Pediatric C-Spine Injuries

1
Pediatric C-Spine Injuries

• Harold K. Simon, MD, MBA Professor, Emory
  Department of Pediatrics Emergency Medicine

2
Objectives

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

3
Inspiration Yet Reality
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Objectives

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

6
Epidemiology Age

• Mean age is 8-9 years old, 21 male to female
• lt 8 years old mainly, ligamentous injuries
• gt 8 years old mainly fractures
• Infants under 1 year old with Cervical Spine
  Injuries are rare

7
Epidemiology Mechanism

• 67 occur with motor vehicle collision
• 33 occupant
• 23 bicyclist vs. auto
• 11 pedestrian vs. auto
• 30 occur with falls and sports injuries
• lt 3 occur with gunshot wounds

8
Epidemiology Associated Injuries

• Of 45 children with Cervical Spine Injuries
• Pulmonary Contusion 10
• Femur Fracture 8
• Hemoperitoneum 6
• Tibial Fracture 5
• Arm Fracture 4
• Rib Fracture 3
• Splenic Laceration 3
• Ruptured Kidney 2
• Pelvis Fracture 2
• Clavicle fracture, pneumothorax, 1 each
• hemothorax, flail chest, liver laceration,
• bowel wall edema, limb amputation

Note 40 of children with cervical spine injury
have no trauma to an other body part Orestein et
al.
9
Objectives

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

10
Anatomy Pediatric versus Adult

• Proportionally larger and heavier head
• Weaker and underdeveloped neck musculature
• Higher center of gravity
• Pediatric C2-C3
• Adult lower cervical vertebrae
• Greater elasticity and laxity of ligaments in
  children
• More horizontal orientation of facet joints

11
Anatomy Pediatric versus Adult

• Relatively wedged anterior vertebral bodies
• Biomechanical and anatomic difference begin to
  disappear around 8-10 years old, but are not
  fully gone until 15-17 years old

12
Anatomy Implications

• Ligamentous laxity
• Allows the spine to absorb and cushion traumatic
  forces, thus protecting the bones and spinal cord
  
• More cervical distraction injuries, as well as
  hyperflexion-extension injuries in rapid
  deceleration accidents (high energy injuries)
• Children may have spinal cord injury in the
  absence of radiographic abnormality (SCIWORA)

13
Objectives

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

14
Question

• 28 month old male
• Fell from shopping cart, landed on head
• Arrives in C-collar
• Primary survey is normal
• Patient is crying and uncooperative
• How would you clear his cervical spine?

15
Which Trauma Patients Should Be Immobilized

• Severe or high risk mechanism of injury,
  instability, or inability to assess

16
Immobilization Techniques

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

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Immobilization Techniques

• Cervical collars - soft foam, firm foam, and
  rigid plastic
• Sandbags/foam cushions/towels/tape
• Backboards/Kendricks extrication
  device/Extriboard
• Combinations usually used in the pre-hospital
  setting

19
Immobilization Techniques
Pediatric patients have disproportionally large
heads that actually cause neck flexion on a rigid
backboard. Padding under the shoulders and back,
or a recessed area for the head is recommended to
keep the patient in the neutral position.
20
Immobilization Techniques

• Pediatric backboards with recessed head areas
• Pre-hospital Use a rigid or firm foam collar in
  combination with other padding, on a rigid
  backboard, with tape to provide the best initial
  immobilization

21
Immobilization Techniques

• Never attempt to straighten a cervical deformity
  when immobilizing a child!
• Cervical collar alone DOES NOT provide full
  immobilization if moving about uncontrollably!
• It may however be an option for a totally
  cooperative patient not moving about and for
  lower risk situations.
• Only mobilization necessary for most in-hospital
  situations

22
Immobilization Techniques
Flexion Extension Rotation
Lateral Pediatric Control 35
45 80 16 Infant Control
35 38 gt90
40 Range of neck motion in mannequins
23
Pitfalls of Pediatric Immobilization
Degrees of
Motion Allowed From Neutral Position in Mannequin
Models Collar Flexion Extension Rotation Latera
l Summed Score () Infant Infant car
seat, padding, tape With foam collar
8 12 2 3 25 (64) Head
Brace 35 38 4 1 78
(205) With Foam Collar 11 19 2
2 34 (87) Half-Spine board, tape 1 1
4 6 12 (23) With Foam Collar 1 1
2 4 8 (17) Kendrick
Extriction 12 10 19 9 50 (92) With
Foam Collar 1 1 4 1 7 (11)
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Pitfalls of Pediatric Immobilization
Child Control



Head Immobilizer



Foam cushions to spine
board 11 18 26 3 58 (122)
With Vertebrace 10 14 1 1
26 (66) Head Brace 16 12 2 1
31 (82) With Flex-Support 7 9 5 2
23 (58) Kendricks Extrication 6 8 4 2
20 (53) With
Flex-Support 4 3 1 2 10 (31) Extriboard
Disposable



Extrication device 9 7 5 4 24
(73)
With Vertebrace 3 2 2 1
8 (20) Half-Spine board tape 10 1 4
7 22 (79)
With Flex-Support Tape 2
3 1 2 8 (26) Full-Spine board
Tape 4 12 5 3 24 (63)

Tape, Beanbag Flex-Sup 10 9 3 2
24 (66) Tape, Beanbag 5 5 0 1 11
(31) Summed
score, arithmatic sum of degrees of motion in
each direction. Degrees of motion
allowed Summed of score, arithmatic sum of
percentage of control motion.
Control
In each direction
25
Pitfalls of Pediatric Immobilization
Degrees of
Motion Allowed From Neutral Position in Mannequin
Models Collar Flexion Extension Rotation Latera
l Summed Score () Infant Control (no
collar) 35 38 180 40 293 (400) Prosplints
Cervical Collar 11 19 12 20 62 (138) Child
Control (no collar) 35 45 80 16 176 (400)
Foam Extrication 35 45 16 11 107 (289)
Disposable Foam 24 32 7 5 68 (180)
Ferno-Fit 36 31 8 6 81 (217)
Standard 21 23 10 3 57 (142)
Hare 35 45 12 6 98 (253) Thomas 24 21
6 7 58 (168) Flex-Support 3 4-way 17 19
4 6 46 (134) Flex-Support 2 4-way 23 23
7 5 58 (157) Vertebrace 20 18 9
7 54 (152) Stiff Neck 20 18 6
8 52 (155) Philadelphia 23 15
5 12 55 (180)
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Objectives

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

27
NEXUS

• National Emergency Medicine X-ray Utilization
  Study
• 23 Center National Cooperative Study
• Viccellio P, Simon HK, Pressman B, Shah M, Mower
  W, Hoffman J, for the NEXUS Group. A Prospective
  Multicenter Study of Cervical Spine Injury in
  Children. Pediatrics August 2001108 e20

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NEXUS Study objectives

• Examine the spectrum of cervical spine (c-spine)
  injuries in children
• Evaluate the efficacy of a decision instrument
  designed to identify which patients are at low
  risk for radiographic c-spine injury

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NEXUS Study Definitions

• Low Risk Patient
• Those with none of the following criteria
• Midline cervical tenderness
• Focal neurologic deficits
• Altered level of alertness
• Evidence of intoxication
• Distracting painful injury

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NEXUS Study Definitions

• High Risk Patient
• Those with any of the following criteria
• Midline cervical tenderness
• Focal neurologic deficits
• Altered level of alertness
• Evidence of intoxication
• Distracting painful injury
• Instability or inability to assess

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NEXUS Study Definitions

• Distracting Injury
• Significant, painful injury Examples
• Skin Large lacerations or heavy bleeding
• Soft tissue Crush injuries
• Muscle
• Bone Any long bone fracture
• Vascular structures
• Viscera Injury requiring surgical consultation
• Any injury causing acute functional impairment

32
NEXUS Study Results

• 34,069 patients enrolled
• 3,065 Pediatric Patients
• (9) were lt 18 yrs
• 603 (19.7) were Low-risk

33
NEXUS Study Results
Age distribution in years - All Nexus Patients
1000
800
600
Number
400
200
0
96
84
72
60
48
36
24
12
0
102
90
78
66
54
42
30
18
6
34
NEXUS Study Results
Age distribution in years - All Nexus Patients
1000
N 34,069
800
600
Number
n 3,065
n 31,004
400
200
0
96
84
72
60
48
36
24
12
0
102
90
78
66
54
42
30
18
6
35
NEXUS Study Results
Age Distribution of Pediatric Patients
N 3,065
36
NEXUS Study Results
Age Distribution of Pediatric Patients
N 3,065
lt2 y.o., n 88
37
NEXUS Study Results
Age Distribution of Pediatric Patients
N 3,065
2-8 y.o., n 817
lt2 y.o., n 88
38
NEXUS Study Results
Age Distribution of Pediatric Patients
N 3,065
2-8 y.o., n 817
9-17 y.o., n 2160
lt2 y.o., n 88
39
NEXUS Study Results

• Of 3,065 children enrolled, 30 had c-spine
  injuries (0.98)
• All children with c-spine injuries were
  prospectively classified as being in the
  high-risk group
• No child from the low-risk group had a c-spine
  injury

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NEXUS Study Results
Of the 30 children with c-spine injuries

• Clinical Features - N/A
• Tenderness 21 4 5
• Neuro deficits 8 19 3
• Altered LOC 6 21 3
• Intoxication 0 27 3
• Distracting injury 11 17 2

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NEXUS Study Results
Of the 30 children with c-spine injuries

• Clinical Features - N/A
• Tenderness 21 4 5
• Neuro deficits 8 19 3
• Altered LOC 6 21 3
• Intoxication 0 27 3
• Distracting injury 11 17 2

42
NEXUS Study Results
Of the 30 children with c-spine injuries

• Clinical Features - N/A
• Tenderness 21 4 5
• Neuro deficits 8 19 3
• Altered LOC 6 21 3
• Intoxication 0 27 3
• Distracting injury 11 17 2

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NEXUS Study Results
Of the 30 children with c-spine injuries

• Clinical Features - N/A
• Tenderness 21 4 5
• Neuro deficits 8 19 3
• Altered LOC 6 21 3
• Intoxication 0 27 3
• Distracting injury 11 17 2

44
NEXUS Study Results
Of the 30 children with c-spine injuries

• Clinical Features - N/A
• Tenderness 21 4 5
• Neuro deficits 8 19 3
• Altered LOC 6 21 3
• Intoxication 0 27 3
• Distracting injury 11 17 2

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NEXUS Study Results
Of the 30 children with c-spine injuries

• Clinical Features - N/A
• Tenderness 21 4 5
• Neuro deficits 8 19 3
• Altered LOC 6 21 3
• Intoxication 0 27 3
• Distracting injury 11 17 2

46
NEXUS Study Results
Of the 3,035 children without c-spine injuries

• Clinical Features - N/A
• Tenderness 1179 1333 523
• Neuro deficits 176 2611 248
• Altered LOC 520 2326 189
• Intoxication 110 2730 195
• Distracting injury 878 1915 242

47
NEXUS Study Results

• Age Sex Fracture type
• 2 F C2 type III odontoid fracture
• 3 M Occipital condyle fracture
• 6 M Cranio-cervical dissociation
• 8 M C1 C2, fractures
• 9 M C4 flexion tear drop fracture
• 11 M Cranio-cervical dissociation
• 11 F C7 burst fracture
• 11 M C5 body fracture
• 11 M C1 lateral mass fracture
• 12 F C2 spinous process fracture
• 13 M C6 spinous process fracture
• 14 M C7 wedge compression
• 14 F C4 - C5 subluxation, C5 - C6 subluxation,
  C5 body and,posterior element fractures, C4-6
  cord contusion
• 16 F C7 compression fracture
• 16 F C6 - C7 fracture
• 16 M C6 burst fracture and bilateral laminar
  fractures, C7 body fractures
• 16 M C5 burst fracture and bilateral laminar
  fractures C5 C6 subluxation
• 16 M C5 body fracture C5-6 sublux

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NEXUS Study Results

• Age Sex Fracture type
• 2 F C2 type III odontoid fracture
• 3 M Occipital condyle fracture
• 6 M Cranio-cervical dissociation
• 8 M C1 C2, fractures
• 9 M C4 flexion tear drop fracture
• 11 M Cranio-cervical dissociation
• 11 F C7 burst fracture
• 11 M C5 body fracture
• 11 M C1 lateral mass fracture
• 12 F C2 spinous process fracture
• 13 M C6 spinous process fracture
• 14 M C7 wedge compression
• 14 F C4 - C5 subluxation, C5 - C6 subluxation,
  C5 body and,posterior element fractures, C4-6
  cord contusion
• 16 F C7 compression fracture
• 16 F C6 - C7 fracture
• 16 M C6 burst fracture and bilateral laminar
  fractures, C7 body fractures
• 16 M C5 burst fracture and bilateral laminar
  fractures C5 C6 subluxation
• 16 M C5 body fracture C5-6 sublux

49
NEXUS Study Results

• Age Sex Fracture type
• 2 F C2 type III odontoid fracture
• 3 M Occipital condyle fracture
• 6 M Cranio-cervical dissociation
• 8 M C1 C2, fractures
• 9 M C4 flexion tear drop fracture
• 11 M Cranio-cervical dissociation
• 11 F C7 burst fracture
• 11 M C5 body fracture
• 11 M C1 lateral mass fracture
• 12 F C2 spinous process fracture
• 13 M C6 spinous process fracture
• 14 M C7 wedge compression
• 14 F C4 - C5 subluxation, C5 - C6 subluxation,
  C5 body and,posterior element fractures, C4-6
  cord contusion
• 16 F C7 compression fracture
• 16 F C6 - C7 fracture
• 16 M C6 burst fracture and bilateral laminar
  fractures, C7 body fractures
• 16 M C5 burst fracture and bilateral laminar
  fractures C5 C6 subluxation
• 16 M C5 body fracture C5-6 sublux

50
NEXUS Study Results
Value (95 CI)
Sensitivity 100 (87.8 100)
Negative Predictive Value 100 (99.2 100)
51
NEXUS Study Results
Value (95 CI)
Sensitivity 100 (87.8 100)
Negative Predictive Value 100 (99.2 100)
52
NEXUS Study Results
Pediatric versus Adult

• Item of interest Age lt18yrs Age 18yrs
• Total of cases 3,065 31,004
• with c-spine injury 30 788
• Injury Rate 0.98 2.54
• Missed injuries 0 8
• (all negative criteria)
• of cases with all (-) criteria 20 12

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NEXUS Study Results
Pediatric versus Adult

• Item of interest Age lt18yrs Age 18yrs
• Total of cases 3,065 31,004
• with c-spine injury 30 788
• Injury Rate 0.98 2.54
• Missed injuries 0 8
• (all negative criteria)
• of cases with all (-) criteria 20 12

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NEXUS Study Results
Pediatric versus Adult

• Item of interest Age lt18yrs Age 18yrs
• Total of cases 3,065 31,004
• with c-spine injury 30 788
• Injury Rate 0.98 2.54
• Missed injuries 0 8
• (all negative criteria)
• of cases with all (-) criteria 20 12

55
NEXUS Study Results
Pediatric versus Adult

• Item of interest Age lt18yrs Age 18yrs
• Total of cases 3,065 31,004
• with c-spine injury 30 788
• Injury Rate 0.98 2.54
• Missed injuries 0 8
• (all negative criteria)
• of cases with all (-) criteria 20 12

56
NEXUS Study Results

• Take Home
• No c-spine injuries occurred in children
  prospectively identified at low-risk
• NEXUS decision instrument could have safely
  reduced c-spine imaging by nearly 20
• Limited data on under 2 years old

57
NEXUS Study Definitions

• Low Risk Patient
• Those with none of the following criteria
• Midline cervical tenderness
• Focal neurologic deficits
• Altered level of alertness
• Evidence of intoxication
• Distracting painful injury

58
Canadian c-spine algorithm
59
Objectives

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

60
Helical CT vs Plain Films

• Advantages
• CT is more sensitive for detecting C-Spine
  Injuries than plain film
• Depending on age may save time
• Disadvantages
• Radiation
• Cost
• May increase time if sedation required

61
Helical CT vs Plain Films

• Randomized trial
• 136 children 0-14yr
• Increased radiation in HCT group
• No reduction in the amount of sedation or LOS in
  the HCT group
• 34 crossover from assigned group secondary to
  perceived advantages

Adelgais KM, Grossman D, et al. Academic Emerg
Med March 2004
62
Helical CT vs Plain Films
Outcome Helical CT (n97) Plain Film (n39) Mean
ED time (min) 243 (CI 143, 343) 174 (CI
154,194) Mean Radiation time (min) 89 (CI 60,
118) 88 (CI 76, 99) Radiographic cost total
RVU 17.3 (CI 15, 19) 10.7 (CI 8.5,
12.9) Total 657 (CI 570, 737) 407 (CI 323,
494) C-Spine RVU 5.9 (CI 5.8, 6.1) 1.8 (CI 1.4,
2.2) C-Spine 224 (CI 220, 232) 68 (CI 53,
84) Rad dose (nRem) 432 (CI 340, 465) 127 (CI
117, 138)
63
Helical CT vs Plain Films
Outcome Helical CT (n97) Plain Film (n39) Mean
ED time (min) 243 (CI 143, 343) 174 (CI
154,194) Mean Radiation time (min) 89 (CI 60,
118) 88 (CI 76, 99) Radiographic cost total
RVU 17.3 (CI 15, 19) 10.7 (CI 8.5,
12.9) Total 657 (CI 570, 737) 407 (CI 323,
494) C-Spine RVU 5.9 (CI 5.8, 6.1) 1.8 (CI 1.4,
2.2) C-Spine 224 (CI 220, 232) 68 (CI 53,
84) Rad dose (nRem) 432 (CI 340, 465) 127 (CI
117, 138)
64
Helical CT vs Plain Films
Outcome Helical CT (n97) Plain Film (n39) Mean
ED time (min) 243 (CI 143, 343) 174 (CI
154,194) Mean Radiation time (min) 89 (CI 60,
118) 88 (CI 76, 99) Radiographic cost total
RVU 17.3 (CI 15, 19) 10.7 (CI 8.5,
12.9) Total 657 (CI 570, 737) 407 (CI 323,
494) C-Spine RVU 5.9 (CI 5.8, 6.1) 1.8 (CI 1.4,
2.2) C-Spine 224 (CI 220, 232) 68 (CI 53,
84) Rad dose (nRem) 432 (CI 340, 465) 127 (CI
117, 138)
65
Helical CT vs Plain Films
Outcome Helical CT (n97) Plain Film (n39) Mean
ED time (min) 243 (CI 143, 343) 174 (CI
154,194) Mean Radiation time (min) 89 (CI 60,
118) 88 (CI 76, 99) Radiographic cost total
RVU 17.3 (CI 15, 19) 10.7 (CI 8.5,
12.9) Total 657 (CI 570, 737) 407 (CI 323,
494) C-Spine RVU 5.9 (CI 5.8, 6.1) 1.8 (CI 1.4,
2.2) C-Spine 224 (CI 220, 232) 68 (CI 53,
84) Rad dose (nRem) 432 (CI 340, 465) 127 (CI
117, 138)
66
Helical CT vs Plain Films
Outcome Helical CT (n97) Plain Film (n39) Mean
ED time (min) 243 (CI 143, 343) 174 (CI
154,194) Mean Radiation time (min) 89 (CI 60,
118) 88 (CI 76, 99) Radiographic cost total
RVU 17.3 (CI 15, 19) 10.7 (CI 8.5,
12.9) Total 657 (CI 570, 737) 407 (CI 323,
494) C-Spine RVU 5.9 (CI 5.8, 6.1) 1.8 (CI 1.4,
2.2) C-Spine 224 (CI 220, 232) 68 (CI 53,
84) Rad dose (nRem) 432 (CI 340, 465) 127 (CI
117, 138)
67
Helical CT vs Plain Films
Outcome Helical CT (n97) Plain Film (n39) Mean
ED time (min) 243 (CI 143, 343) 174 (CI
154,194) Mean Radiation time (min) 89 (CI 60,
118) 88 (CI 76, 99) Radiographic cost total
RVU 17.3 (CI 15, 19) 10.7 (CI 8.5,
12.9) Total 657 (CI 570, 737) 407 (CI 323,
494) C-Spine RVU 5.9 (CI 5.8, 6.1) 1.8 (CI 1.4,
2.2) C-Spine 224 (CI 220, 232) 68 (CI 53,
84) Rad dose (nRem) 432 (CI 340, 465) 127 (CI
117, 138)
68
Objectives

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Clinical versus radiograph clearance
• NEXUS Study
• Canadian Rules
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

69
C-Spine Radiograph

• Lateral film
• Anteroposterior film
• Open-mouth odontoid view

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C-Spine Radiograph

• Lateral Film
• Most injuries picked up with lateral film gt80
• Odontoid view utility questionable in small
  children
• Basic Information
• Jefferson Fracture axial compression
• Burst of C1 ring
• Hangman Fracture hyperextension, then flexion
• C2 pedicle fracture
• Physiologic dislocation
• Usually under 16 years of age
• Anteriorly displacement of C2 on C3

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C-Spine Radiograph

• Focus on the lateral neck
• Film adequacy
• C-spine alignment and curves
• Inter-vertebral spaces discs and joints
• Pre-vertebral space
• Pre-dental space

72
Brief anatomic review
73
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies and 1 thoracic body

74
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies, and 1 thoracic body

75
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies, and 1 thoracic body

76
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies, and 1 thoracic body

77
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies, and 1 thoracic body

78
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies, and 1 thoracic body

79
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies, and 1 thoracic body

80
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies, and 1 thoracic body

81
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Adequacy
• Visualize entire cervical spine
• Count 7 cervical bodies, and 1 thoracic body

82
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Alignment
• C-Spine Curves

83
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Alignment
• C-Spine Curves
• Anterior Vertebral Bodies

84
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Alignment
• C-Spine Curves
• Anterior Vertebral Bodies
• Anterior Spinal Canal

85
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Alignment
• C-Spine Curves
• Anterior Vertebral Bodies
• Anterior Spinal Canal
• Posterior Spinal Canal

86
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Alignment
• C-Spine Curves
• Anterior Vertebral Bodies
• Anterior Spinal Canal
• Posterior Spinal Canal
• Spinous Process Tips

87
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Inter-vertebral spaces
• Disc spaces
• Cartiledge
• Apophyseal joints

88
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Pre-vertebral space

89
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Pre-vertebral space
• Space between vertebral bodies and air column

90
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Pre-vertebral space
• Space between vertebral bodies and air column

91
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Pre-vertebral space
• Space between vertebral bodies and air column
• Must measure space above the glottis
• Normal size
• 1/2 to 2/3 of adjacent vertebral body
• Can be abnormal if
• non-inspiratory film
• Intubated
• Often normal in C-Spine injuries

92
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Pre-Dental Space

93
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Pre-Dental Space
• Space between Dens of C2 and anterior, interior
  side of C1 ring

94
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Pre-Dental Space
• Space between Dens of C2 and anterior, interior
  side of C1 ring

95
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• Pre-Dental Space
• Space between Dens of C2 and anterior, interior
  side of C1 ring
• Must be less than or equal to 5 mm
• Cause of increased space
• transverse ligament injury
• burst fracture of C1

96
Objectives

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Clinical versus radiograph clearance
• NEXUS Study
• Canadian Rules
• CT versus Plain Films
• Interpreting the cervical spine radiograph
• Cases

97
Case 1
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• 4 year old female, restrained, back seat
• High speed, head on, car versus tree
• Eye witnesses noted the passengers heads
  violently snapped forward
• The driver died at the scene
• C-spine immobilized
• Minimally responsive
• Intubated
• Ng-tube placed

98
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
99
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
100
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
Fracture at base of dens with anterior
displacement
101
Case 1
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• The greater elasticity and laxity of ligaments in
  children allow for more hyper flexion and
  extension injuries
• Children with hypoplasia of dens, ie Trisomy 21
• Children with rheumatoid arthritis, are at higher
  risk for atlanto-axial dislocation

102
Case 2
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• 18 month old female, unrestrained, front seat
• Sitting in babysitters lap, babysitter died at
  scene
• C-spine immobilized by gauze strapped with tape
  over childs head
• Alert and awake
• Severe respiratory distress, with decreased
  breath sounds on right chest
• No movement of lower extremities

103
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
104
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
Distraction injury
105
(No Transcript)
106
Case 2
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• C-spine injuries in children are rare
• Up to 40 of children with c-spine injury have
  trauma to another body part
• Must learn to properly immobilize the c-spine

107
Case 3
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• A 4 year old child, fell from shopping cart, no
  loc
• Fever, sore throat, strep positive yesterday
• Not tolerating liquids or solid food
• Temperature104
• Alert, awake and talking with hoarse voice
• Drooling, mild increased work of breathing
• He complains of neck pain

108
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
109
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
Glottis
Abscess
110
Case 3
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• The pre-vertebral space can be enlarged with a
  hematoma post c-spine trauma or general edema

111
Case 4
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• 5 year old male, sitting in seatbelt, front seat
• Airbag deployed
• C-spine immobilized
• Alert and awake
• Numerous abrasions to face, neck and left
  shoulder and arm
• Left arm limp and without sensation

112
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
113
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
Ruptured Transverse Ligament
114
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
C2 - Axis
115
v
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
C1 - Atlas
116
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
ANTERIOR
POSTERIOR
ANTERIOR
117
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
ANTERIOR
POSTERIOR
ANTERIOR
118
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
ANTERIOR
POSTERIOR
ANTERIOR
119
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
ANTERIOR
POSTERIOR
ANTERIOR
120
Adequacy Alignment Spaces Pre-vertebral
Pre-dental
ANTERIOR
ANTERIOR
POSTERIOR
121
Case 4
Adequacy Alignment Spaces Pre-vertebral
Pre-dental

• The safest place for any aged child is the back
  seat
• Air bags can be lethal to children
• AAP Recommends Children ages 12 and younger
  should ride in the back seat
• Must wear seat belts

122
Summary

• Epidemiology
• Anatomy Pediatric versus Adult
• Who should be immobilized
• Immobilization Techniques
• Clinical versus radiograph clearance
• CT versus Plain Films
• Interpreted the cervical spine radiograph