Toddler Takes a Tumble: Persistent Symptoms after Apparent Minor Head Trauma

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1 Toddler Takes a Tumble: Persistent Symptoms after Apparent Minor Head Trauma A 3-year-old child is playing with some older children on a backyard trampoline when he falls from the trampoline and strikes his head on the support. He experiences a transient loss of consciousness and a minor laceration just below the mandible on the right side. His older brother helps him up and he is able to walk inside. He is brought by his mother to the ED for evaluation. In the ED, he is alert, crying and resists examination. He has a small right submandibular laceration which does not require suturing and a right parietal contusion. The rest of the physical examination, including the neurological, is normal. He is discharged to the care of his mother who is given routine head injury instructions. Twenty-four hours later, the child is brought back to the ED by the mother who has noted that he will not move his neck. She states that he cries and says that his neck hurts when he moves it. On examination, he is rigidly holding his neck in neutral position and is tender to palpation of the upper cervical spine area. His neurological examination remains intact. He is immobilized on a long spine board and cervical spine radiographs are obtained. A fracture of the second cervical vertebra is diagnosed and the child is transferred to a pediatric trauma center for neurosurgical evaluation.

2 Toddler Takes a Tumble Page 2 of 16 Key Clinical Questions What is the proper technique for immobilization of the cervical spine in the pediatric patient? Is it possible to clinically clear the cervical spine of the pediatric patient? Can the NEXUS criteria be used? What radiographic views are required to adequately evaluate the pediatric patient who has sustained neck trauma? What are the most common abnormal radiographic findings for the pediatric cervical spine? What are the common normal findings that confound the x-ray diagnosis in pediatric patients? Key Learning Points Immobilization of the cervical spine of the child less than 8 years of age using the technique employed for adults will force the child s cervical spine into flexion. Thoracic elevation or occipital recess is required to properly immobilize a child 8 years of age or younger in the desired neutral position. It is possible to safely clear a child s cervical spine using careful history and physical examination techniques and the NEXUS criteria have performed well in this regard. Radiographic evaluation of the cervical spine of a child 8 years of age or younger consists of anteroposterior and lateral cervical spine x-rays. For children 9 years of age or older, an open-mouth cervical spine x-ray is also obtained. Common abnormal radiographic findings in children, in addition to soft tissue swelling, include: o Rotatory subluxation of the odontoid o Jefferson fracture o Odontoid fracture o Hangman s fracture Radiographic diagnosis of cervical spine injuries in the pediatric patient is complicated by the presence of ossification centers and synchondroses and especially by the effects of ligamentous laxity and hypermobility. Hypermobility frequently results in pseudosubluxation of C2 on C3 and may also produce pseudosubluxation of C3 on C4. Additionally, widening of the atlanto-dens interval, over-riding of the anterior arch of C1 on the odontoid and absence of uniform angulation between vertebrae may be seen.

3 Toddler Takes a Tumble Page 3 of 16 PEDIATRIC CERVICAL SPINE INJURY Background, Risk Factors and Epidemiology Cervical spine injury (CSI) in the pediatric patient is relatively rare but of great diagnostic importance to the emergency physician since CSI can result in catastrophic sequelae. The overall incidence of CSI for all ages in the United States is roughly 10,000 cases per year. Of these, 10% are in the pediatric age group. Half of these are in adolescents or children over the age of 8 years, where the diagnostic and management issues are essentially the same as they are in adults. This leaves about 500 cases of CSI per year that occur in infants or children under the age of 8 years. The Children s National Medical Center has reported a bi-modal distribution of pediatric CSI, with peak incidences between 2 and 4 years of age (toddler exploring behavior) and between 12 and 15 years of age (adolescent risk-taking). Unlike in adolescents and adults where 80% of cases occur in males, the male female distribution in younger children is close to 50:50. The most common etiologic factor in all age groups is the motor vehicle crash (MVC), which accounts of 40% of pediatric CSI and for 80% of the deaths. Falls and sports injuries are the next most common etiologies, responsible for about 20% each. Anatomy and Pathophysiology The cervical spine consists of 7 cervical vertebrae and the ligamentous structures which support them and maintain alignment. The 1 st and 2 nd cervical vertebrae, the atlas and axis, are specialized structures with adaptations for load-bearing and marked rotation. In the pediatric cervical spine, there are ossification centers and synchondroses that increase the complexity of x- ray diagnosis. Ligamentous laxity and hypermobility of spinal structures also give rise to findings not commonly seen in adults. In the atlas (C1), the ossification center for the posterior arch appears en utero and that for the anterior arch appears in the 1 st year of life. The synchondrosis for the spinous process fuses at age 3 and the neurocentral synchondrosis fuses at age 7.

4 Toddler Takes a Tumble Page 4 of 16. In the axis (C2), the ossification centers for the body and arches appear en utero, that for the summit of the odontoid appears by age 3-6 years and that for the inferior epiphyseal ring appears at puberty. The synchondroses for the spinous process, the neurocentral synchondrosis and that at the base of the odontoid fuse at age 3-6 years. One third of people have a visible fusion line at the base of the odontoid throughout life. The synchondrosis at the summit of the odontoid fuses by age 12 years but that for the inferior epiphyseal ring does not fuse until about age 25 years.. For the remaining cervical vertebrae (C3-C7), ossification centers for the superior and inferior epiphyseal rings appear at puberty, as do the secondary ossification centers for bifid spinous processes. Synchondroses for the anterior portion of the transverse processes fuse by age 6 years and those for the spinous processes by age 3 years. The neurocentral synchondoses fuse by age 3-6 years and those for the epiphyseal rings by age 25 years. The structures in the neck of the child are hypermobile for a number of reasons. The supporting ligaments are lax and the facet joints are oriented in a relatively horizontal position. The head is relatively large and the muscles of the neck are under-developed compared to adults. Anterior psuedosubluxation of C2 on C3 is seen in almost half of children x-rayed and is most marked under the age of 8 years. It is accentuated in flexion. Differentiating anterior pseudosubluxation from an occult Hangman s fracture can be accomplished with the use of the posterior cervical line (PCL). The PCL connects the bases of the spinous processes of C1, C2 and C3. If the PCL misses the anterior aspect of the spinous process of C2 by 2 mm or more, a true subluxation is indicated.

5 Toddler Takes a Tumble Page 5 of 16 Posterior pseudosubluxation may also be present with extension. Pseudosubluxation of C3 on C4 is less common but not unusual. Other effects of hypermobility of the pediatric cervical spine are widening of the atlanto-dens interval, which is normally < 3 mm, and over-riding of the anterior arch of C1 on the odontoid with extension. Absence of uniform angulation between the vertebrae, simulating ligamentous disruption, is frequently seen in the neutral position or with flexion, but is reduced with extension. Absence of lordosis in the neutral position, simulating muscle spasm, may also be seen. Another factor that complicates the interpretation of pediatric cervical spine films is the progressive maturation of the vertebral bodies. In infancy, the vertebral body is oval-shaped. As the child gets older, this progresses to an anterior wedge shape which is present throughout the rest of childhood. This shape can simulate a wedge compression fracture. However, in the normal pediatric cervical spine, there should be < 3 mm difference in the height of the anterior and posterior aspects of the vertebral body. The pre-vertebral soft tissue space may appear wide even in the presence of a normal cervical spine, especially when the film is shot in exhalation or in flexion. This space is considered abnormal only when it exceeds ¾ of the anteroposterior width of the adjacent vertebra, about 7 mm at C2-C3. The interspinous space between C1 and C2 may also appear widened, suggesting disruption of the posterior elements, as in a hyperflexion sprain. It is considered abnormal only if it is > 10 mm. ED Presentation Cervical spine injury should be considered in all children sustaining multiple trauma, falls from heights and in those involved in MVCs. In addition, CSI should be considered when there is significant localized trauma to the head or neck. Older children will usually complain of pain localized to the site of injury, while younger, less verbal infants and children will simply cry, especially with attempts to move the head or neck. Altered mental status or distracting injuries may make detection of CSI even more difficult. The head may be rigidly held in neutral position or it may be fixed in torticollis. Palpation of the neck of the responsive child with CSI will reveal midline cervical tenderness and there may be palpable muscle spasm or deformity. Most children with CSI will have a normal neurological examination, but motor, sensory and reflex abnormalities may be seen with more severe injuries. Transient paresthesias (pins and needles, electric shock, numbness or burning) may be seen at the time of injury and may promptly resolve. Nevertheless, such symptoms may be indicators of CSI. Analysis of the National Pediatric Data Registry over a 10-year period, revealed an overall incidence of CSI of 1.5% of injured children. The mean age of those with CSI was 11 years and boys constituted 61% of the cases. Eighty-three percent had bony injury, with 52% involving the upper cervical vertebrae, 28 % the lower cervical vertebrae and 7% involving both. Upper

6 Toddler Takes a Tumble Page 6 of 16 cervical spine injuries were found to occur with relative frequency in both younger children (8 years or less) and in older children (more than 8 years). Lower CSI was seen predominantly in older children. The mortality rate for upper cervical injury was found to be 23%, compared to 4% for lower cervical injury. One third of children had neurological injury, 76% incomplete and 24% complete. Half of those with neurological injury had no radiographic evidence of injury (SCIWORA). Complete cord syndrome is characterized by the absence of all motor and sensory function below the level of injury. Pain at the site of injury is maintained. There is no autonomic function below the level of injury, giving rise to loss of sweating and vasomotor control and in some cases to priapism. A moderate degree of hypotension may be associated. The bulbocavernosus reflex is preserved in all but the most severe complete cord syndromes and its absence carries a grave prognosis. It is elicited by placing a finger into the rectum and then squeezing the glans penis or the clitoris while observing for reflex contracture of the anal sphincter. Incomplete cord syndromes typically consist of either central, anterior or unilateral (Brown- Sequard) cord syndromes. Central cord syndrome is typically associated with a hyperextension mechanism of injury which results in impingement of the ligamentum flavum on the cord. The neurological deficit is more severe in the upper extremities than in the lower extremities due to the way the motor fibers are laid out in the pyramidal tracks. The Brown-Sequard syndrome is characterized by ipsilateral absence of motor and proprioceptive function along with contralateral loss of pain and temperature sensation. It is due to unilateral injury, typically by penetrating trauma or by unilateral facet dislocation. Anterior cord syndrome is characterized by a complete loss of motor function below the level of injury, along with loss of pain and temperature sensation, but with preservation of position and vibration senses. It is frequently due to impingement of bone fragments on the anterior aspect of the cord and may be amenable to early surgical intervention. Spinal cord injury without radiographic abnormality (SCIWORA) is due to non-disruptive, selfreducing, intersegmental deformation that may be associated with variable mechanisms of injury in the child with hypermobility of the cervical spine. In the National Pediatric Trauma Registry review, SCIWORA made up 17% of the cases of CSI. Patients who go on to develop SCIWORA may have transient symptoms that have resolved before presentation. Nevertheless, they may have a delayed deterioration that can be severe. The most common types of vertebral fractures seen in the pediatric age group involve the upper cervical vertebrae. Fracture or subchondral separation of the odontoid is one of the most common. It is thought to be caused by major anterior displacement of the upper cervical spine, resulting in shearing forces applied to the odontoid. In the setting of MVCs, it can occur when infants are secured in forward-facing car seats. Odontoid fracture is frequently not associated with any neurological injury due to the ample space for displacement within the ring of the atlas (C1) without impingement on the cervical cord. The Hangman s fracture is a fracture-subluxation involving the posterior elements of the axis (C2). There is bony disruption through the pedicles with anterior displacement of the body and posterior displacement of the laminae and spinous process. The usual mechanism is hyperextension and distraction. Again, the Hangman s fracture is frequently not associated with

7 Toddler Takes a Tumble Page 7 of 16 neurological injury due to the ample space about the cord at the level of C2 and due to the autodecompression inherent in the injury. Atlanto-axial rotatory subluxation results from disruption of the transverse ligament, the function of which is to keep the odontoid in place in close proximity to the anterior arch of the atlas (C1). The Jefferson fracture occurs when there is disruption of the ring of the atlas (C1), classically in more that one location about the ring. It may be very hard to detect when the disruption is at the site of ossification centers. The mechanism of injury is vertical loading, such as with a fall onto the top of the head. It is frequently associated with no neurological deficit. Atlantooccipital dislocation results from disruptions of the musculature, apical ligament, atlantooccipital joints, and tectorial membrane and is frequently associated with high cord injury. The mortality rate is almost 50%, but some patients, especially those without tectorial membrane disruption can have no neurological abnormality. An interspinous C1-C2:C2-C3 ratio of > 2.5 is predictive of tectorial membrane abnormalities. The atlanto-occipital interval should not be > 5 mm. Physeal injuries may occur at any level of the cervical cord and may occur in adolescents and young adults. The superior and inferior epiphyseal rings are present up to about age 25 years. Diagnostic Workup Lab Studies Laboratory studies are not specifically helpful in the evaluation of CSI and are indicated only as needed for the evaluation of associated illness or injury. Imaging Studies The standard 3-view cervical spine series has traditionally been used for radiological screening for evidence of CSI. It consists of anteroposterior, lateral and open-mouth odontoid views. The odontoid view is difficult to obtain in young children and efforts to obtain it can result in delays in treatment or further damage to the child. In a retrospective, multiinstitutional review of 51 children with CSI, Buhs, et. al. found that the transoral odontoid view was not used to make the diagnosis of CSI in any patients. The American Society of Neurological Surgeons now recommends only anteroposterior and lateral views for the radiological evaluation of children 8 years of age or less. The odontoid view is still recommended for older children. Oblique views are unlikely to be abnormal if no acute abnormalities are evident on standard anteroposterior and lateral radiographs. Their use is not recommended as part of the routine radiographic evaluation of acute cervical trauma. Flexion-extension radiographs may be helpful in revealing ligamentous instability when standard views show suspicious findings. They are unlikely to be abnormal when no abnormality or only loss of normal lordosis is noted on the standard films.

8 Toddler Takes a Tumble Page 8 of 16 Computed tomographic scanning with attention to the suspected level of injury is recommended to exclude occult fractures and to evaluate regions not seen adequately on plain x-rays. Magnetic resonance imaging (MRI) is valuable in the evaluation of potential CSI, especially in obtunded children, in those with equivocal radiographs, and whenever the cervical spine cannot be cleared by traditional means. MRI is also recommended for evaluation of children with neurological symptoms without radiographic findings. Emergency Department Care The first challenge encountered in the management of potential CSI is immobilization of the cervical spine. Due to the relatively large head of the child, immobilization of a child under the age of 8 years on a flat backboard will force the child s head into flexion. The use of a properly fitted semi-rigid collar will reduce the flexion but will not eliminate it. Proper immobilization of the child under the age of 8 years requires either the use of a special board with a recessed area for the occiput or the placement of a double mattress pad under the chest and back. Unstable Patients Airway management is also challenging in the setting of potential CSI. Cervical stabilization is required throughout the process. The technique of choice for opening the airway is the jaw thrust maneuver which can be performed with minimal risk of significant cervical spine movement. For patients requiring support of oxygenation and ventilation, great care should be exercised with the use of bag-valve-mask ventilation. This technique can cause more cervical spine movement than any of the techniques of intubation. The recommended technique for intubation is oral intubation with in-line cervical stabilization. Fiberoptic-assisted intubation may be used when it is available. If oral intubation is not feasible, needle or surgical cricothyrotomy must be considered. Children with potential CSI may require circulatory support due to coexistent injury or may exhibit evidence of neurogenic shock due to loss of sympathetic cardiovascular tone. Regardless of the cause, fluid resuscitation should be instituted immediately, either by intravenous or intraossesous routes. When the cause is neurogenic shock, the blood pressure is usually only moderately low. Continued administration of large volumes of fluid is not likely to be helpful and may result in edema that is detrimental to the damaged cord. Pressors with α-adrenergic effects, such as high-dose dopamine and phenylephrine, may be useful in reversing the effects of loss of sympathetic tone. Bradycardia may be an associated finding and atropine can be used if it is needed. The National Acute Spinal Cord Injury Study, published in 1990, found a beneficial effect of the use of high-dose steroids in the setting of spinal cord injury. The presumed mechanism of action is inhibition of lipid peroxidation and hydrolysis in the injured cord. Methylprednisolone is recommended in a dose of 30 mg/kg over 15 minutes, followed by an infusion of 5.4 mg/kg per hour for 23 hours. There were no children under the age of 12 years in the study population used to substantiate this recommendation. However, most authorities continue to recommend the use of high-dose steroids for children with spinal cord injury, regardless of age.

9 Toddler Takes a Tumble Page 9 of 16 Stable Patients Cervical spine x-rays are not required to exclude CSI in every patient who has experienced trauma. Careful history and physical examination can be used to define a subset of patients that can be clinically cleared. The National Emergency X-Radiography Utilization Study (NEXUS) was a prospective, multicenter study designed to evaluate the efficacy of a decision instrument for obtaining cervical spine radiography in trauma victims. The presence or absence of the following criteria was noted: Midline cervical tenderness Altered level of alertness Evidence of intoxication Neurological abnormality Presence of distracting injury Pediatric patients constituted 3065 (9%) of all NEXUS study patients and 30 (0.98%) had CSI. Only 4 of the 30 children with CSI were younger than 9 years and none were younger than 2 years. The NEXUS decision instrument correctly identified all pediatric CSI victims in this study. Its use could reduce pediatric cervical spine imaging by nearly 20%. Due to the lack of infants and toddlers in the study population, caution in applying the decision rule in this age group is advised. The use of the NEXUS criteria for evaluation of pediatric trauma patients is recommended by the American Society for Neurological Surgeons.

10 Toddler Takes a Tumble Page 10 of 16 References 1. Bracken MB, Shepard MJ, Collins WF, et al: A randomized controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury. N Engl J Med 322: 1405, Buhs C, Cullen M, Klein M, Farmer D: The pediatric trauma C-spine: is the 'odontoid' view necessary? J Pediatr Surg 35(6):994-7, Congress of Neurological Surgeons: Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 50(3 Suppl):S85-99, Dwek JR, Chung CB: Radiography of cervical spine injury in children: Are flexionextension radiographs useful for acute trauma? Am J Roentgenol 174(6):1617-9, Flynn JM, Closkey RF, Mahboubi S, Dormans JP: Role of magnetic resonance imaging in the assessment of pediatric cervical spine injuries. J Pediatr Orthop 22(5):573-7, Furnival RA, Street KA, Schunk JE: Too many pediatric trampoline injuries. Pediatrics 103(5):e57, Odent T, Langlais J, Glorion C, et al: Fractures of the odontoid process: A report of 15 cases in children younger than 6 years. J Pediatr Orthop 19(1):51-4, Pang D, Wilberger JE Jr: Spinal cord injury without radiographic abnormalities in children. J Neurosurg 57:114, Patel JC, Tepas JJ 3 rd, Mollitt DL, Pieper P: Pediatric cervical spine injuries: Defining the disease. J Pediatr Surg 36(2):373-6, Ralston ME, Chung K, Barnes PD, et al: Role of flexion-extension radiographs in blunt pediatric cervical spine injury. Acad Emerg Med 8(3):237-45, Ralston ME, Ecklund K, Emans JB, et al: Role of oblique radiographs in blunt pediatric spine injury. Pediatr Emerg Care 19(2):68-72, Swischuk LE: Anterior displacement of C2 in children. Pediatr Radiol 122:759-63, Sun PP, Poffenbarger GJ, Durham S, Zimmerman RA: Spectrum of occipitoatlantoaxial injury in young children. J Neurosurg 93(1 Suppl):28-39, Viccellio P, Simon H, Pressman BD, et al: A prospective multicenter study of cervical spine injury in children. Pediatrics 108(2):E20, 2001.

11 Toddler Takes a Tumble Page 11 of 16 Patient Outcome Diagnosis: Fracture though the pedicles of the axis (C2) with traumatic subluxation, the Hangman s fracture. No associated neurological impairment. The patient was immobilized using a semi-rigid cervical collar and a long spine board. A double mattress pad was placed under the child s back and shoulders to avoid forcing the neck into flexion during immobilization. Lateral and anteroposterior radiographs were obtained which demonstrated the fracture as outlined above. The patient remained stable and transfer to a pediatric trauma center was arranged. The child arrived in stable condition and was evaluated by the pediatric surgery and neurosurgery services. The child continued to be stable without neurological deficits. It was not felt that adequate immobilization could be obtained with external techniques and the child was taken to the operating room for internal fixation. He did well and was subsequently discharged, after which he wore a cervical collar for 8 weeks. Recovery was complete with no detectable limitation in neck movement.

12 Toddler Takes a Tumble Page 12 of 16 Annotated Bibliography 1. Congress of Neurological Surgeons: Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 50(3 Suppl):S85-99, While concluding that there is insufficient evidence to support diagnostic or treatment standards, the Congress of Neurological Surgeons has published guidelines. The NEXUS criteria are supported for determining which pediatric patients require radiological evaluation. For children under the age of 9 years, anteroposterior and lateral views are recommended; for those 9 years or older, open-mouth odontoid views are also recommended. Thoracic elevation or occipital recess is recommended to prevent flexion of the head or neck during immobilizaiton. 2. Buhs C, Cullen M, Klein M, Farmer D: The pediatric trauma C-spine: Is the 'odontoid' view necessary? J Pediatr Surg 35(6):994-7, A retrospective, multi-institutional review of cervical spine injuries occurring in children under the age of 16 years was conducted over a 10-year period. Fifty-one children were identified. In those < 8 years of age, lateral and antero-posterior views made the diagnosis in 87% of cases and in no cases was the odontoid view needed to make the diagnosis. Since this view is difficult to obtain and can be hazardous in young children, the authors recommend that it should not be considered necessary in "clearing" the pediatric cervical spine. 3. Furnival RA, Street KA, Schunk JE: Too many pediatric trampoline injuries. Pediatrics 103(5):e57, In 1996, 83,000 patients received treatment for trampoline injuries in the US, of which 75% were < 15 years of age. This study is a retrospective review of 727 patients with trampoline injuries presenting to a pediatric ED between 1990 and The annual number of injuries nearly tripled during that period of time. The authors recommend a ban on recreational, school and competitive pediatric use of trampolines. 4. Odent T, Langlais J, Glorion C, et al: Fractures of the odontoid process: A report of 15 cases in children younger than 6 years. J Pediatr Orthop 19(1):51-4, A retrospective review of 15 cases of odontoid process fracture in children younger than 6 years was conducted. Eight of the patients had neurological involvement. Eight patients were secured in forward-facing car seats during motor vehicle crashes. Conservatively treated fractures fused without problems. 5. Patel JC, Tepas JJ 3rd, Mollitt DL, Pieper P: Pediatric cervical spine injuries: Defining the disease. J Peditr Suirg 36(2):373-6, A review of the National Pediatric Trauma Registry over a 10-year period showed 75,172 injured children and 1,098 with cervical spine injury (1.5%). Eighty-three percent had bony spine injury. Upper cervical spine injuries were seen in children of all age groups, while lower cervical spine injuries predominated in children > 8 years of age. One-third had neurological injury. Mortality was nearly 6-fold higher for upper cervical spine injury.

13 Toddler Takes a Tumble Page 13 of Viccellio P, Simon H, Pressman BD, et al: A prospective multicenter study of cervical spine injury in children. Pediatrics 108(2):E20, A prospective, multicenter study to examine the incidence and spectrum of spine injury in patients younger than 18 years and to evaluate the efficacy of the National Emergency X- Radiography Utilization Study (NEXUS) decision instrument for obtaining cervical spine radiography in pediatric trauma victims. The NEXUS decision instrument includes the presence or absence of the following: Midline cervical tenderness Altered level of alertness Evidence of intoxication Neurological abnormality Painful distracting injury The study identified 3,065 patients younger than 18 years, of which 30 (0.98%) sustained cervical spine injury. The decision rule correctly identified all pediatric cervical spine injury victims and had a negative predictive value of 100%. The use of the decision instrument could reduce pediatric cervical spine imaging by nearly 20%. Caution should be used in applying the decision rule to infants and toddlers, since the number of very young children in the study was small.

14 Toddler Takes a Tumble Page 14 of 16 Questions 1. Proper immobilization of the cervical spine of a child less than 8 years of age can be achieved using which of the following techniques? a. Double layer of padding under the child s head b. A special pediatric board with length varying with the age of the patient. c. Avoidance of the use of cervical collars due to difficulty of achieving proper fit and use of sandbags and tape instead. d. Double mattress pad under the chest and back. e. Use or a properly sized semi-rigid collar and a backboard in the same fashion as for an adult. 2. According to the NEXUS criteria, all the following are supportive of the decision to x- ray the neck of an injured child EXCEPT: a. Midline cervical tenderness b. Altered level of alertness c. Distraction mechanism of injury d. Neurological abnormality e. Presence of a painful distracting injury 3. Which of the following series of radiographs is recommended for the evaluation of the cervical spine of a child less than 8 years of age? a. Anteroposterior and lateral views. b. Anteroposterior, lateral and open-mouth odontoid views. c. Anteroposterior, lateral, open-mouth odontoid and oblique views. d. Anteroposterior, lateral and obliques views. e. Lateral view only if low suspicion. 4. Which of the following is true regarding vertebral fractures in children? a. Upper cervical spine injuries are equally prevalent in older and younger children, while lower cervical spine injuries predominate in children over the age of 8 years. b. The mortality rate for upper cervical fracture is the same as that for lower cervical vertebrae. c. Fracture of the odontoid is frequently associated with devastating neurological injury. d. The Jefferson fracture is frequently seen in children who are secured in forward-facing car seats when involved in a MVC. e. An occult Hangman s fracture is suspected when the base of the spinous process of the axis is > 2 mm anterior to the posterior cervical line. 5. Hypermobility of the pediatric cervical spine may be responsible for all the following radiographic findings EXCEPT? a. Anterior psuedosubluxation of C2 on C3. b. Posterior pseudosubluxation of C2 on C3. c. Marked lordosis in the neutral position d. Widening of the atlanto-dens interval. e. Over-riding of the anterior arch of the atlas on the odontoid with extension

15 Toddler Takes a Tumble Page 15 of 16 Answers 1. Answer d. Children less than 8 years of age cannot be immobilized using the standard adult technique. Due to the relatively larger head size, doing so will cause the neck to be forced into flexion. Placing padding under the occiput would accentuate this effect. The length of the board is inconsequential. Use of semi-rigid cervical collars is acceptable but proper size is essential to avoid unwanted movement or excessive extension. Soft towel rolls can be used and taped in place but sandbags are too heavy and can shift during transport leading to further injury. Proper immobilization of the child under 9 years of age requires either a special board with a recessed area for the occiput or elevation of the thorax with padding. 2. Answer c. The NEXUS decision rule for the use of cervical spine radiography performs well in the pediatric age group. The criteria used are midline cervical tenderness, altered level of alertness, evidence of intoxication, neurological abnormality and presence of a painful distracting injury. Mechanism of injury is not included in the decision rule. 3. Answer a. For children younger than 8 years of age, anterioposterior and lateral views only are recommended. Open-mouth odontoid views are recommended as part of the series for children older than 8 years, but are difficult to obtain in younger children and have not been shown to be essential in detecting vertebral pathology. Oblique views are not recommended as part of the initial evaluation. A lateral cervical spine film is used for initial screening but is inadequate for complete evaluation. 4. Answer a. According to data from the National Pediatric Trauma Registry, upper CSI was prevalent in both age groups (42%, age < 8; 58%, age > 8). Lower CSI predominated in older children (85%, age > 8). Mortality is almost 6 times higher for upper cervical injury than it is for lower cervical injury. Odondoid fractures are frequently not associated with neurological injury. Due to the ample space within the ring of the atlas, the odontoid can move significantly without impinging on the cord. Odontoid fractures are frequently seen due to shearing forces when small children are secured in forward-facing car seats, but the Jefferson fracture is usually due to axial loading, as is seen when the vertex of the head strikes the roof of a car or the bottom of a pool. When a Hangman s fracture occurs, the fracture line is usually through the pedicles and the posterior elements of the axis move posteriorly. The base of the spinous process of C2 is therefore posteriorly displaced. When the base of the spinous process of C2 is > 2 mm posterior to the posterior cervical line, an occult Hangman s fracture should be suspected. 5. Answer c. Hypermobility of the pediatric cervical spine may be responsible for anterior or posterior pseudosubluxation of C2 on C3 or C3 on C4, although anterior pseudosubluxation of C2 on C3 is most commonly seen. In addition, an atlanto-dens interval > 3 mm and over-riding of the anterior arch of the atlas on the odontoid in extension may be seen. Straightening of the contour lines in the neutral position, simulating cervical muscle spasm, may also be seen, but accentuation of the normal lordosis seen in adults is not an effect of hypermobility.

16 Toddler Takes a Tumble Page 16 of 16 Acknowledgements Slide 6, 34: American College of Emergency Physicians, American Academy of Pediatrics: Advanced Pediatric Life Support Course, Slides 10-12: Herzenberg JE, Hensinger RN, Dedrick DK, Phillips WA: Emerging transport and positioning of young children who have an injury of the cervical spine. J Bone Joint Surg 71A(1):15-22, Slides 17, 28: Strange GR, Ahrens WR, Lelyveld S, Schafermeyer RW: Pediatric Emergency Medicine: A comprehensive study guide, 2 nd Edition. New York: McGraw-Hill, Slides 18-22: Fielding JW: Cervical spine injuries in children. Jn: The Cervical Spine Research Society (eds): The Cervical Spine. Philadelphia: JB Cippincott; 1983: Slides 24-29: Catell HS, Filtzer DL: Pseudosubluxation and other normal variations in the cervical spine in children: A study of 160 children. J Bone Joint Surg 47A: , Slide 33: Fleisher GR, Ludwig S, et al (eds): Textbook of Pediatric Emergency Medicine, 3 rd Edition. Baltimore: Williams and Wilkins, Slides 35, 38: Swischuk LE: Anterior displacement of C2 in children: Physiologic or pathologic? Radiology 122: , Slide 37: Woods WA: Pediatric cervical spine injuries: Avoiding potential disaster. Trauma Rep 4(4):1-12, 2003.