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Spine Injury: Cervical, Pediatric, Emergency Medicine

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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 bodyWeaker cervical musculatureLigamentous laxityImmature vertebral joints
  • Children >8 yr of age:Increased incidence of pancervical injuriesVertebral body and arch fracturesLower cervical spine injuries more common
  • Special considerations:Down syndromeKlippel " “Feil syndromeMorquio syndromeLarsen syndrome
  • Spinal cord injury without radiographic abnormality (SCIWORA):Based on study population, incidence from 4.5 " “35% of children with spinal injuriesMore common in children <8 yr of ageMay present as definite spinal cord injury:Spinal shockNeurologic deficitsSymptoms may be transient and have resolved by time of evaluation:ParesthesiasBurning sensation of handsWeaknessSymptoms often occur immediately after injury but may have delayed onset (i.e., minutes to days).
  • Spinal fulcrum is higher (C2 " “C3 at birth)
  • Relatively larger head to body
  • Weaker cervical musculature
  • Ligamentous laxity
  • Immature vertebral joints
  • Increased incidence of pancervical injuries
  • Vertebral body and arch fractures
  • Lower cervical spine injuries more common
  • Down syndrome
  • Klippel " “Feil syndrome
  • Morquio syndrome
  • Larsen syndrome
  • 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 shockNeurologic deficits
  • Symptoms may be transient and have resolved by time of evaluation:ParesthesiasBurning sensation of handsWeakness
  • Symptoms often occur immediately after injury but may have delayed onset (i.e., minutes to days).
  • Spinal shock
  • Neurologic deficits
  • Paresthesias
  • Burning sensation of hands
  • Weakness

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:HypotensionBradycardiaHypoventilation or apnea
  • Neck signs:Tender to palpation over cervical spineLimited range of motionMuscle spasm
  • Neurologic signs:Paresthesias or sensory deficitFlaccid toneLoss of rectal toneParalysis
  • Paralysis:Anterior cord syndrome:Hyperflexion injuryParalysisLoss of pain sensation, preservation of light touch, and proprioceptionCentral cord syndrome:Hyperextension injuryWeakness upper greater than lower extremitiesBurning sensation in hands and fingersBrown-Sequard syndrome:Cord hemisectionIspilateral paralysisContralateral loss of painHorners syndrome:Disruption of sympathetic chainIpsilateral ptosis, miosis, anhidrosisAlso consider carotid dissectionQuadriplegiaAbsent reflexes
  • Preverbal child may be unable to express symptoms and may not cooperate during exam.
  • Hypotension
  • Bradycardia
  • Hypoventilation or apnea
  • Tender to palpation over cervical spine
  • Limited range of motion
  • Muscle spasm
  • Paresthesias or sensory deficit
  • Flaccid tone
  • Loss of rectal tone
  • Paralysis
  • Anterior cord syndrome:Hyperflexion injuryParalysisLoss of pain sensation, preservation of light touch, and proprioception
  • Central cord syndrome:Hyperextension injuryWeakness upper greater than lower extremitiesBurning sensation in hands and fingers
  • Brown-Sequard syndrome:Cord hemisectionIspilateral paralysisContralateral loss of pain
  • Horners syndrome:Disruption of sympathetic chainIpsilateral ptosis, miosis, anhidrosisAlso consider carotid dissection
  • Quadriplegia
  • Absent reflexes
  • Hyperflexion injury
  • Paralysis
  • Loss of pain sensation, preservation of light touch, and proprioception
  • Hyperextension injury
  • Weakness upper greater than lower extremities
  • Burning sensation in hands and fingers
  • Cord hemisection
  • Ispilateral paralysis
  • Contralateral loss of pain
  • Disruption of sympathetic chain
  • Ipsilateral ptosis, miosis, anhidrosis
  • Also consider carotid dissection

Essential Workup

  • Obtain cervical spine radiographs for:Cervical spine tendernessAltered mental statusNeurologic deficit (even if transient)Distracting injuryMechanism 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
  • Cervical spine tenderness
  • Altered mental status
  • Neurologic deficit (even if transient)
  • Distracting injury
  • Mechanism of injury

Diagnosis Tests & Interpretation

  • Cervical spine radiographs:Standard initial views: Anteroposterior, cross-table lateral, and open-mouth odontoidCross-table lateral identifies ¢ ˆ ¼80% of fractures, dislocations, and subluxationsAddition of AP and odontoid increases sensitivityNeed to visualize all 7 cervical vertebrae and C7 " “T1 junctionSpace between anterior arch of C1 and anterior aspect of odontoid process:5 mm or smaller in children and 3 mm in adultsThickening of prevertebral soft tissue:Suggests underlying fracture or ligamentous injuryAlso occurs with neck flexion, expiration, swallowingToo 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 variantA result of ligamentous laxity and often resolves by the age of 8 yrC2 anteriorly displaced on C3Posterior 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 " “C3Anterior vertebral wedging of C3 and C4:May be mistaken for compression fractureEpiphyseal 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 useMay be useful if suspected occult ligamentous injuryNegative cervical spine filmsNo neurologic abnormalities
  • CT scan:If fracture suspected despite negative plain radiographsFor further definition of fracture identified on plain radiographsSuspicion of a fracture seen on plain radiographsInadequate radiographs
  • MRI:Suspected spinal cord injury with or without abnormalities found on plain radiographs or CT
  • 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 injuryAlso occurs with neck flexion, expiration, swallowingToo 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 variantA result of ligamentous laxity and often resolves by the age of 8 yrC2 anteriorly displaced on C3Posterior 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 useMay be useful if suspected occult ligamentous injuryNegative cervical spine filmsNo neurologic abnormalities
  • 5 mm or smaller in children and 3 mm in adults
  • 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.
  • 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
  • May be mistaken for compression fracture
  • 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.
  • Limited use
  • May be useful if suspected occult ligamentous injury
  • Negative cervical spine films
  • No neurologic abnormalities
  • 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
  • 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 subluxationFractureTransient or persistent neurologic deficit
  • True subluxation
  • Fracture
  • Transient or persistent neurologic deficit

Medication

  • 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

  • Altered mental status
  • Signs/symptoms of spinal cord injury
  • Fracture
  • Obtain appropriate consultation:NeurosurgeryOrthopedic spine
  • Neurosurgery
  • Orthopedic spine
  • 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.
  • 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)