs). Medical records and diagnostic imaging studies of the cervical vertebral column of EBTs presenting for any reason were reviewed and described. Based on evaluation of the images, EBTs were divided in two groups; axis spinous process malformation and normal cases. Referring veterinary surgeons were contacted for long-term follow-up information. A total of 27 cervical radiographs, 23 CT, and nine MRI studies from 53 EBTs were reviewed. An axis spinous process malformation, characterized by a linear defect of varying length along the base of the spinous process, was identified in 22 of 53 EBTs (41.5%). There was no significant difference in age, body weight, or sex (P < .05) between EBTs with and without the malformation. No traumatic causes or clinical signs were identified in EBTs with the malformation that could be directly attributed to it. To the authors' knowledge, this is the first report of a malformation of the axis spinous process in a sample of EBTs. The malformation was not associated with clinical signs and should not be misinterpreted as a traumatic vertebral fracture or other pathology.

Spinal ligamentous injury in abusive head trauma: a pictorial review

There is growing evidence of spine injury in abusive head trauma (AHT). Historically, spine injury was considered rare in AHT because of a lack of attributable clinical symptoms or signs and a lack of advanced imaging. Increased use of MRI in AHT has been instrumental in helping identify evidence of ligamentous injuries of the spine. These findings can be difficult to identify on autopsy because of the size and location of the ligaments. Because spinal injury in AHT mostly involves ligamentous and soft tissues and only rarely involves bony fractures, more than 90% of the injury findings are missed on CT or radiography of the spine. Investigation of these findings and the injury patterns should lead to a better understanding of the mechanism of spinal injury. In this pictorial review, we describe the various manifestations of spinal ligamentous injury in AHT, as seen on MRI, in children younger than 48 months.

Pediatric cervical spine injury in the United States: Defining the burden of injury, need for operative intervention, and disparities in imaging across trauma centers

BACKGROUND

Pediatric cervical spine injury (PCSI) in children is rare. Incidence of PCSI requiring intervention is not known, and imaging practices for screening in United States trauma centers are not well described.

METHODS

The 2016 NTDB was queried for patients younger than 15 years with PCSI. Incidence of PCSI, operative interventions, and imaging rates were analyzed by age and ACS accreditation status.

RESULTS

Of 84,554 children, 873 (1.03%) had PCSI. Patients <4 years were less likely to have PCSI (0.68% vs. 1.1%, RR 0.59, p < 0.001). 165 children (0.20%) required an intervention for PCSI. 12.8% of all children were screened for PCSI with imaging, 9.3% with CT, and 3.2% with plain X-rays. In spite of similar injury and intervention rates, stand-alone pediatric trauma centers were less likely than others to image patients without PCSI (11% vs. 13% p < 0.001), less likely to utilize CT scan (5.8% vs. 10.6% p < 0.001) and more likely to utilize plain films (5.2% vs. 2.4% p < 0.001).

CONCLUSION

Despite exceedingly low rates of PSCI requiring intervention (0.2%), imaging rates for screening are significant. Stand-alone pediatric trauma centers outperform others in limiting unnecessary imaging.

LEVEL OF EVIDENCE

IV.

Atlantoaxial limited dorsal myeloschisis: A report of two cases and review of literature

Introduction

Limited dorsal myeloschisis (LDM) is a rare form of spinal dysraphism that is characterised by a distinctive fibroneural stalk connecting the spinal cord to the overlying skin lesion. The skin lesions associated with LDM can appear benign clinically and careful evaluation with an MRI scan is essential for diagnosing LDM and to differentiate this entity from other forms of spinal dysraphism and benign causes of skin lesions.

Research question

There is a lack of reported atlantoaxial LDM in the literature. We sought to report the clinical presentation, radiological features and surgical management of the first two reported atlantoaxial LDM.

Material and methods

Clinical findings and radiological images of the two cases of atlantoaxial LDM that underwent surgical intervention at our institution were retrieved from the medical notes, operative records and imaging system.

Results

Both cases of atlantoaxial LDM (C0-1 and C1-2 respectively) underwent successful resection of the overlying cutaneous lesions and stalks to release the tethered spinal cords.

Discussion

The surgical management of LDM have been associated with good outcomes and consists of resecting the fibroneural stalk close to the underlying cord, releasing the tethered spinal cord and removing the overlying cutaneous lesion.

Conclusion

These are the first two reported cases of atlantoaxial LDM in the literature. We aim to raise awareness of this pathological entity and highlight the importance of establishing the correct diagnosis to guide definitive management, and report the favourable neurological outcome in these cases despite the rostral location.

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Limited dorsal myeloschisis is a rare form of closed spinal dysraphism.

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These are the first two reported cases of atlantoaxial limited dorsal myeloschisis.

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Favourable surgical outcomes can be achieved despite the rostral location.

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Dorsal midline cutaneous lesions should be investigated further with MRI scan.

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The fibroneural stalk connects the overlying cutaneous lesion to the spinal cord.

Three-Dimensional Assessment of Cervical Vertebrae Anomalies in Patients With Cleft Lip and Palate

OBJECTIVE

To evaluate the occurrence of cervical vertebrae anomalies (CVA) in patients with unilateral (UCLP) and bilateral cleft lip and palate (BCLP) using cone beam computed tomography (CBCT) examinations.

DESIGN

Retrospective assessment of CBCT images. Descriptive statistics were calculated. Fisher exact test or χ² test was performed to evaluate the differences among each CVA between sex and type of cleft.

SETTING

School of Dentistry.

PARTICIPANTS

One hundred fifty-one patients with cleft lip and palate (103 UCLP/48 BCLP).

INTERVENTIONS

No relevant intervention.

MAIN OUTCOME MEASURES

Cone beam computed tomography images were assessed for the presence or absence of 12 most commonly observed CVA: spina bifida, dehiscence, cleft of the posterior arch, cleft of the anterior arch, fusion between cervical vertebrae, block fusion, occipitalization, narrowing of the intervertebral space, posterior ponticle, os odontoideum, ossiculum terminale, and subdental cartilaginous remnants.

RESULTS

The presence of subdental cartilaginous remnants was the most frequently observed alteration-found in 81.45% of the sample-and it was the only CVA with statistically significant frequencies in the individuals with BCLP. Considering only the other CVA, 22.51% presented 1 and 5.29% presented 2 or more CVA.

CONCLUSIONS

Patients with cleft lip and palate may present an overall high incidence of CVAs. However, when comparing the distribution of the CVAs among sex and types of cleft, the only significant difference noted was a higher incidence of subdental cartilaginous remnants among patients with BCLP.

Pediatric Spine Trauma: A Brief Review

Pediatric spinal trauma is a broad topic with nuances specific to each anatomic region of the spinal column. The purpose of this report is to provide a brief review highlighting the most important and common clinical issues regarding the diagnosis and management of pediatric spine trauma. Detailed descriptions of imaging findings along with specific operative and nonoperative management of each fracture and dislocation type are beyond the scope of this review.

Developmental morphology of the cervical vertebrae and the emergence of sexual dimorphism in size and shape: A computed tomography study

Cervical vertebral bodies undergo substantial morphological development during the first two decades of life that are used clinically to visually determine skeletal maturation with the cervical vertebral maturation index (CVMI). CVMI defines six stages that capture the morphological transformations from 6 years to 18 years. However, CVMI has poor reproducibility given its qualitative nature and does not account for sexual dimorphism. This study aims to quantify the morphological development of the cervical vertebral bodies C2-C7 in size (height and depth) and shape and examine the emergence of sexual dimorphism. Using 115 (70 M;45F) computed tomography studies from typically developing individuals ages 6 months to 20 years, landmarks were placed at the margins of the C2-C7 cervical vertebral bodies in the midsagittal plane for size and shape analysis. Findings revealed a dichotomy in the growth trends of height versus depth. The C2-C7 growth in depth gained the majority of the adult size by age 5 years, while the C3-C7 growth in height displayed two periods of accelerated growth during early childhood and puberty. Significant sex differences were found in height and depth growth trends and the form-space ontogenetic trajectories during puberty, with minor but evident differences emerging at age 3 years. Female C2-C7 depth measures were smaller than males at all ages. However, sex differences in height became evident due to males continuing to grow after females reach maturity. Findings quantify the morphological developmental stages of CVMI and emphasize the need to account for sex differences when assessing skeletal maturation.

Congenital Cervical Spondyloptosis in the Neonate: A Prenatal Diagnosis

Congenital spine abnormalities are rare in the fetus and neonate. The illustrative case described in this article is unique as it depicts a neonate with prenatally diagnosed cervical spondyloptosis. Vertebral instability at any level of the spine, regardless of its etiology, is dangerous as it has the potential for neurologic involvement-making an early diagnosis and treatment paramount. Proper stabilization in the delivery room, transfer to the neonatal intensive care unit, and establishment of a multidisciplinary treatment plan are the mainstays of therapy. Diagnosis is usually obtained through computed tomography and magnetic resonance imaging performed during the fetal or, more commonly, neonatal period. Successful management is often accomplished in consultation with different pediatric subspecialists, particularly orthopedists and neurosurgeons. The definitive therapy is surgical intervention. Prognosis of this condition is dependent upon the severity of the malformation, time to stabilization, successful orthopedic and neurosurgical intervention, and proper adherence to follow-up. [Pediatr Ann. 2020;49(7):e313-e318.].

Anterior cervical corpectomy and fusion in a 7-year-old boy: a case report

Bicycle mishap, a common and ordinary event occurring in children, can have devastating consequences associated with cervical spine injury. Furthermore, either diagnosis or surgical management of cervical spine injury in children is a challenging issue. This research report a challenging case of an anterior cervical corpectomy and fusion with plating in a 7-year-old boy due to cervical spine instability with spinal cord compression after a bicycle mishap. After 20 months of the primary surgery, the titanium-based cervical plate was removed by a second surgery to allow the growth of the cervical spine.

Complete remodelling of a displaced odontoid synchondrosis fracture managed conservatively: a case report

Odontoid synchondrosis fractures are the most common cervical fracture in young children, although their overall incidence is rare. Various strategies have been proposed in the management of injuries with significant displacement or angulation. In this report, we present the long-term functional and radiological outcomes following nonoperative treatment of such a fracture in a 5-year-old female. The patient was referred to our tertiary centre with radiological progression of angulation from 10° to 35° within 5 weeks of the injury, despite wearing a rigid collar. She had no neurological compromise. Although we examined the fracture under general anaesthetic, and subsequently applied halo traction, there was no effect on alignment. The halo device was removed after 11 days and a rigid collar was fitted again. The patient had no pain or neurological symptoms out of the collar at 12 weeks after injury (6 weeks after removal of halo), and a computed tomography scan at 15 weeks confirmed that the fracture had united in malalignment. However, serial radiographs and MRI subsequently have shown that the axis has remodelled completely. At 7 years follow-up, there has been no impact on the patient's functional range of movement or quality of life. This case highlights the preservation of the motion segment and the remarkable remodelling potential of the paediatric cervical spine.

Cervical vertebral body growth and emergence of sexual dimorphism: a developmental study using computed tomography

The size and shape of human cervical vertebral bodies serve as a reference for measurement or treatment planning in multiple disciplines. It is therefore necessary to understand thoroughly the developmental changes in the cervical vertebrae in relation to the changing biomechanical demands on the neck during the first two decades of life. To delineate sex-specific changes in human cervical vertebral bodies, 23 landmarks were placed in the midsagittal plane to define the boundaries of C2 to C7 in 123 (73 M; 50 F) computed tomography scans from individuals, ages 6 months to 19 years. Size was calculated as the geometric area, from which sex-specific growth trend, rate, and type for each vertebral body were determined, as well as length measures of local deformation-based morphometry vectors from the centroid to each landmark. Additionally, for each of the four pubertal-staged age cohorts, sex-specific vertebral body wireframes were superimposed using generalized Procrustes analysis to determine sex-specific changes in form (size and shape) and shape alone. Our findings reveal that C2 was unique in achieving more of its adult size by 5 years, particularly in females. In contrast, C3-C7 had a second period of accelerated growth during puberty. The vertebrae of males and females were significantly different in size, particularly after puberty, when males had larger cervical vertebral bodies. Male growth outpaced female growth around age 10 years and persisted until around age 19-20 years, whereas females completed growth earlier, around age 17-18 years. The greatest shape differences between males and females occurred during puberty. Both sexes had similar growth in the superoinferior height, but males also displayed more growth in anteroposterior depth. Such prominent sex differences in size, shape, and form are likely the result of differences in growth rate and growth duration. Female vertebrae are thus not simply smaller versions of the male vertebrae. Additional research is needed to further quantify growth and help improve age- and sex-specific guidance in clinical practice.

Tales from the Night:: Emergency MR Imaging in Pediatric Patients after Hours

Overnight in-house radiology has rapidly become an important part of contemporary practice models, and is increasingly the norm in pediatric radiology. MR imaging is an indispensable first-line and problem-solving tool in the pediatric population. This has led to increasingly complex MR imaging being performed "after hours" on pediatric patients. This article reviews the factors that have led to widespread overnight subspecialty radiology and the associated challenges for overnight radiologists, and provides an overview of up-to-date imaging techniques and imaging findings of the most common indications for emergent MR imaging in the pediatric population.