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Spine Injury: Cervical, Pediatric, Emergency Medicine


Basics


Description


  • Relatively rare, present in 1 " “2% of patients with severe blunt trauma
  • Children <8 yr of age are more likely to have upper cervical spine injuries (C1 " “C3) and are at risk of growth plate injuries:
    • Spinal fulcrum is higher (C2 " “C3 at birth)
    • Relatively larger head to body
    • Weaker cervical musculature
    • Ligamentous laxity
    • Immature vertebral joints
  • Children >8 yr of age:
    • Increased incidence of pancervical injuries
    • Vertebral body and arch fractures
    • Lower cervical spine injuries more common
  • Special considerations:
    • Down syndrome
    • Klippel " “Feil syndrome
    • Morquio syndrome
    • Larsen syndrome
  • Spinal cord injury without radiographic abnormality (SCIWORA):
    • Based on study population, incidence from 4.5 " “35% of children with spinal injuries
    • More common in children <8 yr of age
    • May present as definite spinal cord injury:
      • Spinal shock
      • Neurologic deficits
    • Symptoms may be transient and have resolved by time of evaluation:
      • Paresthesias
      • Burning sensation of hands
      • Weakness
    • Symptoms often occur immediately after injury but may have delayed onset (i.e., minutes to days).

Etiology


  • Birth " “ breech vaginal delivery
  • <8 yr " “ MVC and falls
  • >8 yr " “ MVC and sports injuries

Diagnosis


Signs and Symptoms


  • Local cervical spine pain
  • Limited range of motion
  • Neurologic deficit (may be transient)
  • May be masked by altered mental status or distracting injury
  • Abnormal vital signs:
    • Hypotension
    • Bradycardia
    • Hypoventilation or apnea
  • Neck signs:
    • Tender to palpation over cervical spine
    • Limited range of motion
    • Muscle spasm
  • Neurologic signs:
    • Paresthesias or sensory deficit
    • Flaccid tone
    • Loss of rectal tone
    • Paralysis
  • Paralysis:
    • Anterior cord syndrome:
      • Hyperflexion injury
      • Paralysis
      • Loss of pain sensation, preservation of light touch, and proprioception
    • Central cord syndrome:
      • Hyperextension injury
      • Weakness upper greater than lower extremities
      • Burning sensation in hands and fingers
    • Brown-Sequard syndrome:
      • Cord hemisection
      • Ispilateral paralysis
      • Contralateral loss of pain
    • Horners syndrome:
      • Disruption of sympathetic chain
      • Ipsilateral ptosis, miosis, anhidrosis
      • Also consider carotid dissection
    • Quadriplegia
    • Absent reflexes
  • Preverbal child may be unable to express symptoms and may not cooperate during exam.

Essential Workup


  • Obtain cervical spine radiographs for:
    • Cervical spine tenderness
    • Altered mental status
    • Neurologic deficit (even if transient)
    • Distracting injury
    • Mechanism of injury
  • Additional imaging studies (CT, MRI) may be indicated if plain radiographs are inconclusive OR clinical exam suggests injury
  • Nexus criteria can be applied safely to children >8 yr of age, but not younger

Diagnosis Tests & Interpretation


Imaging
  • Cervical spine radiographs:
    • Standard initial views: Anteroposterior, cross-table lateral, and open-mouth odontoid
    • Cross-table lateral identifies ¢ ˆ ¼80% of fractures, dislocations, and subluxations
    • Addition of AP and odontoid increases sensitivity
    • Need to visualize all 7 cervical vertebrae and C7 " “T1 junction
    • Space between anterior arch of C1 and anterior aspect of odontoid process:
      • 5 mm or smaller in children and 3 mm in adults
    • Thickening of prevertebral soft tissue:
      • Suggests underlying fracture or ligamentous injury
      • Also occurs with neck flexion, expiration, swallowing
      • Too much variability exists for measurements to be highly sensitive.
      • Soft tissue below the glottis should be approximately twice as thick as above the glottis.
    • Pseudosubluxation of C2:
      • Normal variant
      • A result of ligamentous laxity and often resolves by the age of 8 yr
      • C2 anteriorly displaced on C3
      • Posterior cervical line retains normal relationships.
      • Line drawn between anterior aspect of spinous processes of C1 and C3 should pass within 2 mm of anterior aspect of spinous process of C2.
      • Larger than 2-mm space suggests underlying hangman fracture.
      • Can be applied only at C1 " “C3
    • Anterior vertebral wedging of C3 and C4:
      • May be mistaken for compression fracture
    • Epiphyseal growth plates may resemble fractures:
      • Posterior arch of C1 fuses by 4 yr of age.
      • Anterior arch of C1 fuses by age 6 yr of age.
      • Base of odontoid fuses with body of C2 by 7 yr of age.
    • Flexion and extension views:
      • Limited use
      • May be useful if suspected occult ligamentous injury
      • Negative cervical spine films
      • No neurologic abnormalities
  • CT scan:
    • If fracture suspected despite negative plain radiographs
    • For further definition of fracture identified on plain radiographs
    • Suspicion of a fracture seen on plain radiographs
    • Inadequate radiographs
  • MRI:
    • Suspected spinal cord injury with or without abnormalities found on plain radiographs or CT

Differential Diagnosis


  • Cervical muscle strain
  • Torticollis
  • Cervical adenitis
  • Retropharyngeal abscess
  • Meningitis

Treatment


Pre-Hospital


  • Immobilize all infants and children with potential cervical spine injuries
  • Appropriate size cervical collar
  • Tape, towels, padding in combination with car seat or spine board if formal collar not available
  • Place padding under neck, shoulders, and back, as relatively larger cranium can cause flexion
  • In setting of sports injuries, helmets should be left on

Initial Stabilization/Therapy


  • Maintain cervical spine immobilization.
  • Logroll patient.
  • Maintenance of inline cervical spine immobilization if intubation is required.

Ed Treatment/Procedures


  • Any trauma patient with neurologic deficit consistent with spinal cord injury should have methylprednisolone considered.
  • Neurosurgical consultation:
    • True subluxation
    • Fracture
    • Transient or persistent neurologic deficit

Medication


Controversial
  • Methylprednisolone: Loading dose 30 mg/kg IV over 1 hr; maintenance infusion 5.4 mg/kg/hr over next 23 hr; initiate within 8 hr of injury
  • Can cause immunosuppression and increase risk of infection
  • Recommend discussion with neurosurgery prior to initiation

Follow-Up


Disposition


Admission Criteria
  • Altered mental status
  • Signs/symptoms of spinal cord injury
  • Fracture
  • Obtain appropriate consultation:
    • Neurosurgery
    • Orthopedic spine

Discharge Criteria
  • Completely normal mental status
  • No radiographic abnormalities
  • No transient or persistent neurologic deficit
  • Educate parents:
    • SCIWORA can present with delayed onset of symptoms.
    • Patient should return to hospital if paresthesias, weakness, or paralysis is present.

Follow-Up Recommendations


  • Follow up with orthopedic surgeon or neurosurgeon as directed
  • If concussion suspected, follow-up suggested
  • Children with significant trauma should have psychological follow-up.

Pearls and Pitfalls


  • Maintain appropriate immobilization during evaluation.
  • In most cases, plain radiographs can be used as initial screening tool.
  • Be aware of unique features of pediatric cervical spine.
  • Symptoms of SCIWORA can be transient or delayed.

Additional Reading


  • Bracken ‚  MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev.  2012;1:CD001046. doi:10.1002/14651858.CD001046.pub2.
  • Caviness ‚  AC. Evaluation of cervical spine injuries in children and adolescents. UpToDate. Available at http://www.uptodate.com/contents/evaluation-of-cervical-spine-injuries-in-children-and-adolescents.
  • Mohseni ‚  S, Talving ‚  P, Branco ‚  BC, et al. Effect of age on cervical spine injury in pediatric population: A National Trauma Data Bank review. J Pediatr Surg.  2011;46(9):1771 " “1776.
  • Swischuk ‚  LE. Imaging of the Cervical Spine in Children. New York, NY: Springer-Verlag; 2004.

Codes


ICD9


  • 805.00 Closed fracture of cervical vertebra, unspecified level
  • 847.0 Sprain of neck
  • 959.09 Injury of face and neck
  • 952.00 C1-C4 level with unspecified spinal cord injury
  • 728.4 Laxity of ligament
  • 952.05 C5-C7 level with unspecified spinal cord injury

ICD10


  • S12.9XXA Fracture of neck, unspecified, initial encounter
  • S13.4XXA Sprain of ligaments of cervical spine, initial encounter
  • S19.9XXA Unspecified injury of neck, initial encounter
  • S14.109A Unsp injury at unsp level of cervical spinal cord, init
  • M24.28 Disorder of ligament, vertebrae

SNOMED


  • 262522002 Injury of cervical spine
  • 269062008 Closed fracture of cervical spine
  • 209557005 neck sprain (disorder)
  • 405754008 cervical spinal cord injury (disorder)
  • 298205001 Cervical spine laxity (finding)
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