Pediatric Head and Spinal Trauma Flashcards
- You see a 9-month-old girl in the emergency department after she slipped out of her father’s arms, falling 4 ft and hit her head on a hard floor. There is a tense bruise over the occiput. She is moving all four limbs spontaneously but intermittently, inconsistently inconsolable, moaning, and opens eyes to voice. Which one of the following best describes her Glasgow Coma Scale (GCS)?
a. 9
b. 10
c. 11
d. 12
e. 13
d. 12
A 12-year-old child sustains a head injury and is found to have evidence of venous sinus thrombosis on cranial imaging. Prior to discharge home, he is started on aspirin 25 mg od by the neurologist and the parents are advised that he is at increased risk of Reye syndrome if he develops a febrile illness or viral infection. Which one of the following best describes Reye syndrome?
a. Vomiting, encephalopathy, and hepatic dysfunction
b. Rash, encephalopathy, and renal dysfunction
c. Encephalopathy, renal dysfunction, and hepatic dysfunction
d. Wheeze, encephalopathy, and hepatic dysfunction
e. Vasculitis, encephalopathy, and renal dysfunction
a. Vomiting, encephalopathy, and hepatic dysfunction
Reye syndrome occurs most frequently after a
viral illness and is characterized by the onset of
severe vomiting followed by the development
of encephalopathy and hepatic dysfunction.
The onset of these symptoms typically occurs
within several days after the onset of the viral illness and commonly during a period when the
child seems to be recovering from this illness.
In association with severe—often projectile—
vomiting, which occurs for a transient period,
are progressive encephalopathic changes that
may follow stages from delirium through confusion, agitation, and lethargy to coma if
untreated. It is associated with the ingestion of
aspirin during the antecedent viral illness, hence
aspirin is no longer recommended or used for
the treatment of febrile illnesses in children.
Alternative antipyretics, including nonsteroidal
anti-inflammatory drugs and acetaminophen
(Tylenol), have replaced aspirin as the primary
therapy for such illnesses. Children with some
disorders, including juvenile rheumatoid arthritis and Kawasaki disease, continue to be given
aspirin to treat these disorders (and in this case
CVST). Efforts to reduce the risk for development of Reye syndrome in these children have
included influenza vaccination annually and vaccination against chickenpox. Careful monitoring
of these children also is necessary to ensure early
recognition and treatment of Reye syndrome
should it occur.
Which one of the following statements regarding the US PECARN pediatric head trauma algorithm is LEAST accurate?
a. It aims to calculate the likelihood of clinically important traumatic brain injury needing computed tomography (CT) imaging based on the age group
b. The likelihood of clinically important traumatic brain injury in children with GCS14/15, altered mental status or palpable skull fracture is approximately 4%
c. In a child under 2 years, likelihood of clinically important traumatic brain injury without a scalp hematoma, LOC >5 s, altered behavior, or severe mechanism of injury is <0.02%
d. Severe mechanism of injury include falls of more than 2 ft if <2 years old or 6 ft if >2 years old
e. In a child over 2 years, CT head or observation are appropriate if the child has severe headache
d. Severe mechanism of injury include falls of more than 2 ft if <2 years old or 6 ft if >2 years old
be used to calculate likelihood of clinically important TBI (ciTBI) and need for CT imaging. CT is
recommended in all children with GCS 14 or
altered mental status (agitation, somnolence,
repetitive questioning, slow response to verbal
communication) or palpable skull fracture—4.3-
4.4% risk of ciTBI. If these are not present,
criteria for scanning are based on age of patient.
In those under 2 years old, inpatient observation
or CT head should be considered if there is
occipital/parietal/temporal scalp hematoma,
LOC for >5 sec, not acting normally according
to parent, or a severe mechanism of injury (e.g.
motor vehicle crash with patient ejection, death
of another passenger, or rollover; pedestrian/
cyclist without helmet struck by motor vehicle;
fall of more than 3 ft if <2 years or 5 ft if
>2 years old; head struck by a high impact
object). In those over 2 years old, inpatient observation or CT head should be considered if there is
history of LOC, or vomiting, or a severe mechanism of injury, or severe headache. In the absence
of any of these age-group specific criteria, the risk
of clinically important TBI is <0.02% (under 2)
and <0.05% (over 2) and CT head is not recommended. Decisions regarding whether to observe
or scan a patient should be based on clinical experience, multiple findings rather than isolated,
worsening condition, age <3 months and parental preference.
Which one of the following risk factors in the UK NICE head injury guidelines for children is not sufficient alone to justify CT head scan within 1 h when identified?
a. Suspicion of non-accidental injury
b. Post-traumatic seizure but no history ofepilepsy
c. GCS less than 14/15, or for children
under 1 year GCS less than 15/15 on initial assessment
d. At 2 h after the injury, GCS less than 15
e. Witnessed loss of consciousness lasting
e. Witnessed loss of consciousness lasting
In a ventilated infant following closed head injury which one of the following ICP monitoring values is considered the upper limit of normal?
a. 5 mmHg
b. 7.5 mmHg
c. 10 mmHg
d. 12.5 mmHg
e. 15 mmHg
a. 5 mmHg
The upper limit of normal when measuring ICP in
a child (aged 4-16 years) using lumbar puncture
is generally considered to be 18 cm CSF
(12.9 mmHg). However, this applies to children
who are comfortable in the lateral decubitus position with the knees flexed. A crying, distressed
child will cause the ICP to rise and will be difficult
to interpret. In an infant undergoing ICP measurement in the horizontal position while ventilated following acute head injury, an upper limit of 5 mmHg is considered normal. An older child with a closed skull with the same circumstances and in the same position will have ICP values similar to an adult with an upper limit of normal of 10 mmHg.
An 11-month-old girl was admitted to the hospital because of blunt head trauma. Her initial neurological examination was completely normal except that a depressed fracture was palpated in her right parietal region. CT of the head is shown.
a. Comminuted fracture
b. Growing skull fracture
c. Linear skull fracture
d. Ping-pong fracture
e. Positional plagiocephaly
d. Ping-pong fracture
Depressed skull fractures occur in 7-10% of the
children admitted to hospital with a head injury.
Depressed skull fractures that occur in children
younger than 1 year forms an inward buckling
of the bones forming a “cup shape,” termed a
“ping-pong fracture.” In the neonate, ping-pong
ball or pond fractures occur with indentation of
the bone surface without disruption of the continuity of the bone (similar to green stick fractures
of the long bones). Typically the outer table is
fractured around the periphery, while the inner
table fractures at the center. In newborns, the
main cause of the depressed fractures is birth
trauma, which includes various perinatal factors
such as sacral promontory, uterine fibroids, exostosis of the lumbar vertebra, symphysis pubis, and
ischial spine. However, in the postnatal period,
the main cause is head trauma. For children without evidence of neurological or radiographic
intracranial lesions, there is no differences
between conservative and surgical management
strategy in terms of future neurological sequels
or seizures. The natural history of these
depressed skull fractures is variable, with some
elevating spontaneously over time and others
remaining depressed. Several nonsurgical elevation techniques that use the fact that the bone
is in partial continuity have been demonstrated;
these techniques include elevation using digital
pressure, and vacuum devices such as a breast
pump and a vacuum extractor which carry the disadvantages of patient discomfort, inability to
obtain complete correction of the depression,
and creation of local cephalhematoma with the
procedure. It has been demonstrated that the deeper the depressed bone (>1 cm), the higher the
risk of dural laceration and cortical laceration in
adults and older children, but less clear in neonate
and infant populations. Surgical treatment is
required in cases where the fragments are
depressed to the depth of at least one thickness
of the skull, and in those with intracranial hematoma, dural laceration/CSF leak, cosmetically
deforming defects, gross wound contamination,
and established wound infection.
An 8-month-old female child who previously fell from a changing table. She presented on referral from her pediatrician for evaluation
of a left frontoparietal mass. Which one of the following management strategies is most appropriate?
a. Cranioplasty
b. Conservative management
c. Dural repair
d. Duraplasty and autologous cranioplasty
e. Head bandage
d. Duraplasty and autologous cranioplasty
A rare complication after linear skull fracture in
young children (usually younger than 2 or 3 years)
is a “growing” skull defect at the fracture site. In
these cases, the dura is torn under a linear skull
fracture and a pouch of arachnoid passing
through the defect and expands, acting as a
one-way valve that traps CSF and causes progressive pressure erosion of the fractured edges to
enlarge the fracture. Brain growth which produces pulsating, spreading tensile pressure forces
on the edges of an unrepaired dural laceration
may also contribute to enlargement of the skull
defect, such that cerebral herniation through it
causes a new neurological deficit. Presentation
is with scalp swelling at the site of the fracture,
skull defects, persistent or progressive neurological deficits, and seizures. Ideally, young children
with a linear skull fracture managed conservatively should be followed up (e.g. at 1 year) to
exclude the development of a growing skull fracture. Once the diagnosis of growing skull fracture
is made management is surgical resection of the
leptomeningeal cyst and degenerated brain tissue,
water-tight repair of the dural defect (either primary or with duraplasty) and closure of the bony
skull defect. The dural defect may be larger than
the bone defect, such that sinus bleeding/injury at
one or both ends of the dural tear. In late stages of
growing skull fractures, the size of the bone defect
increases and the deformity of the bone near the
fracture is usually severe. In younger children
(especially infants) it is technically difficult to split
the skull bone to make enough materials for closure of the defect. Issues around cranioplasty
which are controversial: age of the patient, timing, cranioplasty type, and resorption of the
autologous bone. If GSF is diagnosed in the early
stages, especially the prephase of GSF, these
problems can be easily resolved.
Brain trauma foundation guidelines for medical management of TBI in children, which one of the following statements is incorrect:
a. Rewarming after hypothermia should not occur faster than 1 °C/h
b. A minimum CPP of 40 mmHg may be considered
c. 3% hypertonic saline should be considered for the treatment of intracranial hypertension
d. Continuous infusion of propofol for either sedation or the management of refractory intracranial hypertension should be avoided
e. The use of corticosteroids is not recommended to improve outcome or reduce ICP
a. Rewarming after hypothermia should not occur faster than 1 °C/h
Regarding Brain Trauma Foundation guidelines for surgical management of TBI in children which one of the following is LEAST accurate?
a. ICP should be treated when exceeding 15 mmHg in children
b. Simultaneous EVD and lumbar drainage of CSF can be used in refractory intracranial hypertension
c. Decompressive craniectomy should only be considered after the onset of late signs of neurologic deterioration
d. Decompressive craniectomy improves
long-term neurological outcome compared to aggressive medical management of raised ICP
e. ICP monitor placement is recommended for early detection of expanding intracerebral hematomas in coagulopathic children
c. Decompressive craniectomy should only be considered after the onset of late signs of neurologic deterioration
Consider ICP monitoring in infants and children
with severe TBI and treating when ICP exceeds
20-25 mmHg. The presence of coagulopathy
would contraindicate the placement of an ICP
monitor, in which situation the Cushing reflex
and autonomic dysfunction might be the only
indicators of increased ICP. CSF drainage
through an external ventricular drain may be
considered in the management of increased
ICP, with optional addition of a lumbar drain
in refractory intracranial hypertension despite a
functioning external ventricular drain, open basal
cisterns, and no evidence of a mass effect. CSF
drainage via EVD resulted in ICP control in
87% of pediatric patients. These three studies
also confirmed that refractory raised ICP is associated with poor outcome, with 100% mortality in all patients with refractory intracranial hypertension after CSF drainage. Decompressive
craniectomy with duraplasty may be considered
for patients who are showing early signs of
neurologic deterioration or herniation or are
developing intracranial hypertension refractory
to medical management during the early stages
of their treatment. Multiple small case series
also show that craniectomy is an effective rescue
intervention in patients with sustained ICP
greater than 20 mmHg, clearly demonstrating
craniectomy has a role in ICH management. Certain questions are still unanswered, including the ideal timing and method of craniectomy, as well as its impact on long-term outcome.
A 4-month-old girl presenting with apnea and loss of consciousness. CT head scan is shown. Which one of the following is most likely?
a. Fall from 3 ft height
b. Moya disease
c. Traumatic vertebral artery dissection
d. Shaken baby syndrome
e. Benign enlargement of the subdural space
d. Shaken baby syndrome
Abusive head trauma (shaken baby syndrome)
remains the most common cause of death in children who are victims of non-accidental injury
(NAI), and this usually occurs during the first
year of life. The diagnosis is often missed since
no history of head trauma is provided, and the
signs and symptoms the child displays may be
non-specific, such as vomiting, poor feeding,
irritability or lethargy. Primary injuries (consequence of the initial trauma or impact of
force) include epidural hemorrhages, subdural
hemorrhages, subarachnoid hemorrhages, skull
fractures, intraventricular hemorrhages, cortical
contusions, diffuse axonal injury (DAI) and intraparenchymal hematomas. Epidural hemorrhages
in children require a direct impact of forces and
are generally venous bleeds which result from
tears in the dural sinus or diploic veins. Subdural
hemorrhages do not require direct impact
and may result from inertial shearing or rotational forces but most commonly result from
abrupt deceleration. Subdural hemorrhages
occur in a space created by the traumatic separation of the arachnoid from the dura mater and are caused by bleeding from bridging veins. Subdural hematoma suggestive of abuse may be
acute, subacute or chronic, frequently bilateral,
closely related to the falx, layering over the
tentorium and accompanied by hemispheric
hypodensity (HH; hypodense edematous cortex
and underlying white matter in multiple cerebrovascular territories) due to secondary insults
(e.g. cardiac arrest, hypoxia and hypotension).
DAI results from sudden acceleration and
deceleration forces which may be combined with
rotational forces, which disrupts fiber tracts.
Infants are more susceptible to DAI due to their
large head-to-body ratio, weak neck musculature
and thinner skull. DAI typically affects subcortical white matter, the corpus callosum, the brainstem and internal capsule. Intraparenchymal
hematomas can result from shearing-straining
injuries due to rupture of small intraparenchymal
blood vessels and typically occurs in the frontotemporal white matter. The differential diagnosis of a child with intracranial hemorrhage
includes accidental trauma or NAT, birth
trauma, coagulopathy, congenital vascular malformations, spontaneous SDH (related to benign
enlargement of the subdural space), and metabolic deficiencies such as glutaric aciduria type
I. Associated ocular findings which increase the
likelihood of NAI (in the absence of verifiable
history) include retinal hemorrhage, periorbital
hematoma, eyelid laceration, subconjunctival/
intraocular hemorrhage, subluxed or dislocated
lens, cataracts, glaucoma, anterior chamber angle
regression, iridiodialysis, retinal dialysis or
detachment, intraocular hemorrhage, optic atrophy or papilledema. Multiple mechanisms of
retinal hemorrhage have been postulated,
including direct tracking of blood from intracranial hemorrhage, hemorrhage secondary to
raised intracranial pressure or retinoschisis
Which one of the following is not a sensitive finding of non-accidental injury in children?
a. A fractured femur in a pre-mobile child.
b. Bruising away from bony prominences
c. Torn labial frenulum in a mobile child
d. Genital and perineal burns
e. Multiple fractures and/or fractures of
different ages
c. Torn labial frenulum in a mobile child
Abuse can be classified broadly as physical, emotional, sexual and neglect, with overlaps occurring
in most cases. It has been estimated that 10-15%
of childhood injuries resulting in emergency
department visits are caused by abuse. Fractures
are the second most common presentation after
soft-tissue injury and bruising. In general, any
delay in presentation, any injury that does not
fit with the explanation offered or the developmental stage of the child, or a changing or
conflicting account should raise suspicion.
Important differential diagnosis of NAI includes
accidental injury, osteogenesis imperfecta, ITP,
Mongolian blue spot, and scalded skin syndrome.
A 12-year-old child is brought to the emergency department following an occipital head injury without loss of consciousness, but complains of significant headache and has vomited twice. The parents are concerned that he requires a scan. Which one of the following statements regarding the risk of cancer from CT scans in general is most accurate?
a. For a cumulative dose of between 50 and 60 mGy to the head there is a fivefold increase in the risk of brain tumors
b. For a cumulative dose of between 50 and 60 mGy dose to bone marrow there is a fivefold increase in the risk of leukemia
c. The lifetime additional risk of cancer due to CT scans in children is 1 extra case for 10,000 children scanned
d. The baseline incidence of any form of cancer in a child (before the age of 14) is 1 in 1000
e. The baseline incidence of any form of cancer is 1 in 20 in men before the age of 50.
c. The lifetime additional risk of cancer due to CT scans in children is 1 extra case for 10,000 children scanned
Children are considerably more sensitive to radiation than adults, have a longer life expectancy than
adults (a larger window of opportunity for expressing radiation damage), and may receive a higher
radiation dose than necessary if CT settings are
not adjusted for their smaller body size.For a cumulative dose of between 50 and 60 mGy to the head
(i.e. 2-3 CT head scans), the investigators reported
a threefold increase in the risk of brain tumors; the
same dose to bonemarrow (i.e. 5-10CT head scans)
resulted in a threefold increase in the risk of leukemia.However,itisimportant to stress that the absolute additional cancer risks associated with CT
scans (1 additional case for every 2000 people
scanned) are small compared to the baseline cancer
risk (i.e. 1 in 35 (men) or 1 in 20 (female) risk of
cancer before the age of 50, or 1 in 5 lifetime risk).
In children, the lifetime extra risk of cancer from
a single CT scan was small—about one case of
cancer for every 10,000 scans performed on children (baseline 1 in 500 risk of developing some
form of cancer before the age of 14).
Which one of the following factors does not predispose children to cervical cord injuries above C4 level?
a. Large head-to-body ratio
b. Horizontal, shallow facet joints
c. Ligamentous laxity
d. Increased spinal column elasticity
e. Age over 9 years
e. Age over 9 years
The pediatric cervical spine does not become
adult like until about the age of 8 years. These factors increase the risk of injury/instability to the
levels of C1-C3 include large head-to-body ratio,
ligamentous laxity, relative paraspinal muscle
weakness, horizontal/shallow facets. Cervical
spine injuries occur mainly in the upper cervical
spine above C4 in patients 8 years of age or younger which most often involve the occiput, C1, and
C2 complex and thus carries increased risk
of fatality. Patients older than 8 years of age
typically sustain more injuries below C4 and carry
a much lower fatality rate. Because of these
biomechanical differences, younger children
(0-8 years) tend to have fewer fractures and
greater incidence of SCIWORA (spinal cord
injury without radiographic abnormality).
Which one of the following statements
regarding history of spine trauma is LEAST accurate?
a. In young children aged 0-9 years, the predominant cause of injury is falls and automobile-versus-pedestrian accidents (>75%)
b. In children aged 10-14 years, motor vehicle accidents (40%) are the major cause of lumbar fractures, and falls and automobile-versus-pedestrian accidents are less prevalent
c. In children 15-17 years of age, motor vehicle and motorcycle accidents become the leading cause of spine injuries (>70%), and there is also an increase in sports-related spine trauma
d. SCI should be suspected if the child reports transient neurological symptoms at the time of injury, even if they are now resolved
e. Children with Down’s syndrome are at
higher risk of cervical injuries as it is associated with congenital fusion of cervical vertebrae
e. Children with Down’s syndrome are at
higher risk of cervical injuries as it is associated with congenital fusion of cervical vertebrae
Spine fractures are usually the result of highspeed and impact injuries such as a motor vehicle
accident or a fall from great height. Spine
Extra-CNS Signs of Physical Abuse Situations Highly Suspicious of NAI
Burns A high percentage of childhood burns are due to abuse (2-35% overall; up to 45% for
genital and perineal burns). The two kinds of burns most often seen in abused
children are scald burns (from contact with hot liquids) and thermal burns (contact
with hot objects). In accidental burns, the head, neck, anterior trunk, and arms are
the most often affected. In cases of abuse, hands, legs, feet, and buttocks were more
likely to be involved. The anterior aspect of the hand was more likely to be involved
in accidental burns and the dorsum of the hand was more likely involved in abuse
cases. Suspicious burns include patterned contact burns in clear shape of hot object
(fork, clothing iron, curling iron, cigarette lighter) and classic forced immersion burn
patterns with sharp stocking-and-glove demarcation and sparing of flexed protected
areas. In addition, splash/spill burn patterns in children which is not consistent with
the history of the child’s developmental level should be considered suspicious.
Cigarette burns should always raise concern for abuse, as should any evidence of
delay in seeking medical treatment
fractures in children represent 1-3% of all pediatric fractures. The incidence of pediatric spine
injuries peaks in 2 age groups; children
<5 years old and children >10 years old. There
is a seasonal peak of pediatric spinal injuries from
June to September, during summer break. There
is another seasonal peak in the 2 weeks surrounding the Christmas holiday. The mechanism of injury in the pediatric population varies with age. In young children aged 0-9 years, the predominant causes of injury are falls and
automobile-versus-pedestrian accidents
(>75%). In children aged 10-14 years, motor
vehicle accidents (40%) are the major cause of
lumbar fractures, and falls and automobile-versus-pedestrian accidents are less prevalent. In
children 15-17 years of age, motor vehicle and
motorcycle accidents become the leading cause
of spine injuries (>70%), and there is also an
increase in sports-related spine trauma. A spinal
cord injury should be suspected if the child has
a history of numbness, tingling, or brief paralysis
even if it has recovered subsequently. Some children are predisposed to cervical injuries more
than others includes children with Down’s Syndrome (atlanto-axial instability), Klippel-Feil
syndrome (congenital fusion of cervical spine),
previous cervical spine surgery, and other syndromes affecting the cervical spine. Hyperflexion
injuries are most common and are associated with
wedge fractures of the anterior cervical bodies
with disruption of posterior aspects. The classic
triad of symptoms of cervical spine injury is localized neck tenderness, muscle spasm and
decreased range of motion.
A 9-year-old girl is involved in a MVA and experiences a hyperflexion injury to the neck. She develops numbness and tingling in her arms and legs which progressed to an incomplete quadraparesis. GCS is 15/15. CT cervical spine does not show any fracture. MRI is shown below, and STIR sequences do not show any ligamentous disruption. Which one of the following statements is most accurate?
a. She should be managed in halo immobilization
b. Flexion-extensions should be done at the earliest opportunity
c. Somatosensory evokes potentials are
likely to be of value in localizing the injury
d. Spinal angiography should be performed to exclude dissection
e. In the presence of normal dynamic cervical X-rays, cervicothoracic bracing for 12 weeks is appropriate initially
e. In the presence of normal dynamic cervical X-rays, cervicothoracic bracing for 12 weeks is appropriate initially
SCIWORA is a widely recognized form of spinal
cord injury, occurring almost exclusively in children (due to relative elasticity of the spinal column relative to the spinal cord), and is
characterized by objective signs of myelopathy
as a result of trauma in the absence of any radiographically evident fracture, dislocation, or ligamentous instability (on static or dynamic X-rays
or CT). Children presenting with a history of
transient neurological signs or symptoms referable to the spinal cord after a traumatic event
but normal neurological examination can develop
delayed onset SCIWORA, hence there is debate
as to whether they should just be managed as such
initially despite the absence of objective signs. By
definition, normal acute flexion/extension X-rays
are required for a diagnosis of SCIWORA. If
paraspinous muscle spasm, pain, or uncooperation prevents dynamic studies, they recommended external immobilization until the child
can cooperatively flex and extend the spine for
dynamic X-ray assessment. Although concern
exists for the late development of pathological
intersegmental motion in children with SCIWORA following normal flexion and extension
studies, there has been no documentation of such
instability ever developing. MRI is recommended
in children with potential SCIWORA as it may
include identifying signal change or intramedullary injury (prognostic value), excluding compressive lesions of the cord/roots needing surgery,
exclude spinal ligamentous disruption that might
warrant surgical intervention (in situations where
dynamic flexion/extension radiographs cannot be
done or would be superfluous preoperatively),
guiding treatment regarding length of external
immobilization (e.g. evidence of residual ligamentous injury), and/or determining when to allow patients to return to full activity.
Pang has also recommended somatosensory
evoked potential (SSEP) screening of children
with presumed SCIWORA to detect subtle posterior column dysfunction when clinical findings are inconclusive, evaluating head-injured, comatose, or pharmacologically paralyzed children, distinguishing between intracranial, spinal, or peripheral nerve injuries, and/or providing a baseline for comparison with subsequent evaluations. Neither spinal angiography nor myelography is recommended in the evaluation of patients with SCIWORA. Because subluxation and/or malalignment/ligamentous instability are, by definition, absent in SCIWORA, the mainstay of treatment has been immobilization and avoidance of activity that may either lead to exacerbation of the present (ligamentous and spina cord) strain/injury or increase the potential for recurrent injury. Medical management issues such as blood pressure support and pharmacological therapy apply. Treatment consisting of cervicothoracic bracing for patients with cervical-level SCIWORA for 12 week and avoidance of activities that encourage flexion and extension of the neck for an additional
12 weeks (i.e. 6 months total) has not been associatedwith recurrentinjury. Patientswith normal MRI and SSEP findings following transient deficits or “symptoms only” may be managed with a cervical collar for 1-2 weeks. Despite this, it is
unclear what role immobilization plays given that
dynamic radiographs have confirmed the absence
of instability required for diagnosing SCIWORA, and furthermore, that follow-up with
dynamic radiographs in these children has not
shown development of delayed pathological
intersegmental motion. However, if (normal)
physiological motion of the spinal column can
potentiate spinal cord injury in these patients
when there is no malalignment, subluxation, or
lesion causing cord compression, then immobilization may be warranted.
Which one of the following statements regarding imaging of the cervical spine after trauma in children is most accurate?
a. Overriding of the anterior atlas in relation to the odontoid on extension is a normal finding on cervical radiographs in young children
b. In children older than 9 years, open
mouth X-ray views are not recommended
c. Children over 3 years of age should not have cervical spine imaging if they are alert, have no neurological deficit, no midline cervical tenderness, no painful distracting injury, no unexplained hypotension, and are not intoxicated
d. In a child under 3 years of age with a GCS of 14/15 cervical spine imaging is mandatory after trauma
e. If gross ligamentous instability is suspected on static radiographs MRI should be performed urgently
c. Children over 3 years of age should not have cervical spine imaging if they are alert, have no neurological deficit, no midline cervical tenderness, no painful distracting injury, no unexplained hypotension, and are not intoxicated
Anteroposterior (AP) and lateral cervical spine
radiography (plus open mouth views if >9 years
old) or high-resolution CT is recommended to
assess the cervical spine in children. Highresolution CT scan with attention to the suspected level of neurological injury, radiographic abnormality or area not adequately visualized on plain films. Flexion and extension cervical radiographs or fluoroscopy are recommended to exclude gross ligamentous instability if suspected following static radiographs/CT. MRI is recommended to exclude spinal cord or nerve root compression, evaluate ligamentous integrity, or provide information regarding neurological prognosis. Common normal findings on cervical spine radiographs obtained on young childrenwhich may be mistaken for acute
traumatic injuries are pseudosubluxation of C2 on
C3, overriding of the anterior atlas in relation to
the odontoid on extension, exaggerated atlantodens intervals, and the radiolucent synchondrosis between the odontoid and C2 body.
A 10-year-old child presents with an abnormal head posture as shown below after a recent respiratory tract infection. Which one of the following is most likely?
a. Atlanto-occipital dislocation
b. DYT-1 dystonia
c. Atlanto-axial rotatory subluxation (or fixation)
d. Odontoid epiphysiolysis
e. Subaxial cervical subluxation
c. Atlanto-axial rotatory subluxation (or
fixation)
Fixed rotatory subluxation of the atlanto-axial
complex (AARF) is not unique to children but
is more common during childhood. AARF may
present following minor trauma (30%), in association with an upper respiratory infection, or without an identifiable inciting event. It is associated
with Down’s syndrome, Morquio syndrome,
spondyloepiphyseal dysplasia, Larsen’s syndrome, achondroplasia and Grisel’s syndrome
(post-inflammatory). The head is rotated to one
side with the head tilted to the other side (due
to SCM spasm) causing the so-called “cockrobin” appearance mimicking torticollis, unable
to turn his/her head past the midline, attempts
to move the neck are often painful and usually
there is no neurological deficit. Plain cervical
spine radiographs may reveal the lateral mass of
C1 rotated anterior to the odontoid on a lateral
view. Fielding and Hawkins type I rotatory subluxation is characterized by rotatory fixation
without anterior shift of the atlas (transverse ligament intact), type II consists of rotatory subluxation with an anterior shift (ADI) of greater than
3 mm but less than 5 mm due to transverse ligament compromise and may also be associated
with spinal instability. Type III involves rotatory
subluxation with an ADI of greater than 5 mm.
Type IV is a rare and usually fatal injury that
involves rotatory fixation with a posterior shift.
If the diagnosis of AARF is suspected after clinical
examination and plain radiographic study, a
dynamic CT study should be obtained (threeposition CT with C1-C2 motion analysis). The
longer AARF is present before attempted treatment, the less likely reduction can be accomplished or maintained. Acute AARF (<4 weeks
since onset) that has not reduced spontaneously
should undergo attempted reduction with manipulation or halter traction. Chronic AARF (4 weeks
duration or more since onset) should undergo
attempted reduction with halter or skull tong/
halo traction. Reductions achieved with manipulation or halter traction should be immobilized
with a cervicothoracic (Minerva) brace, while
those requiring tong/halo traction should be
immobilized in a halo. Length of immobilization
should be proportional to the length of time that
the subluxation was present before treatment.
Surgical arthrodesis can be considered for those
with irreducible subluxations, recurrent subluxations, or subluxations present for 3 months’
duration.
Green’s skeletal trauma in children. Fielding
and Hawkins classification of atlanto-axial
rotatory displacement
