Cervical injury (peds)

Background

C-spine injury uncommon in children but large head in age <8 create system for upper cervical injury. Injuries most feared include atlanto-occipital dislocation(AOD) and atlantoaxial rotatory subluxation or fixation (AARF). Guidelines come from American Association of Neurological Surgeons and Congress of Neurological Surgeons in 2013.

Clinical Features

• Blunt trauma in pediatric population.
• AARF- may occur spontaneously or in trauma- exam shows head rotated, tilted or unable to turn past midline

C-Spine Clearance Without Imaging

• >3 years old

1. alert
2. no neurological deficit
3. no midline cervical ttp
4. no painful distracting injury
5. no unexplained hypotension
6. not intoxicated

• <3 years old

1. GCS>13
2. no neurological deficit
3. no midline cervical ttp
4. no painful distracting injury
5. no unexplained hypotension
6. not intoxicated
7. mechanism--not MVC, fall >10 feet, non-accidental trauma known or suspected

SCIWORA

• Spinal cord injury without radiographic abnormality
• Exam findings of myelopathy without abnormalities on XR or CT

Workup

• No imaging if above criteria met based upon age.
• CT c-spine for concern of Atlanto-occipital dislocation(AOD) or atlantoaxial rotatory subluxation or fixation (AARF)

1. AOD- CT to look for condyle-C1 interval (CCI)
2. AARF- C1-C2 motion analysis on CT to characterize injury(three positions)
3. Plain films otherwise acceptable

• SCIWORA- full spinal column radiographical imaging
  • MRI of suspected area of spinal damage
  • Assess spinal stability acutely and in follow-up with flex/ex films

Management

• Immobilization must account for relatively larger occiput using occipital recess or thoracic elevation to maintain c-spine neutrality.

See Also

• C-spine (nexus)

Sources

• EB Medicine- EM Practice Guideline Update- Sept 2014- Updated Guidelines For Management Of Acute Cervical Spine And Spinal Cord Injury In Pediatric Patients