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706 SECTION 12: Pediatrics Cervical Spine Injury in Infants and Children Julie C. Leonard INTRODUCTION AND EPIDEMIOLOGY Cervical spine injuries occur in approximately 1.8% of pediatric blunt trauma patients.1,2 Although the incidence of cervical spine injuries in children is lower than adults (2.4%), children have higher rates of mor tality (7.4%) compared to adults (1.2%). 3-6 In children <8 years old, nearly three fourths of all spinal injuries occur in the cervical spine,7 and three fourths of the cervical spine injuries involve the axial cervical spine (occiput through C2). 3 Cervical spine injuries in these younger children are more likely associated with neurologic deficits and head or other major organ injury. 3,8 In addition, spinal cord injury without radio graphic abnormality (SCIWORA) may occur in children and typically involves the cervical spine. The incidence of SCIWORA among pediatric trauma patients ranges from 0.15% to 0.2%, comprising 4.5% to 35% of pediatric spine injuries. 3,9-11 Motor vehicle crashes are the most com mon mechanism of cervical spine injuries, followed by falls, and in teenagers, diving and sports injuries. 3 Boys are affected more often than girls. Child abuse can result in cervical spine injuries in younger patients via a shaking mechanism, although this is a rare manifestation of inflicted injury. 12 Note that injuries to the spine and spinal cord outside of the cervical spine are discussed in Chapter 110, “Pediatric Trauma. ” PATHOPHYSIOLOGY A number of anatomic differences between the pediatric and adult cervical spine predispose children to different patterns of injury (Table 112-1). In particular, the larger head-to-body ratio in young children creates a fulcrum at C2–C3 (compared to C5–C6 in adults) that accounts for higher rates of cervical spine injury above C3 in children. Weaker muscles and ligaments combined with anterior wedging and shallow facets connecting cervical vertebrae and immature growth centers together allow for easier anterior-posterior slipping of the vertebrae than in adults. Patients younger than 8 years of age incur high ligamentous injuries more often than older children and adults. Fractures tend to occur at the weak points in the bones—synchondroses and ossification centers. Dens fractures occur most commonly along the synchondrosis, especially in children younger than age 7 years. The mechanism of injury is usually a forward-facing child in a high-speed motor vehicle crash with rapid forward flexion. Atlanto-occipital and atlantoaxial dislocation injuries are devastating vertical distraction injuries that occur in the very young child, most commonly from a motor vehicle crash, and usually result in rapid death (Figure 112-1). SPINAL MOTION RESTRICTION IN INFANTS AND CHILDREN When cervical spine injury is suspected, measures to restrict the motion of the cervical spine can be challenging. Spinal motion restriction may be difficult in young children who are frightened or agitated, and placement of a cervical collar in young children while on a flat surface CHAPTER TABLE 112-1 Anatomic Considerations in the Pediatric Cervical Spine •   Large head •   Ligamentous laxity •   Absent cervical lordosis •   Weak neck muscles •   Anterior wedging of vertebrae •   Shallow and horizontal vertebral facets •   Ossification centers and synchondroses FIGURE 112-1. Atlantoaxial dislocation in a 6-year-old boy involved in a motor vehicle crash. A.

ervical Spine •   Large head •   Ligamentous laxity •   Absent cervical lordosis •   Weak neck muscles •   Anterior wedging of vertebrae •   Shallow and horizontal vertebral facets •   Ossification centers and synchondroses FIGURE 112-1. Atlantoaxial dislocation in a 6-year-old boy involved in a motor vehicle crash. A. Lateral plain radiograph reveals atlantoaxial dislocation ( blue arrow). B. MRI of the same patient reveals a near-complete transection of the brainstem at the level of the distal medulla, extensive ligamentous injury with resulting atlantoaxial dissociation, extensive intrathecal hematoma and hemorrhage, C1–C2 interspinous ligament tear, and prevertebral soft tissue swelling and edema around the nuchal ligament ( blue arrows). (e.g., rigid long board) may cause unwanted flexion of the cervical spine. A number of untoward effects have been associated with the use of a rigid long backboard including development of decubitus ulcers, flexion of the neck, and impedance of chest wall motion causing respiratory compromise, worsening of atlanto-occipital distraction injury, increased intracranial pressure, and musculoskeletal pain that may mimic injury and lead to increased radiologic investigation. 13-25 Tintinalli_Sec12_p0669-0996.indd 706 8/2/19 7:49 PM

ion of the neck, and impedance of chest wall motion causing respiratory compromise, worsening of atlanto-occipital distraction injury, increased intracranial pressure, and musculoskeletal pain that may mimic injury and lead to increased radiologic investigation. 13-25 Tintinalli_Sec12_p0669-0996.indd 706 8/2/19 7:49 PM CHAPTER 112: Cervical Spine Injury in Infants and Children 707 TABLE 112-2 Risk Factors for Pediatric Cervical Spine Injury •   Altered mental status •   Focal neurologic examination •   Neck pain •   Torticollis •   High-risk motor vehicle crash •   Substantial torso injury •   Predisposing condition associated with cervical spine injury •   Diving For those at significant risk for cervical spine injury, neutral positioning of the neck is important; for those in the supine position, consider elevating the torso 2.5 cm (or more for children <4 years of age) in order to alleviate neck flexion caused by the large occiput. Neutral position is achieved by aligning the external auditory meatus with the shoulders. Proper sizing of pediatric cervical collars is equally important and varies depending on the device used. If the proper-size collar is not available or if cervical collar placement initially results in extreme agitation of the child, use padding such as towel rolls or foam blocks placed on both sides of the child’s head to help limit motion. Due to the risks associated with the rigid long board, use should be restricted to children with injuries that limit their ability to self-extricate in the prehospital setting (e.g., obtunded or unable to ambulate). 26,27 If used, upon arrival to the hospital, children should be quickly moved from the rigid long board to a mattress gurney using the log roll maneuver or a slide board. CLINICAL FEATURES  HISTORY Ask parents, witnesses, or prehospital personnel about the mechanism of injury: children with cervical spine injury will usually have a history of high-force acceleration/deceleration (as seen in motor vehicle crashes) or axial loading trauma (falls, diving injuries). Trivial mechanisms such as a ground-level fall usually do not lead to serious spine injury unless the patient has a condition associated with cervical spine instability (see “Special Considerations” later in the chapter). In the cooperative, verbal child, ask about symptoms such as neck pain, difficulty moving the neck, sensory deficits, or weakness.  PHYSICAL EXAMINATION Examine the child with a primary survey of airway, breathing, and circulation, followed by a complete head-to-toe examination to identify major comorbid injuries that increase the risk of cervical spine injury, particularly injuries to the head and thorax. Pay careful attention to breathing, because damage to C3–C5 can injure the phrenic nerve, impairing innervation to the diaphragm, compromising respiratory mechanics, and leading to apnea. Injury to the high cervical spine can affect hemodynamic stability from spinal shock. Spinal shock is characterized by hypotension in the setting of a normal heart rate. For intubated or obtunded trauma patients, leave a cervical collar in place and obtain imaging. In children who are cooperative and alert, assess for midline neck tenderness, the presence of torticollis, and neurologic deficits while maintaining inline stabilization of the neck. Sensory symptoms such as numbness or tingling are the most common neurologic deficits among pediatric cervical spine injury patients, and persistent sensory deficits may help localize the level of the injury. Test for motor function in the cooperative child: shoulder shrug is controlled by C5, elbow flexion and wrist extension by C6, elbow extension and wrist flexion by C7, and finger flexion by C8.

its among pediatric cervical spine injury patients, and persistent sensory deficits may help localize the level of the injury. Test for motor function in the cooperative child: shoulder shrug is controlled by C5, elbow flexion and wrist extension by C6, elbow extension and wrist flexion by C7, and finger flexion by C8. Also check deep tendon reflexes; the biceps reflex tests C5, the brachioradialis reflex tests C6, and the triceps reflex tests C7. DIAGNOSIS Distinguishing between radiographically apparent cervical spine injury, SCIWORA, and peripheral nerve injury (brachial plexus) can be chal lenging. Transient burning sensation of the hands and fingers is a concerning complaint described by young athletes with neck injuries, particularly football players. These symptoms can be caused by either neck hyperextension and central cord contusion or stretching or direct blow (supraclavicular fossa) to the brachial plexus. Patients with brachial plexus injuries will not report lower extremity symptoms or posterior midline neck complaints, and compression to the top of the head may reproduce the symptoms (Spurling test). Torticollis and neck pain are presenting findings of cervical spine injury in children. It can be difficult to differentiate decreased movement from direct muscle injury versus muscle spasms due to cervical spine injury. A common cervical spine injury in young children is atlantoaxial rotatory subluxation . 28 These injuries can result from very minor traumatic events and present with neck pain and torticollis that is characterized by the head being tilted in one direction and turned in the other ( cock robin deformity). Atlantoaxial rotatory subluxation can also occur in the setting of positioning for head and neck surgery or spontaneously in the setting of upper respiratory infection (Grisel’s syndrome). In most circumstances, atlantoaxial rotatory subluxation is self-limiting with rest and the use of NSAIDs and muscle relaxants.  LABORATORY TESTING Routine laboratory testing is not helpful in the general evaluation of cervical spine injury in children but may be useful in the context of multisystem trauma.  IMAGING Imaging should follow the U.S. Nuclear Regulatory Commission guidelines for using the “as low as reasonably achievable” principle. In practice, this means both selecting the right imaging study using clinical criteria and ensuring that imaging protocols are adapted to lower dosing for children. Choice of imaging should be guided by the history and physical examination. Adult decision rules such as NEXUS (National Emergency X-Radiography Utilization Study) and the Canadian Cervical Spine Rule (see Tables 258-4 and 258-5) for cervical spine clearance may be useful in guiding imaging practice in older children and teens but have limitations. The Canadian rule did not include children in its derivation, and NEXUS did not include children <2 years old and included only four patients <9 years old. 2,29-33 A prospective study applying NEXUS in children showed that NEXUS did in fact miss two fractures, both in children under 2 years of age, highlighting the difficulty of rul ing out cervical spine injury in the very young patient. 34 The Pediatric Emergency Care Applied Research Network conducted a multicenter retrospective case-control study of 540 children with cervical spine injuries matched to noninjured children who underwent cervical spine imaging. This study identified eight factors that were 98% sensitive and 26% specific for cervical spine injury after blunt trauma (Table 112-2). If these risk factors had been used to guide clinical decision making, radiographic testing would have been reduced by approximately 25%.

hildren who underwent cervical spine imaging. This study identified eight factors that were 98% sensitive and 26% specific for cervical spine injury after blunt trauma (Table 112-2). If these risk factors had been used to guide clinical decision making, radiographic testing would have been reduced by approximately 25%. The pediatric cervical spine injury risk factors are currently undergoing prospective evaluation for use in a clinical decision tool. Suggested clinical algorithms have been published by the Trauma Association of Canada’s Pediatric Subcommittee 36 and more recently by the Pediatric Orthopedic Society of North America Cervical Spine Clearance Working Group (see Figure 112-4). Plain Radiographs For patients in whom a cervical spine injury is suspected, plain radiographs should be considered first. The sensitivity of plain radiographs for identifying fractures, dislocations, and sublux ations in children varies across the literature, ranging from 74% to 98%, with sensitivity increasing with the number of views taken. 37-44 Combining the cross-table lateral and anterior-posterior views identifies 87% of significant cervical spine injury in children younger than 8 years of age. Consider the addition of an odontoid (open mouth) view in cooperative Tintinalli_Sec12_p0669-0996.indd 707 8/2/19 7:49 PM

sing with the number of views taken. 37-44 Combining the cross-table lateral and anterior-posterior views identifies 87% of significant cervical spine injury in children younger than 8 years of age. Consider the addition of an odontoid (open mouth) view in cooperative Tintinalli_Sec12_p0669-0996.indd 707 8/2/19 7:49 PM 708 SECTION 12: Pediatrics older children, although the added value in children younger than age 8 years has been questioned.44 Interpreting pediatric cervical spine radiographs can be challenging as a result of the anatomic differences across the spectrum of age. The principles of evaluation are similar to adults: assess the anterior and posterior vertebral lines, the spinolaminal line, and the spinous processes for alignment; and carefully examine the soft tissue spaces for swelling that might indicate subtle fracture. Widening of the soft tissue space >7 mm in the retropharyngeal space and >14 mm in the retrotracheal space on lateral radiograph may be an indirect sign of cervical spine injury. In addition, assess the pediatric cervical spine for atlantoaxial instability. Useful measurements include Wackenheim’s clivus line (a line along the posterior edge of the clivus should intersect the odontoid) and the rule of thirds (the dens, cord, and empty space should each occupy one third of the spinal space). Craniocervical dislocation is suggested by a C1–C2:C2–C3 ratio >2.5. Important differences between pediatric and adult cervical spine radiographs include: 1. Normal cervical lordosis may be absent in children when imaged in the supine position and/or when a rigid collar is in place. 2. The posterior arch of C1 fuses by age 3 years and the anterior arch by age 10 years. 3. Anterior wedging of the vertebrae caused by secondary growth cen ters may be mistaken for compression fractures in children under 7 years old. 4. Posterior laminar fusion lines may be mistaken for fractures in children under 7 years old. 5. Children younger than 8 years old may demonstrate pseudosublux ation (up to 46%) on lateral radiograph, usually at the C2–C3 level (Figure 112-2). Swischuk developed a method for distinguishing between true sub luxation and pseudosubluxation: draw a line connecting the posterior cortex of the spinous process of C1 to the cortex of the spinous process of C3 ( Figure 112-3). If this line is >2 mm anterior to the spinous process of C2, suspect cervical pathology, such as a hangman’s fracture. There is little role for flexion/extension plain radiographs in the ED for children. Obtain an MRI if ligamentous instability is suspected. Although CT is the most cost-effective modality for imaging the cervical spine in adults, it is unclear if this is true for children, in whom radiation exposure is of particular concern. CT scanning exposes a child to 10 to 90 times the radiation of plain films, with an estimated 18-fold increase in thyroid malignancy in a theoretical model if all plain films are replaced by CT scans. 46,47 Given the potential risks and unclear advantages of CT in children, this modality should be reserved for those with abnormal or suspicious plain radiographs and those with signifi cant mechanism of injury who are obtunded or intubated and undergoing CT evaluation for other injuries. MRI is the modality of choice for the diagnosis and evaluation of children with focal neurologic deficits on exam or those who report persistent severe cervical spine pain with normal plain radiographs. 9 Patients with normal MRI examinations and SCIWORA have very favorable prognoses; those with minor find ings such as cord edema or a minor hemorrhage have good prognoses, whereas those with major hemorrhage or cord transections have poor prognoses for recovery.

severe cervical spine pain with normal plain radiographs. 9 Patients with normal MRI examinations and SCIWORA have very favorable prognoses; those with minor find ings such as cord edema or a minor hemorrhage have good prognoses, whereas those with major hemorrhage or cord transections have poor prognoses for recovery. 48,49 MRI should also be strongly considered as an adjunct test when evaluating for abusive head trauma in infants and young children, as emerging evidence supports a higher rate of cervical spine injury in this subpopulation. The injury patterns in these children are typically multilevel ligamentous injuries and intraspinal hemorrhages. 50-58 TREATMENT The ED management of the child with potential cervical spine injury should follow the principles of advanced trauma life support with primary attention to assessment and management of the airway and breathing (especially with a high cervical spine injury, which may compromise respiratory effort) and circulation (particularly in spinal shock). Spinal shock is not responsive to volume expansion and must be treated with vasopressors. In adult cervical spine injury, steroids are no longer favored (see Chapter 258, “Spine Trauma”), and no large studies have examined the efficacy of steroids in pediatric spine injury, so steroids are not standard of care for children. FIGURE 112-2. Pseudosubluxation of C2 on C3. [Reprinted with permission from Yamamoto LG: Cervical spine malalignment—true or pseudosubluxation? In: Yamamoto LG, Inaba AS, DiMauro R (eds): Radiology Cases in Pediatric Emergency Medicine, Vol. 1, Case 5. Honolulu, HI: University of Hawaii John A. Burns School of Medicine, Department of Pediatrics, 1994. http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c05.html.] FIGURE 112-3. Posterior cervical line of Swischuk. [Reprinted with permission from Yamamoto L: Cervical spine malalignment—true or pseudosubluxation? In: Yamamoto LG, Inaba AS, DiMauro R (eds): Radiology Cases in Pediatric Emergency Medicine, Vol. 1, Case 5. Honolulu, HI: University of Hawaii John A. Burns School of Medicine, Department of Pediatrics, 1994. http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c05.html.] Tintinalli_Sec12_p0669-0996.indd 708 8/2/19 7:49 PM

Yamamoto LG, Inaba AS, DiMauro R (eds): Radiology Cases in Pediatric Emergency Medicine, Vol. 1, Case 5. Honolulu, HI: University of Hawaii John A. Burns School of Medicine, Department of Pediatrics, 1994. http://www.hawaii.edu/medicine/pediatrics/pemxray/v1c05.html.] Tintinalli_Sec12_p0669-0996.indd 708 8/2/19 7:49 PM CHAPTER 112: Cervical Spine Injury in Infants and Children 709 Definitive management of cervical spine injury is primarily surgical, through consultation with pediatric neurosurgery or orthopedics. DISPOSITION AND FOLLOW-UP Unstable patients and those with radiographic evidence of cervical spine injury require admission, usually to intensive care, and consultation with a spine surgeon. Compared to adults, children’s cervical spine injuries infrequently require surgery (15.7%) or traction or halo (16.9%). Due to the age-related variation in cervical spine injury patterns and management, transferring these children to pediatric trauma centers for definitive care is strongly recommended. Children with persistent neck pain despite normal neurologic exam and normal radiographs and/or CT need further evaluation. If the mechanism of injury is mild, the child may be discharged with an appropriately sized cervical collar and close outpatient medical followup. If the mechanism of injury is severe, it is prudent to obtain a spine consultation to determine further evaluation. Children without neck pain or neurologic symptoms or deficits who have normal radiographs and those who have been cleared clinically should be discharged with instructions to return for symptoms of numbness, tingling, or weakness in the arms, hands, legs, or feet. SPECIAL CONSIDERATIONS Certain conditions predispose patients to cervical spine injury as a result of associated abnormalities causing cervical spine instability. These are listed in Table 112-3. Children with these conditions should be con sidered at high risk for cervical spine injury and undergo conservative/ extensive evaluation. CLINICAL ALGORITHMS FOR CERVICAL SPINE CLEARANCE In 2011, the Trauma Association of Canada’s Pediatric Subcommittee National Pediatric Cervical Spine Evaluation Pathway released a consensus guideline for evaluation of the pediatric patient and divided its algorithms into two parts: the reliable patient and the unreliable patient. More recently, the Pediatric Orthopedic Society of North America Cer vical Spine Clearance Working Group released a consensus algorithm based on Glasgow Coma Scale score rather than age (Figure 112-4). TABLE 112-3 Predispositions to Cervical Spine Injury in Children Genetic syndromes associated with spine malformations; examples: •   Down syndrome: 15% atlantoaxial instability •   Klippel-Feil syndrome: cervical vertebral defects •   Morquio’s syndrome (type IV mucopolysaccharidosis): odontoid hypoplasia Connective tissue disorders associated with ligamentous laxity; examples: •   Marfan’s syndrome •   Ehlers-Danlos syndrome Spondyloarthopathies; examples: •   Ankylosing spondylitis •   Rheumatoid arthritis Disorders of bone metabolism; examples: •   Osteoporosis •   Rickets Previous cervical spine surgeries Pediatric Cervical Spine Clearance Working Group Algorithm *Stronger consideration for imaging should be given towards patients with the following mechanisms of injury (MOl): diving, axial load, clothes-lining and high-risk MVC (HR-MVC), however the literature findings are controversial. HR-MVC is defined as a head-on collision, rollover, ejected from the vehicle, death in the same crash, or speed > 55mph **Substantial injury is defined as an observable injury that is life-threatening, warrants surgical intervention, or warrants inpatient observation.

however the literature findings are controversial. HR-MVC is defined as a head-on collision, rollover, ejected from the vehicle, death in the same crash, or speed > 55mph **Substantial injury is defined as an observable injury that is life-threatening, warrants surgical intervention, or warrants inpatient observation. # All Imaging should be read by an attending physician +Adequate flexion/extension is defined as ≥ 30 degrees of flexion and ≥ 30 degrees of extension ‡Patient has achieved GSC 14 – 15 and no longer presents with abnormal head posture, persistent neck pain, or difficulty in neck movement GCS = 9–13 Yes Yes YesNoNormal Normal‡Abnormal Abnormal Abnormal History* • Child or parent reports persistent neck pain, abnormal head posture, or difficulty with neck movement • History of focal sensory abnormality or motor deficit Physical Exam • Torticollis/abnormal head position • Posterior midline neck tenderness • Limited cervical range of motion • Not able to maintain focus due to other injuries • Visible known substantial injury to chest, abdomen, or pelvis** Answer “No” to all of the above Answer “Yes” to any of the above Plain radiograph # (lateral view minimum) Plain radiograph# (lateral view minimum) Static Magnetic Resonance Imaging# CT# Repeat clinical exam within 12 hours Repeat clinical exam Normal Normal Normal Abnormal Abnormal Normal Abnormal GCS = 14 or 15 Patient has improved to a GCS = 14 or 15? Anticipate that the patient will improve to GCS 14/15 within 72 hours Potential to improve mental status to a GCS of 14 or 15? GCS ≤ 8 And reasonable suspicion for cervical spine injury Spine consult Spine consult Clear c-spine Clear c-spine Clear c-spine Options: 1) Clear c-spine if physical exam findings resolve 2) Obtain flexion/extension radiographs #+ 3) Maintain collar and re-evaluate in 2 weeks 4 Spine consult FIGURE 112-4. Algorithm for evaluation of the pediatric cervical spine (C-spine) in the pediatric patient. GCS = Glasgow Coma Scale. [Reproduced with permission from Herman MJ, Brown KO, Sponseller PD, et al: Pediatric Cervical Spine Clearance: a consensus statement and algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am 2018; Jan 2;101(1):e1. Tintinalli_Sec12_p0669-0996.indd 709 8/2/19 7:49 PM