CERVICAL SPINE INJURY: PEDIATRICS

LEONARD E. SWISCHUK, M.D.

THE UNIVERSITY OF TEXAS MEDICAL BRANCH GALVESTON, TX

CHILDHOOD INJURIES LESS COMMON THAN IN ADULTS

MORE INJURIES OCCUR IN THE UPPER CERVICAL SPINE IN INFANTS AND YOUNG CHILDREN

WHY ?

APEX OF THE FLEXION CURVE IN UPPER SPINE

DIVIDE PATIENTS BY AGE GROUP

– 0 to 5 – 6 to 10 – 11 and over

PREVERTEBRAL SOFT TISSUES ─ Buckling and pseudothickening ─ Full inspiration-extension ─ Pharyngeal-tracheal stepoff ─ Don’t spend too much time

OTHER PROBLEMS

– Infant and children are hypermobile – Physiologic motion may be pronounced – Immature spine – Synchondroses, etc.

DENS FRACTURES

– Occur through dens body synchondrosis in infants – In infants, not the same as in adults – Fragmented os terminale, pseudo fracture – Os odontoideum pseudo fracture

DENS FX ANTERIOR

OS TERMINALE

FRAGMENTED OS TERMIONALE NORMAL

FRAGMENTED OS TERMINALE NORMAL

PSEUDO FX OS ODNTOIDEUM

HANGMAN FRACTURES

– These occur in infants – Heavy head is the mechanism – Differentiate from congenital defects

CONGENITAL DEFECT

C2 SYNCHONDROSES (PSEDUOFRACTURES) ─ Dens-body ─ Dens-neural arch ─ Oblique view ─ CT-parasagittal view ─ Aberrant synchondroses

FLEXION – ROTATION INJURIES

– Same as in adults – Usually mid cervical spine – Usually older children

FX WEDGING ANT HYPERFLEX

NORMAL ANTERIOR WEDGING

– C3, C4

WEDGING NORMAL C3 C4

WEDGING NORMAL C3

ANTERIOR SUBLUXATION

(Physiologic) – C2-C3 (mostly) – C3-C4

ANT SUBLUX C2-C3 PHYSIOLOGIC

HYPEREXTENSION INJURIES

– Same and in adults – Not as common as in adults

WIDE DISC HYPEREXTENSION AND FX

FX POSTERIOR ARCH C1

CONGENITAL DEFECT POST ARCH C1

DISLOCATION C1 – C2

– Relatively uncommon overall – Requires severe injury – Can be seen in infants – May disrupt blood supply to os terminale

DISLOCATION C1-C2

PREDENTAL DISTANCE

– Maybe very prominent in normal infants and children – Up to 5 mm – 2 mm flexion extension movement is normal

PREDENTAL DISTANCE 5 MM EXTENSION NORMAL

SAME PATIENT FLEXION 5MM NORMAL

RULE OF 2 ─ 2 mm or less ─ Any movement ─ Usually normal

INTERSPINOUS DISTANCE C1, C2

– Maybe very generous in infants and young children – May open 10 to 12 mm and still be normal – Look for anterior displacement of the anterior arch of C1 with true injury

ABNORMAL C1-C2 DISLOCATION

NORMAL NO DISLOCATION

AXIAL LOAD INJURIES

– Same as in adults – Usually older children

JEFFERSON FRACTURES

– Very rare in infants – Differentiate from synchondroses

JEFFERSON FX

JEFFERSON FRACTURE

SYNCHONDROSES NORMAL

NORMAL - PSEUDO OFF SET - UP TO 2 YTS

INFANTS AND CHILDREN ARE HYPERMOBILE

TORTE COLLIS

SUGGESTED READING

– Platzer P, Manuela J, Thalhammer G, et al: J Trauma 62:389-396, Feb. 2007.

– Apple JS, Kirks DR, Merten DF, et al: Pediatr Radiol 17:45-49, 1987.

– Hadley MN, Babramski JM, Browner CM, et al: J Neurosurg 68:18-24, 1988.

–

“Imaging of the Cervical Spine in Children”

Swischuk, LE, 2002 Springer-Verlag, New York, pgs. 75-121.

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