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Pediatric C-Spine Injury

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Pediatric C-Spine Injury Joshua Rocker, MD Schneider Children s Hospital LIJ Medical Center Anatomical Considerations Embryology Risk Factors Causes of Injury ... – PowerPoint PPT presentation

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Title: Pediatric C-Spine Injury


1
Pediatric C-Spine Injury
  • Joshua Rocker, MD
  • Schneider Childrens Hospital
  • LIJ Medical Center

2
  • Anatomical Considerations
  • Embryology
  • Risk Factors
  • Causes of Injury
  • Immobilization
  • Symptoms and Physical Exam
  • Radiography
  • Prediction Rules

3
Anatomical Considerations
4
Children lt8 years old
  • Relatively larger heads than body
  • Head circumference 50 adult by 2 yrs vs
    chest circumference, 8 yrs

5
Children lt8 years old
  • Cervical spine fulcrum
  • Moves caudally
  • C2-C3 at birth
  • C5-6 at 8 yr and older

6
Children lt8 years old
  • Weaker cervical musculature and increased laxity
    of ligaments
  • Immature vertebral joints
  • Horizontally inclined articulating facets
  • Facilitate sliding of upper c-spine

7
Childrens C-spine Injuries
  • More susceptible to
  • fractures through growth plates
  • ligamentous injuries
  • Why
  • Growth centers fragile to sheer forces during
    rapid decel or flex/ext
  • (particularly at the synchondrosis b/n odontoid
    and body of C2)

8
SCIWORA
  • Spinal Cord Injury without Radiological
    Abnormality
  • Theoretical increase risk in children
  • Young spinal column more elastic than spinal
    cord- can handle more distraction before rupture
  • 5cm vs 5-6mm

9
Children 8yrs and older
  • Equivalent to adult
  • Most injuries to vertebral bodies and arch
  • Lower C-spine

10
Embryology and why pediatric C-spines are
difficult to interpret
11
Embryological Considerations
  • C1 (Atlas) formed by 3 ossification sites
  • Anterior arch and 2 neural arches

12
Embryology C1
  • Anterior arch fuses with neural arches by 7 yrs.
    Before this non-fusion can be mistaken as fracture

13
Embryology C2
  • C2 (Axis) has four ossification centers
  • 2 neural arches
  • 1 for the body
  • 1 odontoid

14
Embryology C2
  • Body fuses with dens at 3-6 yrs
  • The fusion line or remnant of cartilagenous
    synchondrosis can be seen till 11 yrs

15
Embryology C3-C7
  • Same developmental pattern
  • 3 ossification centers
  • Neural arches fuse posteriorly 2-3 yrs
  • Body fuses with arches 3-6 yrs

16
Embryology
  • Coronal view Notice synchondroses

17
Predisposing risk factors
18
Congenital abnormalities
  • Downs Syndrome
  • 15 with atlantoaxial instability

19
Congenital abnormalities
  • Klippel-Feil
  • Fusion of cervical vertebrae

20
Congenital abnormalities
  • Morquio (MPS IV)
  • No galctose 6-sulfatase
  • Hypoplasia of odontoid

21
Congenital abnormalities
  • Larsens Syndrome
  • skeletal dysplasia with multiple joint
    dislocations, short stature, abnormal facial
    features

22
At Risk by History
  • Spinal Cord surgery
  • C-spine arthritis

23
Causes of Injuries
24
Causes of Injuries By age
  • Infants
  • Birth Trauma
  • 1-8 yrs
  • MVAs and falls
  • gt 8 yrs
  • Sports Injuries and MVAs

25
Causes of Injuries
  • Direct severe force to neck
  • Diving
  • Acceleration-deceleration

26
Causes of Injuries Mechanism
  • Hyperflexion
  • Hyperextension
  • Axial Load
  • Roatational
  • Blow to Chin

27
Causes of InjuriesHyperflexion
  • Most common
  • Cause wedge fracture of anterior vertebral bodies
  • Disruption of posterior elements
  • Ex
  • Clay-shovelers,
  • anterior teardrop fracture

28
Hyperflexion Clay-shovelers

29
Hyperflexion Teardrop fracture of anteroinferior
portion of vertebral body

30
Causes of Injuries Hyperextension
  • Compression of posterior elements
  • Disruption of anterior longitudinal ligament
  • Ex
  • Hangmans

31
Hyperextension Hangmans Fracture
32
Causes of injuries Axial Load
  • Direct load on top of head
  • May cause burst or comminuted fracture of C1.
  • May also cause injury caudal to C-spine
  • Ex
  • Jefferson fracture

33
Axial Load Jefferson fracture

34
Causes of Injuries
  • Rotational
  • Usually associated with additional injuries
  • Chin Trauma
  • Fractures of posterior teeth and mandibular
    condyles seen as a single injury pattern

35
Immobilization

36
Indications
  • Mechanism
  • Severe force
  • Diving
  • Accel-dec
  • PE
  • AMS
  • Neuro deficits
  • Multi-system trauma
  • Neck pain/tenderness
  • Distracting injuries

37
Ouch!!!!
  • 3-25 of patients with SC injury develop
    neurological deficits caused by manipulation
    during resuscitation or transport

38
Immobilize
  • Neck- in collar
  • Stif-Neck
  • Philadelphia
  • ProSplint
  • Body- on long backboard

39
Neutral Position
  • Not well defined
  • anatomical position of the head and torso that
    one assumes when standing and looking straight
    ahead
  • External auditory meatus is in line with the
    shoulder in the coronal plane
  • Supine without rotating or bending the spinal
    column ATLS

40
Neutral Position
  • Adults (gt8 yrs)
  • Require occiput elevation (1.3-9.5, 2cm)
  • Children
  • Special allowance b/c relatively large heads
  • Special peds boards with depressed area for head
  • Elevate back with padding (2.5cm)

41
Protocols
  • Do not reduce obvious deformities
  • Keep helmets in place unless need airway
  • Log roll onto board with support of head/neck and
    torso
  • Place wedges beside head to limit lateral movement

42
Protocols Airway
  • Jaw-thrust maneuver with in-line traction

43
Protocol Surgical Airway
  • Nasotracheal intubation
  • Contraindicated apnea, facial injuries (?fx of
    cribiform plate)
  • Orotracheal intubation with in-line stabilization
  • Surgical airway
  • Maxillofacial or laryngotracheal trauma

44
Symptoms and Physical Exam
45
Symptoms
  • Classic Triad
  • Local pain, muscle spasm and decreased ROM
  • Transient or persistent parasthesias or weakness
  • SCIWORA

46
Symptoms
  • Burning hands
  • Seen with football players
  • Transient burning in hands/fingers
  • Hyperextension of C-spine with SC contusion
  • Asymptomatic
  • Significant mechanism or distracting injury

47
Physical Exam
  • Essentials
  • Vital Signs
  • Neuro
  • Neck

48
Physical Exam
  • Vitals
  • Apnea or hypoventilation
  • Injuries to C3-C5
  • Spinal Shock
  • Hypotension, bradycardia, temperature instability

49
Physical Exam
  • Neuro exam
  • Tone, strength, sensation and reflexes
  • Up to 50 of children with C-spine injuries have
    neuro deficits

50
Tone
  • Loss of spontaneous breathing if injury above C4
  • Hypotonia
  • Lower motor neuron deficit
  • Spinal shock

51
Tone
  • Rectal tone
  • Absence- poor prognostic sign
  • Bulbocavernous reflex (S3-S4)
  • Squeezing glans, tapping on mons pubis, pulling
    on foley
  • Stimulate trigone of the bladder ? reflex
    contraction of anal sphincter

52
Strength
  • Dorsiflexion of the wrist
  • C6
  • Extension of the elbow
  • C7
  • Extension of the knee
  • L2-L4
  • Dorsiflexion of the great toe
  • L5

53
Sensory
  • Most common deficit with SC injuries
  • Level of sensory impairment localizes level of
    injury

54
Reflexes
  • Areflexia indicates spinal shock
  • Usually lasts less than 24 hours

55
Specific Injuries
  • Anterior Cord Syndrome
  • Hyperflexion and anterior cord compression
  • Paralysis and loss of pain WITHOUT loss of light
    touch or proprioception

56
Specific Injuries
  • Central Cord Syndrome
  • Hyperextension Injuries
  • Weakness greater in upper vs lower extremities

57
Specific Injuries
  • Brown-Sequard syndrome
  • Cord Hemisection
  • Ipsilateral
  • Paralysis, Loss of proprioception and light touch
  • Contralateral
  • Loss of pain and temperature

58
Specific Inuries
  • Horners Syndrome
  • Disruption of cervical sympathetic chain
  • Ptosis, miosis and anhidrosis

59
Neck Exam
  • Maintain in-line stabilization
  • Palpate spinous processes
  • Assess muscle spasm
  • Assess for deformities

60
Radiography
61
What to do?
  • If your suspicion of injury is high
  • get CT!!! (gt98 sensitive)
  • If low to moderate
  • get 3 view radiographs
  • AP, cross table lateral, odontoid (open mouth)
  • Lateral view identifies approx. 80-90 of fx,
    dislocations and subluxations

62
Plain Radiographs
  • Lateral
  • Must visualize all 7 cervical vertebrae
  • Include C7-T1 junction
  • If difficult visualizing
  • Gentle traction on arms (?)
  • Transaxillary (swimmers) view

63
Lateral view 4 curvilineal contour lines
  • Anterior vert body
  • Posterior vert body
  • Spinolaminar line
  • Tips of spinous
  • processes

64

65
Psuedosubluxation
  • C2 on C3
  • 20-40 of children
  • C3 on C4
  • 14

66
Swischuk line
  • line from the anterior
  • aspect of C1-C3
  • spinous processes
  • anterior C2
  • spinous process
  • within 2 mm

67
Soft tissue spaces
  • Prevertebral space/
  • Retropharngeal
  • C2- lt6mm
  • C6- lt22mm
  • C3/C4
  • lt8 yrs lt ½-2/3 diameter
  • of AP vertebral body
  • gt8 yrs lt 7mm

68
Soft tissue spaces
  • Predental space
  • lt8 yrs lt 4-5mm
  • gt8 yrs lt 3mm
  • Represents
  • Atlantoaxial instability or
  • rotational sublux or Jefferson fx

69
AP View
  • Height of vertebral
  • bodies similar
  • Spinous processess
  • aligned

70
Odontoid
  • Equal amounts of space
  • on each side of the dens
  • Lateral aspects of C1
  • should line up with the
  • lateral aspects of C2

71
Odontoid fractures
  • Types
  • 1
  • Apex of dens
  • 2
  • Base of dens
  • 3
  • Extends into body of C2

72
Odontoid Fracture types
73
Flexion-Extension View
  • May identify cervical instability, atlantoaxial
    joint instability or ligamentous injury
  • If suspicion still present with negative films
  • Adds little to evaluation

74
Oblique View
  • Better visualization of pedicules, facet
    alignment and posterior lamina or articular mass
    fractures
  • Usually add nothing

75
Prediction Rules
76
Prediction Rules
  • In alert and stable trauma patients establish
    rule to avoid irradiating low risk patients

77
Canadian C-Spine Rule
  • Stiell, et al JAMA, 2001
  • Prospective, but Canadian
  • 8924
  • Blunt trauma
  • GCS- 15
  • Stable vitals
  • SCI in 151 (1.7)
  • Rule 100 sensitive

78
Canadian Rule
  • High risk
  • gt 65 yrs
  • Dangerous mechanism
  • Fall gt1m/5 stairs
  • Axial load
  • MVA gt100km/hr
  • Motorized recreational vehicle
  • Bicycle vs immobile object
  • Paresthesias in extremities

79
Canadian Rule
  • Low risk if
  • Simple rear end MVA
  • Sitting position in ER
  • Ambulatory at scene
  • No neck pain at scene
  • Absence of mid-line tenderness

80
Canadian Rule
  • If low risk
  • Voluntarily and actively rotate neck 45 degrees
    both left and right
  • If able- no Xray

81
Canadian Rule
  • Validated study
  • 8923 enrolled
  • 169 with SCI (2)
  • Sensitivity 99.4
  • Specificity 45.1
  • But

82
Canadian C-Spine Rule
  • In adults!!!!!!!!

83
NEXUS National Emergency X-Radiography
Utilization Study
  • Hoffman, et al, NEJM, 2000
  • Prospective
  • 34,069 enrolled
  • Blunt trauma

84
NEXUS Rule
  • Get radiography unless all are met
  • No midline tenderness
  • Not intoxicated
  • No AMS
  • No focal neuro deficits
  • No distracting injuries

85
NEXUS Rule
  • SCI- 818 (2.4)
  • Sensitivity 99.6
  • Specificity 12.9

86
Comparing Canadian and NEXUS
  • Canadian rule more sensitive and more specific
  • Neither have been validated in settings other
    than where they were established

87
NEXUS- Children
  • Viccellio, et al, Pediatrics, 2001
  • NEXUS data, extract pediatric info
  • 3065 pts (9 of total)
  • lt18 yrs
  • SCI- 30 (0.98)

88
Viccellio, et al
  • SCIWORA- 0
  • SCI
  • Only 4/30 13.3 were younger then 9 yrs (said
    population made up 29.5 of total)
  • 0/30 0 younger than 2 yrs (2.9 of total)

89
Viccellio, et al
  • NEXUS decision rule 100 sensitive
  • Low risk- 603 of 3065
  • Reduction of Xrays in 19.7

90
Viccellio, et al
  • Conclusion
  • NEXUS is sensitive for peds
  • Need a prospective study of 80,000 cases to
    improve CI and even more for youngest peds
  • Can only be generalized for the adolescent
    population
  • SCIWORA more common in adults

91
Viccellio, et al
  • Discussion
  • Rarity of SCI in infants
  • Doesnt occur or lethal because of anatomy
    (damage to higher C-spine)

92
Jaffe, et al
  • Ann Emerg Med, 1987
  • Retrospective review of 206 children lt16
  • 8 variables neck pain, neck tenderness, limited
    ROM, hx of trauma to neck, abnl
    reflexes/sensation or MS.
  • 98 sensitive if 1 positive
  • Avoided radiation in 38

93
SO..
94
Remember
  • Anatomy
  • Risk factors
  • Mechanism
  • Symptoms
  • If Radiography
  • Ossification centers

95
Thank you!!!
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