Transcript Pediatric Spine Injuries - Emory University Department of Pediatrics

Traumatic Spine and Spinal Cord Injuries
Dafina M. Good, MD
Emory University School of Medicine
Children’s Healthcare of Atlanta
Pediatric Emergency Medicine Fellow
Objectives
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To review the epidemiology of Spinal Cord Injuries
(SCI) in children
To review the Anatomy of the spine and spinal cord
To review pertinent history and physical exam findings
involved in SCI’s
To review the radiologic evaluation of spinal trauma
To review traumatic spine fractures
To review some partial spinal cord syndromes
Epidemiology of Spinal Trauma in Children
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Spinal injury is rare in children
Higher mortality in children
Pediatric vertebral injuries occur 60-80% of the time in the cervical region
(30-40% of all vertebral injuries in adults)
Overall incidence of spinal injury in children is 1-2%
Almost 1500 children are admitted to US hospitals each year for treatment of
SCI’s
Motor Vehicle Accidents are the leading cause of pediatric SCI (60% of
cases)…with falls and sports injuries (football and diving) thereafter
M:F ratio of 2:1
Avg age is 14 to 15 yrs old
2006 study from the NTDB & the KID found that almost 70% of children
injured in MVA’s from 1997-2000 were not wearing a seatbelt and in 30% of
those cases alcohol or drugs were involved
Cervical Spine Anatomy
Spine Vertebrae Anatomy
Spine Vertebrae Anatomy
Cervical Spine Anatomy
Cervical Spine Anatomy
Atlas-Dens Relationship
Anatomy of the Spinal Columns
Pediatric vs. Adult Spine Anatomy
……..Not just little adults!
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Children younger than 8yrs are more susceptible to C-spine
injuries because;
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Larger head to body proportion
Higher fulcrum……. “point of maximal mobility” (C2-3 at birth, C3-5 at
8-12yrs old to C5-6 at 12yrs old and adults)
Weaker cervical musculature
Increased ligamentous laxity leading to greater mobility of the c-spine
Immature joints and Ossification centers
Horizontal facet joints that facilitate sliding of the upper C-spine
More susceptible to subluxation and distraction injuries
Spinal columns are more elastic than the spinal cord (tolerating more
distraction before rupture……. Thus leading to SCIWORA
Key History and PE Components
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History
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Vital signs
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Cause…. MVA, Sports (Football/Diving), Falls
Mechanism….. Hyperflexion (Clay shoveler’s or Teardrop Fx’s), hyperextension
(Hangman’s Fx), Rotational (Jumped Facets), Compression or axial loading
(Jefferson/Burst Fx)
Symptoms….. Numbness, tingling, or weakness during any time since accident
even if resolved
Predisposing conditions….. 15% Down’s Syndrome pts have atlantoaxial
instability, Achondroplasia (Cervicomedullary Junction stenosis)
Hypotension, Bradycardia….. Can be signs of Neurogenic shock
Physical Exam
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Testing for motor or sensory deficits and levels if present
DTR’s and rectal tone
High index for Multisystem trauma (40% of cases have associated intrabdominal
injuries)
Radiologic Evaluation of Spine Injuries
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Are Xrays indicated?
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NEXUS Study Criteria (National Emergency X-Radiography Utilization Study)
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Based on 5 low-risk criteria that allows physicians to avoid Xray evaluation
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Lateral, AP and Odontoid view
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Indicated if normal 3views of the c-spine but focal neck pain persists….. ie. Concerns
for ligamentous injury
Only in conscious patients who can limit their neck motion
CT C-spine
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3 views picks up >90% of all unstable C-spine injuries
Lateral is the most important view. Lateral alone has a very high sensitivity
Difficult to obtain odontoid views in pediatrics
Swimmer’s view used as adjunct to Lateral if not able to visualize C7-T1 junction
Flexion-Extension views
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Must have absence of….. Midline cervical tenderness, evidence of intoxication, altered level of
alertness, focal neurological deficit, and a distracting painful injury.
Excellent sensitivity for identifying fractures (Sensitivity of 97%)
Limited in showing ligamentous injury
MRI
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Indicated in any patient with neurological deficits
C-spine film evaluation
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Measurable Parameters of Normal Cervical Spine Radiographs
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Adequacy of C-spine views
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C1- top of T1
3 views vs. Single Lateral view
Swischuk's Lines- 4 Lordotic curves aligned
Predental space (5 mm or less)
C2-C3 pseudosubluxation (4 to 5 mm or less)
Retropharyngeal or Prevertebral space (1/2 to 2/3 vertebral body)
Intervertebral disk space symmetry
If a C-spine fracture found….. Requires radiologic evaluation of entire spine.
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Approximately 10% of patients with a C-spine fracture have a second vertebral
column fracture
C-spine Lateral View
C-spine AP View
C-spine Odontoid View
C-spine Odontoid View
Swischuk’s Lines
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LINES OF LIFE: There are 4 basic parallel lines to evaluate alignment that help determine cspine injuries.
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Anterior vertebral body line
Posterior vertebral bodyline
Spinal Laminar line
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Posterior spinous process
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C-spine Films
Predental Space
Space should be no more than
5mm
Intervertebral Disk Spaces
“7yr old fell off her bunk bed 3 days ago and still has a crook
in her neck”
C1-C2 Rotary Subluxation
Abnormal Odontoid View
Abnormal Odontoid View
Jefferson Fracture (C1 Burst Fracture)
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Axial loading or vertebral compression
Displaced lateral masses of C1
Predental space increased
Moderately unstable
Transverse Ligament Rupture
Transverse Ligament Rupture
Transverse Ligament Rupture
Atlanto-occipital Dislocation
Atlanto-Occipital Dislocation
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Widening of the atlanto-occipital joint >5mm
Prevertebral swelling
Usually fatal
Patients usually apneic at the scene
5X more common in children
Odontoid View
Type II Dens Fracture
Hangman’s Fracture
Clay-Shoveler’s Fracture
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Spinous process avulsion fracture
Very stable
Flexion Teardrop Fracture
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Sudden hyperflexion with axial compression
Involves disruption of all columns
Usually presents with neurological impairment
(Anterior cord syndrome)
Highly unstable
Bilateral Facet Dislocation
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Hyperflexion with Rotation (MVA/Diving)
Disruption of all the spinal ligamentous columns
Highly unstable
Almost always quadriplegic (Poor prognosis)
Chance Fracture
AP Thoracic Spine
Chance Fracture
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Hyperflexion injury
Lap belt injury
Transverse fractures through the VB
50% associated with intrabdominal
organ injuries
Posterior column disruption
Spinal Cord Injury Without Radiographic Abnormality
SCIWORA
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First described in 1982
Defined as traumatic myelopathy in the absence of findings on plain
radiographs, flexion-extension radiographs and cervical CT scan.
Almost unique to pediatrics. Occurs most often in children younger than
eight years of age
Pediatric predominance likely related to the high elasticity of the spinal
column in comparison to the spinal cord
Usual mechanism is acceleration-deceleration or rotation injury
Almost 20-50% of SCI’s in children have no radiographic abnormalities
Almost 30-50% of patients have delayed onset of neurologic deficits from
30mins-4 days
If SCIWORA is suspected then an MRI should be done
These patients require immobilization to prevent secondary insults to the
spinal cord
Review of
Traumatic Spinal Cord Syndromes
Motor Innervation of the Nervous
System
Sensory Innervation of the Nervous System
3 Main Spinal Cord Tracts
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Corticospinal tract carries motor fibers to the ipsilateral side of the body
Posterior columns carry fine touch, vibration, proprioception, and pressure from the ipsilateral side.
Spinothalamic tract carries pain and temperature fibers from the contralateral side of the body.
Partial Cord Syndromes
Central Cord Syndrome
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Most common of the partial cord syndromes
Hyperextension injury in athletes
Ligamentum flavum buckles and increases pressure on the cord
Bilateral motor paresis greater in the upper than lower extremities
Shawl distribution pain and temperature loss
Sparing of light touch and proprioception
Good prognosis
3 Main Spinal Cord Tracts
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Corticospinal tract carries motor fibers to the ipsilateral side of the body
Posterior columns carry fine touch, vibration, proprioception, and pressure from the ipsilateral side.
Spinothalamic tract carries pain and temperature fibers from the contralateral side of the body.
Anterior Cord Syndrome
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Crush Injury or compression from a hematoma
Compression of the Anterior Spinal artery
Paraplegia below the lesion
Pain and temperature loss below the lesion
Sparing of dorsal column sensation
Brown Sequard Syndrome
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Hemisection of the spinal cord
Usually from penetrating trauma
Ipsilateral plegia below the lesion
Ipsilateral proprioception and light touch loss
below the lesion
Contralateral pain and temperature loss
below the lesion
Rare injury