Pediatric cervical injuriesAHMAD ALTHEKAIR, MDCONSULTANT, PEDIATRIC EMERGENCY AND TRAUMA

Objectives Epidemiology

Mechanism of injury

Clinical presentation

Approach

Clinical vs. radiological clearance

Current evidence

Incidence Annually 30-46/1,000,000

Males 60-80%

MVCs35%

Falls25%

MVC vs. pedestrian

20%

Diving6%

sports14%

LEONARD ET AL, PEDIATRICS VOLUME 133, NUMBER 5, MAY 2014

Age variation <8 years are susceptible to higher cervical injuries (C1-C3) because of:

1. Larger heads than bodies2. Position of C-spine fulcrum3. Weaker cervical muscles4. Increased laxity of ligaments5. Immature vertebral joints

Anatomical predispositions

Causes

Mechanism of injury

COURTESY OF ALISON CHANTAL CAVINESS, MD.

Evaluation Symptoms:

◦ Classic triad of: local pain, muscle spasm, and decreased range of motion of the neck.

◦ Also may complain of transient or persistent paresthesia or weakness.◦ A retrospective review of 72 previously normal children with cervical spine

injury found that all those with asymptomatic injuries had both a high-risk injury mechanism and a distracting injury.

◦ “Burning hand syndrome”

“Neck immobilization should be maintained during evaluation and management”

BAKER ET A, AM J EMERG MED. 1999;17(3):230.

Evaluation Physical Examination:

◦ Vital signs, Neck exam and Neurologic exam.

In toddlers and infants with minor trauma and normal neurological exam; palpate C-spine and assess ROM. If normal, clinically cleared.

NEXUS criteria1. No cervical midline tenderness

2. No focal neurological deficit

3. No intoxication

4. Normal alertness

5. No painful distracting injuries

34,069 trauma victims in 21 nation-wide Emergency departments had 99% sensitivity for C-spine injuries and 99.6% for clinically significant C-spine injuries in adults.

HOFFMAN ET AL, N. ENGL. J. MED. 2000;343:94-9

Limitations in Pediatric 3,065 children were involved, 30 had C-spine injuries. Sensitivity 100% , Specificity 19.9%. None of the children studied was younger than 2 years, and only 817 (27%)

were younger than age 8 years .

PEDIATRICS 2001;108:E20

Further studies Single-center, 20-year review applied the NEXUS criteria to 190 children with significant cervical spine injury found that the criteria were 94% sensitive among children aged less than 8 years and 100% sensitive in those greater than age 8 years.

A Pediatric Emergency Care Applied Research Network (PECARN) study found that the NEXUS criteria were 83% sensitive among 539 children with spinal injury who presented to the emergency department. Of the 90 children missed by the NEXUS criteria, 58 (64%) were younger than 8 years of age.

GARTON ET AL, NEUROSURGERY 2008;62:700-8LEONARD ET AL, ANN EMERG MED 2011 AUG;58(2):145-55

Canadian C-spine Rules

Canadian C-spine vs. NEXUS

Canadian C-spine NEXUS

Sensitivity 99.4% 90.7% P<0.001

Specificity 45.1% 36.8% P<0.001

Radiography rates 55.9% 66.6% P<0.001

The Canadian C-spine Rule would have missed 1 patient and the NEXUS would have missed 16 patients with important injuries.

But, both are not meant for pediatric population.

STIELL ET AL, N ENGL J MED 2003; 349:2510-2518

Trauma Association of Canada

CHUNG ET AL, TRAUMA ASSOCIATION OF CANADA PEDIATRIC SUBCOMMITTEE NATIONAL PEDIATRIC CERVICAL SPINE EVALUATION PATHWAY: CONSENSUS GUIDELINES. J TRAUMA 2011

Trauma Association of Canada

CHUNG ET AL, TRAUMA ASSOCIATION OF CANADA PEDIATRIC SUBCOMMITTEE NATIONAL PEDIATRIC CERVICAL SPINE EVALUATION PATHWAY: CONSENSUS GUIDELINES. J TRAUMA 2011

Radiological evaluation Children with suspected cervical spine injury based on history or physical

examination must undergo radiologic evaluation (Cross-table lateral, AP and when obtainable open-mouth odontoid).

Indications High risk-mechanism:

◦ High speed motor vehicle collision, bicycle injury, diving or other activity with hyperextension or hyperflexion of neck, falls greater than body height, and other acceleration-deceleration injuries of the head.

Multiple system with severe injuries

Distracting pain

Injury above clavicle

Altered mental status

Neck pain, tenderness or limitation of movement

Acute neurological deficit

C-spine xrays• Coverage• Alignment• Disc spaces• Prevertebral soft tissues• Edge of image

Anterior vertebral linePosterior vertebral lineSpinolaminar line

C-spine xrays• Coverage• Alignment• Bone• Spacing• Soft tissues• Edge of image

C-spine xrays• This view is considered

adequate if it shows the alignment of the lateral processes of C1 and C2 (red circles)

• The distance between the peg and the lateral masses of C1 (asterisks) should be equal on each side

Extra views?

If C7/T1 has not been adequately viewed on the lateral image

Flexion / Extension views

If Normal plain films AND No neurological deficit AND continued neck pain AND can actively flex/extend neck for examination.

Efforts to reduce radiation A simple decision instrument based on clinical criteria can help physicians to identify reliably the patients who need radiography of the cervical spine after blunt trauma. Application of this instrument could reduce the use of imaging in such patients.

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.

HOFFMAN ET AL, N ENGL J MED. 2000;343(2):94.VICCELLIO ET AL, PEDIATRICS. 2001;108(2):E20.

More effortsCSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

The protocol used has been effective in detecting cervical spine injuries in noncommunicative children after trauma. The combination of clinical information and radiographic studies is essential for safely clearing the cervical spine in these complex situations. Clearance of the cervical spine without CT or MR imaging studies is possible in the majority of cases, even in very young patients.

PIERETTI-VANMARCKE ET AL, J TRAUMA. 2009;67(3):543.ANDERSON ET AL, J NEUROSURG PEDIATR. 2010;5(3):292.

Indications for CT C-spineLower or upper C-spines not visualized on plain films

Abnormal or suspicious C-spine on plain films

Suspicion of injury despite normal plain cervical radiographs

As part of initial evaluation of severe head trauma (GCS ≤12) instead of plain films

CHUNG ET AL, TRAUMA ASSOCIATION OF CANADA PEDIATRIC SUBCOMMITTEE NATIONAL PEDIATRIC CERVICAL SPINE EVALUATION PATHWAY: CONSENSUS GUIDELINES. J TRAUMA 2011; 70:873.

Indications for MRIChildren with an abnormal neurologic examination and those requiring imaging of the soft tissues of the spinal column and spinal cord

Patients with normal plain films but persistent concern for neurologic injury based upon history

Patients with prolonged loss of consciousness in whom cervical spine cannot be cleared by 24 to 72 hours post injury

CHUNG ET AL, TRAUMA ASSOCIATION OF CANADA PEDIATRIC SUBCOMMITTEE NATIONAL PEDIATRIC CERVICAL SPINE EVALUATION PATHWAY: CONSENSUS GUIDELINES. J TRAUMA 2011; 70:873.

Real life cases 7 year old girl cheerleader, fell from 4 meters on the back of her head and had loss of consciousness. C/O tingling sensation at her arms.

Case 2 14 year old involved in a fight and was hit with a stick to his forhead.

C/O multiple facial fractures

Case 3 11 year old boy on a bicycle not wearing helmet, smashed a phone booth and fell with severe orbital swelling.

Case 4 1 year and 6/12 old girl fell from 2nd floor balcony to the street. Unwitnessed. Crying from neck pain.

Take home messageThe patient's ability to walk does not exclude cervical spine injury.

Immobilization should be maintained until clearance.

Spinal cord injury can happen without radiological evidence.

Thank you