Pediatric Cervical Spine

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Pediatric Cervical Spine

• X-ray Rounds, Phil Ukrainetz, MD, PGY5
• December 5, 2002

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Normal anatomy

• C-spine ABCs
• Corresponding anatomy
• Pseudosubluxation
• Positioning

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C-spine ABCs

• Alignment
• Bone
• Cartilage
• Soft tissue

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C-spine ABCs
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C-spine ABCs
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Anatomy
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Pseudosubluxation

• Physiologic anterior translation of C2 on C3 in
  children
• Seen in 25 of children lt 8 yoa
• May be seen up to 16 yoa
• Seen in up to 1/3 of all pediatric neck films

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Why do they pseudosublux?

• Horizontal facets
• Weak neck musculature
• Cartilage artifact
• Ligamentous laxity
• Increased with neck flexion

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Causes of anterior translation of C2 on C3 in
children

• Pseudosubluxation
• Hangmans fracture

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Swischuk line

• Posterior cervical line
• Draw from C1 posterior arch to the cortex of the
  posterior cortex of C3 arch
• Line should pass through or be less than 1 mm
  anterior to the posterior arch of C2
• Swischuk LE. Radiology 1977 122 759-763

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Swischuk Line
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Problems with Swischuk Line

• We see normal Swischuk line with hangmans
  fractures - not sensitive or positive in disease
• We see abnormal Swischuk line with normal necks
  in flexion - not specific or negative in health
• A value gt1.5 -2mm suggests an occult hangmans
  fracture
• Woodward GA, Neck Trauma, Fleisher/Text Ped Emerg
  Med, Fourth Ed. 2000, pp 1327

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In Swischuks words..

• The posterior cervical line should only be
  applied when C2 is displaced anteriorly on C3

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Positioning

• Huge cranium
• Exhalation
• Neck spasm flexion

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Extension
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Neutral
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Flexion
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Nasty MVC - child badly hurt
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Normal Swischuk Line with a Hangmans Fracture
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Asymptomatic neck film with Swischuk line gt 1mm
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Summary

• Swischuk line is a diagnostic adjunct
• Consider pre-test probability
• Consider concordance with tests
• Low likelihood of injury and abnormal film -
  consider repositioning/disregard
• High likelihood of injury and normal film -
  continue investigating

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Case II
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Open mouth view
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Abnormal lateral masses
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Normal and abnormal open mouth odontoid
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Normal open mouth odontoid
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Unstable C-spine fractures

• Jefferson (C1 burst)
• Bit (Bilateral facets)
• Off (Odontoid)
• A (Any fracture dislocation)
• Hangmans (C2 pedicle fracture)
• Tit (Flexion/Extension teardrop)

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Pediatric c- spine gallery...
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