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?
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.
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.
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.
Money-back GuaranteeAndrew Dixon, MD, FRCPC
March 2, 2016
April 2, 2019
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