Clearing the pediatric cervical spine following injury

Injury to the pediatric cervical spine is uncommon; however, a missed or delayed diagnosis can lead to disastrous consequences. Thus, following trauma, clearance of the pediatric cervical spine is important. Problematic issues include child compliance with examination, the complex anatomy of the pediatric cervical spine, lack of agreement on definitive imaging modalities, and the coordination of multiple medical specialties. Expediting clearance of the pediatric cervical spine requires an organized, multidisciplinary approach. In addition to systematic procedures within the emergency department, preventing missed and delayed diagnoses of cervical spine injury can be facilitated by applying a clear methodology for reviewing radiographs in conjunction with the child's clinical examination. This algorithm considers the adequacy of the images, alignment of the bony and soft-tissue elements, assessment of the cervical intervals, and the presence of abnormal angulation. Together with standard treatment, this protocol facilitates effective and expeditious clearance of the cervical spine.     

颈前路撑开提拉复位法治疗外伤性颈椎脱位

目的探讨外伤性颈椎脱位的改良复位术式及应用价值。方法对24例外伤性颈椎脱位采用前入路撑开提拉复位并行植骨内固定。采用日本骨科协会评分(JOA)、疼痛视觉模拟评分(VAS)对术前和术后1周、3个月、6个月、12个月、48个月治疗效果进行评定。结果所有患者获得随访3~48个月,术后颈椎脱位矫正率、受损椎体间高度及颈椎稳定性恢复良好、颈椎生理曲度和内固定装置位置良好,植骨融合;脊髓功能恢复情况:B级2例,C级3例,D级10例,E级9例。术后1周~48个月VAS、JOA评分均较术前明显改善,差异有统计学意义(P0.01)。结论前路撑开提拉复位法可早期对颈椎脱位进行有效复位,前路植骨内固定术后并发症少,减少受损神经细胞的死亡,进一步保护了神经功能,术后缩短了神经功能的恢复时间,适合临床推广应用。     

Traumatic extradural hematoma of the cervical spine

An example of a traumatic extradural hematoma of the cervical spine that occurred in a 32-year-old man who suffered from chronic ankylosing spondylitis is reported. Progressive sensory and motor deficit ensued some 3 hours after the patient fell from a standing position. The patient landed on his back, striking his head on the floor. After being helped up, he was able to walk unassisted to a nearby chair, where he sat down until his left lower extremity--and shortly afterwards, the right one--became numb and weak. On admission, the patient was found to have tetraparesis that was more pronounced in the lower extremities and associated with incomplete sensation to pinprick at level T7-T10. He also had painless distention of the urinary bladder. After a few hours, the weakness in his limbs increased and his sensory level rose to C5 bilaterally. A horizontal diastatic fracture across the vertebral body of C7 was discovered on plain x-ray films of the spine, and an extradural hematoma extending dorsally from C5 to T1 was revealed by emergency magnetic resonance imaging. After an emergency decompressive cervical laminectomy and removal of the clot, the patient rapidly regained complete neurological function, except with regard to both the urinary bladder and the rectum, which remained abnormal for almost 7 weeks after the operation.     

Characteristics of pediatric cervical spine injuries

PURPOSE: The objective of this study was to assess the mechanisms and patterns of injury and outcome in children with cervical (C) spine trauma. METHODS: We reviewed the National Pediatric Trauma Registry between April 1994 and March 1999 and identified (by ICD-9 criteria) all cases of blunt trauma victims with cervical fractures, dislocations, and spinal cord injuries without radiographic abnormality (SCIWORA). Data are shown as mean +/- SEM. RESULTS: During the 5-year period, the incidence of blunt C-spine injury was 1.6% (n = 408 of 24,740 total entries). Mean age was 10.5+/-0.3 (1 to 20) years, and 59% were boys. Leading mechanisms were motor vehicle accidents (n = 179; 44%), sports (n = 66; 16%), and pedestrian injuries (n = 57, 14%). Younger (< or =10 years) children more often sustained high (C1 to C4) vs low (C5 to C7) injuries (85% v 57%; P<.01) and also had a higher incidence of dislocations (31% v 20%; P<.01) and cord injuries (26% v 14%; P<.01), whereas older children had more C-spine fractures (66% v 43%; P<0.01). Mortality rates (overall, 17%) were higher in younger children (n = 180) when compared with older children (n = 228; 30% v 7%; P<.01). Overall, the majority of deaths (93%) were associated with brain injuries. No children with cervical dislocations had neurologic sequelae. The preponderance of children with fractures (83%) also were without neurologic injury, whereas those associated with SCIWORA usually were (80%) partial. Overall, complete cord lesions were infrequent (4%). CONCLUSIONS: These data, representing the largest series to date, confirm that blunt C-spine injuries in children are rare. Patterns of injury vary significantly according to child age. Major neurologic sequelae in survivors is uncommon, does not correlate well with cord level, and rarely is complete.     

Traumatic subluxation of the axis after hyperflexion injury of the cervical spine in children

Six cases of children (four boys and two girls, mean age 11 years) who had traumatic subluxation of the axis (C2) were reviewed retrospectively. Initial radiographs demonstrated no detectable vertebral fracture in any of the children. However, a slight anterior subluxation of C2 was observed in three of the patients. Radiographs, taken at 1 month after injury in all but one patient, revealed a progression of the subluxation and a local kyphosis in all of the patients. Four of the children were treated conservatively with a cervical brace, and an improvement of both the kyphosis and the anterior slippage of C2 was obtained accompanied by an anteroposterior growth of the C3 vertebral body. The kyphosis of two of the patients became severe and, ultimately, these patients underwent fusion surgery. At the follow-up, none of the patients presented with any significant symptom. For the correct diagnosis of traumatic subluxation of C2, sequential radiographs to confirm the progression of subluxation and local kyphosis are mandatory. Conservative treatment rather than early surgical treatment may be chosen for this injury, because mild and moderate kyphosis can be corrected spontaneously by remodeling of the cervical spine.     

Management of cervical spine injury

Field assessment, neck immobilization, oxygenation and maintenance of the airway occur in suspected cervical-spine-injured patients before transport to a regional spinal cord injury centre. After cervical spine radiography, bony alignment of the spinal column is re-established and mean blood pressure is maintained at 80–90mmHg with fluids and, if necessary, inotropic support. Predetermined guidelines are used for intubation and ventilation and for invasive monitoring of patients in spinal shock. Fluid challenge is used to assess reserve cardiac function and the need for fluid infusion, restriction or inotropic support. Evoked potential monitoring provides a non-invasive, objective and sensitive method to assess neuroconduction through a spinal cord injury and may be used to replace a wake-up test intraoperatively. There are no randomized prospective studies showing that surgical decompression and/or internal stabilization improves outcome compared with non-surgical treatment of acute cervical spine injury. Respiratory failure is managed by long-term ventilator support, diaphragm pacing or use of glossopharyngeal breathing. Chest physiotherapy is helpful in reducing the occurrence of atelectasis and pneumonia. Hyperreflexic syndromes during surgery are avoided with adequate anaesthesia during stimulation. An area with a population near one million should designate a regional spinal cord injury centre. Such centres decrease the proportion of patients with complete neurological injury.     

Kinematics of cervical spine injury

Summary This paper, based on functional radiological knowledge of normal cervical spine kinematics, develops the hypothesis that compressive vertebral injury can be produced by abrupt reversal of curve between hyperflexed and hyperextended parts of the cervical spine. Reversal of curve occurs when the main vector of a compressive force passes between two centers of flexion-extension motion. The hypothesis more clearly explains reverse dislocation of fractured vertebrae than the current concept of Whitley and Forsyth of motion of the head through an arc. The mechanism of injuries with characteristics of hyperflexion of one segment and hyperextension of an adjacent segment, e.g., in certain types of hangman's fractures, is better understood. The hypothesis is expected to be helpful in guiding experimental cervical spine injury, as it relates direction of force to level and type of the resulting vertebral injury.     

Traumatic rotatory displacement of the lower cervical spine

The authors describe the classification for traumatic rotary injuries of the cervical spine. The classification is based on a review of 306 severe lower cervical spine injuries observed in 255 patients between 1980 and 1994. Traumatic rotatory displacements (TRD) represented 39% of the 306 severe injuries. Three different lesions were observed: unilateral facet fractures, fracture-separation of the articular pillars, and unilateral facet dislocations.     

Traumatic and neoplastic instability of the cervical spine

Determining the stability of the cervical spine is paramount to the successful management of patients with cervical spine trauma or neoplastic disease. While this article will discuss both traumatic instability and neoplastic instability, the underlying pathology of each requires a different approach. Traumatic cervical spine injuries must be broken down into upper and lower cervical spine injuries, and the stability is predicated on both the boney and ligamentous injury. This article will go through the different fracture patterns and discuss the stability of each one. Additionally, it will discuss the important biomechanical and clinical issues that lead to the diagnosis of metastatic instability in the cervical spine.     

Traumatic cervical spine injuries in childhood and adolescence

Of 84 consecutive children and adolescents with traumatic cervical spine injuries treated over a 10-year period, 61 (73%) were available for review. Age ranged from the newborn period to 17 years. Analysis of injury type revealed four groups of roughly equal incidence: atlantoaxial rotary subluxation, upper cervical fracture or dislocation, lower cervical injury, and spinal cord injury without radiographic abnormality. Forty-four percent of patients incurred a neurologic injury. Falling from a height was the most common mechanism of injury. Apart from patients with complete neurologic deficits, the prognosis for these injuries is good.     

Traumatic brain injury in pediatric patients

Traumatic brain injury (TBI) in children is frequent, sometimes lethal, and may have life-long consequences in survivors. Prevention at school and in sports, including both kids and families, is of paramount importance. Scarce data are available in terms of epidemiology, physiopathology, management and prognosis. This non-systematic review suggests that rational organization of rescue and transport to designated hospitals, linked with early diagnosis/removal of surgical masses and comprehensive monitoring and intensive care, offer the best chances for reducing mortality and morbidity in severe cases. After the acute phase rehabilitation and families play a fundamental role.     

Occult ligamentous injury of the cervical spine associated with cervical spine fracture

We report the case of a 20-year-old patient with a C5 cervical spine fracture and an undetected ligamentous lesion between C1 and C2. Cervical spine lesion protocols and the rates of lesions that are not diagnosed with standard evaluation protocols are reviewed, with particular emphasis on comatose patients. Dynamic studies during the surgical procedure for fixation of the fracture are recommended to increase the detection of ligamentous lesions.     

Risk factors for cervical spine injury

IntroductionThe early recognition of cervical spine injury remains a top priority of acute trauma care. Missed diagnoses can lead to exacerbation of an existing injury and potentially devastating consequences. We sought to identify predictors of cervical spine injury.MethodsTrauma registry records for blunt trauma patients cared for at a Level I Trauma Centre from 1997 to 2002 were examined. Cervical spine injury included all cervical dislocations, fractures, fractures with spinal cord injury, and isolated spinal cord injuries. Univariate and adjusted odds ratios (ORs) were calculated to identify potential risk factors. Variables and two-way interaction terms were subjected to multivariate analysis using backward conditional stepwise logistic regression.ResultsData from 18,644 patients, with 55,609 injuries, were examined. A total of 1255 individuals (6.7%) had cervical spine injuries. Motor Vehicle Collision (MVC) (odds ratio (OR) of 1.61 (1.26, 2.06)), fall (OR of 2.14 (1.63, 2.79)), age <40 (OR of 1.75 (1.38–2.17)), pelvic fracture (OR of 9.18 (6.96, 12.11)), Injury Severity Score (ISS) >15 (OR of 7.55 (6.16–9.25)), were all significant individual predictors of cervical spine injury. Neither facial fracture nor head injury alone were associated with an increased risk of cervical spine injury. Significant interactions between pelvic fracture and fall and pelvic fracture and head injury were associated with a markedly increased risk of cervical spine (OR 19.6 (13.1, 28.8)) and (OR 27.2 (10.0–51.3)).ConclusionsMVC and falls were independently associated with cervical spine injury. Pelvic fracture and fall and pelvic fracture and head injury, had a greater than multiplicative interaction and high risk for cervical spine injury, warranting increased vigilance in the evaluation of patients with this combination of injuries.