Cervical Spine Injury

<Presentations>

<Index>

 

-  Paeds (<16yrs)

 

Features

-   

 

Ix

-   

 

Mx

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Cervical Spine Injury - Paediatric

<C Spine Injury>

 

 

Definition

-  Injury to cervical spine in children & adolescents

 

Features

-  Rare in children

-  Usually from severe blunt trauma

-  <8yrs more susceptible to C1 – C3 injuries

-  Head to body proportion

-  Cervical spine fulcrum progressively moves caudally from C2/3 at birth to C5/6 at 8yrs

-  Immature vertebral joints

-  >8yrs vertebral body or arch fractures in lower cervical spine

 

Risk Factors

-  Syndromes

-  Down syndrome: 15% have atlantoaxial instability

-  Klippel-Feil syndrome

-  Morquio syndrome

-  Larsen syndrome..

-  Hx of cervical spine surgery or arthritis

 

Cause

-  Birth: breech delivery

-  0 – 8yrs: MVA, fall

-  >8yrs: MVA, sports

-  Most cord injuries from fracture fragments or vertebral subluxation

-  Mechanism

-  Assume injury based on mechanism if <3yrs old

-  Hyperflexion

-   Most common

-   Cause wedge fractures of anterior body + disruption of posterior elements

-   Clay-shovellers fracture

-   Teardrop fracture

-  Hyperextension

-   Cause compression of posterior elements + disruption of ant. longitudinal ligament

-   Hangmans fracture

-  Axial loading

-   Cause burst or comminuted fractures of C1 arch

-   Jefferson burst fracture

-  Rotational

-   Facet fracture or dislocation

 

Associated S/S

-  Chin trauma may be associated w C-Spine injuries

-  Some pts asymptomatic

-  Neck exam

-  Decreased ROM

-  Spinous process tenderness

-  Muscle spasm

-  Deformity

-  Neuro exam

-  50% w cord injuries have neuro defecit

-  Transient or persistant paresthesia or weakness

-   Burning hand syndrome

-   Transient S/S may be only indication of cord injury

-  Some pts may be albe to walk immediately post event

-  Strength

-   Wrist dorsiflexion: C6

-   Elbow extension: C7

-   Knee extension: L2 – L4

-   1st toe dorsiflexion: L5

-  Sensory defecit

-   Most common neuro finding

-   Ipsilateral post column + contralateral ant column by light touch

-   Anterolateral column by pinprick

-   Ipsilateral post column by propioception

-  Rectal tone

-   Absence is poor prognostic sign

 

Cervical Spinal Cord Syndromes

-  Anterior Cord Syndromes

-  From hyperflexion

-  Caused by ant cord compression

-  Paralysis & loss of pain wo loss of light touch or propioception below injury

-  Central Cord Syndromes

-  From hyperextension

-  Weakness greater in upper vs lower extremity

-  Transient burning sensation in hands & fingers

-  Brown-Sequard Syndrome

-  Cord hemisection

-  Ipsilateral paralysis, loss of propioception & light touch

-  Contralateral loss of pain & temp

-  Horners Syndrome

 

Ix

-  Vitals

-  Apnoea, hyperventilation: C3 – C5 injury

-  Hypotension, bradycardia: spinal shock

-  Temp instability: spinal shock

-  X-Rays

-  Cross table lateral, AP +/- open mouth odontoid

-   Lateral views

-   80% fractures, dislocations & subluxations

-   Must visualise all 7 cervical vertebrae (+/- Swimmers view if necessary)

-   Alterations in height or uniformity of disc spaces

-   Overriding of facets

-   Rotation of spinous process

-   Disruption in one of 4 curvilinear contour lines

-  Ant vertebral body line

-  Post vertebral body line

-  Spinolaminar line

-  Spinous process tips line

-   AP view

-   Lateral mass fractures

-   Spinous processes in midline

-   Odontoid view

-   In children >9yrs old

-   Longitudinal or transverse fractures

-   Lateral aspect C1

-  Symetric & equal distance from dens

-  Line up w lateral aspect C2

-  Careful examination for C1 – C3 injuries

-   Odontoid fractures

-   Atlantoaxial dislocations or subluxations

-   Hyperextension fractures of axis

-   DDx normal anatomical variants

-  +/- CT

-  Not routine

-  Indicated if

-   Inadequate X-rays

-   Suspicious X-rays

-   Fracture or displacement on X-rays

-   High clinical suspicion w normal X-rays

-  +/- MRI

 

Mx

-  Cervical collar

-  All children suspected of injury need immobilisation until excluded

-  NEXUS criteria: C-Spine clearance

-  Neurosurgical opinion

 

 

 

References

 

Upto Date: Evaluation of Cervical Spine Injuries in Children & Adolescents: Jan 2011