Radiography of cervical spine injury in children: are flexion-extension radiographs useful for acute trauma?

Cervical spine flexion-extension radiography versus magnetic resonance imaging in pediatric patients following blunt traumatic injury

Background

In pediatric trauma patients, 60-80% of spinal cord injuries involve the cervical vertebrae. While the American College of Radiology offers guidelines for best imaging practices in the setting of acute pediatric trauma, there is a lack of uniformity in imaging-decision protocols across institutions. MRI has been shown to demonstrate high sensitivity for both bony and ligamentous injuries while also avoiding unnecessary radiation exposure in the pediatric patient population. However, the efficacy of flexion-extension (FE) radiography following initial MRI has not been evaluated in children. Our hypothesis is that FE radiography conducted following an initial MRI does not contribute significant diagnostic information or reduce time to cervical collar removal and thus can be removed from institutional protocols in order to avoid unnecessary testing and reduce pediatric radiation exposure.

Methods

Trauma data were collected for pediatric patients presenting with suspected acute cervical spine injury from 2014 to 2021. A total of 108 patients were subdivided into 41 patients who received "MRI Only" and 67 patients who received both "MRI and FE" diagnostic cervical spine imaging. Chi-square testing and t-tests were performed to determine differences between MRI and FE radiographic detection rates of bony and ligamentous injuries in the subgroups.

Results

In patients for whom FE did not find any injury, MRI detected bony and ligamentous injuries in 9/63 and 12/65 cases, respectively. In 3/21 (14.3%) cases in which MRI detected a bony and/or ligamentous injury and FE did not, patients eventually required surgical intervention for c-spine stabilization. No patients required surgical fixation when FE radiography showed an abnormality and MRI was normal. Addition of follow-up FE radiography after initial MRI did not have a significant effect on overall hospital length of stay (MRI Only vs MRI+FE: 9.2±12.0 days vs 8.6±13.5 days, p=0.816) or on rates of collar removal at discharge or greater than 48 hours after imaging (MRI Only vs MRI+FE: 41.5% vs 56.7%, p=0.124).

Conclusions

FE radiography following initial MRI did not have a significant effect on reducing time to cervical collar removal or overall hospital length of stay. In addition, in 3 of 6 cases (50.0%) in which surgical fixation was required, MRI detected ligamentous and/or bony injury while FE radiography was normal.

Level of Evidence

This study contributes Level 2b scientific evidence consistent with a well-designed cohort or case-control analytic study.

A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries

CONTEXT

Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system.

EVIDENCE ACQUISITION

The data on pediatric traumatic spinal cord injuries has been narratively reviewed.

RESULTS

Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges.

CONCLUSION

Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.

Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database

Background

The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database.

Methods

The Kids' Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ² for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P < .05.

Results

A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P < .001).

Conclusions

Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines.

Level of Evidence

III.

Clinical Relevance

Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Current Concepts in Pediatric Cervical Spine Trauma

Background:

Pediatric spinal trauma is rare and challenging entity. Although cervical spine is commonly affected, it is often missed on routine imaging investigations. Therefore better understanding of growing spine and its patho-physiology is crucial.

Methods:

Articles related to pediatric cervical trauma were searched on Pubmed and other online research data banks. We have summarized unique anatomy of pediatric spine, investigations followed by common injury patterns, their diagnostic challenges and management.

Results:

Immature spine follows typical injury patterns, so thorough knowledge of its presentation should be known. Primary physicians should be able to perform initial assessment based on clinical examination and investigations for early diagnosis. High index of suspicion and strategic approach leads to early diagnosis and prevents further morbidity and mortality.

Conclusion:

Spinal injuries in children are rare and typical. They are often missed and can have fatal consequences. Thorough understanding of pediatric anatomy and injury patterns helps in early diagnosis.

Craniovertebral junction injuries in children. A Review

The craniovertebral junction (CVJ) is the most complex and dynamic region of the cervical spine. The wide range of movements possible at this region makes it vulnerable to injury and instability. The special anatomical features make children more prone to injuries of CVJ than adults where lower cervical spine is involved more frequently. The classical clinical manifestation in CVJ injury patients are pyramidal signs including weakness and spasticity, stigmata of CVJ anomalies (short neck, low hair line, facial or hand asymmetry, high arched palate, ), torticolis and neck movement restriction. The history of transient loss of consciousness or sudden neurological deterioration following minor trauma may be elicited. Most authors advocate conservative management (in form of immobilization) of CVJ injuries in children as is true in adults. Halo vest provides superior immobilization in upper cervical and CVJ injuries and can be used in a child as young as 1 year of age with minimal difficulty. Early surgical intervention, i.e. within 2 weeks of injury include is indicated in injuries that cannot be reduced and stabilized by external means, partial spinal cord injury with progressive neurological deficit and in children with extradural hematoma.

Imaging investigations in Spine Trauma: The value of commonly used imaging modalities and emerging imaging modalities

Traumatic spine injuries can be devastating for patients affected and for health care professionals if preventable neurological deterioration occurs. This review discusses the imaging options for the diagnosis of spinal trauma. It lays out when imaging is appropriate and when it is not. It discusses strength and weakness of available imaging modalities. Advanced techniques for spinal injury imaging will be explored. The review concludes with a review of imaging protocols adjusted to clinical circumstances.

Pediatric cervical spine in emergency: radiographic features of normal anatomy, variants and pitfalls

Injuries of the cervical spine are uncommon in children. The distribution of injuries, when they do occur, differs according to age. Young children aged less than 8 years usually have upper cervical injuries because of the anatomic and biomechanical properties of their immature spine, whereas older children, whose biomechanics more closely resemble those of adults, are prone to lower cervical injuries. In all cases, the pediatric cervical spine has distinct radiographic features, making the emergency radiological analysis of it difficult. Such features as hypermobility between C2 and C3, pseudospread of the atlas on the axis, pseudosubluxation, the absence of lordosis, anterior wedging of vertebral bodies, pseudowidening of prevertebral soft tissue and incomplete ossification of synchondrosis can be mistaken for traumatic injuries. The interpretation of a plain radiograph of the pediatric cervical spine following trauma must take into account the age of the child, the location of the injury and the mechanism of trauma. Comprehensive knowledge of the specific anatomy and biomechanics of the childhood spine is essential for the diagnosis of suspected cervical spine injury. With it, the physician can, on one hand, differentiate normal physes or synchondroses from pathological fractures or ligamentous disruptions and, on the other, identify any possible congenital anomalies that may also be mistaken for injury. Thus, in the present work, we discuss normal radiological features of the pediatric cervical spine, variants that may be encountered and pitfalls that must be avoided when interpreting plain radiographs taken in an emergency setting following trauma.

Classification and Management of Pediatric Subaxial Cervical Spine Injuries

Appropriate management of subaxial spine injury in children requires an appreciation for the differences in anatomy, biomechanics, injury patterns, and treatment options compared with adult patients. Increased flexibility, weak neck muscles, and cranial disproportion predispose younger children to upper cervical injuries and spinal cord injury without radiographic abnormality. A majority of subaxial cervical spine injuries can be treated nonoperatively. Surgical instrumentation options for children have significantly increased in recent years. Future studies of outcomes for children with subaxial cervical spine injury should focus on injury classification and standardized outcome measures to ensure continued improvement in quality of care for this patient population.

Heterogeneity in cervical spine assessment in paediatric trauma: A survey of physicians' knowledge and application at a paediatric major trauma centre

OBJECTIVE

Evidence-based decision-making tools are widely used to guide cervical spine assessment in adult trauma patients. Similar tools validated for use in injured children are lacking. A paediatric-specific approach is appropriate given important differences in cervical spine anatomy, mechanism of spinal injury and concerns over ionising radiation in children. The present study aims to survey physicians' knowledge and application of cervical spine assessment in injured children.

METHODS

A cross-sectional survey of physicians actively engaged in trauma care within a paediatric trauma centre was undertaken. Participation was voluntary and responses de-idenitified. The survey comprised 20 questions regarding initial assessment, imaging, immobilisation and perioperative management. Physicians' responses were compared with available current evidence.

RESULTS

Sixty-seven physicians (28% registrars, 17% fellows and 55.2% consultants) participated. Physicians rated altered mental state, intoxication and distracting injury as the most important contraindications to cervical spine clearance in children. Fifty-four per cent considered adequate plain imaging to be 3-view cervical spine radiographs (anterior-posterior, lateral and odontoid), whereas 30% considered CT the most sensitive modality for detecting unstable cervical spine injuries. Physicians' responses reflected marked heterogeneity regarding semi-rigid cervical collars and what constitutes cervical spine 'clearance'. Greater consensus existed for perioperative precautions in this setting.

CONCLUSIONS

Physicians actively engaged in paediatric trauma care demonstrate marked heterogeneity in their knowledge and application of cervical spine assessment. This is compounded by a lack of paediatric-specific evidence and definitions, involvement of multiple specialties and staff turnover within busy departments. A validated decision-making tool for cervical spine assessment will represent an important advance in paediatric trauma.

Imaging, clearance, and controversies in pediatric cervical spine trauma

Diagnosing cervical spine injury in children can be difficult because the clinical examination can be unreliable, and evidence-based consensus guidelines for cervical spine injury evaluation in children have not been established. However, the consequences of cervical spine injuries are significant. Therefore, practitioners should understand common patterns of cervical spine injury in children, the evidence and indications for cervical spine imaging, and which imaging modalities to use. Herein, we review the epidemiology and unique anatomical features of pediatric cervical spine injury. In addition, we will summarize current practice for clearance and imaging of the pediatric cervical spine in trauma.

Cervical spine evaluation in pediatric trauma

OBJECTIVE

This article will review the current literature as it relates to imaging of the child suspected to have cervical spine injury (CSI) and the imaging findings of pediatric CSI, focusing on strategies to minimize radiation dose while maximizing diagnostic yield.

CONCLUSION

Although CSI is uncommon in children, the clinical implications of failure to correctly diagnose CSI are significant. Clinical decision rules proven effective in predicting CSI in adults cannot be uniformly applied to children.

Clearing the cervical spine in children

Increasing evidence from adult trauma patients has allowed the formation of some international consensus on clearance protocols. The evidence for paediatric trauma remains more fragmented, making the creation of definitive protocols difficult. Spinal injury in children differs from that in adults by injury distribution and prevalence, as well as anatomical and radiological differences. This complicates the process of clearance of the cervical spine in children. The evidence for clearance can be considered in terms of three groups of patients – the alert and asymptomatic child, the conscious child with high-risk criteria and the unconscious or obtunded child. This systematic review summarises the available evidence to clarify the current best practice for each group of patients.

Pediatric cervical spine injuries: a comprehensive review

INTRODUCTION

Cervical spine injuries can be life-altering issues in the pediatric population. The aim of the present paper was to review this literature.

CONCLUSIONS

A comprehensive knowledge of the special anatomy and biomechanics of the spine of children is essential in diagnosis and treating issues related to spine injuries.

Current issues in the diagnosis of pediatric cervical spine injury

Cervical spine injury in pediatric trauma occurs rarely; however, there is significant potential for considerable morbidity when it does occur. Screening for cervical spine injuries has been shown to be most sensitive in adult trauma centers when combined with reliable physical examination findings. Because pediatric trauma patients suffer from a different range of injuries than adults, and often are not reliable due to age limitations or associated head injury, the same strategies employed in adult trauma do not always hold true in children. We look at the differences in adult and pediatric cervical spine anatomy and traumatic mechanisms, as well as the differences between cervical spine injury in infants/children and adolescents/teens. In addition, we examine the literature currently available in each population and derive consensuses on the issues that are important in managing the pediatric cervical spine. We hope to provide a framework that trauma centers can use to develop safe and effective cervical spine clearance protocols.

Instable cervical spine injury in a toddler: technical note

PURPOSE

Instable upper cervical spine injuries (CSI) in very young children are rare and consecutively only few data on the treatment and operative approaches exist in the literature. Hence, we suggest an operative strategy in the case of a 15-month-old infant treated for an instable CSI at the level of C2/3 at our department. Detailed steps of the operation with special consideration to the challenging anatomy of the immature spine are presented.

METHODS

A toddler suffered a CSI without neurological deficits after a stair fall. Computer tomography (CT) and magnetic resonance imaging (MRI) of the cervical spine revealed an instable luxation fracture of C2/3. As repositioning in the halo vest immobilization failed, surgical fusion was indicated.

RESULTS

Via a posterior midline approach, the lamina of C2 and C3 was conflated in a modified sublaminar wiring technique using non-resorbable sutures, sparing the ossification zones of the vertebral arches. Postoperative immobilization in a halo vest facilitated bony fusion of the laminae at C2/3 without lordotic displacement of the cervical spine.

CONCLUSIONS

We consider the instable CSI of the immature cervical in the very young a challenging situation for every treating physician. The particular features of the growing spine require special attention to avoid damage to the growth centers of the vertebrae. To our knowledge, this is the first technical report giving detailed information of an operative approach to the severely injured immature cervical spine and postoperative management.

`Clearing' the cervical spine in conscious trauma patients

This is a systematic review of published evidence regarding management of the cervical spine in conscious and co-operative trauma patients. We examine the literature in the following sections: clinical evaluation of the cervical spine; use of plain radiography; use of additional radiographic views; use of computed tomography; use of magnetic resonance imaging. Finally we consider the elderly and paediatric populations, particularly where there are significant differences compared to the general adult population. This paper also reviews the literature regarding non-medical assessment of the cervical spine. We conclude that there are well-validated decision rules available to guide the clinician, and that each imaging strategy has distinct advantages and disadvantages. Familiarity with these issues provides a sound basis for safe and effective decision-making.

Pediatric cervical spine trauma imaging: a practical approach

Cervical spine trauma in children is rare and the diagnosis can be challenging due to anatomical and biomechanical differences as compared to adults. A variety of algorithms have been used in adults to accurately diagnose injuries, but have not been fully studied in pediatric patients. In this article we review suggested imaging protocols and the general characteristics, types of injuries, and measurements used to diagnose cervical spine injuries in children.

Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN

Best evidence synthesis.

OBJECTIVE

To critically appraise and synthesize the literature on assessment of neck pain.

SUMMARY OF BACKGROUND DATA

The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature.

METHODS

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain.

RESULTS

We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain.

CONCLUSION

The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.

Cervical spine injuries in children: attention to radiographic differences and stability compared to those in the adult patient

The relative rarity of pediatric cervical spine injuries can impede rapid response and efficient care of this patient population. An understanding of the unique anatomical, radiographic, and biomechanical characteristics of the pediatric cervical spine is essential to the appropriate care of these challenging patients. Patterns of injury, diagnosis, and issues related to operative and nonoperative management are discussed with a focus on the developing spine. Our aim is to improve the understanding of traumatic cervical spine injuries in children for all practitioners involved with their care.

Detection of pediatric cervical spine injury

OBJECTIVE

In evaluating the pediatric cervical spine for injury, the use of adult protocols without sufficient sensitivity to pediatric injury patterns may lead to excessive radiation doses. Data on injury location and means of detection can inform pediatric-specific guideline development.

METHODS

We retrospectively identified pediatric patients with codes from the International Classification of Diseases, 9th Revision, for cervical spine injury treated between 1980 and 2000. Collected data included physical findings, radiographic means of detection, and location of injury. Sensitivity of plain x-rays and diagnostic yield from additional radiographic studies were calculated.

RESULTS

Of 239 patients, 190 had true injuries and adequate medical records; of these, 187 had adequate radiology records. Patients without radiographic abnormality were excluded. In 34 children younger than 8 years, National Emergency X-Radiography Utilization Study criteria missed two injuries (sensitivity, 94%), with 76% of injuries occurring from occiput-C2. In 158 children older than 8 years, National Emergency X-Radiography Utilization Study criteria identified all injured patients (sensitivity, 100%), with 25% of injuries occurring from occiput-C2. For children younger than 8 years, plain-film sensitivity was 75% and combination plain-film/occiput-C3 computed tomographic scan had a sensitivity of 94%, whereas combination plain-film and flexion-extension views had 81% sensitivity. In patients older than 8 years, the sensitivities were 93%, 97%, and 94%, respectively.

CONCLUSION

Younger children tend to have more rostral (occiput-C2) injuries compared with older children. The National Emergency X-Radiography Utilization Study protocol may have lower sensitivity in young children than in adults. Limited computed tomography from occiput-C3 may increase diagnostic yield appreciably in young children compared with flexion-extension views. Further prospective studies, especially of young children, are needed to develop reliable pediatric protocols.

Threshold cervical range-of-motion necessary to detect abnormal intervertebral motion in cervical spine radiographs

STUDY DESIGN

Whole human cadaver model to assess a common diagnostic test for cervical spine stability.

OBJECTIVE

Determine criteria that can be used to determine if sagittal plane angular motion of the head/neck during a cervical spine flexion/extension study is adequate to reliably assess intervertebral motion (IVM).

SUMMARY OF BACKGROUND DATA

Flexion/Extension radiographs of the cervical spine are commonly used to help identify specific abnormalities in IVM. Several authors have recognized that inadequate patient effort can make flexion/extension studies unreliable, but validated guidelines for assessing the adequacy of these studies are not available.

METHODS

Increasingly severe anterior-to-posterior (N = 6), and posterior-to-anterior (N = 6) soft tissue injuries were simulated in the cervical spines of 12 human cadavers. Sagittal plane radiographic images were taken with 4 gradually increasing amounts of overall flexion and extension motion of the head. IVM was measured for each level of sagittal plane rotation of the head/neck using previously validated computer-assisted methods.

RESULTS

With less than 60 degrees of sagittal plane rotation of the head/neck, intervertebral rotation or displacement was almost never greater than the 95% confidence interval previously established for asymptomatic people. Even with 60 degrees or more motion, intervertebral rotation and displacement were within normal limits after extensive damage to the soft-tissues. The center-of-rotation was the most sensitive measure for detecting soft tissue damage.

CONCLUSION

The results of this study suggest that clinicians should make sure patients can flex and extend their head/neck to a minimum range of 60 degrees before evaluating them for a dynamic motion study to assess cervical spine stability. Even with adequate motion, interverterbral rotation and translation can remain within normal limits in the presence of extensive soft tissue damage. The most sensitive measure for detecting soft tissue damage was center-of-rotation although it lacks specificity, particularly in the presence of underlying degenerative changes, and is not readily assessed in most clinical situations.

Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN

Best evidence synthesis.

OBJECTIVE

To critically appraise and synthesize the literature on assessment of neck pain.

SUMMARY OF BACKGROUND DATA

The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature.

METHODS

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain.

RESULTS

We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain.

CONCLUSION

The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.

Controversies in "clearing" trauma to the cervical spine

Clearance of the traumatic cervical spine is a subject affecting most healthcare professionals dealing with trauma patients. There is a host of often contradictory literature making it hard for an interested reader to come to their own informed opinion based on the current evidence. This review aims to outline the relevant literature for the clearance of the traumatic cervical spine with the particular aim of highlighting the contradictions, controversies and unanswered questions still besetting this important subject. A brief, subjective opinion for a combined clinical and imaging protocol for clearance of the traumatic cervical spine is given.

Imaging of cervical spine injuries of childhood

Cervical spine injuries of children, though rare, have a high morbidity and mortality. The pediatric cervical spine is anatomically and biomechanically different from that of adults. Hence, the type, level and outcome of cervical spine injuries in children are different from those seen in adults. Normal developmental variants seen in children can make evaluation of the pediatric cervical spine challenging. This article reviews the epidemiology of pediatric cervical spine trauma, normal variants seen in children and specific injuries that are more common in the pediatric population. We also propose an evidence-based imaging protocol to avoid unnecessary imaging studies and minimize radiation exposure in children.

[Spasmodic torticollis caused by metoclopramide: a rare etiology of C1-C2 rotatory pseudoluxation in children]

Torticollis in children must always instigate a search for trauma. Many other etiologies can be found. The authors report a case of postmedicinal atlantoaxial rotatory pseudoluxation (AARP) occurring in a child. This child had fallen down in the morning with head trauma followed by headache. Clinically, a stiff neck with an irreducible right rotation of his neck, and an osteotendinous hyperreflexia were noted. There was a C1-C2 rotatory dislocation with no traumatic lesion on the cervical CT scan. After a few hours, the torticollis spontaneously reduced and then reappeared on the left side. This clinical fluctuation and the absorption of metoclopramide (Primpéran) started in the morning for acute gastroenteritis provided the diagnosis of AARP. This entity was confirmed by the good clinical and radiological follow-up and was caused by the substantial ligament laxity of the craniovertebral junction encountered in children. The analysis of medical imaging and the systematic search for a medicinal cause helped make the right diagnosis.

Cervical spine trauma in children: a review

Injuries of the cervical spine are relatively rare in children but are a distinct clinical entity compared with those found in adults. The unique biomechanics of the pediatric cervical spine lead to a different distribution of injuries and distinct radiographic features. Children younger than 9 years of age usually have upper cervical injuries, whereas older children, whose biomechanics more closely resemble those of adults, are prone to lower cervical injuries. Pediatric cervical injuries are more frequently ligamentous in nature, and children are also more prone to spinal cord injury without radiographic abnormality than adults are. Physical injuries are specific only to children. Radiographically benign findings, such as pseudosubluxation and synchondrosis, can be mistaken for traumatic injuries. External immobilization with a halo brace can be difficult and is associated with a high complication rate because of the thin calvaria in children. Surgical options have improved with the development of instrumentation specifically for children, but special considerations exist, such as the small size and growth potential of the pediatric spine.

Imaging in spinal trauma

Because it may cause paralysis, injury to the spine is one of the most feared traumas, and spinal cord injury is a major cause of disability. In the USA approximately 10,000 traumatic cervical spine fractures and 4000 traumatic thoracolumbar fractures are diagnosed each year. Although the number of individuals sustaining paralysis is far less than those with moderate or severe brain injury, the socioeconomic costs are significant. Since most of the spinal trauma patients survive their injuries, almost one out of 1000 inhabitants in the USA are currently being cared for partial or complete paralysis. Little controversy exists regarding the need for accurate and emergent imaging assessment of the traumatized spine in order to evaluate spinal stability and integrity of neural elements. Because clinicians fear missing occult spine injuries, they obtain radiographs for nearly all patients who present with blunt trauma. We are influenced on one side by fear of litigation and the possible devastating medical, psychologic and financial consequences of cervical spine injury, and on the other side by pressure to reduce health care costs. A set of clinical and/or anamnestic criteria, however, can be very useful in identifying patients who have an extremely low probability of injury and who consequently have no need for imaging studies. Multidetector (or multislice) computed tomography (MDCT) is the preferred primary imaging modality in blunt spinal trauma patients who do need imaging. Not only is CT more accurate in diagnosing spinal injury, it also reduces imaging time and patient manipulation. Evidence-based research has established that MDCT improves patient outcome and saves money in comparison to plain film. This review discusses the use, advantages and disadvantages of the different imaging techniques used in spinal trauma patients and the criteria used in selecting patients who do not need imaging. Finally an overview of different types of spinal injuries is given.

Imaging of acute cervical spine injuries: review and outlook

Advances in imaging technology have been successfully applied in the emergency trauma setting with great benefit providing early, accurate and efficient diagnoses. Gaps in the knowledge of imaging acute spinal injury remain, despite a vast wealth of useful research and publications on the role of CT and MRI. This article reviews in a balanced manner the main questions that still face the attending radiologist by embracing the current and evolving concepts to help define and provide answers to the following; Imaging techniques -- strengths and weaknesses; what are the implications of a missed cervical spine injury?; who should be imaged?; how should they be imaged?; spinal immobilisation -- help or hazard?; residual open questions; what does all this mean?; and what are the implications for the radiologist? Although there are many helpful guidelines, the residual gaps in the knowledge base result in incomplete answers to the questions posed. The identification of these gaps in knowledge however should act as the initiating stimulus for further research. All too often there is a danger that the performance and productivity of the imaging modalities is the main research focus and not enough attention is given to the two fundamental prerequisites to the assessment of any imaging technology -- the clinical selection criteria for imaging and the level of expertise of the appropriate clinician interpreting the images.

Controversies in cervical spine imaging in trauma patients

No area of emergency radiology has generated as much discussion in recent years as the subject of cervical spine imaging for trauma patients. This review will be in three parts. The first will examine the indications for cervical imaging and will focus on those factors that make patients at high risk or low risk for cervical injury. The second part will discuss the merits of radiography and computed tomography as the main screening diagnostic examination. In addition to the roles of each modality in the evaluation process, such factors as efficacy of diagnosis, time (duration) of study, and cost will be discussed. Finally, the third part will explore the methods currently employed to "clear" the cervical spine in comatose patients.

Pediatric cervical spine: normal anatomy, variants, and trauma

Emergency radiologic evaluation of the pediatric cervical spine can be challenging because of the confusing appearance of synchondroses, normal anatomic variants, and injuries that are unique to children. Cervical spine injuries in children are usually seen in the upper cervical region owing to the unique biomechanics and anatomy of the pediatric cervical spine. Knowledge of the normal embryologic development and anatomy of the cervical spine is important to avoid mistaking synchondroses for fractures in the setting of trauma. Familiarity with anatomic variants is also important for correct image interpretation. These variants include pseudosubluxation, absence of cervical lordosis, wedging of the C3 vertebra, widening of the predental space, prevertebral soft-tissue widening, intervertebral widening, and "pseudo-Jefferson fracture." In addition, familiarity with mechanisms of injury and appropriate imaging modalities will aid in the correct interpretation of radiologic images of the pediatric cervical spine.

Management of pediatric cervical spine and spinal cord injuries

DIAGNOSTIC

STANDARDS

There is insufficient evidence to support diagnostic standards.

GUIDELINES

In children who have experienced trauma and are alert, conversant, have no neurological deficit, no midline cervical tenderness, and no painful distracting injury, and are not intoxicated, cervical spine x-rays are not necessary to exclude cervical spine injury and are not recommended. In children who have experienced trauma and who are either not alert, nonconversant, or have neurological deficit, midline cervical tenderness, or painful distracting injury, or are intoxicated, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained.

OPTIONS

In children younger than age 9 years who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. In children age 9 years or older who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior, lateral, and open-mouth cervical spine x-rays be obtained. Computed tomographic scanning with attention to the suspected level of neurological injury to exclude occult fractures or to evaluate regions not seen adequately on plain x-rays is recommended. Flexion/extension cervical x-rays or fluoroscopy may be considered to exclude gross ligamentous instability when there remains a suspicion of cervical spine instability after static x-rays are obtained. Magnetic resonance imaging of the cervical spine may be considered to exclude cord or nerve root compression, evaluate ligamentous integrity, or provide information regarding neurological prognosis.

TREATMENT

STANDARDS

There is insufficient evidence to support treatment standards.

GUIDELINES

There is insufficient evidence to support treatment guidelines.

OPTIONS

Thoracic elevation or an occipital recess to prevent flexion of the head and neck when restrained supine on an otherwise flat backboard may allow for better neutral alignment and immobilization of the cervical spine in children younger than 8 years because of the relatively large head in these younger children and is recommended. Closed reduction and halo immobilization for injuries of the C2 synchondrosis between the body and odontoid is recommended in children younger than 7 years. Consideration of primary operative therapy is recommended for isolated ligamentous injuries of the cervical spine with associated deformity.