Pediatric Cervical Spine Injuries
Abstract & commentary
Synopsis: The RESCI group showed the lateral cervical spinal view to have the highest sensitivity. Sports injury was the most common cause of pediatric cervical spine injury.
Source: Baker C, et al. Evaluation of pediatric cervical spine injuries. Am J Emerg Med 1999;17:230-234.
Baker and colleagues performed a five-year retrospective review of pediatric (age < 18 years) cervical spine injury patients discharged from their tertiary care pediatric hospital and regional trauma center. Data were collected on children with both radiographically evident cervical spine injury (RESCI) and spinal cord injury without radiographic abnormality (SCIWORA). The goal was to analyze features of the history, physical examination, and radiographic evaluation of patients with cervical spine injury.
Seventy-two patients met the study criteria: 40 (56%) had RESCI and 32 (44%) had SCIWORA. Sports injury was the most common cause of injury (34%), followed by motor vehicle accident (23%), fall (20%), trampoline (11%), diving (4%), and miscellaneous (8%). In children younger than 8 years old, motor vehicle accidents and falls were the most common precipitating events. Of the 40 patients with RESCI, younger children tended to have higher cervical spine injuries but the difference was not significant. Of the 61 patients (RESCI and SCIWORA) with data available on neck examination, 51 (84%) had at least one of the following on clinical examination: midline cervical tenderness, paraspinous muscle tenderness, or cervical muscle spasm. Of those patients with one of these three findings, most (36/51, or 76%) had midline tenderness of the cervical spine. Thirty-eight of the 72 patients (57%) had abnormal neurological examinations; by definition all of the SCIWORA patients had them and an additional six patients with RESCI had focal neurological findings. The remaining 18% of patients in the RESCI group who had neither focal neurological findings nor isolated neck findings had both high-risk mechanisms of injury and distracting painful injuries; thus, no child had a truly unsuspected, asymptomatic cervical spine injury.
Radiographic examination data from the RESCI group revealed the lateral cervical spine view to have the highest sensitivity (79%), with the sensitivity increasing to 94% when considering the standard three-view series (lateral, anteroposterior, and odontoid). The SCIWORA group, which by definition had negative plain x-rays, had 14 patients who underwent MRI examination; 50% of these had abnormalities, including spinal cord contusions and spinal cord hematomas.
Comment by Richard A. Harrigan, MD, FACEP
The data presented from this study offered few surprises. The finding that sports was the most common cause of injury is at odds with prior studies, wherein motor vehicle accident has traditionally been found to be the most common cause of pediatric cervical spine injury.1 This discrepancy is likely due to the study location (Utah), as Baker et al hypothesize that urban areas would be associated with more motor vehicle accidents. The incidence of trampoline-related cervical spine injury was strikingly high and should serve as a warning. Cervical spine injuries in children younger than 8 years old usually occur above C4, due to the high location of the anatomic fulcrum of the cervical spine in young children at the C1-C3 level.2 Although there was a trend toward this, the results were not significant and perhaps can be attributed to a rather small sample size. The poor sensitivity of the lateral view alone was again shown, a point that deserves mention and reminds us that radiographic clearance involves at least a three-view series in children as it does in adults.1 CT adds further sensitivity to the detection of cervical spine injury.
The concept of SCIWORA must be considered when evaluating the pediatric cervical spine. Nearly one-half of the patients in this series had SCIWORA, which is consistent with previous data.1 SCIWORA is more common in children than in adults due to the greater flexibility of the ligaments, cartilage, and joint capsules in the pediatric population, allowing contusion of the cord from multiple mechanisms of stress. For example, buckling of the ligamentum flavum after hyperextension can cause a central cord syndrome in children without evidence of bony fracture on plain films.1,2 SCIWORA should be considered in patients with neurological findings despite a negative three-view series of cervical spine films; MRI is helpful in evaluating the ligaments and spinal cord in this circumstance.
References
1. Bonadio WA. Cervical spine trauma in children: Part I. General concepts, normal anatomy, radiographic evaluation. Am J Emerg Med 1993;11:158-165.
2. Bonadio WA. Cervical spine trauma in children: Part II. Mechanisms and manifestations of injury, therapeutic considerations. Am J Emerg Med 1993;11:256-278.
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