Pediatric Cervical Spine Injury

Aka: Pediatric Cervical Spine Injury, Spinal Cord Injury without Radiographic Abnormality, SCIWORA

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II. Epidemiology

  1. Pediatric Cervical Spine Injury is a rare event, but requires vigilance in all potential cases (see pitfalls)
    1. Percentage that children under age 8 represent of all Cervical Spine injuries: <4%
    2. Percentage of Pediatric Trauma patients with a Cervical Spine Injury: <1%
      1. Age <9 years old with C-Spine Injury: 0.1% of Pediatric Trauma patients
  2. Most common Cervical Spine injuries in children
    1. Ligamentous Injury (Cervical Spine instability risk)
      1. Incidence thought to be higher in children, but in NEXUS study, no children had SCIWORA
    2. Spinal cord Hemorrhage or edema
    3. C1-C3 Level Injury represented 83% of cases in children age <8 years with Cervical Spine injuries

III. Pitfalls

  1. Missing a Cervical Spine Injury can have devastating effects
    1. Have a high index of suspicion in high mechanism injury
  2. Young children cannot verbalize focal pain and associated neurologic symptoms
    1. Younger children have the most serious injuries missed (often with delays up to 3-5 days)
  3. Upper Cervical Spine is difficult to xray in children (esp. odontoid view)
    1. Upper Cervical Spine (esp. C1-C3 Level) represents 75-83% of pediatric Cervical Spine injuries
    2. Children have a higher neck flexion point than adults (related to large head and Cervical Spine curvature)
  4. CT Imaging related radiation exposure carries a greater malignancy risk in children
  5. Clinical Decision Rules (e.g. NEXUS Criteria) are unreliable in under age 2 (and questionable in under age 8 years old)
  6. Red Flag: New radiculopathy or Myelopathy (hyperreflexia, Clonus, babinski, weakness), esp. if bilateral
    1. Obtain MRI prior to discharge (even with negative CT or other imaging)
    2. MRI for ligamentous instability with subluxation, Central Cord Syndrome, Vertebral Fracture
    3. Claudius and Gruen in Herbert (2018) EM:Rap 18(4): 16-7

IV. Physiology: Unique aspects of the pediatric Cervical Spine (under age 8 years old)

  1. Disproportionately large head
  2. Small caliber neck with weak Muscles and ligaments
  3. Vertebral Anatomy allows for greater slippage
    1. Vertebrae slope anteriorly to allow forward slippage
    2. Facet joints are shallow and more horizontal in children
  4. Discrepancy between spine flexibility and neurovacular flexibility
    1. Bony skeleton can stretch 2 inches without serious injury
    2. Neurovascular structures can withstand Stretching to only 0.25 inches

V. Mechanism

  1. Highest risk events or activities related to Cervical Spine Injury in children
    1. High speed Motor Vehicle Accidents (50-60% of all Cervical Spine injuries)
    2. Falls in younger children (20-30% of all Cervical Spine injuries)
    3. High impact sports (football, diving)
    4. Hanging Injury
  2. C-Spine Levels most commonly involved
    1. Infants and Toddlers (or Marfan Syndrome, Down Syndrome) up to age 9 years
      1. Atlanto-occipital joints (C1)
      2. Atlantoaxial joints (C1-C2)
    2. School Age Children and Teens
      1. Lower Cervical Spine (C5-C7)

VI. Risk Factors: Cervical Spine Injury After Blunt Trauma (Test Sensitivity: 92-98% for injury)

  1. Altered Mental Status
  2. Intubation
  3. Respiratory Distress
  4. Focal Neurologic Deficits
  5. Neck Pain
  6. Torticollis or inability to move neck
  7. Significant torso injury
  8. High risk mechanisms
    1. Diving Injury (or other axial load injury)
    2. High Risk MVA (head-on collision, rollover, ejection, death at scene, speed >55 MPH)
  9. Underlying comorbidity predisposing to spine injury
    1. Ankylosing Spondylitis
    2. Down Syndrome
  10. References
    1. Leonard (2011) Ann Emerg Med 58(2):145-55 +PMID:21035905 [PubMed]
    2. Leonard (2019) Pediatrics 144(1) +PMID:31221898 [PubMed]

VII. Types: SCIWORA

  1. Definition: Spinal Cord Injury without Radiographic Abnormality (SCIWORA)
    1. Normal CT and Cervical Spine XRay
    2. MRI Cervical Spine typically identifies significant injuries and predicts prognosis
  2. Background
    1. Increased elasticity of Cervical Spine ligaments
    2. Important cause of pediatric Spinal Cord Injury
    3. May be responsible for pre-hospital Trauma-related deaths
  3. Timing of neurologic deficit
    1. Most have onset in the first 24 hours
    2. Some presentations may be delayed weeks (or until future minor neck injury)
  4. MRI Cervical Spine
    1. Emergent indications
      1. Neurologic symptoms (Paresthesias, weakness or sensory deficits)
      2. Children under age 2 years with limited head movement
      3. Child Abuse
    2. Interpretation
      1. Best prognosis: Normal MRI or mild cord edema
      2. Worst prognosis: Major Hemorrhage

VIII. Types: Atlanto-occipital and atlanto-axial dislocations

  1. Age
    1. Age <3 years most commonly affected
  2. Mechanism
    1. High Cervical Spine Injury secondary to vertical distraction
    2. Typically seen in high speed Motor Vehicle Accidents
  3. Presentation
    1. Most commonly fatal at the accident scene
    2. Cervical Collars may provoke the distraction
  4. Findings on CT
    1. Joint widening between occiput-C1 or C1-C2 (unilateral or bilateral)
    2. Retropharyngeal space widening on C2

IX. Types: Dens Fracture

  1. Age
    1. Age <7 years old
  2. Findings on Cervical Spine XRay
    1. Peg of the dens is displaced anteriorly
    2. Fracture occurs at the synchondrosis (weak bony Growth Plate)

X. Imaging: Cervical Spine XRay

  1. See PECARN C-Spine Imaging Rule
  2. Precautions
    1. Cervical Spine XRay can not rule out high suspicion Pediatric C-Spine Injury
    2. CT Cervical Spine or MRI Cervical Spine is indicated where suspicion is high
  3. Odontoid view
    1. Unreliable in children under age 5 years old (due to compliance)
    2. When Pediatric Cervical Spine Injury occurs, it affects the upper Cervical Spine in 75% of cases
    3. If CT Head is done, ask radiology to extend CT to include C3
  4. Predental space
    1. Normal up to 5 mm in children
  5. Pseudo-subluxation of C2-C3
    1. Normal pediatric variant in 20% of children
    2. Line of Swischuk
      1. Line drawn between each anterior spinous process cortex
      2. Expect up to a 2mm displacement posteriorly of the C2 spinous process
      3. A difference >2mm is abnormal
  6. Efficacy
    1. C-Spine XRay Test Sensitivity in children: 90% (but only 83% in age <8 years old)
      1. Lack of odontoid views did not change Test Sensitivity
      2. Nigrovic (2012) Pediatr Emerg Care 28(5): 426-32 +PMID:22531194 [PubMed]
    2. Negative good quality C-Spine XRay in children does not require MRI confirmation
      1. However Fracture on C-Spine XRay should prompt MRI (changes management in 20% of cases)
      2. Derderian (2019) J Trauma Acute Care Surg 87(6): 1328-35 [PubMed]

XI. Imaging: Advanced Imaging

  1. See PECARN C-Spine Imaging Rule
  2. Precautions
    1. If CT Head is being performed, include C1-C3 on CT (esp. age <9 years old)
  3. CT Cervical Spine
    1. Given a high risk injury (see above), CT Cervical Spine is appropriate even in a younger child
      1. Consider CT Cervical Spine especially in the severe multi-system Trauma patient
      2. Cervical Spine XRay is preferred in lower risk injuries (ground level fall, minor MVA)
        1. Hannon (2015) Ann Emerg Med 65(3): 239-47 +PMID:25441248 [PubMed]
      3. Cervical MRI is preferred definitive evaluation in stable patients with moderate to high risk
    2. Risk of CT related malignancy from cervical CT
      1. Risk varies from 0.7% at age 1 year old for a girl down to 0.1% at age 15 years in a boy
      2. See Cancer Risk due to Diagnostic Radiology
      3. Brenner (2001) AJR Am J Roentgenol 176(2):289-96 +PMID:11159059 [PubMed]
  4. MRI Cervical Spine
    1. Consider as an alternative to CT in high risk injury, in a clinically stable patient who can undergo MRI
    2. Preferred advanced imaging if required as it demonstrates Ligamentous Injury (the higher risk in children)
    3. Indicated in neurologic deficits, transient Paresthesias, high level suspicion but negative CT Cervical Spine
    4. Younger children will require more resources (although 3 tesla MRI may allow images with only mild sedation)

XII. Management: Approach

  1. Assume Cervical Spine Injury present
    1. All children with multiple injuries or significant mechanism (e.g. MVA)
    2. Maintain C-Spine immobilzation until full clinical evaluation
    3. Clinical Decision Rules (e.g. NEXUS Criteria) may be unreliable in children
      1. Avoid in under age 2 years old
      2. Use only with caution in under age 8 years old (Test Sensitivity: 94%)
      3. Garton (2008) Neurosurgery 62(3): 700-8 [PubMed]
    4. Children under age 2 years (pre-verbal) warrant the closest of observation
      1. Most difficult to clear the Cervical Spine
  2. Falls less than 5 feet rarely cause C-Spine Injury
    1. XRay not needed if C-Spine ROM normal and no pain
    2. Schwartz (1997) Ann Emerg Med 30:249-52 [PubMed]
  3. Children under age 5 years old have significantly different injuries than older children and adults
    1. Spinal injuries in under age 5 years are typically ligamentous and higher level
    2. Those who have spinal injuries appear significantly ill or injured
      1. Brain injury (GCS <14 or GCS-eye:1)
      2. Intubated
    3. Children under age 5 years need spine imaging only if the following criteria are not met
      1. Not intubated and not comatose
      2. No motor or sensory neurologic findings
      3. No neck symptoms (no pain or Torticollis and freely moves neck)
      4. No painful distracting injury
      5. No unexplained Hypotension
    4. Clearing the c-spine
      1. Indicated if above criteria met (asymptomatic, normal Neurologic Exam)
      2. Remove Cervical Collar and palpate the neck for midline tenderness or deformity
      3. Observe for normal range of motion (direct neck movement if child can follow commands)
    5. References
      1. Arora and Menchine in Herbert (2015) EM:Rap 15(10): 10
      2. Hale (2015) J Trauma Acute Care Surg 78(5): 943-8 +PMID:25909413 [PubMed]
      3. Pieretti-Vanmarcke (2009) J Trauma 67(3): 543-9 [PubMed]
      4. Rozelle (2013) Neurosurgery 72 Suppl 2:205-26 +PMID:23417192 [PubMed]

XIII. Management: Canadian Pediatric Trauma Consensus Guidelines (2011)

  1. Unreliable patient (<2 years old, comatose)
    1. Abnormal Neurologic Exam
      1. Leave the Cervical Collar in place
      2. Cervical Spine MRI (or Cervical Spine CT)
      3. Spine Consult
    2. Normal Neurologic Exam
      1. Leave the Cervical Collar in place
      2. Imaging (Cervical Spine XRays and consider Cervical Spine CT)
        1. Spine imaging abnormal: Spine Consult
        2. Spine imaging normal
          1. Frequently reassess
          2. Spine consult if no improvement in Level of Consciousness within 24 to 72 hours
  2. Reliable patient
    1. Clear patient if able via Clinical Decision Rules (e.g. NEXUS Criteria)
      1. Discontinue Cervical Collar
    2. Obtain Cervical Spine XRay if unable to clear patient via decision rules
      1. Obtain AP and Lateral views (and odontoid if cooperative)
      2. Abnormal Neurologic Exam or abnormal or non-diagnostic XRay
        1. Leave the Cervical Collar in place
        2. Cervical Spine MRI (or Cervical Spine CT)
      3. Normal Neurologic Exam
        1. Age >8 years old: Clear based on repeat exam and history
        2. Age <8 years old
          1. If obtaining Head CT, extend down to include C3 (if radiology able to perform)
          2. Consider clearing patient based on serial exams and history
          3. If in doubt
            1. Obtain MRI Cervical Spine
            2. Consider Consultation with Spine Surgery
            3. Consider inpatient observation with serial exams
  3. References
    1. Chung (2011) J Trauma 70(4): 873-84 [PubMed]

XIV. References

  1. Claudius and Behar in Herbert (2012) EM:Rap 12(6): 6-8
  2. Gharahbaghian in Herbert (2017) EM:Rap 12(6): 7-9
  3. Spangler and Inaba in Herbert (2015) EM:Rap 15(12): 7-8

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