Tiffany's Spine Cards Flashcards
What are kids predisposed to upper cervical spine #s? (3)
- Horizontal cervical facets
- Ligamentous laxity
- Large head to body ratio
In pediatric spine trauma, where are the majority of injuries?
80% are in c-spine. Younger kids (<8yo) are mostly upper cspine. Older kids are throughout cspine.
In adults, 30% spine trauma involve cspine
How do you properly immobilize pediatric c-spines in trauma? (2)
2 options given large head to body ratio
1. Backboard w recess for occiput
2. Standard backboard w pad under torso
Normal spine board causes forced cspine flexion
What is pseudosubluxation of the c-spine? What locations are the most common?
Anatomic variant in kids <8yo due to more horizontal facet joints. Most common C2 on C3. 2nd most common is C3 on C4
How do you differentiate cervical pseudosubluxation from true injury? (4)
What fracture may be a cause of true C2 on C3 subluxation?
- Pseudosubluxation reduces on extension lateral views
- No hx of trauma
- No anterior soft tissue swelling
- Swischuk’s line: within 1.5mm of C2
True injury: hangman’s #
What is Swischuk’s line?
Differentiate cervical pseudosubluxation in kids from true traumatic injury
Swischuk’s line on lateral XR. AKA spinolaminar line
Draw along anterior cortex of posterior arch from C1 to C3
If physiologic variant, anterior cortex of C2 posterior arch will be within 1mm of line
True injury if >1.5mm from line
True or False: cervical pseudosubluxation in kids is associated w increased morbidity and mortality
False. No increase in either. Treatment is observation
Describe how pediatric C-spine lordosis changes w positioning
With neutral position, loss of lordosis. Lordosis restored w extension. This is physiologic
What is normal ADI for kids and adults?
Kids <8yo : <5mm
Kids >8yo and adults : <3mm
This excludes conditions such as RA or syndromes where there is ligamentous laxity. In these conditions, ADI is less useful. Better to look at SAC
True or False: in pediatric trauma, CT is an appropriate screening tool for c-spine trauma?
False. Inappropriate radiation dose and most injuries seen on XR
Can consider CTA to R/O vertebral artery injury in c-spine #s
In pediatric trauma, when is MRI an appropriate screening tool for s-spine trauma? (2)
- Obtunded
- Neuro deficit
In traumatic pediatric atlantoaxial instability due to ligamentous injury, what are the treatment options for younger and older kids?
- Younger: Brooks fixation + halo
- Older: C1 lateral mass to C2 pedicle screw fusion. May not need halo
RC: Which of the following is associated w an increased risk of complications w halo treatment in kids?
A. Re-tightening the screws at an appropriate interval
B. Placing the ring 2cm above the pinna
C. Placing the ring closer to the skull
D. using 6 pins instead of 4
Answer: B
This was a tough question and still not sure what is the best answer. Maybe some misremembering
Halo pin should be tightened. Ring should be 1cm superior to pinna. Any higher may risk ring migration and dislodgement.
Ring should have 1-2cm clearance. Not sure what “closer to skull” means
Kids should have more than 4 pins. Typically 8
What is SCIWORA?
Spinal cord injury without radiographic abnormality. Only in kids
Diagnosis of exclusion
Occurs because spine is more elastic than spinal cord. Spine may have stretched without #, injury cord
May not have XR or MRI findings
Why may patients w SCIWORA present w delayed neuro deficits?
2 theories
1. Poor initial exam
2. Hypotension
Describe the differences in SCIWORA injuries in younger kids (<10yo) and older kids
- Younger: more cervicothoracic junction injuries. Complete injuries
- Older kids: more mid-thoracic injuries. Incomplete injuries. More likely to have recovery
What is the treatment for SCIWORA?
No anatomic injury to fix. External immobilization x12ks then activity modification x12wks
RC: In pediatric patients w SCIWORA, all are true except:
A. Thoracic spine is most common
B. Anatomic and physiologic injuries don’t match
C. Cervical neuro injury has worse prognosis than lumbar neuro injury
D. 25% can present w delayed neuro changes
Answer: A (thoracic is most common. Not true)
Cervical SCIWORA is most common
Anatomic and physiologic injuries don’t match: neuro manifestations don’t match anatomic injuries seen on imaging
They can present w delayed neuro changes
What is an apophyseal ring?
Secondary ossification center of vertebral body. Connects to disc annulus fibrosus via Sharpey’s fibers. Completely ossifies at 18yo. Weak point that may fracture
What are apophyseal ring #s?
AKA limbus #. Unique to kids. More common in lumbar spine. Present w radicular pain
Treatment: excise fragment. Unlikely to improve nonop
What are the causes of atlantoaxial rotatory subluxation in kids? (5)
- Infection: most common. Grisel’s disease
- Trauma: 2nd most common
- Recent head or neck surgery
- Congenital
- Associated conditions: Down’s, RA, tumor
What is Grisel’s disease?
Atlantoaxial rotatory subluxation due to infection. After upper respiratory or retropharyngeal infection, lymphatic edema may cause subluxation. Usually lasts 1wk
What is the Fielding classification?
Atlantoaxial rotatory subluxation
Type 1: unilateral facet subluxation w intact transverse ligament. Most common
Pivots on odontoid
Type 2: unilateral facet subluxation w 3-5mm anterior displacement
Other facet acts as pivot. Transverse ligament may rupture
Type 3: Bilateral anterior facet displacement, >5mm
Decreases SAC. Risk decrease neuro deficit
Type 4: posterior displacement of C1
Due to hypoplastic dens or odontoid #. Decreases SAC. Risk serious neuro deficit
How do the presentations of traumatic vs congenital torticollis differ?
Traumatic: primary cause is facet subluxation. Head tilted towards subluxation. Chin and secondary sternocleidomastoid (SCM) spasticity on opposite side. SCM prevents further subluxation.
Congenital: primary cause is SCM spasticity. Head tilted towards SCM, chin on opposite side.
Summary: in traumatic, chin and SCM on same side. In congenital, SCM and chin on opposite sides
