Pediatric Cervical Spine Injury and Immobilization

Authors: Kevin Gutermuth, MD, FAAP; Alicia Hereford, MD; Shea Duerring, MD, FAAP, FACEP, FAEMS

Overview

Trauma remains the number one killer of children in the United States. Luckily, pediatric spinal injuries are very rare. Of the pediatric spinal injuries that do occur, 60-80% are in the cervical spine.¹⁶ Overall, pediatric cervical spine injuries (CSIs) occur in 1-2% of pediatric blunt trauma.¹⁵ The most common mechanism of injury in those less than 2 years old by far were motor vehicle collisions (MVCs), followed by falls.⁷ For those between 2 and 7 years of age, MVCs, falls, and pedestrian struck by motor vehicles were most the common mechanisms.⁷ From 8 to 15 years, most common mechanisms of injuries were MVCs and sports injuries, but falls and diving injuries were also important.⁷ Injury patterns begin to resemble those in adults by the age of 12.⁷ Of note, remember that non-accidental trauma (NAT) is also a cause of CSI in children and is most likely more common than originally thought due to underreporting.

As children grow, their anatomy changes causing different locations of injuries. Children have a larger head compared to their body leading to a higher fulcrum thus resulting in higher level CSIs. As the child matures, the cervical spine fulcrum progresses caudally, changing from C2-C3 at birth to C5-C6 by age 12.¹⁶ The axial region was involved in 74% of CSIs, with atlanto-axial dislocation being the most common injury, in those less than 2 years of age.⁷ 78% of CSIs also occurred in the axial region in children aged 2-7 years old.⁷ Children also have open ossification centers predisposing them to atlanto-axial injuries – these injuries occur 2.5 times more often in children than in adults.⁷ Subaxial injuries were the most common (53%) in 8- to 15-year-old children, with the most common injury being subaxial vertebral body fractures.⁷Secondly, children have increased laxity of ligaments allowing for greater mobility of the upper cervical spine.^3,4,16Although the spinal column is flexible and can be distracted by 5 cm without structural injury, the spinal cord is not, possibly leading to Spinal Cord Injury Without Radiographic Abnormality (SCIWORA).¹⁶ The spinal cord can only withstand 5mm of distraction before injury can occur.¹⁶ Children also have weaker cervical musculature offering less protection compared to adults.^4,16 Lastly, children have immature vertebral joints, horizontally inclined articulating facets, and anteriorly wedged vertebral bodies that facilitate sliding of the upper cervical spine causing dislocation.¹⁶These anatomic differences are why those less than 8 years of age have an increased number of injuries to the axial cervical spine compared to older children and adults.

Backboards, C-collars, etc.:

Backboards are still generally used in transfer of trauma patients with blunt trauma and altered level of consciousness, focal neurologic deficits, spinal pain or tenderness, deformity of the spine, high energy mechanism with intoxication, distracting injury, or inability to communicate, to help reduce the chance of spinal cord injury.¹⁰ The benefit of backboards has yet to be proven and can lead to complications such as pressure ulcers, pain, increased agitation, and respiratory compromise.¹⁰ If a patient arrives to the ED on a backboard, it should be removed immediately.

After a trauma, if the child has neck pain, torticollis, neurologic deficit, altered mental status (GCS <15, intoxication, agitation, apnea, hypopnea, etc.), high-risk MVC, high impact diving injury, or substantial torso injury, a cervical collar (c-collar) should be placed for immobilization. One should also be placed if there is a high suspicion for CSI. While C-collars prevent motion that may worsen an existing injury, C-collars also come with associated risks –such as pressure ulcers, anxiety, discomfort, and difficulty with airway and respiratory management.

Clearing C-collars in children with trauma can be extremely challenging. This will be discussed more in depth later.

Examination/Evaluation:

As with any trauma, ATLS protocols should be followed starting with the primary assessment (ABCDE) and moving to the secondary assessment. If a patient has a high CSI, they may present with apnea, hypotension, AMS, etc. Close examination of the cervical spine – assessing for any tenderness to palpation and/or deformities. If there is midline tenderness, range of motion should be deferred. A thorough neurologic examination should also be performed. These evaluations can be challenging due to the patient’s age, ineffective communication, difficulty following commands, etc. If a child has multisystem trauma and/or a head injury, there should be an increased suspicion for CSI. Predisposing conditions for cervical spine injuries such as prior cervical spine surgeries, cervical spine arthritis, or congenital syndromes (Down syndrome, etc.) should also be accounted for.¹⁶

Clinical Decision Tools:

Currently, there are no validated pediatric cervical spine clinical imaging tools available. Adults have multiple clinical decision tools, such as NEXUS and Canadian C-Spine, that have insufficient sensitivity for excluding CSI in children, especially younger children.^6,14 NEXUS had a limited number of children, with only four being under the age of 9 years old, and the Canadian C-spine study did not include any children under age 16.^6,14 The PECARN C-spine Injury Risk Factors include eight risk factors that when all are absent, there is a 98% sensitivity and 26% specificity.⁸ Unfortunately, these risk factors have yet to be fully validated.⁸ The PECARN C-spine Injury Risk Factors include altered mental status, focal neurologic deficits, substantial torso injury, neck pain, torticollis, conditions predisposing to cervical injury, diving, and high-risk motor vehicle crash.⁸

Imaging/Clearing C-spine:

In young children with normal mentation and low mechanisms of injury, plain films with 2-3 views (AP, lateral, +/- open-mouth odontoid) can be used and in a few studies were found to be decently sensitive for excluding significant CSIs with sensitivity of 90% overall.² A study from Vanderbilt in 2017 found that the sensitivity was 50.7% for all injuries, both significant and non-significant CSIs, and only 62.3% sensitive for clinically significant injuries.⁵ The study from Vanderbilt is very concerning. To further complicate this, open ossification centers can make interpretation of plain films more difficult.

If unable to obtain adequate plain films, concern for CSI, or GCS 8 or less, CT imaging should be obtained. CTs are 98% sensitive and specific for bony injuries, but do not assess for ligamentous injuries.^9,13 A limited CT up to C3 is also an option in patients less than 8 to help limit radiation exposure, especially if they are already getting a CT head. In a recent single-institution retrospective review of pediatric blunt trauma, they found that CT was 100% sensitive for identifying clinically significant CSIs.¹² Obtaining a CT on pediatric patients shouldn’t be taken lightly since there is a large increase in radiation exposure, however it appears to outperform plain films and if there is significant enough concern, CT would be indicated for quick and reliable imaging, especially if ready access to MRI is unavailable.

If a patient has continued midline tenderness to palpation or a neurologic deficit concerning for SCIWORA, MRI can be extremely useful for assessing soft tissues, intervertebral discs, ligaments, and the spinal cord.¹ MRIs are costly and timely, sometimes requiring sedation, which prevents the regular use of them.

In 2019, an expert panel of 25 physicians (pediatric orthopedic surgeon, pediatric emergency medicine, pediatric trauma surgeon, pediatric neurosurgeon, pediatric radiologist) from 20 different institutions made a comprehensive algorithm, based on 80% agreement of committee members, to help with the conundrum of clearing pediatric c-collars.¹¹ The algorithm is based on 3 ranges of GCS score: 14-15, 9-13, and 8 or less. If the patient has a GCS of 14 or 15, holding their neck normally with normal range of motion, no cervical tenderness, and moving all extremities with no focal neurologic deficits, their c-collar can be cleared with one exception.¹¹ If the child has significant injury to the chest, abdomen, or pelvis, the panel does not recommend clearing c-spine.¹¹ In this algorithm, it was debatable on what imaging to obtain if the patient has a GCS of 14 or 15 with an abnormal exam finding.¹¹ At minimum, a lateral plain radiograph should be obtained, but many experts advocated for a CT given its better sensitivity.¹¹ For those with GCS 9-13, if there is a potential for improvement of mental status, then plain radiographs may be sufficient.¹¹ If low potential for GCS improvement, then CT should be obtained. Children with GCS 8 or below with reasonable suspicion for CSI, obtaining CT imaging is recommended.¹¹

Conclusion/Application for Prehospital Clinicians:

As discussed, the pathophysiology and confounding variables surrounding traumatic injuries can make detection of spinal cord injuries difficult in the prehospital setting. A high index of suspicion should be utilized when determining if cervical spine and/or spinal immobilization techniques should be used. There is wide heterogeneity in application of cervical spine immobilization within prehospital systems, and validated clinical decision tools are currently lacking.¹⁷ The PECARN group performed a retrospective derivation study in the study emergency departments, and identified 8 predictors of CSI in children with blunt trauma: altered mental status (GCS<15, intoxication, and other signs ex: agitation, apnea, hypopnea, somnolence, etc.), focal neurologic deficits, neck pain, torticollis, substantial torso injury, conditions predisposing to CSI (ex: Trisomy 21), diving mechanism, and high-risk MVC.¹⁸ While these have not yet been prospectively validated, but have been advocated for as indicators for CSI in the most recent consensus statement from American College of Surgeons Committee on Trauma(ACS-COT), American College of Emergency Physicians(ACEP), and the National Association of EMS Physicians(NAEMSP) in 2018.¹⁹ Therefore, we encourage prehospital providers to utilize these factors in conjunction with local protocols, in addition to obtained history and physical exam, when considering application of CSI in pediatric patients.

References

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Editing by James Li, MD NAEMSP Blog Editor