Paediatric Cervical Spine

Original Editor - Rachael Lowe Top Contributors - Rachael Lowe, Lucinda hampton, Kim Jackson and George Prudden

Introduction

Cervical spine injury (CSI) in children is unique in both the wide anatomic differences and the variety of mechanisms of injury. In children,

  • The head is larger relative to the body, resulting in a higher center of gravity and fulcrum of neck motion
  • There are multiple vertebral ossification centers
  • The ligamentous structures are lax[1].  

The younger the age, the more flexible the spine is and neural damage occurs in children much earlier than musculoskeletal injury. As age increases the likelihood of cervical cord injury decreases (with up to 75% of injuries occurring in infancy up to 8 years old) because the fulcrum of cervical mobility moves progressively downward with the child’s increasing age.[2]

  • Younger than eight years: C1 and C3
  • Eight to 12 years: C3 and C5
  • Older than 12 years: C5 and C6

Mechanisms of CSIs also differ between children and adults.

  • The adult cervical spine is are injured predominantly in motor vehicle crashes (MVCs) and falls
  • Children experience a broader range of traumatic events eg pedestrians and inflicted injuries[1][3] that place them at risk for CSIs[4] while MVCs are also a common mechanism of injury and some have suggested that efforts should be focused on refinement of motor vehicle restraint devices in young school-aged children[5].

Clinical Anatomy

There are several anatomical difference in the paediatric cervical spine that can influence injuries that may occur:

  • More horizontal facets
  • Flatter vertebral bodies
  • Smaller occipital condyles
  • Ligamentous laxity
  • Unfused synchondroses eg  sub-dental
  • Undeveloped uncinate processes and absence of uncovertebral joints (C3 to C7) - Although the uncinate processes are present in utero, they start to enlarge gradually between the ages of 9 to 14 years reaching their maximum height.[6]
  • A larger head to body ratio which raises the fulcrum of motion- the fulcrum of motion in the cervical spine in children is at the C2-C3 level; in the adult cervical spine, the fulcrum is at the C5-C6 level.[7]

The immature spine is hypermobile because of ligamentous laxity, shallow and angled facet joints, underdeveloped spinous processes, and physiologic anterior wedging of vertebral bodies. Incomplete ossification of the odontoid process, a relatively large head, and weak neck muscles are other factors that predispose to instability of the paediatric cervical spine[7]. The fulcrum of motion in the cervical spine in children is at the C2-C3 level; in the adult cervical spine, the fulcrum is at the C5-C6 level.[7]

Developmental maturation of the paediatric cervical spine occurs in school age children, at this age the synchondroses have fused, and the fulcrum of motion of the cervical spine has shifted caudally[1]. When referring to younger children the literature often uses under 8 years old, and older children as over 8 years old. By the time a child is 8–10 years old, the cervical spine reaches adult proportions[7]. Injury patterns in children, once they have reached the age of 12, more closely resemble those of adults[1].

Normal anatomic variants include pseudosubluxation, absence of cervical lordosis, wedging of the C3 vertebra, widening of the predental space, prevertebral soft-tissue widening, intervertebral widening, and “pseudo–Jefferson fracture.”[7] 

Injuries

Although CSI is uncommon in children, accounting for only 1–2% of paediatric trauma[3], the clinical implications of failure to correctly diagnose CSI are significant.  Spinal injuries in children are more likely and have significant consequences with permanent neurologic damage in up to 66% and mortality as high as 40%[3][1].

Younger children have more injuries of the upper cervical spine, whereas children in the older age group sustain more injuries of the lower cervical spine[1].  Although motor vehicle accidents and falls are common in children, young children under 8 years of age are more vulnerable to pedestrian and inflicted injuries, whereas older children above 8 years of age most commonly sustain recreational and sports-related injuries[3][1].

Cervical spine injuries in younger children are usually seen in the upper cervical region owing to the unique biomechanics and anatomy of the paediatric cervical spine[7]. Younger children have a relatively higher fulcrum with a larger head, predisposing to occipital cervical injuries, with distraction and ligamentous injuries being more common than bony injury[3]. Unfused synchondroses, especially at the level of the dens, are susceptible to trauma and notoriously difficult to diagnose[3]. Knowledge of the normal embryologic development and anatomy of the cervical spine plus familiarity with anatomic variants is important to avoid mistaking synchondroses for fractures[7].

Neurological Injury

  • Neurological injury is known to have a better prognosis in children when compared to adults. Incomplete lesions have a better prognosis compared to complete lesions. Ten per cent to 25% of patients recover after complete spinal cord injuries. Sixty-four per cent showed partial recovery.
  • The management of pediatric spinal trauma is with an interprofessional team.
  • The outlook of children is significantly better than in adults but the recovery can be prolonged. Those with severe neurological deficits at presentation may have residual deficits even after full recovery.[2]

Imaging

The interpretation of cervical spine images can be challenging even for the most experienced radiologist. Radiologic evaluation of the pediatric cervical spine can be even more challenging due to the wide range of normal anatomic variants and synchondroses, combined with various injuries and biomechanical forces that are unique to children. [8]

Spinal cord injuries without radiologic abnormalities (SCIWORA)[9] can occur due to the ligamentous elasticity and flexibility of the paediatric vertebral column which can withstand injuries without evidence of deformity, these are only seen in the younger age group[1]. SCIWORA was also frequently associated with sports[1].

Overview

This 10 minute video, below, is a good summary of paediatric cervical spine injury.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Platzer P, Jaindl M, Thalhammer G, Dittrich S, Kutscha-Lissberg F, Vecsei V, Gaebler C. Cervical spine injuries in pediatric patients. Journal of Trauma and Acute Care Surgery. 2007 Feb 1;62(2):389-96.
  2. 2.0 2.1 Mandadi AR, Waseem M. Pediatric Spine Trauma. InStatPearls [Internet] 2019 Mar 4. StatPearls Publishing.available from:https://www.ncbi.nlm.nih.gov/books/NBK442027/ (last accessed 1.2.2020)
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Booth TN. Cervical spine evaluation in pediatric trauma. American Journal of Roentgenology. 2012 May;198(5):W417-25.
  4. Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC, Pediatric Emergency Care Applied Research Network, Cervical Spine Study Group. Cervical spine injury patterns in children. Pediatrics. 2014 Apr 1:peds-2013.
  5. Givens TG, Polley KA, Smith GF, Hardin WD. Pediatric cervical spine injury: a three-year experience. Journal of Trauma and Acute Care Surgery. 1996 Aug 1;41(2):310-4.
  6. Forrester-Gale, G and Paneris, I.  The Cervical Spine.  Chapter 9.1 in: Jull et al (Editors). Greive's Modern Musculoskeletal Physiotherapy. Elsevier, 2015.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 7.6 Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, Brown JH, Diamond AS, Black K, Singh S. Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics. 2003 May;23(3):539-60.
  8. Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, Brown JH, Diamond AS, Black K, Singh S. Pediatric cervical spine: normal anatomy, variants, and trauma. Radiographics. 2003 May;23(3):539-60. Available from:https://pubs.rsna.org/doi/full/10.1148/rg.233025121 (last accessed 1.2.2020)
  9. Szwedowski D, Walecki J. Spinal cord injury without radiographic abnormality (SCIWORA)–clinical and radiological aspects. Polish journal of radiology. 2014;79:461.