Pediatric cervical spine, blunt cerebrovascular, and penetrating palate injuries are rare but potentially life-threatening injuries that demand immediate stabilization and treatment. Balancing the risk of a missed injury with radiation exposure and the need for sedation is critical in evaluating children for these injuries. Unfortunately, effective clinical decision tools used in adult trauma cannot be uniformly applied to children. Careful risk stratification based on history, mechanism and examination is imperative to evaluate these injuries judiciously in the pediatric population. This article presents a review of the most up-to-date literature on pediatric neck trauma.
Key points
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Cervical spine injuries are less common in the pediatric population compared to adults.
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There are many immobilization and imaging protocols for pediatric cervical spine clearance. Research is ongoing to create a national, best practice pediatric cervical spine clearance protocol.
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To minimize radiation exposure, effort should be made to clinically clear the cervical spine and use radiographs as the initial imaging modality when appropriate.
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The cervical seatbelt sign, in isolation, is not a predictor of blunt cerebrovascular injuries in children.
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Penetrating palatal injuries in children are common. Neurologic complications are exceedingly rare but carry a high risk of morbidity and mortality.
Cervical spine injuries
Background and Epidemiology
Pediatric cervical spine injuries (CSIs) are fortunately rare, occurring in 1% to 2% of pediatric trauma patients admitted to the hospital. The overall incidence of CSIs is low. However, CSIs can result in devastating injuries, so it is crucial for emergency medicine providers to understand how to properly evaluate for CSIs in the pediatric population. Evaluating for CSIs in children presents a unique challenge due to age-related anatomic differences that exist until 8 years of age. , In addition, the benefits and risks of imaging, including radiation exposure and the potential need for sedation, must be considered when evaluating children for CSIs.
Children less than 8 years old are more susceptible to injury higher in the cervical spine (c-spine) compared to older children due to several key features. At birth, the c-spine fulcrum is at C2–C3 and progresses caudally as the child grows to be close to adult configuration at C5–C6 by 8 years of age. Children have larger heads compared with body size; by approximately 2 years of age, a child’s head is 50% of adult size. Children have underdeveloped paraspinous muscles to support an already large head compared with overall body size, more laxity in the ligaments, immature joints, and horizontal oriented facets in the upper c-spine, allowing for an increasing range of flexion and extension. As a result of these anatomic differences, children less than 8 years old are more likely to injure the axial region (C1–C2), which account for 74% of CSIs under 2 years old and 78% in those ages 2 to 7 years. Special consideration should also be given to those children with underlying medical conditions that predispose them to c-spine instability. , , Special consideration should be given to children with medical conditions that increase their risk of CSI due to atlantoaxial instability, increased joint laxity, decreased range of motion, and abnormal bone integrity ( Table 1 ). ,
| Category | Conditions |
|---|---|
| Abnormal development of the c-spine |
|
| Abnormal bone and soft tissue |
|
| Arthritis |
|
| History of CSI or surgery |
As the c-spine matures, the injury pattern and risk change. Older children, age 8 to 15 years old, are more likely to have subaxial (C3–C7) injuries (53%). Motor vehicle crashes (MVCs) are the most common cause of CSIs in children up to age 8 year old, comprising 56% to 73% of CSIs in this age group. , Children older than 8 years of age are more susceptible to fractures compared with younger children. MVCs and sports-related injuries are the most common mechanism of injury for children 8 years of age and older. Football, diving, and bicycle accidents, in descending order, are the sports related injuries most frequently associated with c-spine injury.
Clinical Relevance
Evaluating children for CSIs can be challenging, particularly if the child is preverbal or is developmentally delayed. Injured children often present to the emergency department with their c-spine already immobilized. In patients who are not in c-spine immobilization, careful observation of neck movement before touching the child is important. A lack of movement or restricted range of motion can be signs of pain or weakness. Retrospectively, 8 factors have been identified to predict CSI in children: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to c-spine vulnerability, diving, and high-risk MVC. This 8-variable model for CSI is currently under prospective investigation for validation. Children are at increased odds of having CSIs from sports or recreational injuries if they have focal neurologic abnormalities or neck pain on examination and if they report diving or significant axial load.
Evaluation
Patients presenting with altered mental status, neurologic deficit, neck pain, severe mechanism such as a diving injury, high-risk MVC, or distracting injury should have their c-spine immobilized immediately in a rigid cervical collar. The challenge in evaluating pediatric patients for CSIs is determining which children can have their c-spine cleared clinically and which ones warrant imaging. Unfortunately, frequently used c-spine radiograph guidelines in adults derived from the National Emergency Radiography Utilization Low-Risk Criteria and Canadian C-spine Rule have not been shown to be sensitive or specific enough to be used in the pediatric population.
The Pediatric C-spine Clearance Working Group (PCSCWG) published a comprehensive pediatric c-spine clearance algorithm in Pediatrics in 2019. Based on the PCSCWG clearance algorithm, a provider may clinically clear a c-spine given a low-risk mechanism, provided the patient’s history and clinical examination are without risk factors ( Table 2 ).
| History | Physical Examination |
|---|---|
| Child or parent reports persistent neck pain, abnormal head posture, or difficulty with neck movement | Visible known substantial injury to chest, abdomen or pelvis (injury that is life-threatening, warrants surgical intervention or inpatient admission) |
| History of focal sensory abnormality or motor deficit | GCS of <14 |
| Torticollis/abnormal head position | |
| Posterior midline neck tenderness | |
| Limited cervical range of motion | |
| Inability to maintain focus due to other injuries |
Clinically clearing a c-spine suggests low clinical concern for an acute fracture, ligamentous, or neurologic injury to the c-spine. This evaluation can be done in patients with a low-risk history for a CSI, no neurologic deficits or symptoms, a Glasgow Coma Scale of 14 to 15, and without a significant distracting injury. The process of clinically clearing a c-spine in children is similar to the process in adults.
Imaging
The decision to obtain imaging should balance the index of suspicion of injury with the risks and costs of exposing a pediatric patient to radiation. To guide imaging choices, many pediatric trauma centers, such as Children’s National Hospital in Washington, DC, have developed their own algorithms ( Fig. 1 ), based on a hybrid of National Emergency Radiography Utilization Low-Risk and Canadian C-spine Rule. In 2019, the PCSCWG published an algorithm, like many pediatric trauma centers. The PCSCWG algorithm incorporates consultation with a spine service earlier in their decision tree, which could be a barrier at institutions without a pediatric spine service. However, providers should strongly consider transferring any pediatric patient less than 15 years old with a c-spine injury to a center with specialized pediatric spine care.
When clinical clearance is not possible, the initial default imaging modality should be radiographs in a patient without focal neurologic deficits and a Glasgow Coma Score (GCS) of 14 to 15. Routinely, a lateral c-spine radiograph should be obtained ( Fig. 2 ). An anterior–posterior view should be considered in those patients that are likely to be discharged home. Odontoid views can be challenging to obtain due to positioning and cooperation in younger children and should only be obtained for concerning mechanisms of injury, such as hanging or clotheslining injuries ( Fig. 3 ). The Water’s view is an alternative to the odontoid view for children who cannot cooperate with the open-mouth positioning when detailed view of C1 to C2 is necessary. If radiographs are normal and a GCS of 14 to 15 without focal neurologic deficits, the provider should attempt to clinically clear the c-spine after analgesia.
If clinical clearance is still not possible, the next step suggested is to obtain a computed tomography (CT) scan of the c-spine without contrast. A CT scan without contrast should be the initial imaging modality if the patient has an abnormal neurologic examination or a GCS of less than 8. A conventional CT scan is preferred over a helical CT scan to minimize the radiation exposure while still obtaining the radiographical information necessary to make clinical decisions. , Neurosurgery should be involved in the care of patients who have an abnormality on a CT scan or focal neurologic deficits. If the CT scan of the c-spine is normal, you are unable to clinically clear the c-spine based on examination, and there is no other indication for admission, the patient should be discharged home in a rigid c-collar, with strict C-spine immobilization precautions and follow-up with either trauma surgery or neurosurgery in 1 to 2 weeks.
Other imaging modalities such as MRI are indicated for infants with CSIs due to nonaccidental trauma and patients with focal neurologic abnormalities. Obtaining an MRI from the emergency department can be challenging due to the length of the study and potential need for sedation. For this reason, if an MRI is indicated, the decision should be made with the subspecialists involved (trauma surgery, neurosurgery, orthopedic surgery) to determine if the patient should be admitted with c-spine immobilization for an inpatient MRI.
Considerations
Children are susceptible to many of the same CSIs as adults. However, there are several CSIs that are unique to the pediatric population: atlantoaxial rotary subluxation, pseudosubluxation, and spinal cord injury without radiographic abnormality (SCIWORA). Acute post-traumatic atlantoaxial rotary subluxation occurs when C1 rotates on C2 after an injury of the alar ligaments, although this injury is not always visualized on MRI. The instability at the craniovertebral junction occurs secondary to increased ligamental laxity, horizontal configuration of the C1 to C2 articular facets and the larger head–body proportion of pediatric patients. This infrequent condition classically presents in a school-aged child who has persistent pain after traumatic torticollis due to a fall. Atlantoaxial rotary subluxation is diagnosed with a dynamic neck CT scan. Fortunately, this condition typically resolves within a couple of weeks with c-spine immobilization. ,
Pseudosubluxation is an important entity to consider because it is a normal variant and can only be differentiated from true subluxation by carefully evaluating C2 to C3 on a lateral c-spine radiograph ( Fig. 4 ). Pseudosubluxation can be differentiated from true subluxation by drawing a line from the anterior aspect of the posterior arch of C1 to the anterior aspect of the posterior arch of C3. The anterior aspect of the posterior arch of C2 should be within 2 mm of this line, known as Swischuk line (see Fig. 4 ). This condition contrasts with true subluxation, which occurs when the anterior aspect of the posterior arch of C2 is deviated by more than 2 mm.
SCIWORA should be suspected in a patient with persistent midline spinal tenderness without abnormalities on radiograph or CT scan, even with a normal neurologic examination. The mechanism and pathophysiology of SCIWORA is not completely clear. It is thought that the relative flexibility of the musculature and ligaments surrounding the vertebral column allows for movement beyond what is physiologic, allowing for injury to the spinal cord without fracture. The spinal cord injury occurs by contusion or ischemia from temporary impingement of the vertebral arteries during the injury. The onset of neurologic symptoms can be delayed up to 48 hours, so a normal neurologic examination immediately after the injury does not rule out SCIWORA. ,
Children with sports and recreational injuries are at increased odds of SCIWORA compared with injuries from other mechanisms. In younger children, child abuse, falls, and MVCs are the most common mechanisms of injury for SCIWORA. Interestingly, the distribution of c-spine SCIWORA does not follow the same age-related distribution seen with other CSIs, because most SCIWORA (80% in 1 study) occurs in the upper c-spine (C1–C4).
Pediatric blunt cerebrovascular injuries and the seatbelt sign
Introduction
In children, blunt cerebrovascular injuries (BCVIs), defined as blunt injuries to the carotid or vertebral arteries, are rare ( Fig. 5 ). The exact incidence of BCVIs in children is unclear given its rarity. They have been reported in 0.03% to 1.30% of blunt traumatic injuries. In adults, the incidence is approximately 1% to 3%. It remains unclear whether the lower incidence of BCVI in children is related to a lower incidence of screening or to protective anatomic or physiologic mechanisms in the pediatric population, such as increased ligamentous laxity, increased vascular elasticity, and lack of atherosclerosis.
