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Lynge S, Vach W, Dissing KB, Hestbaek L. Potential effect modifiers for treatment with chiropractic manipulation versus sham manipulation for recurrent headaches in children aged 7-14 years: development of and results from a secondary analysis of a randomised clinical trial. Chiropr Man Therap 2023; 31:20. [PMID: 37434189 PMCID: PMC10337090 DOI: 10.1186/s12998-023-00492-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/15/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND A recent randomized controlled trial (RCT) investigating the effect of chiropractic manipulation in 199 children aged 7-14 years with recurrent headaches demonstrated a significant reduction of number of days with headache and a better global perceived effect (GPE) in the chiropractic manipulation group compared to a sham manipulation group. However, potential modifiers for the effectiveness of chiropractic manipulation of children with recurrent headaches have never been identified. The present study is a secondary analysis of data from that RCT and will investigate potential effect modifiers for the benefit of chiropractic manipulation for children with headache. METHODS Sixteen potential effect modifiers were identified from the literature and a summary index was prespecified based on clinical experience. Relevant variables were extracted from baseline questionnaires, and outcomes were obtained by means of short text messages. The modifying effect of the candidate variables was assessed by fitting interaction models to the data of the RCT. In addition, an attempt to define a new summary index was made. RESULTS The prespecified index showed no modifying effect. Four single variables demonstrated a treatment effect difference of more than 1 day with headache per week between the lower and the upper end of the spectrum: intensity of headache (p = 0.122), Frequency of headache (p = 0.031), sleep duration (p = 0.243), and Socioeconomic status (p = 0.082). Five variables had a treatment effect difference of more than 0.7 points on the GPE scale between the lower and the upper end of the spectrum: Frequency of headache (p = 0.056), Sport activity (p = 0.110), Sleep duration (p = 0.080), History of neck pain (p = 0.011), and Headache in the family (0.050). A new summary index could be constructed giving highest weight to History of neck pain and Headache in the family and Frequency of headache. The index suggests a difference of about 1 point in GPE between low and high values of the index. CONCLUSION Chiropractic manipulation offers a moderate benefit for a broad spectrum of children. However, it cannot be excluded that specific headache characteristics, family factors, or a history of neck pain may modify the effect. This question must be addressed in future studies. TRIAL REGISTRATION ClinicalTrials.gov (Albers et al in Curr Pain Headache Rep 19:3-4, 2015), identifier NCT02684916, registered 02/18/2016-retrospectively registered.
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Affiliation(s)
- Susanne Lynge
- Private Chiropractic Practice, Vivaldisvej 6, 9700, Broenderslev, Denmark
| | - Werner Vach
- The Chiropractic Knowledge Hub, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
- Basel Academy for Quality and Research in Medicine, Steinenring 6, 4051, Basel, Switzerland
| | - Kristina Boe Dissing
- The Chiropractic Knowledge Hub, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
| | - Lise Hestbaek
- The Chiropractic Knowledge Hub, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark.
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense C, Denmark.
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Zeng J, Jiang H, Zhuo Y, Xu Y, Deng Z. A case report on a child with fracture and dislocation of the upper cervical spine accompanied by spinal cord injury. Medicine (Baltimore) 2022; 101:e29717. [PMID: 35905208 PMCID: PMC9333534 DOI: 10.1097/md.0000000000029717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE This study describes an 8-year-old boy with a C2 fracture and dislocation with a left C2-C3 articular process interlocking and spinal cord injury who underwent open reduction and internal fixation using the posterior cervical approach and achieved satisfactory results. PATIENT CONCERNS An 8-year-old boy underwent an emergency transfer from a previous hospital after a car accident. DIAGNOSES Axial fracture and dislocation with spinal cord injury (American Spinal Injury Association grade C), traumatic shock, brain contusion, intracranial hemorrhage, mandibular fracture, pulmonary contusion and hemorrhage, left vertebral artery stenosis, and multiple fractures throughout the body. Radiological examination revealed a fracture of the lower edge of the C2 vertebral body, fourth-degree anterior spondylolisthesis of the C2 vertebral body, interlocking of the left C2-C3 articular processes, widening of the C2-C3 vertebral space, and occlusion of the V1 and 2 segments of the left vertebral artery. INTERVENTIONS The boy was immediately intubated and transferred to the pediatric intensive care unit for rescue treatment. However, the reduction was unsuccessful with 2 weeks of cranial traction. Thus, an open reduction was performed under general anesthesia. One month after the surgery, the boy was discharged from the hospital on foot after rehabilitation treatment. OUTCOMES The boy was discharged from the hospital 1 month after surgery. At the 8-month follow-up, a radiological examination showed that the corrected C2 vertebral body fracture and dislocation were satisfactorily reduced, and the spinal cord was adequately decompressed. The internal fixation position was also good, and the spinal sequence had recovered well. In summary, except for the muscle strength of the right upper limb, which was slightly worse, the other clinical symptoms were significantly improved. LESSONS In treating cervical fracture and dislocation with unilateral facet lock, the posterior open reduction of pedicle screw and lateral mass screw internal fixation achieved satisfactory results. Consequently, treating complex cervical spine injuries in children requires an accurate diagnosis and careful treatment strategy.
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Affiliation(s)
- Jiayu Zeng
- School of Clinical Medicine, Guizhou Medical University, Guiyang City, Guizhou Province, People’s Republic of China
| | - Hua Jiang
- Department of Pediatric Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang City, Guizhou Province, People’s Republic of China
| | - Yingquan Zhuo
- Department of Pediatric Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang City, Guizhou Province, People’s Republic of China
| | - Yongkang Xu
- The Second Affiliated Hospital of Nanchang University, Nanchang University, Nanchang City, Jiangxi Province, People’s Republic of China
| | - Zhigang Deng
- School of Clinical Medicine, Guizhou Medical University, Guiyang City, Guizhou Province, People’s Republic of China
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An S, Hyun SJ. Pediatric Spine Trauma. J Korean Neurosurg Soc 2022; 65:361-369. [PMID: 35462522 PMCID: PMC9082124 DOI: 10.3340/jkns.2021.0282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/25/2022] [Indexed: 11/27/2022] Open
Abstract
Pediatric spine has growth potential with incomplete ossification, and also unique biomechanics which have important implications for trauma patients. This article intends to review various aspects of pediatric spine trauma including epidemiology, anatomy and biomechanics, and clinically relevant details of each type of injury based on the location and mechanism of injury. With the appropriate but not superfluous treatment, pediatric spine trauma patients can have better chance of recovery. Therefore, as a spine surgeon, understanding the general concept for each injury subtype together with the debate and progress in the field is inevitable.
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Mistry D, Munjal H, Ellika S, Chaturvedi A. Pediatric spine trauma: A comprehensive review. Clin Imaging 2022; 87:61-76. [DOI: 10.1016/j.clinimag.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 03/26/2022] [Accepted: 04/21/2022] [Indexed: 11/03/2022]
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Sivakanthan S, Feroze A, Eaton J, Saigal R. Three Column Cervical Fracture-Dislocation in a 3-Year-Old Boy. Cureus 2022; 14:e23213. [PMID: 35449661 PMCID: PMC9012570 DOI: 10.7759/cureus.23213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/07/2022] Open
Abstract
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.
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Finley SM, Astin JH, Joyce E, Dailey AT, Brockmeyer DL, Ellis BJ. FEBio finite element model of a pediatric cervical spine. J Neurosurg Pediatr 2022; 29:218-224. [PMID: 34678779 DOI: 10.3171/2021.7.peds21276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The underlying biomechanical differences between the pediatric and adult cervical spine are incompletely understood. Computational spine modeling can address that knowledge gap. Using a computational method known as finite element modeling, the authors describe the creation and evaluation of a complete pediatric cervical spine model. METHODS Using a thin-slice CT scan of the cervical spine from a 5-year-old boy, a 3D model was created for finite element analysis. The material properties and boundary and loading conditions were created and model analysis performed using open-source software. Because the precise material properties of the pediatric cervical spine are not known, a published parametric approach of scaling adult properties by 50%, 25%, and 10% was used. Each scaled finite element model (FEM) underwent two types of simulations for pediatric cadaver testing (axial tension and cardinal ranges of motion [ROMs]) to assess axial stiffness, ROM, and facet joint force (FJF). The authors evaluated the axial stiffness and flexion-extension ROM predicted by the model using previously published experimental measurements obtained from pediatric cadaveric tissues. RESULTS In the axial tension simulation, the model with 50% adult ligamentous and annulus material properties predicted an axial stiffness of 49 N/mm, which corresponded with previously published data from similarly aged cadavers (46.1 ± 9.6 N/mm). In the flexion-extension simulation, the same 50% model predicted an ROM that was within the range of the similarly aged cohort of cadavers. The subaxial FJFs predicted by the model in extension, lateral bending, and axial rotation were in the range of 1-4 N and, as expected, tended to increase as the ligament and disc material properties decreased. CONCLUSIONS A pediatric cervical spine FEM was created that accurately predicts axial tension and flexion-extension ROM when ligamentous and annulus material properties are reduced to 50% of published adult properties. This model shows promise for use in surgical simulation procedures and as a normal comparison for disease-specific FEMs.
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Affiliation(s)
- Sean M Finley
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, and
| | - J Harley Astin
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, and
| | - Evan Joyce
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Andrew T Dailey
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Douglas L Brockmeyer
- 2Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Benjamin J Ellis
- 1Department of Biomedical Engineering and Scientific Computing and Imaging Institute, and
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O'Neill C, Wenzel A, Walterscheid Z, Carmouche J. Distinguishing Pseudosubluxation From True Injury: A Case of C2-3 and C3-4 Subluxation in a Pediatric Patient. J Am Acad Orthop Surg Glob Res Rev 2021; 5:01979360-202112000-00002. [PMID: 34860729 DOI: 10.5435/jaaosglobal-d-20-00238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/08/2021] [Indexed: 06/13/2023]
Abstract
A 6-year-old girl presented with a one-week history of neck pain after a trampoline accident. Cervical radiographs interpreted as pseudosubluxation of C2 on C3. CT demonstrated the reversal of lordosis with anterolisthesis of C2-C3 and C3-C4. Ten weeks after two months of halo traction, radiographs demonstrated anatomic alignment and maintained disk heights. This case highlights the similarities of pseudosubluxation and true injury, emphasizing the need for high index of suspicion in this population and a successful treatment of subluxation using a halo construct.
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Affiliation(s)
- Conor O'Neill
- From the Virginia Commonwealth University Department of Orthopaedics, Richmond, VA (Dr. O'Neill); Virginia Tech Carilion School of Medicine, Roanoke, VA (Ms. Wenzel and Dr. Carmouche); University of Washington Department of Orthopaedic and Sports Medicine, Seattle, WA (Dr. Walterscheid); and Carilion Clinic Department of Orthopaedics, Roanoke, VA (Dr. Carmouche)
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Kim SK, Chang DG, Park JB, Seo HY, Kim YH. Traumatic atlanto-axial rotatory subluxation and dens fracture with subaxial SCIWORA of Brown-Sequard syndrome: A case report. Medicine (Baltimore) 2021; 100:e25588. [PMID: 33879718 PMCID: PMC8078422 DOI: 10.1097/md.0000000000025588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/31/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE A case of traumatic atlanto-axial rotatory subluxation (AARS), dens fracture, rupture of transverse atlantal ligament (TAL), and subaxial spinal cord injury without radiographic abnormality (SCIWORA) of Brown-Sequard syndrome has never been reported in a child. PATIENT CONCERNS A 7-year-old boy presented to hospital with torticollis, neck pain, and limited neck rotation after a seat-belt injury sustained during a car accident. Neurologic examination revealed right-side motor weakness and left-side sensory abnormality, known as Brown-Sequard syndrome. DIAGNOSIS Radiologic examinations revealed type II AARS (Fielding and Hawkins classification), increased atlanto-dental interval (ADI) of 4.5 mm due to a type 1B TAL rupture (Dickman classification), a displaced transverse dens fracture along with an ossiculum terminale, and an intramedullary hemorrhage on the right side of the spinal cord at C3-4. INTERVENTIONS The patient immediately received methylprednisolone, and his motor weakness and sensory abnormality gradually improved. At the same time, the patient underwent initial halter traction for 2 weeks, but he failed to achieve successful reduction and required manual reduction under general anesthesia. OUTCOMES At the 7-month follow-up visit, radiologic examinations showed a corrected type II AARS that was well maintained and normalization of the ADI to 2 mm. The reduced transverse dens fracture was well maintained but still not united. All clinical symptoms were significantly improved, except the remaining motor weakness of the right upper extremity. LESSONS To the best of our knowledge, this is the first report of traumatic AARS, dens fracture, TAL rupture, and subaxial SCIWORA of Brown-Sequard syndrome in a child. Appropriate diagnosis and careful treatment strategy are required for successful management of complex cervical injuries in a child.
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Affiliation(s)
- Sung-Kyu Kim
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyoung-Yeon Seo
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju
| | - Yun Hwan Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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da Silva AJF, Lopes FAC, Mendes WR. Multiple-level cervical spine trauma in children: Case report and literature review. Trauma Case Rep 2020; 27:100298. [PMID: 32420441 PMCID: PMC7217991 DOI: 10.1016/j.tcr.2020.100298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2020] [Indexed: 11/27/2022] Open
Abstract
Spinal trauma is rare in children, but when it occurs, trauma of the cervical spine corresponds to 60%–80% of all cases. The most common causes of pediatric cervical spine injuries are automobile accidents, sports activities, and leisure-related accidents. Herein we report a surgically-treated case of cervical spine trauma with fractures of multiple vertebrae. A 12-year-old female victim of a high fall (from a tree) was admitted to the emergency room with neck pain and weakness in all the limbs. On examination, she was conscious, breathing spontaneously, with grade-4 tetraparesis, and preserved sphincter control. Cervical spine computed tomography (CT) revealed a burst fracture of the C4 body with retropulsion into the spinal cord and fractures of the C5 body and posterior elements of C2, C3, and C4. Cervical spine magnetic resonance imaging (MRI) revealed a hypersignal of the spinal cord from C3 to C6 in T2, indicating contusion. Because no signs of posterior spine instability (ligament lesions) were noted on MRI, we decided to perform a C3–C5 anterior arthrodesis with C4 corpectomy and autologous (iliac) graft placement. The patient had a good postoperative evolution. Furthermore, the patient had no motor deficit, but due to the other fractures in the spine, we chose to keep the cervical collar for 3 months and followed-up on an outpatient basis. Although spinal trauma is less frequent in children than in adults, children can have severe cervical spine injuries (multiple fractures with spinal contusion), and then surgery plays a key role in stabilizing the spine and decompressing the spinal cord to avoid sequelae.
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Affiliation(s)
- A J F da Silva
- Neurosurgeon at the Manoel André Hospital Complex, Arapiraca, State of Alagoas, Brazil, and at the Pediatric Neurosurgery Division of the Santa Mônica Teaching Maternity - Alagoas State University of Health Sciences, Maceió, State of Alagoas, Brazil.,Manoel André Hospital Complex, Arapiraca, State of Alagoas, Brazil
| | | | - Wallan R Mendes
- Manoel André Hospital Complex, Arapiraca, State of Alagoas, Brazil
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Poorman GW, Segreto FA, Beaubrun BM, Jalai CM, Horn SR, Bortz CA, Diebo BG, Vira S, Bono OJ, DE LA Garza-Ramos R, Moon JY, Wang C, Hirsch BP, Tishelman JC, Zhou PL, Gerling M, Passias PG. Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database. Int J Spine Surg 2019; 13:68-78. [PMID: 30805288 DOI: 10.14444/6009] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Gregory W Poorman
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Frank A Segreto
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Bryan M Beaubrun
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Cyrus M Jalai
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Samantha R Horn
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Cole A Bortz
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York
| | - Shaleen Vira
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Olivia J Bono
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | | | - John Y Moon
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Charles Wang
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Brandon P Hirsch
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Jared C Tishelman
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Peter L Zhou
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Michael Gerling
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
| | - Peter G Passias
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, Hospital for Joint Diseases at NYU Langone Medical Center, NYU School of Medicine, New York, New York
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Bonfanti L, Donelli V, Lunian M, Cerasti D, Cobianchi F, Cervellin G. Adult Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). Two case reports and a narrative review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 89:593-598. [PMID: 30657112 PMCID: PMC6502103 DOI: 10.23750/abm.v89i4.7532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 02/08/2023]
Abstract
The term SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) indicates a clinically appreciable post-traumatic myelopathy in the absence of spinal column findings on radiographs and/or computed tomography (CT), but with pathologic findings at magnetic resonance imaging (MRI) in approximately two-thirds of cases. Affecting mainly children younger than 8 years, SCIWORA has been, however, also described in adult patients, but, due to the uncertainty of classification and frequent co-morbidity, the term “adult SCIWORA” has generated controversy, and some debate is still active. In this article, we report two different cases of adult SCIWORA involving cervical spinal cord, characterized by distinct and peculiar clinical features. A literature review and some clinical suggestions are also reported, mainly focused on the importance of a high level of suspicion in order to achieve a timely diagnosis and optimize the management and, consequently, the outcome of these trauma patients. (www.actabiomedica.it)
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12
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Abstract
Acute onset of neurological signs and symptoms referable to the spine including difficulty walking, bowel and bladder dysfunction, and paresthesias in the extremities may be manifestations of pediatric spine emergency. Trauma is the most common etiology for a pediatric spinal emergency. Because a history of trauma is often available, the role of imaging involves detection of spinal injuries. Other pathologies such as infection, inflammation, vascular, and neoplasms may lead to pediatric spinal emergencies that also require imaging for assistance in determining the etiology and appropriate management.
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Affiliation(s)
- Katie Suzanne Traylor
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Stephen F Kralik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Rupa Radhakrishnan
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN 46202.
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Li C, Li L, Duan J, Zhang L, Liu Z. Surgical treatment for old subaxial cervical dislocation with bilateral locked facets in a 3-year-old girl: A case report. Medicine (Baltimore) 2018; 97:e0553. [PMID: 29718848 PMCID: PMC6393066 DOI: 10.1097/md.0000000000010553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE This study aimed to describe the case of a 3-year-old girl with old bilateral facet dislocation on cervical vertebrae 6 and 7, who had spinal cord transection, received surgical treatment, and achieved a relative satisfactory therapeutic effect. PATIENT CONCERNS A 3-year-old girl was urgently transferred to the hospital after a car accident. DIAGNOSES:: she was diagnosed with splenic rupture, intracranial hemorrhage, cervical dislocation, spinal transection, and Monteggia fracture of the left upper limb. INTERVENTIONS The girl underwent emergency splenectomy and was transferred to the intensive care unit of the hospital 15 days later. One-stage anterior-posterior approach surgery (anterior discectomy, posterior laminectomy, and pedicle screw fixation) was performed when the patient stabilized after 45-day symptomatic treatment. The operation was uneventful. OUTCOMES The reduction of lower cervical dislocation was satisfactory, with sufficient spinal cord decompression. The internal fixation position was good, and the spinal sequence was well restored. The girl was discharged 2 weeks later after the operation and followed up for 2 years. The major nerve function of both upper limbs was recovered, with no obvious retardation of the growth of immature spine. LESSONS A satisfactory therapeutic effect was achieved for a pediatric old subaxial cervical dislocation with bilateral locked facets using anterior discectomy, posterior laminectomy, and pedicle screw fixation. The posterior pedicle screw fixation provided a good three-dimensional stability of the spine, with reduced risk and complications caused by anterior internal fixation. The growth of immature spine was not obviously affected during the 2-year follow-up.
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Abstract
“Spinal Cord Injury without Radiographic Abnormality” (SCIWORA) is a term that denotes objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine. SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood. However, SCIWORA can also be seen in adults and, in rare cases, the thoracolumbar spinal cord can be affected too. Magnetic resonance imaging (MRI) has become a valuable diagnostic tool in patients with SCIWORA because of its superior ability to identify soft tissue lesions such as cord edema, hematomas and transections, and discoligamentous injuries that may not be visualized in plain radiographs and CT. The mainstay of treatment in patients with SCIWORA is nonoperative management including steroid therapy, immobilization, and avoidance of activities that may increase the risk of exacerbation or recurrent injury. Although the role of operative treatment in SCIWORA can be controversial, surgical alternatives such as decompression and fusion should be considered in selected patients with clinical and MRI evidence of persistent spinal cord compression and instability.
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Madura CJ, Johnston JM. Classification and Management of Pediatric Subaxial Cervical Spine Injuries. Neurosurg Clin N Am 2016; 28:91-102. [PMID: 27886885 DOI: 10.1016/j.nec.2016.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Casey J Madura
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 400, Birmingham, Alabama 35233, USA
| | - James M Johnston
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder Suite 400, Birmingham, Alabama 35233, USA.
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Johnson KT, Al-Holou WN, Anderson RCE, Wilson TJ, Karnati T, Ibrahim M, Garton HJL, Maher CO. Morphometric analysis of the developing pediatric cervical spine. J Neurosurg Pediatr 2016; 18:377-89. [PMID: 27231821 DOI: 10.3171/2016.3.peds1612] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Our understanding of pediatric cervical spine development remains incomplete. The purpose of this analysis was to quantitatively define cervical spine growth in a population of children with normal CT scans. METHODS A total of 1458 children older than 1 year and younger than 18 years of age who had undergone a cervical spine CT scan at the authors' institution were identified. Subjects were separated by sex and age (in years) into 34 groups. Following this assignment, subjects within each group were randomly selected for inclusion until a target of 15 subjects in each group had been measured. Linear measurements were performed on the midsagittal image of the cervical spine. Twenty-three unique measurements were obtained for each subject. RESULTS Data showed that normal vertical growth of the pediatric cervical spine continues up to 18 years of age in boys and 14 years of age in girls. Approximately 75% of the vertical growth occurs throughout the subaxial spine and 25% occurs across the craniovertebral region. The C-2 body is the largest single-segment contributor to vertical growth, but the subaxial vertebral bodies and disc spaces also contribute. Overall vertical growth of the cervical spine throughout childhood is dependent on individual vertebral body growth as well as vertical growth of the disc spaces. The majority of spinal canal diameter growth occurs by 4 years of age. CONCLUSIONS The authors' morphometric analyses establish parameters for normal pediatric cervical spine growth up to 18 years of age. These data should be considered when evaluating children for potential surgical intervention and provide a basis of comparison for studies investigating the effects of cervical spine instrumentation and fusion on subsequent growth.
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Epidemiology of spinal cord injury without radiographic abnormality in children: a nationwide perspective. J Child Orthop 2016; 10:255-60. [PMID: 27209042 PMCID: PMC4909655 DOI: 10.1007/s11832-016-0740-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 04/29/2016] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To characterize the epidemiology and costs associated with spinal cord injury without radiographic abnormality (SCIWORA) based on patient age. METHODS An analysis of data complied for 2012 in the Healthcare Utilization Project KID database (HCUP-KID), which represents a nationwide database of pediatric admissions, was performed. An initial search identified all children diagnosed with SCIWORA based on International Classification of Diseases, 9th edition (ICD-9) codes. Only data on patients aged <18 years were included in the analysis. The associated codes were then searched to identify the cause of injury. Pertinent epidemiologic data were collected from the database, including age, gender, and racial group. Injury level and pattern were determined from the associated ICD-9 codes, as were associated injuries. Hospital data included length of stay, in-hospital mortality, total hospital charges, and primary payer. All data were compiled and stratified based on patient age into three groups: group 1, age 0-3 years; group 2, age 4-10 years; group 3, age 11-17 years. These data were compared using Student's t test and Chi-squared analyses. RESULTS A total of 297 patients were identified who met the inclusion criteria. There was a slight predominance of females among the youngest patients (53 %) with a significant dominance of males in the oldest group (72 %) (p < 0.001). The most common race among the patients studied was white (50 %) followed by Hispanic (14 %), Black (12 %), Asian/Pacific Islander (4 %), and Native American (1 %). Overall, the most common cause of injury was sports injuries, which were responsible for 122/297 (41 %) injuries, followed by motor vehicle collisions (26 %). Mechanisms of injury were significantly varied based on age group, with motor vehicle collisions the most common cause in the youngest two age groups and sports injuries the most common in the oldest age group (p < 0.05). The most common location injured was the cervical spine (46 %), with the upper cervical spine most commonly injured, particularly in the younger age groups. Additional injuries were found in 158/297 (53 %) of patients, and these were more common among younger patients. Head trauma was the most common associated injury in all age groups, but the highest rate was found the youngest age groups (p < 0.0001). The average hospital stay for all patients was 13 days, with longer stays seen in younger age groups (p < 0.05). In-hospital mortality was uncommon among these patients and occurred in only 6/297 (2 %) of patients. Hospital charges were highest in the younger age groups, with an average charge of $210,772 for those in the youngest age group, decreasing to $72,178 for those in group 3 (p < 0.0005). The most common payer was public insurance/medicaid in the youngest age group and private insurance in groups 2 and 3 (p < 0.0001). CONCLUSIONS SCIWORA is an uncommon but potentially devastating injury in children. As with many pediatric injuries, this injury is heterogeneous between children of differing ages. This analysis of a nationwide series of children with such injuries identified significant differences in injury location, causes of injury, associated injuries, and hospital charges associated with this diagnosis.
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Chang PT, Yang E, Swenson DW, Lee EY. Pediatric Emergency Magnetic Resonance Imaging: Current Indications, Techniques, and Clinical Applications. Magn Reson Imaging Clin N Am 2016; 24:449-80. [PMID: 27150329 DOI: 10.1016/j.mric.2015.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
MR imaging plays an important role in the detection and characterization of several pediatric disease entities that can occur in the emergent setting because of its cross-sectional imaging capability, lack of ionizing radiation exposure, and superior soft tissue contrast. In the age of as low as reasonably achievable, these advantages have made MR imaging an increasingly preferred modality for diagnostic evaluations even in time-sensitive settings. In this article, the authors discuss the current indications, techniques, and clinical applications of MR imaging in the evaluation of pediatric emergencies.
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Affiliation(s)
- Patricia T Chang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - David W Swenson
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Edward Y Lee
- Division of Thoracic Imaging, Department of Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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Congenital subaxial cervical subluxation presenting as a bilateral Erb's palsy: surgical management, rehabilitation, and outcome. Childs Nerv Syst 2016; 32:849-55. [PMID: 26552384 DOI: 10.1007/s00381-015-2946-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/25/2015] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Subaxial spine injuries during infancy are uncommon. CASE REPORT We present the case of an infant referred to our brachial plexus clinic with proximal weakness of both arms noted immediately following a complicated breech delivery. Nerve conduction studies were consistent with bilateral proximal upper plexus injury; however, radiological evaluation revealed a C4-C5 subluxation and MRI features of bilateral C5 root avulsions. He was immobilized in a cervical-body orthosis and underwent open reduction and posterior C4-C5-C6 fixation at 10 weeks age using luque rods, sublaminar wires, and rib graft. The spine was immobilized in a custom molded cervicothoracic brace for a total of 3 months, and a home exercise program prescribed. Follow-up radiographic evaluation showed good posterior bony fusion by 2 months but persistent bilateral proximal upper limb weakness with reduced compound motor action potential (CMAP) amplitudes of the axillary and musculocutaneous nerves. Bilateral supraclavicular exploration and C5 root neurotization using the ipsilateral C7 nerve roots were performed at 7 months of age. Voluntary biceps activity followed by voluntary external rotation with gravity eliminated was noted within the next 2-3 months. He progressed to develop near normal motor control of bilateral upper limbs within 1 year. CONCLUSIONS We wish to report this rare entity and our favorable outcome using a strategy of early spinal stabilization and neurotization repair to restore function following proximal nerve root injury.
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Kurd MF, Alijanipour P, Schroeder GD, Millhouse PW, Vaccaro A. Magnetic Resonance Imaging Following Spine Trauma. JBJS Rev 2015; 3:01874474-201510000-00006. [PMID: 27490791 DOI: 10.2106/jbjs.rvw.o.00014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Mark F Kurd
- Rothman Institute at Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107
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21
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Junctional susceptibility of the pediatric spine: a case report. Childs Nerv Syst 2015; 31:797-800. [PMID: 25260546 DOI: 10.1007/s00381-014-2564-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 09/23/2014] [Indexed: 10/24/2022]
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22
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Highly unstable cervical spine injury in an infant: a case report. Childs Nerv Syst 2015; 31:341-6. [PMID: 25142687 DOI: 10.1007/s00381-014-2527-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 08/10/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Although the rate of surgical intervention for pediatric cervical spine injuries has risen, none of these instrumentation techniques has been reported in children less than 1 year of age. Additional consideration with placement of wires or cables is not safe because of the presence of cartilaginous bone and poor bone strength. The authors report a technique of internal fixation without fusion using nonabsorbable synthetic suture in an infant with unstable cervical injury. METHODS A 5-month-old girl was transported to emergency department and computed tomography showed severe distraction injury at the C6-7 level with total disruption of the facet joints bilaterally. To improve her general condition, she was placed in a customized occipito-cervical brace until surgical stabilization could be performed. After 1 month, surgical fixation was performed. After removing all soft tissues at the appropriate level, a hole was made in the center of the superior articular process of C6. A nonabsorbable suture (2-0 Ethibond; Ethicon, Somerville, NJ, USA) was passed from the superior articular process to the facet joint. The suture was passed into the spinous process of the lower level, and it was progressively tightened and radiographs were taken until anatomic reduction was achieved. RESULTS After surgery, solid fusion was achieved. She was able to sit up in a stroller after 6 months. CONCLUSION As surgical treatment of pediatric cervical spine injuries is unsuitable for infants, the Ethibond sutures are strong enough to hold and stabilize the spine. This suturing technique can be used as an alternative treatment for cervical injury in infants.
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Huisman TAGM, Wagner MW, Bosemani T, Tekes A, Poretti A. Pediatric spinal trauma. J Neuroimaging 2014; 25:337-53. [PMID: 25512255 DOI: 10.1111/jon.12201] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 07/23/2014] [Accepted: 08/16/2014] [Indexed: 12/19/2022] Open
Abstract
Pediatric spinal trauma is unique. The developing pediatric spinal column and spinal cord deal with direct impact and indirect acceleration/deceleration or shear forces very different compared to adult patients. In addition children are exposed to different kind of traumas. Moreover, each age group has its unique patterns of injury. Familiarity with the normal developing spinal anatomy and kind of traumas is essential to correctly diagnose injury. Various imaging modalities can be used. Ultrasound is limited to the neonatal time period; plain radiography and computer tomography are typically used in the acute work-up and give highly detailed information about the osseous lesions. Magnetic resonance imaging is more sensitive for disco-ligamentous and spinal cord injuries. Depending on the clinical presentation and timing of trauma the various imaging modalities will be employed. In the current review article, a summary of the epidemiology and distribution of posttraumatic lesions is discussed in the context of the normal anatomical variations due to progressing development of the child.
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Affiliation(s)
- Thierry A G M Huisman
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Pediatric Radiology, Section of Pediatric Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, MD
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Dong L, Mao H, Li G, Yang KH. Investigation of pediatric neck response and muscle activation in low-speed frontal impacts. Comput Methods Biomech Biomed Engin 2014; 18:1680-92. [DOI: 10.1080/10255842.2014.946914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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25
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Cullen A, Terris M, Ford R. Spinal clearance in unconscious children following traumatic brain injury. Paediatr Anaesth 2014; 24:711-6. [PMID: 24697966 DOI: 10.1111/pan.12395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2014] [Indexed: 10/25/2022]
Abstract
Spinal clearance in unconscious children following traumatic brain injury is an area of controversy. The risk of significant injury in this high-risk group needs to be balanced against that of prolonged spinal immobilization and all its implications. No national or international guideline exists to aid clinicians faced with such a scenario. This article reviews traumatic spinal injury in children looking at prevalence, risk factors, anatomical considerations, and radiological investigation. Spinal immobilization is discussed along with the use of appropriate and targeted radiological investigations to aid clearance.
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Affiliation(s)
- Aidan Cullen
- Paediatric Intensive Care Unit, Royal Belfast Hospital for Sick Children, Belfast, UK
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26
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Matsumoto T, Kawakami M, Ando M, Yoshida M. Rare case of survival after traumatic disruption of the cervical spine with combined complete spinal cord injury and bilateral vertebral arterial breakdown in an 18-month-old patient. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 24 Suppl 1:S311-4. [PMID: 24752652 DOI: 10.1007/s00590-014-1462-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 04/08/2014] [Indexed: 11/25/2022]
Abstract
Complete cervical disruption is a rare and lethal injury secondary to high-energy trauma. Bilateral vertebral arterial breakdown is also a rare and lethal injury. This is the first reported clinical case of an 18-month-old girl who survived after combined cervical spinal cord disruption and bilateral vertebral arterial breakdown. Although she developed cardiopulmonary arrest at the accident site, resuscitation by a bystander, early fluid resuscitation, appropriate respiratory management, and subsequent surgical stabilization resulted in survival and preservation of higher cortical functions. She underwent surgery 1 week after hospitalization; her cervical spine was stabilized by posterior fixation using pedicle screws and transarticular screws. After the operation, the burst vertebra was gradually remodeled. Approximately 4 months later, she was transferred to a rehabilitation facility. Ten years later, she is attending to an elementary school, and she is able to speak and operate a wheelchair using a portable respiratory organ. We herein report an exceedingly rare case of cervical cord injury involving a combination of disruption of the cervical spine and bilateral vertebral arterial breakdown in a young child.
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Affiliation(s)
- Takuji Matsumoto
- Department of Orthopedic Surgery, Wakayama Rosai Hospital, 93-3, Kinomoto, Wakayama City, Wakayama, 640-8505, Japan,
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Special considerations in the interpretation of plain radiographs of the cervical spine in children. A review of the literature. Eur J Trauma Emerg Surg 2013; 39:647-52. [PMID: 26815550 DOI: 10.1007/s00068-013-0305-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 05/19/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION This review provides an overview of the special considerations with regard to correct diagnosis of plain radiographs of the pediatric cervical spine. Injuries to the cervical spine are rare in children. The leading trauma mechanism is motor vehicle injury. Plain radiographs are a common tool in the search for a diagnosis. Taking the growth process into account there are many differences to be found compared to the adult c-spine. Knowledge of these differences is important when working towards the correct interpretation of plain radiographs of the pediatric c-spine. METHODS To create this review, a literature search of the electronic databases Cochrane, PubMed/MEDLINE and Embase was conducted. RESULTS Special considerations of plain radiographs of the pediatric c-spine are presented. Biomechanical and embryology specifics have been a focus of this review. They are explained relating on the development of the c-spine. The known auxiliary lines used in the interpreting of the pediatric c-spine are reported. A selection of these auxiliary lines is shown. CONCLUSION Knowledge of the c-spines characteristics is of major importance for every physician involved in pediatric trauma care. This could lead to not only avoiding misdiagnosis but could also lead to avoiding the overuse of computed tomography of the pediatric c-spine.
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Henry M, Riesenburger RI, Kryzanski J, Jea A, Hwang SW. A retrospective comparison of CT and MRI in detecting pediatric cervical spine injury. Childs Nerv Syst 2013; 29:1333-8. [PMID: 23584614 DOI: 10.1007/s00381-013-2092-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 03/21/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Although clinical criteria have been applied in the assessment of pediatric cervical spine trauma, no consensus has been established when imaging is required. With the increasing prevalence of computed tomography (CT) use in pediatric trauma and the concern for radiation in children, we sought to evaluate magnetic resonance imaging (MRI) and CT in detecting pediatric cervical spine injuries. METHODS We retrospectively queried a pediatric trauma database and identified pediatric patients who underwent both CT and MRI studies of the cervical spine and derived the statistical measures of each imaging modality to detect osseous and ligamentous/soft tissue injury. RESULTS Eighty-four patients were identified with a mean age of 9.0 ± 5.8 years (56% male). Sixteen patients were identified with injury, 12 with soft tissue abnormalities on MRI (nine edema and six ligamentous), and 6 with osseous abnormalities on CTs (six osseous fractures and one discogenic injury). Of the six patients who presented with CT-identified osseous injuries, MRI detected all six fractures as well as an additional compression fracture. CONCLUSION Using CT as the standard for osseous injury, MRI had a sensitivity of 100%, specificity of 97%, negative predictive value (NPV) of 75%, and positive predictive value (PPV) of 100%. Using MRI as the standard for soft tissue injury, CT had a sensitivity of 23%, specificity of 100%, NPV of 88%, and PPV of 100%. Further studies are required to investigate the use of MRI to detect osseous injuries.
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Affiliation(s)
- Mark Henry
- Department of Neurosurgery, Tufts Medical Center, Floating Hospital for Children, 800 Washington Street, Boston, MA, USA
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29
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Dong L, Li G, Mao H, Marek S, Yang KH. Development and validation of a 10-year-old child ligamentous cervical spine finite element model. Ann Biomed Eng 2013; 41:2538-52. [PMID: 23817769 PMCID: PMC3825549 DOI: 10.1007/s10439-013-0858-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Accepted: 06/24/2013] [Indexed: 11/30/2022]
Abstract
Although a number of finite element (FE) adult cervical spine models have been developed to understand the injury mechanisms of the neck in automotive related crash scenarios, there have been fewer efforts to develop a child neck model. In this study, a 10-year-old ligamentous cervical spine FE model was developed for application in the improvement of pediatric safety related to motor vehicle crashes. The model geometry was obtained from medical scans and meshed using a multi-block approach. Appropriate properties based on review of literature in conjunction with scaling were assigned to different parts of the model. Child tensile force–deformation data in three segments, Occipital-C2 (C0–C2), C4–C5 and C6–C7, were used to validate the cervical spine model and predict failure forces and displacements. Design of computer experiments was performed to determine failure properties for intervertebral discs and ligaments needed to set up the FE model. The model-predicted ultimate displacements and forces were within the experimental range. The cervical spine FE model was validated in flexion and extension against the child experimental data in three segments, C0–C2, C4–C5 and C6–C7. Other model predictions were found to be consistent with the experimental responses scaled from adult data. The whole cervical spine model was also validated in tension, flexion and extension against the child experimental data. This study provided methods for developing a child ligamentous cervical spine FE model and to predict soft tissue failures in tension.
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Affiliation(s)
- Liqiang Dong
- The State Key Laboratory of Advanced Design and Manufacturing for Vehicle Body, Hunan University, Changsha, Hunan, China
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30
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Developmental biomechanics of the human cervical spine. J Biomech 2013; 46:1147-54. [DOI: 10.1016/j.jbiomech.2013.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 11/22/2022]
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Severe spinal cord injury in craniocervical dislocation. Case-based update. Childs Nerv Syst 2013; 29:187-94. [PMID: 22961360 DOI: 10.1007/s00381-012-1915-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 08/27/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Craniocervical distraction injuries, including atlanto-axial dislocation (AAD) and atlanto-ocipital dislocation (AOD), are often associated with severe spinal cord involvement with high morbidity and mortality rates. Many patients with these injuries die at the accident scene, but advances in emergency resuscitation and transport permit that many patients arrive alive to hospitals. DISCUSSION Children with craniocervical distraction injuries usually present with a severe cranioencephalic traumatism that is the most relevant lesion at admission. After resuscitation and hemodynamic stabilization, the spinal cord damage appears as the main lesion. Apnea and quadriparesis, or quadriplegia, are usually present at the onset. Early diagnosis and management perhaps decrease life-threatening manifestations of the spinal lesion. But even so, the primary spinal cord insult is often irreversible and precludes obtaining a satisfactory functional outcome. PATIENTS AND METHODS We report the findings of four children with craniocervical distraction injuries (AOD and AAD) who presented with severe spinal cord damage. All patients were admitted with respiratory distress or apnea together with significant brain injuries. The medical records pertaining to these patients are summarized in regard to clinical features, management, and outcome. CONCLUSIONS In spite of timely and aggressive management, craniocervical injuries with spinal cord involvement continue to have a dismal prognosis. Outcome is closely related to the severity of the initial brain and spinal cord damage and is nearly always fatal in cases of complete spinal cord transection. Priority should be given to life-threatening complications. Ethic issues on indications for surgery deserve a detailed discussion with the children's parents.
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Lavallee AV, Ching RP, Nuckley DJ. Developmental biomechanics of neck musculature. J Biomech 2013; 46:527-34. [PMID: 23127787 PMCID: PMC3582332 DOI: 10.1016/j.jbiomech.2012.09.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 09/27/2012] [Accepted: 09/29/2012] [Indexed: 11/17/2022]
Abstract
Neck mechanics is central to head injury prevention since it is the musculoskeletal neck, which dictates the position and movement of the head. In the US, traumatic injury is the leading cause of death for children; however prevention is hampered by the lack of data concerning the mechanics of the immature head-and-neck. Thus, the objective of this study was to quantify neck muscle strength and endurance across the maturation spectrum and correlate these with head-and-neck anthropometry. A factorial study was performed on 91 human subjects measuring head-and-neck anthropometry and neck strength and endurance in three bending directions (flexion, extension, and lateral) as a function of age (6-23 years). Using a custom device, neck maximum voluntary contraction (MVC) force was measured in triplicate. Next, neck muscle endurance (sustained effort) was measured as the subjects' ability to maintain 70% of peak force over 30s. Linear regression of peak force and endurance as a function of age revealed each direction to significantly (p<0.0001) increase with age. The MVC force, averaged across all directions and normalized to the adult values, exhibits the following maturation curve: %MVC Force=-0.0879(age)(2)+6.018(age)+8.120. Neck muscle strength, similar between young males and females, becomes disparate in adolescence and adulthood with males exhibiting greater strength. Bending direction differences were also found with extension strength being the greatest regardless of age and sex. Furthermore, neck circumference appears predictive of neck strength and endurance in children. Together, these relationships may facilitate improved design of injury prevention interventions.
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Affiliation(s)
- Amy V. Lavallee
- Applied Biomechanics Laboratory, Department of Mechanical Engineering, University of Washington, USA
| | - Randal P. Ching
- Applied Biomechanics Laboratory, Department of Mechanical Engineering, University of Washington, USA
| | - David J. Nuckley
- Applied Biomechanics Laboratory, Department of Mechanical Engineering, University of Washington, USA
- Musculoskeletal Biomechanics Research Laboratory, Department of Physical Medicine and Rehabilitation, University of Minnesota, USA
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Dawson RM, Latif Z, Haacke EM, Cavanaugh JM. Magnetic resonance imaging-based relationships between neck muscle cross-sectional area and neck circumference for adults and children. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:446-52. [PMID: 22926433 DOI: 10.1007/s00586-012-2482-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 07/31/2012] [Accepted: 08/10/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Computer models and human surrogates used to study the forces and motion of the human neck under various loading conditions are based solely on adult data. Pediatric computer models and dummy surrogates used to improve the safety of children could be improved with the inclusion of previously unavailable pediatric muscle data. METHODS Measurements of neck circumference and neck muscle cross-sectional area (CSA) were taken from ten 50th percentile adult male and ten 10-year old male volunteer subjects. Muscle cross-sectional areas were calculated from magnetic resonance images of axial cross-sections of the neck. RESULTS Neck muscle cross-sectional area was calculated for six muscles/muscle groups. A power-law regression analysis was used to describe the relationship between neck circumference and neck muscle cross-sectional area. CONCLUSIONS The cross-sectional area and the power-law functions determined by the data in this study provide a means of calculating muscle cross-sectional area for young children, where such data are currently unavailable. This will provide an opportunity to develop more representative pediatric neck models.
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Affiliation(s)
- Renée M Dawson
- Department of Biomedical Engineering, Wayne State University, 818W Hancock, Detroit, MI 48201, USA.
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Abstract
About 5% of spinal injuries occur in children – however the consequences to the society are devastating, all the more so because the cervical spine is more commonly affected. Anatomical differences with adults along with the inherent elasticity of the pediatric spine, makes these injuries a biomechanically separate entity. Hence clinical manifestations are unique, one of which is the Spinal Cord Injury Without Radiological Abnormality. With the advent of high quality MRI and CT scan along with digital X-ray, it is now possible to exactly delineate the anatomical location, geometrical configuration, and the pathological extent of the injury. This has improved the management strategies of these unfortunate children and the role of surgical stabilization in unstable injuries can be more sharply defined. However these patients should be followed up diligently because of the recognized long term complications of spinal deformity and syringomyelia.
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Ramrattan NN, Oner FC, Boszczyk BM, Castelein RM, Heini PF. Cervical spine injury in the young child. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 21:2205-11. [PMID: 22732825 PMCID: PMC3481107 DOI: 10.1007/s00586-012-2292-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 03/29/2012] [Indexed: 11/29/2022]
Abstract
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This Grand Rounds is about the clinical and radiological presentation, treatment and outcome of pediatric cervical spine injury. A 15-month-old girl suffers from a motor vehicle accident and is intubated on-site because of progressive agitation. Whole body trauma CT was read as normal. When sedation was discontinued after 24 h she was found to be tetraplegic below C6 level. MRI shows a total disruption between C6 and C7 that in hindsight was also visible on the initial trauma CT. She was treated surgically by an anterior and posterior reconstruction and was post-operatively treated with a halo vest. Clearing the cervical spine in young children is deceptively difficult. Meticulous review and interpretation of conventional radiographs and CT are important yet MRI should be considered in uncertain cases. Severe ligamentous injury without concomitant bony injury occurs more frequently than in older children and adults, with sometimes devastating consequences.
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Affiliation(s)
- Navin N Ramrattan
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham University Hospitals, West Block D Floor, Derby Road, Nottingham, NG7 2UH, UK.
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Chien LC, Wu JC, Chen YC, Liu L, Huang WC, Chen TJ, Thien PF, Lo SS, Cheng H. Age, sex, and socio-economic status affect the incidence of pediatric spinal cord injury: an eleven-year national cohort study. PLoS One 2012; 7:e39264. [PMID: 22761749 PMCID: PMC3382245 DOI: 10.1371/journal.pone.0039264] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 05/22/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Few studies focus on pediatric spinal cord injury (SCI) and there is little information regarding the cause, anatomic level, and high risk population of SCI in children. This study aims to investigate the incidence and risk factors of pediatric SCI. METHODS A nationwide cohort of 8.7 million children aged<18 years in an 11-year period was analyzed for causes, age at injury, anatomic sites, disability, and familial socio-economic factors. Incidence rates and Cox regression analysis were conducted. RESULTS A total of 4949 SCI patients were analyzed. The incidence rates of cervical, thoracic, lumbar, and other SCI were 4.06, 0.34, 0.75, and 0.85 per 100,000 person-years, respectively. The proportional composition of gender, age, and socio-economic status of SCI patients were significantly different than those of non-SCI patients (all p<0.001). Male children were significantly more likely to have SCI than females in both the cervical and the other SCI groups [Incidence rate ratio (IRR) = 2.03 and 1.52; both p<0.001]. Young adults and teenagers were also significantly more likely to have SCI than pre-school age children in the cervical SCI (IRR = 28.55 and 10.50, both p<0.001) and other SCI groups (IRR = 18.8 and 7.47, both p<0.001). Children in families of lower socio-economic status were also significantly more likely to have SCI (p<0.05). CONCLUSIONS In the pediatric population, the overall SCI incidence rate is 5.99 per 100,000 person-years, with traumatic cervical SCI accounting for the majority. The incidence rate increases abruptly in male teenagers. Gender, age, and socio-economic status are independent risk factors that should be considered.
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Affiliation(s)
- Li-Chien Chien
- Department of Surgery, National Yang-Ming University Hospital, I-Lan, Taiwan
- Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jau-Ching Wu
- Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Chun Chen
- Department of Medical Research and Education, National Yang-Ming University Hospital, I-Lan, Taiwan
- Institute of Hospital and Health Care Administration, National Yang-Ming University School of Medicine, Taipei, Taiwan
- * E-mail:
| | - Laura Liu
- Department of Ophthalmology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Cheng Huang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Institute of Hospital and Health Care Administration, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Peck-Foong Thien
- Department of Medical Research and Education, National Yang-Ming University Hospital, I-Lan, Taiwan
- Department of Pediatrics, National Yang-Ming University Hospital, I-Lan, Taiwan
| | - Su-Shun Lo
- Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Henrich Cheng
- Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Abstract
Pediatric cervical spine injuries are rare and are associated with significant morbidity and mortality. Pediatric anatomy and physiology predispose to upper cervical spine injury and spinal cord injury without radiologic abnormality in contrast to lower cervical spine injury seen in adults. Care of pediatric patients is difficult because they have a greater head-to-body ratio than adults and may have difficulty cooperating with a history and physical examination. In evaluating a child with a suspected cervical spine injury, radiography may be supplemented with CT or MRI. Definitive management of pediatric cervical spine trauma must be adapted to the distinctive anatomy and growth potential of the patient. As with all injuries, prevention is necessary to reduce the incidence of trauma to the pediatric spine.
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Abstract
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.
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Affiliation(s)
- Lynn Hutchings
- The Kadoorie Centre for Critical Care Research, The Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The University of Oxford, Oxford, UK
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Abstract
AIM This article explores lumbar disc herniation in young children through focusing on matters relevant to patient presentation, physical examination, differential diagnosis, imaging and treatment. METHODS Major databases were searched for studies that addressed lumbar disc herniation in young children. RESULTS Diagnosis of lumbar disc herniation in young children is usually delayed because of the rarity and lack of experience with this entity and the difficulty in extracting a reliable medical history. Nevertheless, lumbar disc herniation should be considered in the differential diagnosis of any young child presenting with a chief complaint of back pain and/or radiculopathy, especially in the setting of recent trauma. This should be coupled with a directed physical examination to elicit signs and narrow the differential diagnosis. Imaging studies, mainly magnetic resonance imaging, will help establish a diagnosis; yet radiographs are still required to exclude other spinal lesions. The initial management of lumbar disc herniation in children is the same as that in adults and consists of conservative treatment unless lumbar disc herniation affects the patient's motor and neurological functions in which case, early surgical treatment must be undertaken. Although the latter remains more difficult, current experience suggests a favourable outcome. CONCLUSION Awareness of lumbar disc herniation will help the paediatrician extract a relevant medical history, perform a directed physical examination, and order appropriate imaging studies. This will aid in initiating early intervention, be it conservative or operative, and achieving a favourable outcome.
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Affiliation(s)
- R Haidar
- Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Patel NB, Hazzard MA, Ackerman LL, Horn EM. Circumferential fixation with craniofacial miniplates for a cervical spine injury in a child. J Neurosurg Pediatr 2009; 4:429-33. [PMID: 19877774 DOI: 10.3171/2009.6.peds0913] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Unstable pediatric cervical spine injuries present significant challenges in terms of fixation. Given the smaller cervical vertebral bodies in the preschool-aged population, commercially available pediatric cervical fixation instrumentation may be unsuitable because of the inappropriately large size of the screws and plates. The authors describe a 2-year-old girl who sustained an unstable C6-7 distraction injury during a motor vehicle accident. Because of the small size of her vertebral bodies, standard cervical spine instrumentation was not feasible, and posterior wiring alone was believed to be insufficient because of the complete distraction of all 3 spinal columns. The patient was taken to the operating room where craniofacial plates with an inherent locking mechanism were used to circumferentially stabilize the cervical spine. Follow-up examination 6 months postoperatively demonstrated stable cervical spine alignment and fusion with no evidence of the failure of either the anterior or posterior hardware. The use of craniofacial miniplates with an intrinsic locking mechanism represents a superior alternative for both anterior and posterior cervical fixations when spinal instrumentation is needed in the pediatric age group.
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Affiliation(s)
- Neal B Patel
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202-5124, USA
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Hopf S, Buchalla R, Elhöft H, Rubarth O, Börm W. [Atypical dislocated dens fracture type II with rotational atlantoaxial luxation after a riding accident]. Unfallchirurg 2009; 112:517-20. [PMID: 19404596 DOI: 10.1007/s00113-008-1542-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We present a rare case of a combined dislocated odontoid dens fracture type II (Anderson/D'Alonzo) and rotational atlantoaxial luxation in a 15-year-old girl who was involved in a riding accident.She fell off her horse after it had stopped suddenly, losing consciousness for a few minutes. At presentation in the hospital, she had no complaints other than limited, painful neck movement. Radiologically, a posterior dislocation of an odontoid type II fracture (Anderson/D'Alonzo) was found. Computed tomography reconstruction demonstrated a rotational, hooklike fixed luxation of the left atlantoaxial facet joint. Manual repositioning after application of a cervical collar failed. Therefore, operative treatment was indicated for this highly unstable fracture. Posterior transarticular atlantoaxial screw fixation according to Magerl was performed; an iliac corticocancellous bone graft was harvested and shaped to conform to the posterior processes of C1 and C2. Additionally a hook-claw atlas fixation of C1 was done.To our knowledge, this is the first case of adolescent atlantoaxial cervical spine trauma in combination with an odontoid fracture and fixed rotational luxation reported in literature.
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Affiliation(s)
- S Hopf
- Neurochirurgische Klinik, Diakonissenkrankenhaus Flensburg, Flensburg, Germany.
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Occult injury of the pediatric craniocervical junction. Emerg Radiol 2009; 16:483-8. [PMID: 19396479 DOI: 10.1007/s10140-009-0814-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 04/06/2009] [Indexed: 10/20/2022]
Abstract
The objective of this study is to review the occurrence of occult craniocervical junction injury in children. All patients <18 years of age with negative CT of the craniocervical junction and subsequent MRI between July 2003 and June 2008 were included. Age, gender, mechanism of injury, and presence of injuries below C2 were tabulated. Of the forty-five patients with negative CT of the craniocervical junction, 30 had positive MRI findings at the craniocervical junction. Seventeen of the 30 patients fulfilled criteria for significant craniocervical junction injury by MRI. Eleven of 17 patients with significant craniocervical junction injury were less than 8 years old and 13 of 17 were involved in motor vehicle accidents. Six of 12 patients with injury below C2 had significant craniocervical injury. Pediatric craniocervical injuries are often not evident on radiographic or CT imaging but present on MR imaging. Craniocervical injury is most common in younger age groups and is associated with motor vehicle accidents and injuries of the lower cervical spine.
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Klimo P, Ware ML, Gupta N, Brockmeyer D. Cervical spine trauma in the pediatric patient. Neurosurg Clin N Am 2008; 18:599-620. [PMID: 17991586 DOI: 10.1016/j.nec.2007.09.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Injuries to the pediatric cervical spine occur infrequently. Numerous unique anatomic and biomechanical features of the pediatric spine render it much more flexible than the adult spine. These features give rise to significant differences in the presentation, diagnosis, treatment, and prognosis of pediatric cervical trauma compared with adults. Younger children more often suffer injury to the upper cervical spine with greater neurologic injury and fewer fractures. Once the child reaches the age of 10 years, he or she develops a more adult-type spine, and injuries are thus more similar to those seen in the adult population. The unique anatomic and biomechanical differences in the pediatric spine are discussed, along with the various common and unique injuries.
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Affiliation(s)
- Paul Klimo
- 88th Medical Group, 4881 Sugar Maple Drive, Wright-Patterson Air Force Base, OH 45431, USA.
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Abstract
Intervertebral disk herniation in pediatric patients is a rare but potentially disabling entity that is frequently difficult to diagnose. This article reviews the fundamentals of pediatric intervertebral disk herniation with the intention of presenting a rational and simple strategy for the evaluation and treatment of disk herniation in children, with specific emphasis on how it differs from adult disk disease in presentation, pathologic findings, and treatment options.
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Affiliation(s)
- Jonathan R Slotkin
- Department of Neurosurgery, The Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Abstract
Spinal surgery is performed in children of all age groups. Some of these children will have significant, other medical problems. For most, surgery will be performed in the prone position. Blood loss may be high for some types of surgery, and patients will benefit from use of a blood-sparing technique. Many patients will require spinal cord monitoring to assess cord function and to prevent neurological deficit.
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Affiliation(s)
- N Soundararajan
- Jackson Rees Department of Paediatric Anaesthesia, Royal Liverpool Children's Hospital - Alder Hey, Eaton Road, Liverpool L12 2AP, UK
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47
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Abstract
Approximately 30,000 spinal injuries occur in the United States every year. Injuries to the spine and its contents affect predominately young, healthy individuals and are a major cause of disability, with significant socioeconomic consequences. The main cause for spinal injuries is blunt trauma, most commonly caused by motor vehicle accidents, followed by falls and sport injuries. Already, in the initial evaluation of patients who have blunt trauma, multislice CT with two-dimensional (and threedimensional) reformatting is the method of choice. The liberal use of MR imaging is recommended to assess for injuries to soft tissue, the spine and its contents, intervertebral discs, and ligaments.
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Affiliation(s)
- Pia C Sundgren
- Department of Radiology, University of Michigan Health Systems, 1500 East Medical Center Drive, Ann Arbor, MI 48104, USA.
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Abstract
OBJECTIVE The purpose of this work was to assess the frequency of clinically relevant findings from plain films of infants evaluated for torticollis. PATIENTS AND METHODS After institutional review board approval, radiology records were searched for infants 0 to 12 months of age who underwent plain film study for torticollis or "head tilt." Infants evaluated for trauma or Down syndrome were excluded. All of the studies were reviewed, demographic data was recorded, and any additional imaging studies were examined. RESULTS A total of 502 patients (189 girls and 313 boys) were identified with an average age of 0.37 +/- 0.2 years. Head tilt was to the left in two thirds of patients. Ten patients had abnormal findings reported. Six of these proved normal on subsequent studies (3 suspected occipital-C1 fusions, 2 suspected cervical fusions, and 1 suspected hemivertebra). Four patients had true bony vertebral abnormalities including absent left C7 pedicle, multiple fusion anomalies from C4 to T2, C3 hemivertebra and thoracic spine anomalies, and C4 hypoplasia. This last patient had abnormal kyphosis on physical examination and demonstrated instability with dynamic testing. Twenty-five additional patients with normal plain films underwent spine computed tomography or magnetic resonance imaging; all were normal. CONCLUSIONS The true-positive yield of plain films in nontraumatic infant torticollis was low (4 of 502). There were more false-positive than true-positive results. A common rationale for imaging is to exclude craniocervical or other unstable abnormalities that might contraindicate physical therapy, seen in only 1 of the 502 cases. Close physical examination could safely eliminate most patients sent for radiography.
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Affiliation(s)
- Emma M Snyder
- Department of Radiology, Columbus Children's Hospital, 700 Children's Dr, Columbus, OH 43205, USA
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