Cervical Spine Injuries In Children Research Articles

A prospective multicenter study of cervical spine injury in children.

Pediatric victims of blunt trauma have developmental and anatomic characteristics that can make it difficult to assess their risk of cervical spine injury (CSI). Previous reports, all retrospective in nature, have not identified any cases of CSI in either children or adults in the absence of neck pain, neurologic symptoms, distracting injury, or altered mental status. The objective of this study was to examine the incidence and spectrum of spine injury in patients who are younger than 18 years and to evaluate the efficacy of the National Emergency X-Radiography Utilization Study (NEXUS) decision instrument for obtaining cervical spine radiography in pediatric trauma victims. We performed a prospective, multicenter study to evaluate pediatric blunt trauma victims. All patients who presented to participating emergency departments underwent clinical evaluation before radiographic imaging. The presence or absence of the following criteria was noted: midline cervical tenderness, altered level of alertness, evidence of intoxication, neurologic abnormality, and presence of painful distracting injury. Presence or absence of each individual criterion was documented for each patient before radiographic imaging, unless the patient was judged to be too unstable to complete the clinical evaluation before radiographs. The decision to radiograph a patient was entirely at the physician's discretion and not driven by the NEXUS questionnaire. The presence or absence of CSI was based on the final interpretation of all radiographic studies. Data on all patients who were younger than 18 years were sequestered from the main database for separate analysis. There were 3065 patients (9.0% of all NEXUS patients) who were younger than 18 years in this cohort, 30 of whom (0.98%) sustained a CSI. Included in the study were 88 children who were younger than 2, 817 who were between 2 and 8, and 2160 who were 8 to 17. Fractures of the lower cervical vertebrae (C5-C7) accounted for 45.9% of pediatric CSIs. No case of spinal cord injury without radiographic abnormality was reported in any child in this study, although 22 cases were reported in adults. Only 4 of the 30 injured children were younger than 9 years, and none was younger than 2 years. Tenderness and distracting injury were the 2 most common abnormalities noted in patients with and without CSI. The decision rule correctly identified all pediatric CSI victims (sensitivity: 100.0%; 95% confidence interval: 87.8%-100.0%) and correctly designated 603 patients as low risk for CSI (negative predictive value: 100.0%; 95% confidence interval: 99.4%-100.0%). The lower cervical spine is the most common site of CSI in children, and fractures are the most common type of injury. CSI is rare among patients aged 8 years or younger. The NEXUS decision instrument performed well in children, and its use could reduce pediatric cervical spine imaging by nearly 20%. However, the small number of infants and toddlers in the study suggests caution in applying the NEXUS criteria to this particular age group.

Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center

Purpose: Cervical spine (C-spine) injuries occur infrequently in children but may be associated with significant disability and mortality. The purpose of this study was to review the experience of a level 1 pediatric trauma center to determine the epidemiology, risk factors, mechanisms, levels, types of injury, comorbid factors, and outcomes associated with these potentially devastating injuries. Methods: A retrospective analysis of 103 consecutive C-spine injuries treated at a level 1 pediatric trauma center over a 9½-year period (January 1991 through August 2000) was performed. Results: The mean age was 10.3 ± 5.2 years, and the male-to-female ratio was 1.6:1. The most common mechanism of injury was motor vehicle related (52%), followed by sporting injuries (27%). Football injuries accounted for 29% of all sports-related injuries. Sixty-eight percent of all children sustained injuries to C1 to C4; 25% to C5 to C7; and 7% to both. Spinal cord injury without radiographic abnormality (SCIWORA) occurred in 38%. Five patients had complete cord lesions involving the lower C-spine (C4 to C7); 4 of these were motor vehicle related, and all 4 patients died. Isolated C-spine injuries occurred in 43%, whereas 38% had associated closed head injuries (CHI). The overall mortality rate was 18.5%, most commonly motor vehicle related (95%), occurring in younger children (mean and median age 5 years) and associated with upper C-spine injuries (74%) and CHI (89%). C1 dislocations occurred in younger children (mean age, 6.6 years), most often as a result of motor vehicle-related trauma (especially pedestrians) and were associated with the highest injury severity score (ISS), longest length of stay (LOS), most CHIs, and the highest mortality rate (50%). C-spine fractures with or without SCI occurred most commonly as a result of falls and dives. Sporting injuries occurred almost exclusively in adolescent boys (mean age, 13.8 years) and were isolated injuries associated with a relatively low ISS and shorter LOS. Interestingly, 75% of sporting injuries showed SCIWORA, and all infants suffering from child abuse had SCIWORA. Conclusions: Mechanisms of injury are age related, with younger children sustaining C-spine injuries as a result of motor vehicle-related trauma and older adolescents commonly injured during sporting activities. C-spine injuries in children most commonly involve the upper C-spine, but complete lesions of the cord are associated more frequently with lower C-spine injuries. The type of C-spine injury is related to the mechanism of injury: SCIWORA is associated with sporting activities and child abuse, C-spine dislocations most commonly result from motor vehicle-related trauma (especially among pedestrians), and C-spine fractures occur most commonly as a result of falls and dives. Predictors of mortality include younger age, motor vehicle-related mechanism, C1 dislocations, high ISS greater than 25, and associated CHI. A high index of suspicion for SCIWORA is essential when evaluating adolescents with neck trauma associated with sporting injuries or victims of child abuse. J Pediatr Surg 36:1107-1114. Copyright © 2001 by W.B. Saunders Company.

Cervical spine trauma in the injured child: A tragic injury with potential for salvageable functional outcome

Background/Purpose: Cervical spine injuries are uncommon in children, and, therefore, presumptive immobilization and diagnosis remain controversial. The purpose of this study was to review the author's experience with cervical spine injuries in children to determine the incidence, injury mechanism, pattern of injury, and subsequent functional outcome. Methods: Fifty-two children over a 6-year period (1994 to 1999) with a cervical spine injury secondary to blunt trauma were identified (1.3% incidence). The functional independent measure (FIM) was assessed at the time of discharge in each of 3 categories: communication, feeding, and locomotion. Results: Mean age of the study children was 10.7 ± 0.7 years. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanism of injury included motor vehicle crash (52%), falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents (8%), and motorcycle crashes (4%). Seven patients died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlanto-occipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries. FIM scores were recorded for 18 patients. Seventeen communicated independently, 14 fed themselves independently, and 12 had independent locomotive function. Conclusions: Cervical spine injuries occur in children across a spectrum of ages. Although atlanto-occipital dislocation is a highly lethal event, children with C1 to C7 injuries have a high likelihood of reasonable independent functioning. J Pediatr Surg 35:1571-1575. Copyright © 2000 by W.B. Saunders Company.

Radiography of cervical spine injury in children: are flexion-extension radiographs useful for acute trauma?

We assessed the role of cervical spine flexion-extension radiographs in the acute evaluation of pediatric trauma patients. We performed a retrospective review of all pediatric trauma patients who underwent static cervical spine radiography followed by flexion-extension radiography during a 22-month period. We reviewed the mechanism of injury, physical examination findings, and patient age, and tabulated the results of initial and follow-up imaging studies. Two hundred forty seven children (age range, 1.6-18 years; mean age, 11.5 years) with a history of trauma underwent cervical spine radiography followed by flexion-extension radiography. Static cervical spine radiographs revealed normal findings in 224 patients (91%). Flexion-extension radiographs revealed normal findings for all patients with normal findings on cervical spine radiographs. Of 23 children (9%) with abnormal findings on static cervical spine radiographs, seven (30%) had congenital abnormalities visible on flexion-extension radiographs; 10 (43%) had traumatic injuries including fracture, subluxation, or soft-tissue swelling; two (9%) had instability; and six (26%) had questionable abnormalities that were noted on static cervical spine radiographs. In four patients (66%) with abnormal findings on static cervical spine radiographs, flexion-extension radiographs were helpful in ruling out abnormality. In children with a history of trauma and normal findings on static cervical spine radiographs, additional flexion-extension radiographs are of questionable use.

Evaluation of pediatric cervical spine injuries

To compare historical features, clinical examination findings, and radiographic results among pediatric patients with cervical spine injury (CSI), a retrospective review of patients who were diagnosed with CSI was undertaken. Two main groups were identified: radiographically evident cervical spine injury (RESCI), and spinal cord injury without radiographic abnormality (SCIWORA). Demographic, historical, clinical, and radiographic information was obtained from patients' charts and analyzed to determine factors associated with CSI and to determine the efficacy of the various radiographic views. Seventy-two children, ages from 1 month to 15 years (median age, 9 yrs), were included in the study. Sports-related injuries were the most common. Forty patients had RESCI and 32 had SCIWORA. Forty-nine (80%) of all the patients had abnormal findings on neck examination, and six (16%) of the RECSI group had abnormal neurological findings. Lateral radiographs had a sensitivity for CSI of 79%; a three-view radiographic series had a sensitivity of 94%. All patients with CSI who were clinically asymptomatic had both a high-risk injury mechanism and a distracting injury. CSI should be suspected in any child with abnormal findings on neck or neurological examination. A minimum of three radiographic cervical spine views should be obtained in the evaluation of CSI in children. Even in the face of a three-view series, CSI should be suspected in patients with an abnormal neck or neurological exam, high-risk mechanism of injury, or distracting injury.

Major Cervical Spine Injuries in Children and Adolescents

A population-based study of pediatric cervical spine trauma in the Auckland region over 7 years starting in March 1989 identified 32 patients younger than 15 years of age who sustained a fracture, dislocation, or major ligamentous injury including SCIWORA (spinal cord injury without radiographic abnormality). Thirty-one percent had associated injuries and 53% had abnormal neurologic findings on presentation. Children younger than 10 years of age with cervical spine trauma more commonly sustained the injury in a motor vehicle accident and had a preponderance of injuries of the upper cervical spine. Children 10 years of age or older were more often injured during sport or recreational activity and the injuries followed a more typically adult pattern. Treatment included closed reduction in two patients and posterior open reduction and stabilization in eight patients (25%) with one of these also requiring decompression. All patients treated surgically had a very satisfactory outcome.

Cervical spine injuries in children.

While cervical spine injuries are unusual in children, when they occur they frequently cause death or life-long disability. The primary care practitioner should be familiar with the signs and symptoms of cervical spine injuries, know the proper techniques of initial management, and engage in anticipatory guidance to prevent these injuries.

The Anterior Cervical Approach for Traumatic Injuries to the Cervical Spine in Children

In most cases of traumatic cervical spine injuries in children, nonoperative treatment, mainly external stabilization, is sufficient. When operative treatment is chosen, surgeons often recommend posterior stabilization. In a subset of pediatric patients, the anterior approach is indicated. The anterior operative approach was employed in six children three to 14 years of age who sustained trauma to the cervical spine. The injuries included severe hyperflexion injury with crush fracture and avulsion of the vertebral body, fracture-dislocation of the vertebral body with involvement of the posterior elements and the disk, and injuries that caused major anatomic deformity of the cervical spine with cord compression. Anterior decompression with bony fusion led to normal anatomic alignment with neurologic improvement in all patients. Follow-up evaluation as long as eight years showed solid fusion and remodeling of the bone grafts. The anterior approach should be used more frequently as the surgical procedure of choice in children with traumatic lesions of the cervical spine. The anterior approach provided direct visualization of the lesion, which enabled effective repair and stabilization, early ambulation with minimal morbidity, and significant long-term neurologic improvement.

Is Maxillofacial Injury an Indicator of Cervical Spine Injury in Children?

Is Maxillofacial Injury an Indicator of Cervical Spine Injury in Children?

Cervical Spine Injuries in Children

Cardiorespiratory arrest occurring immediately after multiple injuries is usually assumed to be due to severe cerebral injury, acute hemorrhage, or airway obstruction. We have identified a group of 19 children (mean age, 6.3 years) who presented with absent vital signs (VSA) or severe hypotension, unexplained by blood loss, where these findings were caused by injury to the high cervical spine and cord, demonstrated either by X-ray or postmortem examination. Fourteen had radiologic evidence of injury to the spine between C1 and C3. In two patients the bony injury was at the C6-7 level, while in two patients the cervical spine X-ray was normal. Eighteen of the 19 children were initially resuscitated but died from a combination of hypoxic/ischemic encephalopathy and cerebral injury. Sixteen patients underwent postmortem examination and in 13 there was evidence of cord laceration, up to and including cord transection. These findings demonstrate a distinct pattern of “juvenile” cervical spine injury involving the high spine and cord which results in either apnea and cardiorespiratory arrest, or severe hypotension. This previously unrecognized cause of cardiorespiratory arrest should be considered in all children presenting with VSA after multiple trauma, even when there is no apparent radiologic abnormality of the cervical spine.

Cervical Spine Injuries in Children

Cardiorespiratory arrest occurring immediately after multiple injuries is usually assumed to be due to severe cerebral injury, acute hemorrhage, or airway obstruction. We have identified a group of 19 children (mean age, 6.3 years) who presented with absent vital signs (VSA) or severe hypotension, unexplained by blood loss, where these findings were caused by injury to the high cervical spine and cord, demonstrated either by X-ray or postmortem examination. Fourteen had radiologic evidence of injury to the spine between C1 and C3. In two patients the bony injury was at the C6-7 level, while in two patients the cervical spine X-ray was normal. Eighteen of the 19 children were initially resuscitated but died from a combination of hypoxic/ischemic encephalopathy and cerebral injury. Sixteen patients underwent postmortem examination and in 13 there was evidence of cord laceration, up to and including cord transection. These findings demonstrate a distinct pattern of "juvenile" cervical spine injury involving the high spine and cord which results in either apnea and cardiorespiratory arrest, or severe hypotension. This previously unrecognized cause of cardiorespiratory arrest should be considered in all children presenting with VSA after multiple trauma, even when there is no apparent radiologic abnormality of the cervical spine.

Cervical spine injuries in children.

Review of 24 consecutive cases of cervical spine injuries in children were reviewed showed that this uncommon injury occurred at a rate of 1.2 cases per year. Associated injuries occurred in 38%, and neurologic injury occurred in 29%, including two deaths. Results showed that 43% of children with neurologic injuries recovered. Nonoperative treatment was successful in 95%; however, 14% later developed kyphotic deformities. Surgical stabilization is recommended for flexion injuries associated with late sequelae and for compression (burst) fractures associated with neurologic injuries.

Cervical spine injury in children: radiologic manifestations.

Cervical spine injury in children: radiologic manifestations.

Clinical Prediction of Cervical Spine Injuries in Children

Clinical Prediction of Cervical Spine Injuries in Children

Clinical prediction of cervical spine injuries in children. Radiographic abnormalities.

During the seven-year period from 1976 through 1982, 2133 cervical spine radiographs were obtained for children less than 18 years of age at two hospitals in Tucson. Twenty-five children (1.2%) had x-ray evidence of a cervical spine injury, with a male to female ratio of 4:1. Vehicular accidents accounted for 36% of cervical spine radiographic abnormalities, and sports or playground accidents accounted for an additional 36%. In an attempt to find clinical predictors that might identify x-ray abnormalities, we reviewed the medical records of these 25 children with abnormalities and 713 randomly selected children without x-ray evidence of cervical spine injuries for the following: method of injury, presenting complaints, physical examination findings, therapy, and complications. No single clinical predictor had a sensitivity of 100% when considered in isolation, but clinical assessment consisting of EITHER a complaint of neck pain OR involvement in a vehicular accident with head trauma would have correctly identified all 25 cases of cervical spine injury. If this information had been used prospectively, the number of cervical spine radiographs ordered would have been reduced by 32%. We conclude that the use of this clinical "marker" would have positively identified all children with cervical spine injuries and would have reduced by one third the cost and radiation exposure associated with cervical spine radiographs. Because of the serious consequences of missing a cervical spine injury, we suggest that other studies confirm these results before this information is accepted as a recommendation.

Cervical spine injuries in children.

Cervical spine injuries in children.

Clinical review of cervical spine injuries in children.

Clinical presentation is made of 18 cervical fractures occurring in children age 15 and under. Seven of 18 patients sustained neurological complications. The incidence of childhood cervical spine injury increases with age. Sixteen of 18 lesions were found in the C1 through C4 area in contrast to a greater involvement in adults in levels of C4 through C7. Although normal variations and anomalies are frequent in cervical spines in children, over treatment, at least initially, is recommended in all cases in which the diagnosis is in doubt.

Cervical-Spine Injuries in Children

Some children up to the age of nine years, who are normal otherwise, may show a partial anterior subluxation of the second on the third cervical vertebra. This is considered a normal variant in the appearance of lateral roentgenograms of the flexed cervical spine. A survey of forty-seven children in three different children's hospitals, all without symptoms or clinical evidence of neck disability, revealed that five children had marked subluxation of the second on the third cervical vertebra, and that three had borderline dislocations. Children who have these normal variations should not be subjected to extensive orthopaedic treatment, unless there has been a history of sufficient injury to the neck and clinical examination bears out the probability that these are pathological subluxations.