Cervical injury (peds)

Background

  • C-spine injury uncommon in children but large head in age <8 creates system for upper cervical injury
  • Injuries most feared include atlanto-occipital dissociation (AOD) and atlantoaxial rotatory subluxation or fixation (AARF).

SCIWORA

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

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
  • AOD- can be devastating injury or even fatal

Differential Diagnosis

Cervical Spine Fractures and Dislocations

Evaluation

Algorithm for the evaluation of pediatric cervical spine injuries

C-Spine Clearance Without Imaging

<3 years old

  • GCS>13
  • no neurological deficit
  • no midline cervical tenderness to palpation
  • no painful distracting injury
  • no unexplained hypotension
  • not intoxicated
  • mechanism-image if: MVC, fall >10 feet, non-accidental trauma known or suspected

>3 years old

  • alert
  • no neurological deficit
  • no midline cervical ttp
  • no painful distracting injury
  • no unexplained hypotension
  • not intoxicated

Imaging

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 to characterize injury(3 position CT)
  3. Plain films otherwise acceptable
  • SCIWORA- full spinal column radiographic 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.
  • Neurosurgery consult for abnormalities

See Also

General/Adult

Pediatric

References

  • EB Medicine- EM Practice Guideline Update- Sept 2014- Updated Guidelines For Management Of Acute Cervical Spine And Spinal Cord Injury In Pediatric Patients
  • American Association of Neurological Surgeons and Congress of Neurological Surgeons in 2013.

Authors:

Ross Donaldson