Pediatric Cervical Spinal Injury After Trauma: Clearance Guidelines, Radiology, C-spine CT | EB Medicine
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Cervical Spinal Injury In Pediatric Blunt Trauma Patients: Management In The Emergency Department (Trauma CME)

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology And Pathophysiology
  6. Differential Diagnosis
    1. Cervical Spine Injuries
      1. Second Spinal Fractures
      2. Spinal Shock
      3. Spinal Cord Injury Without Radiographic Abnormality
      4. Atlantoaxial Rotary Injuries
  7. Prehospital Care
    1. Spinal Immobilization
      1. Spinal Immobilization Of Children
    2. Patient Transfer
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Examination Of The Cervical Spine
  9. Diagnostic Studies
    1. Low-Risk Criteria For Cervical Spinal Injury
      1. The National Emergency X-Radiography Utilization Study (NEXUS) And The Canadian C-Spine Rule
      2. Other Studies Addressing Low-Risk Criteria
    2. Plain Film Radiography
      1. Challenges In Interpretation Of Plain Films
        • Pseudosubluxation
        • Other Normal Variants In Pediatric Cervical Spines
        • Misdiagnosis And Missed Injuries
        • Swimmer's View
    3. Computed Tomography
    4. Magnetic Resonance Imaging
    5. Diagnostic Studies Summary
  10. Treatment
    1. Initial Stabilization
    2. Management Of Neurogenic Shock
    3. Pain Management
    4. Use Of Steroids For Cervical Spine Injuries
    5. Surgical Consultation
  11. Special Population
  12. Controversies And Cutting Edge
    1. Therapeutic Hypothermia
    2. Minocycline
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls For Patients With Cervical Spine Injuries
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Management In The Emergency Department Of Pediatric Patients With Suspected Cervical Spinal Cord Injury
  19. Tables and Figures
    1. Table 1. Incomplete Spinal Cord Injury Patterns
    2. Table 2. Common Axial Vertebral Column Injuries (More Common In Children Aged < 8 Years)
    3. Table 3. Common Subaxial Vertebral Column Injuries (More Common In Children Aged > 8 Years)
    4. Table 4. Physical Examination Findings Concerning For Cervical Spinal Cord Injury
    5. Table 5. Low-Risk Criteria For Cervical Spinal Injury In Children
    6. Table 6. Prognostic Factors For Spinal Cord Injury Without Radiologic Abnormality.
    7. Figure 1. C2 Fracture With Anterior Dislocation
    8. Figure 2. Normal Anatomy Of The Pediatric Cervical Spine On Plain Radiograph
    9. Figure 3. C5 Flexion Teardrop Fracture
    10. Figure 4. Pseudosubluxation Of C2-C3 And C3-C4
    11. Figure 5. Undisplaced Jefferson Fracture Observed On X-Ray And Computed Tomography Scan
  20. References

Abstract

Spinal injuries from blunt trauma are uncommon in pediatric patients, representing only about 1.5% of all blunt trauma patients. However, the potentially fatal consequences of spinal injuries make them of great concern to emergency clinicians. Clinical goals in the emergency department are to identify all injuries using selective imaging and to minimize further harm from spinal cord injury. Achieving these goals requires an understanding of the age-related physiologic differences that affect patterns of injury and radiologic interpretation in children, as well as an appreciation of high-risk clinical clues and mechanisms. This issue reviews current approaches to prehospital immobilization, identification of low-risk patients who may be clinically cleared from immobilization, a rational approach to the use of radiologic imaging, and the existing evidence for medical management of spinal cord injuries.

Case Presentations

A 3-year-old girl presents to the ED after a highway motor vehicle crash. The car she was riding in was traveling at 70 mph when it struck another car that was turning onto the highway. The child was in an appropriate child-restraint seat in the rear passenger seat. The driver was declared dead on the scene and the front passenger was severely injured. The child was boarded and collared on scene, and was hemodynamically stable during transport. A primary survey reveals no concerning physical findings. On secondary survey, she has midline tenderness at C2. There are no neurologic deficits, and she has a GCS score of 15. You are concerned about a spinal injury, but how do you proceed to investigate and manage this patient? Does the history of the incident make a spinal cord injury more or less likely? How likely is a cervical spine injury in a young child? Are there normal differences in the radiologic findings for young children? Do you have to perform imaging to clear a cervical spine, or is a clinical examination sufficient at this age? If you image, what do you choose, plain x-ray, CT, or MRI?

A 10-year-old boy is checked from behind while playing hockey. He went headfirst into the boards, striking the top of his head. EMS was called, and he was collared on the ice and transported to the ED. The paramedics noted weakness in both arms and legs on initial examination. The patient reported tingling sensations in his arms. On presentation to the ED, the patient is noted to have 5:5 strength in all limbs and midline tenderness from C3- C7. No other injuries are detected and his cervical spine series is normal. Does this child have SCIWORA? Is a traditional flat spine board appropriate for children? Are there guidelines or tools for clearance of a cervical spine without radiologic investigation that are validated and applicable for older children?

A 16-year-old adolescent boy presents to the ED after being ejected from the back of a pickup truck traveling at approximately 50 mph. He was boarded and collared at the scene. EMS gave 1 L of intravenous crystalloid to treat hypotension of 95/50 mm Hg, which improved to 115/60 mm Hg postbolus. On presentation to the ED, he is drowsy, but arousable. His vital signs are: blood pressure, 90/50 mm Hg; heart rate, 145 beats/min; respiratory rate, 18 breaths/min; oxygen saturation, 96% on 5 L/ min O2; and temperature, 36.5°C. There is no movement in any of his limbs, his chest is clear, and his abdomen is somewhat distended, though soft and nontender. He has an obvious right lower leg fracture. You suspect a cervical spinal injury. Are there other physical findings that would make a spinal cord injury more likely? How should you immobilize the patient safely? Why is his blood pressure low? Is this neurogenic shock or something else? How do you treat him to minimize further cord injury? Should you give him steroids?

Introduction

A major challenge with spinal cord injury in children is the combination of its relative rarity and its potentially serious consequences. Missed diagnosis of a spinal injury (eg, a C2 fracture with anterior dislocation [see Figure 1]) can lead to permanent injury. Cervical spinal injury (CSI) occurs in about 1% to 1.5% of children evaluated following blunt trauma.1,2 The majority of these injuries are in older children; < 5% of CSIs are in children aged < 2 years.3 In the largest review of pediatric CSI (75,172 children) by Patel et al, 1098 children were found to have CSI, an overall incidence of 1.5%.1 The mean age of patients with a CSI was 11 years +/- 5 years, and there was a slight predominance of CSI in boys (61%). The vast majority of the injuries (83%) involved the bony structures. Upper CSIs (C1-C4) were seen with equal frequency across all age groups (42% in children aged ≤ 8 years; 58% in children aged > 8 years). Lower CSIs (C5-C7) were most commonly seen in older children (85% in children aged > 8 years). Importantly, 7% of these children had both upper and lower CSIs.

Approximately one-third of the children had neurologic impairment, and 24% of those were complete cord injuries. Approximately half of those with neurologic impairment had no radiographic evidence of bony injury.1

Injury patterns differ with age and, thus, interpretation of radiographs is dependent on knowledge of age-related development of the osseous and ligamentous anatomy.

Mortality and morbidity are high, with mortality ranging from 13% to 28%.4-6 Mortality is highest in young children and in those with upper cervical spinal injuries.6 Morbidity is variable, but can be severe. In a retrospective trauma registry review of 37 CSIs, 25 patients (67.6%) completely recovered, 3 patients (8.1%) partially recovered, and 9 patients (24.3%) had no recovery.5 A study of spinal cord injury patient outcomes determined that out of 23 patients, only 14 could feed themselves, and 12 could walk well enough to perform daily activities.6

The task of separating patients with cervical spine fractures and cord injuries from the multitude of patients with sore necks posttrauma is certainly a challenging one. This issue of Pediatric Emergency Medicine Practice addresses this challenge, and reviews the diagnosis and management of spinal fractures and spinal cord injuries in children. The cervical spine is the focus, as it has been the area of greatest concern for clinicians and the subject of the greatest amount of research. Based on existing literature, an approach to efficiently, cost-effectively, and safely diagnosing these “can’t miss” injuries is proposed.

Critical Appraisal Of The Literature

A literature search was performed in PubMed utilizing the medical subject headingschild, spinal cord injury, and trauma. A total of 3328 articles were reviewed, and 78 were chosen for this review. A search of the Cochrane Database of Systematic Reviews using the search term spinal cord injuries (not specific to pediatrics) identified 31 articles. Pediatric guidelines from 2013 from the Congress of Neurological Surgeons7 and general guidelines from 2001 from the American Association of Neurological Surgeons were also reviewed. There were several large studies attempting to determine low-risk criteria for cervical spinal injuries. These mostly focused on adults, but smaller studies have looked at pediatric CSIs. There are limited data on thoracolumbar injuries and, therefore, these are not a focus of this issue. There are no specific pediatric studies regarding pharmacologic therapies for spinal cord injury (ie, whether or not steroids are effective), and relatively few good-quality studies in adults, some of which included older pediatric patients.

Risk Management Pitfalls For Patients With Cervical Spine Injuries

  1. “The patient didn’t seem to be very uncomfortable, so I didn’t ask about pain or offer any analgesics.”
    Clinicians tend to underestimate the pain suffered by patients. Every trauma patient should be asked to rate his or her pain on an appropriate pediatric pain scale and be offered appropriate analgesia.

  2. “A 6-year-old who fell from a balcony presented with neck pain, but no other injuries. On the lateral plain radiograph, C2 was anteriorly displaced with respect to C3. I immediately consulted neurosurgery.”
    C2-C3 pseudosubluxation is the most common normal variant in children that is mistaken for injury. To differentiate between pseudosubluxation and true subluxation, a line should be drawn through the posterior arches of C1 and C3. In a pseudosubluxation, the posterior arch of C2 should not be posteriorly displaced > 2.0 mm from the C1-C3 line.

  3. “I image the cervical spines of all the pediatric traumas I see.”
    There is clear evidence that there are certain patients who can be cleared in the absence of imaging. For patients aged > 9 years, adult-derived rules such as the CCR and the NEXUS criteria are applicable. Acceptable low-risk criteria for younger children are also reasonably well elucidated.

  4. “An 8-year-old fell from a window (about 15 feet) and presented with bilateral tibia and fibula fractures. He was placed on a spine board and in a collar. He had no neck pain, tenderness, or neurologic deficit, so I cleared his spine and removed the spinal precautions.”
    Cervical spine clearance with low-risk criteria without imaging is not possible in the presence of a painful or distracting injury. Even an examination that reveals no pain is not reliable in this patient, due to the lower limb fractures. By some rules, the mechanism of his fall would also preclude a no-imaging clearance. Plain radiograph imaging is indicated for this patient, with further imaging as needed.

  5. “The patient kept complaining about neck pain even though her CT scan was normal. So I reassured her that she just had muscular pain. I took off her collar and sent her home.”
    A normal CT scan does not exclude the possibility of a CSI. Some studies indicated sensitivities for bony injuries as low as 90%. Additionally, ligamentous injuries are detected at much lower rates with CT. MRI is often needed to find a ligamentous injury, some of which require surgical management. Discharge in a collar with re-evaluation in 10 to 14 days is an appropriate management plan.

  6. “We really needed to clear the trauma room for other patients, so I evaluated a 15-year-old to quickly clear him. He had no neurologic signs or symptoms, and there was no midline tenderness, so I cleared him and removed his spinal precautions. When I took his history later, he admitted to drinking and he had an ethanol level of 70 mmol/L.”
    It is important to take a brief history to determine whether there are any conditions present that would make a patient ineligible for low-risk criteria. In an intoxicated patient, plain radiography should be obtained and clearance delayed until the intoxication has resolved.

  7. “I was having a lot of trouble with the airway, so I removed his cervical collar to intubate him.”
    Endotracheal intubation is a very high-risk procedure for anyone with a CSI. Unfortunately, the degree of other associated injuries often makes it necessary. It is of vital importance that the cervical spine remain in a neutral position during intubation to prevent additional cord injury. This may be accomplished by a rigid collar, or by a second person performing in-line stabilization.

  8. “A 9-year-old was complaining of neck and back pain after a fall. His cervical plain films showed a compression fracture at C5. I did not do further imaging as we had found his injury.”
    Any mechanism that caused a spinal fracture has a relatively high likelihood of causing more than 1 spinal fracture. Any patient with an identified injury needs careful evaluation with examination and imaging for a second injury.

  9. “A 14-year-old who was involved in an MVC had persistent hypotension despite 2 liters of crystalloid solution. I presumed he must have intra-abdominal or intrathoracic bleeding and called general surgery to take him to the operating room.”
    Unexplained hypotension in a trauma patient may be the result of neurogenic, hypovolemic, or cardiogenic shock. All hypotensive patients should be carefully evaluated for spinal injury by physical examination and imaging prior to assuming another mechanism of shock is responsible.

  10. “I spoke to the neurosurgeon about a 16-year-old with a C5 fracture and generalized weakness. They were going to be unavailable for 6 to 7 hours, so I kept the patient in a rigid cervical collar on a backboard for protection.”
    Backboards are transportation devices only. Even with an identified cord injury, lying flat in a bed in a rigid cervical collar with a slider for transfers is adequate spinal protection. Prolonged periods on backboards are very uncomfortable, and pressure sores may begin to develop within 6 hours, especially with cord injuries.

Tables and Figures

Table 1. Incomplete Spinal Cord Injury Patterns

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study are included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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