Spine Peds Flashcards
What is the pseudoluxation of the cervical spine?
A physiologic (normal) pseudosubluxation of cervical vertebrae of up to 40% (or 4 mm) seen in young children.
In who do we see it more frequently?
seen in children less than 8 years
What is the location?
C2 on C3 is most common
C3 on C4 is second most common
What is the Pathophysiology?
◦ caused by the horizontal nature of the facet joints at younger ages
facet joints become more vertical with age
What are the recommended views and Findings?
1- Lateral radiograph with flexion and extension
2- reduction of subluxation with extension xrays
3- absence of anterior soft-tissue swelling (usually seen with traumatic cause)
4- Swischuk’s line
Spino-laminar line drawn from spino-laminar point on C1 to C3
Spino-laminar point on C2 should be within 1.5 mm of spino-laminar line
helpful to differentiate pseudo-subluxation from true injury
DDx Pseudosubluxation
Hangman Fx
Normal findings in children cervical spine
- Pre-vertebral swelling < 2/3 of adjacent vertebral width
- Smooth contour lines of
- anterior vertebral bodies
- posterior vertebral bodies
- Spino-laminar line (inside lamina)
- tips of spinous process
- Parallel facet joints
- Normal Retro-Pharyngeal space
- < 6 mm at C2
- Retro-tracheal space < 14 mm
- Atlanto-Dens interval < 5 mm in children and < 3 mm adolescents
- Absent vertebral body wedging : 7% of normal children have a wedge shaped C3 vertebral body
- Absence of cervical lordosis: loss of cervical lordosis may be found in 14% of normal children
- C2-3 or C3-4 pseudo-subluxation < 4mm: considered normal as long as the posterior laminar line is contiguous
Cervical immobilization peds partiuclarity
using an adult backboard for pediatric patients creates a dangerous level of cervical flexion
transporting patients less than 8 years of age requires a spine board with occipital depression or enough thoracic elevation to align the cervical and thoracic segments of the spine
Collar immobilization: indications
▪ stable odontoid fractures
Atlanto-axial instability
acute atlanto-axial rotatory displacement (AARD)
stable subaxial cervical spine trauma
Modalities: rigid collar vs. soft collar (depends on injury, often controversial)
Recommendations regarding car seating for children according to age
- Rear-facing car seat in the rear center seat until at least 1 years of age and weighing at least 20lbs.
- Front-facing car seat in the rear center seat until at least 4 years of age or weighing at least 40lbs.
- This child should be in more than a simple seat belt restraint. The child meets criteria to ride in a booster seat, (over 40 pounds and older than 4 years of age), and should be seated in the rear center seat.
- Riding in the front seat is typically not recommended until the age of 13 with the caveat of any child under 80 pounds in the front seat should have the airbag turned off.
Position of cervical immobilization in children and adults
- Cervical spine injuries should be immobilized in a postion of relative extension in both children and adults.
- Applying cervical traction with the external auditory meatus in-line with the shoulders can serve as a guideline.
What is the most common cause of infantile torticolis?
Congenital Muscular Torticolis
What are the risk factors for congenital muscular torticolis?
- Oligo-hydramnios
- first pregnancy (limited intrauterine space)
- traumatic delivery
- breech delivery
What is the Pathophysiology of congenital muscular torticolis?
Contracture of the sternocleidomastoid (SCM)
Cervical rotational deformity with chin rotation away from the affected side and head tilt towards the affected side
What are the Associated conditions with congenital muscular torticolis?
◦ associated with other packaging disorders
- DDH
- metatarsus adductus
- calcaneovalgus feet
- plagiocephaly (asymmetric flattening of the skull)occurs on contralateral side
- congenital atlanto-occipital abnormalities
What is the Prognosis of congenital muscular torticolis?
◦ typically resolves with stretching within the first year
if left untreated
permanent rotational deformity
positional plagiocephaly
craniofacial deformities
facial asymmetry
facial hemihypoplasia
compensatory scoliosis
What are the clinical findings in congenital muscular torticolis and what test should we order?
- Palpable neck mass
US
CT dynamic for AARD
MRI for central causes of torticolis
What is the DDx of congenital muscular torticolis?
- AARD: painful (compared to painless for congenital muscular torticollis)post-traumatic or post-infectious (Grisel’s disease)
- Klippel-Feil syndrome classic triad: short webbed neck; low posterior hairline; limited cervical range of motion
- Ophthalmologic and vestibular conditions
- Lesions of central and peripheral nervous system
What is the TREATMENT of congenital muscular torticolis?
Nonoperative:
passive stretching
condition present for less than 1 year
less than 30° limitation in ROM
outcomes: 90-95% respond to passive stretching in the first year of life
Operative:
bipolar release of SCM or Z-lengthening
indications
failed response to at least 1 year of stretching
outcomes: good outcomes (92% success), even in older children
facial asymmetry can improve as long as release done prior to 10 years of age
What are the COMPLICATIONS of congenital muscular torticolis?
1- Permanent rotational deformity
risk factors: left untreated or unnoticed
2- Positional plagiocephaly
risk factors: left untreated or unnoticed
3- Craniofacial deformities
facial asymmetry
facial hemi-hypoplasia
4- Compensatory scoliosis
What is AARD?
C1-C2 rotatory instability (fixed rotation of C1 on C2) caused by subluxation or facet dislocation
What are the common causes of AARD?
What are the associated conditions with AARD?
- Infection (~35%): may have history of pharyngitis or otitis media; Grisel’s disease is the condition of AARD following a respiratory infection or retro-pharyngeal abscess; thought to be linked to lymphatic edema in area of cervical spine
- trauma (~24%)
- recent head or neck surgery (~20%)
- idiopathic
Associated conditions:
- Down’s syndrome
- rheumatoid arthritis
- tumors
- congenital anomalies
What is the diagnostic gold standard of AARD?
How to do it and what do you see?
Dynamic CT
take CT with head straight forward, and then in maximal rotation to right and left
will see fixed rotation of C1 on C2 which does not change with dynamic rotation
Clinical exam of AARD?
ipsilateral rotation and contralateral tilt of the head in relation to the lateral mass of C1
chin rotated to the side opposite the facet subluxation (e.g. right sided facet subluxation will have chin rotated to the left)
contra-lateral sternocleidomastoid may be spasticsternocleidomastoid (SCM) spasm occurs on the SAME side as the chin (e.g. right sided facet subluxation will have chin rotated to the left, and left SCM will be spastic)
this protective spasticity occurs to reduce further subluxation
C1-C2 subluxation (and resultant chin position) is primary, SCM spasm is secondary/reactive
