Cervical Spine Injury

Carolyn Calpin

Introduction

Pediatric Differences

Increased mobility of the spine in children due to:
- Laxity of ligaments and spinous muscles
- Anterior wedging of vertebrae
- Shallow (horizontal) plane of facet joints, predisposes to subluxation rather than bony injury
- Poorly formed uncinate processes (lateral superior edge of vertebral body which forms bilateral ridges): risk of SCIWORA—Spinal Cord Injury Without Radiographic Abnormality
Larger head and weaker neck musculature in children cause 60-70% of C-spine fractures to occur in the C1/C2 range vs 16% in adults
More room around spinal cord in children; therefore, decreased incidence of neurologic deficits
More radiolucent cartilage in children, tapered (anterior sloped) vertebrae, multiple growth centers make X-rays difficult to interpret
Increased incidence of physiologic subluxation in children < 8 yrs: 24% at C2/C3, 14% at C3/C4

Age

Fulcrum

< 3

C2/C3

3-8

C3/C4

9-11

C4/C5

> 12

C5/C6
Variable interspinous distances especially between C6/C7, C1/C2

Cervical Spine Immobilization

Indications

Trauma with severe forces (motor vehicle accident, falls > child’s height)
Trauma associated with high-risk sports (diving, football, gymnastics, hockey)
Posttraumatic neck or back pain or tenderness
Posttraumatic limitation of neck mobility
Posttraumatic neurologic symptoms or signs
Multiple system trauma
Severe acceleration/deceleration events of the head
Suspected cervical neck injury for any reason
Trauma in a child with cervical spine vulnerability (Down syndrome, Klippel-Feil, Morquio, arthritis of the spine)

Immobilize with Cervical Collar and Spine Boards

Cervical Collar

Use appropriate size collar
If collar does not fit, use towels, other padding, or sandbags to deter movement

Spine Boards

Secure body as a unit:

Child’s neck is in relative kyphosis on hard spine board due to proportionately larger head size; can increase the risk of anterior subluxation with unstable fracture
Place padding under torso to extend head approximately 30° (neutral)
Align external auditory meatus with shoulders in a coronal plane
Tape head to board to prevent additional movement of cervical spine

Radiologic Approach

ABCs: Anatomy, Alignment, Bones, Cartilage, Soft Tissues

Anatomy	Visualize entire C-spine including C7-T1 junction
Alignment	Normal lordotic curves
	▪	Anterior vertebral line
	▪	Posterior vertebral line
	▪	Spinolaminar line
	▪	Spinous process tips
	▪	Superior tip of odontoid should align with anterior margin of foramen magnum
Bones	Anterior spinal column: vertebral bodies, intervertebral disc spaces
	▪	Posterior spinal column: pedicles, lamina, transverse processes, articulating pillars, spinous processes
	▪	Loss of height, abnormal wedging (> 3 mm), fractures
Cartilage	Intervertebral discs, growth plate
Soft Tissues	Predental, prevertebral spaces, anterior fat pad