Pediatric cervical spine trauma

Pediatric cervical spine injuries are rare and are associated with significant morbidity and mortality. Pediatric anatomy and physiology predispose to upper cervical spine injury and spinal cord injury without radiologic abnormality in contrast to lower cervical spine injury seen in adults. Care of pediatric patients is difficult because they have a greater head-to-body ratio than adults and may have difficulty cooperating with a history and physical examination. In evaluating a child with a suspected cervical spine injury, radiography may be supplemented with CT or MRI. Definitive management of pediatric cervical spine trauma must be adapted to the distinctive anatomy and growth potential of the patient. As with all injuries, prevention is necessary to reduce the incidence of trauma to the pediatric spine.     

Pediatric cervical spine instability

Cervical spine instability in children is rare but not exceptional and may be due to many factors. Although it mostly occurs at the upper cervical spine, all vertebrae from the occiput to T1 may be involved. It may be acute or chronic, occurring secondary to trauma or due to congenital anomaly, skeletal or metabolic dystrophy or rheumatoid arthritis. It can be isolated or associated with other musculoskeletal or visceral anomalies. A thorough knowledge of embryology, anatomy, physiology and physiopathology of the cervical spine in children is essential to avoid pitfalls, recognize normal variants and identify children at risk of developing cervical spine instability and undertake the appropriate treatment.     

Pediatric cervical spine injuries: defining the disease

BACKGROUND/PURPOSE: Pediatric cervical spine injuries are uncommon. Most previous studies have been hampered by the small number of patients available for evaluation. The purpose of this study is to determine the incidence and characteristics of pediatric cervical spine injury utilizing a multiinstitutional pediatric trauma database, and to assess the impact of age and level of spine injury on mortality rate. METHODS: All children with cervical spine injury entered into the National Pediatric Trauma Registry over a consecutive 10-year period were identified. Patients were stratified by age, mortality, presence or absence of bony injury, level of cervical spine injury, and presence of neurologic deficit. Data were analyzed utilizing Student's t test for continuous variables and chi(2) analysis for categorical variables. Statistical significance was accepted at the P less than .05 level. RESULTS: From a database of 75,172 injured children, 1,098 were identified with cervical spine injury, overall incidence 1.5%. The mean age of the study group was 11 +/- 5 years, and 61% were boys. Nine hundred eight children (83%) had bony spine injury. Distribution of bony injury among upper cervical spine, lower cervical spine, or both was 52%, 28%, and 7%, respectively. The remaining 13% comprised unspecified levels of injury. Upper cervical spine injuries were prevalent among all age groups (42%, age < or = 8; 58%, age > 8), whereas lower spine injuries predominated in older children (85%, age > 8). One third of children in the study group had neurologic injury, and half of these had no radiographic evidence of bony injury. Ninety-four children (24%) had a complete cord injury, and the remaining 76% had an incomplete spinal cord injury. One hundred eleven children (23%) with upper spine injury died compared with 11 children (4%) with lower spine injury. Mortality rate was highest (48%) in those with atlanto-occipital dislocation. CONCLUSIONS: From this, the largest experience with pediatric cervical spine injury, several conclusions can be drawn. (1) Cervical spine injury occurs in 1.5% of injured children. (2) Upper cervical spine injuries are not limited to younger children but are equally prevalent in both age groups. (3) Associated mortality rate is nearly 6-fold higher in patients with upper cervical injury. (4) Seventeen percent of children with cervical spine trauma show no radiologic anomaly, yet 50% of children with cervical spinal cord injury have no initial radiologic abnormalities. (5) Of those in whom cervical spine injury is associated with a neurologic deficit, the deficit is complete in 24% of children.     

Controversial cervical spine fractures: Classification and treatment

Cervical spine fractures remain a major source of morbidity and mortality but the treatment of many fractures is controversial. Recent studies have demonstrated that surgical treatment of many type II odontoid fractures leads to decreased morbidity and mortality. Controversy still remains about the treatment of C1 fractures, but the specific injury to the alar ligament can be helpful in guiding treatment. Subaxial cervical spine injury classification systems assess which injuries require surgery. These systems suggest burst fractures with neurologic deficits should be managed surgically, whereas those that lack neurologic symptoms and have an intact disco-ligamentous complex heal with orthotic treatment.     

Sagittal fractures of the cervical spine

Two cases of sagittal fracture of cervical vertebral bodies have been studied. The findings indicate that the fractures were a consequence of forces directed forwards against the posterior surfaces of the vertebral bodies due to flattening of the vertebral rings in an anterior-posterior direction.     

Pediatric spine fractures: a review of 137 hospital admissions

OBJECTIVE: The anatomy and biomechanics of the growing spine produce failure patterns different from those in adults. Spinal injury in the pediatric patient is a concern as prevention of further neurologic damage and deformity and the good potential for recovery make timely identification and appropriate treatment of such injury critical. A retrospective clinical case series was conducted to present data from a large series of pediatric patients with spine injuries from a single regional trauma center. METHODS: One hundred thirty-seven children with spine injuries were seen over 10 years and were divided into three age groups: 0-9, 10-14, and 15-17 years. Analysis of variance and chi2 were used to analyze differences between groups. RESULTS: There were 36 patients aged 0-9, 49 aged 10-14, and 52 aged 15-17. Spine injury incidence increased with age. Motor vehicular accidents were the most common cause in this series. There were 36% cervical, 34% thoracic, 29% lumbar, 34% multilevel contiguous, and 7% multilevel noncontiguous involvement. Nineteen percent had spinal cord injury. Thirteen of 21 complete neurologic injuries and all 3 incomplete injuries improved. Cord injury was more common in the 0-9 age group. Four of five patients with spinal cord injury without radiographic abnormality (SCIWORA) were in the 0-9 age group and had complete neurologic injuries. Young children with cervical injuries were more likely to die than older children. Fifty-three percent had associated injuries. Eighteen percent underwent decompression, fusion, and instrumentation. Two patients developed scoliosis. The complication rate in surgical patients was higher than in patients treated nonsurgically and in polytrauma patients. This may be related to the severity of the initial injury. CONCLUSIONS: Our results suggest age-related patterns of injury that differ from previous work. The incidence of cord injury is 20% with higher frequencies in the young child. Potential for neurologic recovery is good. Young children have a higher risk for death than older children. There was no predominance of cervical injuries in the young child. The incidence of SCIWORA was low. Higher complication rates were seen in polytrauma and surgical patients.     

Functional recovery after decompressive spine operation for cervical spine fractures

Ninety-nine patients with cervical spine fractures from C-4 through C-7 were operated upon from 1975 to 1981. Operation was performed to restore normal relationships between the spinal cord and roots and the spinal canal and foramina and to maintain these relationships by fusion when necessary. Neurological function was recorded pre- and postoperatively using a functional scale. Satisfactory fusion without adverse change in vertebral alignment was achieved in each patient. The average interval between injury and operation was 29 days. When neurological recovery was observed, it began promptly after operation, suggesting a cause and effect relationship.     

Multiple noncontiguous fractures of the cervical spine

Multiple noncontiguous fracture-subluxations of the cervical spine are fractures and subluxations separated by at least one normal intervening cervical vertebra. A review of all 66 consecutive cervical spine fractures treated by the Division of Neurosurgery at the University of Ottawa during 26 consecutive months revealed six such cases (9%). These injuries are more common than previously recognized. Special consideration is required in their treatment because of the presence of a mobile intermediate segment in some of these patients.     

Double level fractures of the cervical spine

Summary Sixten cases of double level fracture of the cervical spine treated at the Orthopaedic Clinic of Athens University from 1970 to 1983 are presented. These comprise 5.5% of all cervical fractures. The aetiology, mechanism of injury, neurological complications and management of these injuries is discussed. Awareness of double level fracture in the cervical spine will alert the clinician to a more careful examination allowing earlier diagnosis and treatment of these injuries. The problems in management are stressed.

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Résumé Présentation de 16 cas de fractures à deux niveaux du rachis cervical, traités à la clinique orthopédique de l'Université d'Athènes, de 1970 à 1983. Ceci représente 5,5% de l'ensemble des fractures cervicales. On discute létiologie, le mécanisme du traumatisme, les complications neurologiques et le traitement de ces lésions. La constation d'une fracture à deux niveaux du rachis cervical doit inciter le clinicien à un examen particulièrement minutieux, permettant un diagnostic et un traitement plus précoces. Les problèmes d'indication thérapeutique posés par ces fractures sont soulignés.

     

Anterior cervical spine fusion for unstable fractures

We present in this report the operative method we have used in 7 cases of fracture-dislocation of the lower cervical spine. The technique includes partial resection of the fractured vertebral body, removal of the adjacent discs, excision of posteriorly displaced bone and disc and anterior interbody fusion between the three vertebrae. The latter is performed using a cortico-cancellous graft taken from the iliac crest and further stability is achieved by a small AO plate. All the cases started motion 48 hours after operation without further external support. Although 6 of the cases showed neurological improvement, this cannot be at this stage attributed to the surgical treatment. Nevertheless, none was made worse by the operation.     

Anterior fusion for rotationally unstable cervical spine fractures

STUDY DESIGN: A retrospective analysis of 32 rotationally unstable cervical fractures treated by brace, halo vest, or posterior surgical constructs plus fusion is compared with a second, prospective study of 18 similar fractures treated by early anterior discectomy, fusion, and plating. OBJECTIVES: To characterize an often unrecognized fracture pattern and compare various methods of management to identify the most effective treatment. SUMMARY OF BACKGROUND DATA: The rotationally unstable cervical spine fracture (compression-extension Stage 1) involves a hyperextension and lateral flexion injury, resulting in a unilateral pedicle, facet complex, and/or lamina fracture under compression and anterior annular disruption under tension. This fracture pattern allows a rotatory spondylolisthesis of the spine around the axis of the intact lateral mass and facet complex. METHODS: A retrospective review was made of 284 cervical fractures, identifying 32 compression-extension Stage 1 fractures that were treated by a variety of techniques. The results of that study led to a second (prospective) study, in which 18 similar fractures were treated by early anterior discectomy, fusion, and plating. RESULTS: Nonoperative treatment was uniformly unsuccessful. Posterior stabilization and fusion procedures led to unsuccessful results in 45%, related either to late kyphosis because of disc collapse or the inability of midline stabilization procedures to control rotational instability. Anterior fusion resulted in solid union without residual deformity in all cases. All four patients in the prospective study with incomplete cord lesions showed improvement in cord function, as did seven patients who had radiculopathy. CONCLUSION: Although posterior bony injury is the usual radiographic finding, the anterior disc and anterior longitudinal ligament disruption are the more significant injuries and lead to late collapse and kyphotic deformity. Early anterior fusion is recommended in compression- extension Stage 1 cervical spine injuries.     

Brachial plexus injuries associated with cervical spine fractures

The concomitant occurrence of brachial plexus injuries and cervical spine fractures in three recent patients is reviewed. The injuries included a fracture or dislocation of the upper portion of the cervical spine and damage to the upper roots of the brachial plexus. All of the patients had associated head injuries and two suffered a spinal cord injury. Recognition of the brachial plexus injury was delayed in each case because of the associated injuries. Probable mechanisms of injury include forced lateral bending of the cervical spine, with or without rotation, combined with forcible depression of the shoulder. All three patients required surgical fusion and/or halo bracing. Two have persistent Erb-type palsies. Brachial plexus injuries must be suspected in all cervical spine injury patients.     

Epidemiology of cervical spine fractures in the US military

Background contextThe epidemiology of cervical spine fractures and associated spinal cord injury (SCI) has not previously been estimated within the American population.PurposeTo determine the incidence of cervical spine fractures and associated SCI and identify potential risk factors for these injuries in a large multicultural military population.Study designQuery of a prospectively collected military database.Patient sampleThe 13,813,333 military servicemembers serving in the US Armed Forces between 2000 and 2009.Outcome measuresThe Defense Medical Epidemiology Database (DMED) was queried to identify all servicemembers diagnosed with cervical spine fractures with and without SCI during the time period under investigation. Data were used to determine the incidence of cervical spine fractures and SCI as well as identify risk factors for their development.MethodsThe DMED was queried for the years 2000 to 2009 using the International Classification of Diseases, Ninth Revision, Clinical Modification code for cervical spine fractures with and without SCI (805.0, 805.1, 806.0, and 806.1). The database was also used to determine the total number of servicemembers within the military during the same period. The incidence of cervical spine fractures and fractures associated with SCI was determined, and unadjusted incidence rates were calculated for the demographic characteristics of sex, race, military rank, branch of service, and age. Adjusted incidence rate ratios were then determined using multivariate Poisson regression analysis to control for other factors in the model and identify significant risk factors for cervical spine fractures and cervical injuries associated with SCI.ResultsFrom 2000 to 2009, there were 4,048 cervical spine fractures in a population at risk of 13,813,333 servicemembers. The overall incidence of cervical spine fractures was 0.29 per 1,000 person-years, and the incidence of fracture associated SCI was 70 per 1,000,000. The cohorts at highest risk of cervical spine fracture were males, whites, Enlisted personnel, those serving in the Army, Navy, or Marine Corps, and servicemembers aged 20 to 29. Risk of fracture-associated SCI was significantly increased in males, Enlisted personnel, servicemembers in the Army, Navy, or Marines, and those aged 20 to 29.ConclusionsThis study is the largest population-based investigation to be conducted within the United States regarding the incidence of SCI and the only study addressing incidence and risk factors for cervical spine fractures. Male sex, white race, Enlisted military rank, service in the Army, Navy, or Marine Corps, and ages 20 to 29 were found to significantly increase the risk for cervical fractures and/or fracture associated SCI. Our findings support previously published data but also represent best available evidence based on the size and diversity of the population under study.Level of evidencePrognostic; Level II.     

‘Bouncy castles’ and cervical spine fractures: an under-recognized hazard

We have recently treated two adult patients with significant spinal injuries after using an inflatable ‘bouncy castle’. We highlight the risks associated with these devices in the adult age group and review the current literature. We conclude that these devices should carry a clear warning to adults that their use by above-14 is hazardous.