Paediatric Cervical Spine: Difference between revisions
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<div class="editorbox"> | <div class="editorbox"> '''Original Editor '''- [[User:Rachael Lowe|Rachael Lowe]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div> | ||
'''Original Editor '''- | |||
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} | |||
</div> | |||
==Introduction== | ==Introduction== | ||
[[Cervical Anatomy|Cervical]] spine injury (CSI) in children is unique in both the wide anatomic differences and the variety of mechanisms of injury. In children, | [[Cervical Anatomy|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<ref name=":22">Platzer P, Jaindl M, Thalhammer G, Dittrich S, Kutscha-Lissberg F, Vecsei V, Gaebler C. [https://www.ncbi.nlm.nih.gov/pubmed/17297330 Cervical spine injuries in pediatric patients]. Journal of Trauma and Acute Care Surgery. 2007 Feb 1;62(2):389-96.</ref>. | ||
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.<ref name=":0">Mandadi AR, Waseem M. [https://www.ncbi.nlm.nih.gov/books/NBK442027/ 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)</ref> | 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.<ref name=":0">Mandadi AR, Waseem M. [https://www.ncbi.nlm.nih.gov/books/NBK442027/ 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)</ref> | ||
* Younger than eight years: C1 and C3 | * Younger than eight years: C1 and C3 | ||
| Line 15: | Line 11: | ||
Mechanisms of CSIs also differ between children and adults. | Mechanisms of CSIs also differ between children and adults. | ||
* The adult cervical spine is are injured predominantly in motor vehicle crashes (MVCs) and [[Falls in Young Adults|falls]] | * The adult cervical spine is are injured predominantly in motor vehicle crashes (MVCs) and [[Falls in Young Adults|falls]] | ||
* | * Children experience a broader range of traumatic events eg pedestrians and inflicted injuries<ref name=":22" /><ref name=":12" /> that place them at risk for CSIs<ref>Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC, Pediatric Emergency Care Applied Research Network, Cervical Spine Study Group. [http://pediatrics.aappublications.org/content/133/5/e1179 Cervical spine injury patterns in children]. Pediatrics. 2014 Apr 1:peds-2013.</ref> 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<ref>Givens TG, Polley KA, Smith GF, Hardin WD. [https://www.ncbi.nlm.nih.gov/pubmed/8760542 Pediatric cervical spine injury: a three-year experience.] Journal of Trauma and Acute Care Surgery. 1996 Aug 1;41(2):310-4.</ref>. | ||
==Clinical Anatomy== | ==Clinical Anatomy== | ||
There are several anatomical difference in the paediatric cervical spine that can influence injuries that may occur: | There are several anatomical difference in the paediatric cervical spine that can influence injuries that may occur: | ||
* | *More horizontal [[Facet Joints|facets]] | ||
* | *Flatter vertebral bodies | ||
* | *Smaller occipital condyles | ||
* | *Ligamentous laxity | ||
* | *Unfused [[Joint Classification|synchondroses]] eg sub-dental | ||
* | *Undeveloped [[Uncinate Process|uncinate]] processes and absence of [[Uncovertebral Joints|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.<ref>Forrester-Gale, G and Paneris, I. The Cervical Spine. Chapter 9.1 in: Jull et al (Editors). Greive's Modern Musculoskeletal Physiotherapy. Elsevier, 2015.</ref> | ||
* | *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 [[Axis|C2]]-C3 level; in the adult cervical spine, the fulcrum is at the C5-C6 level.<ref name=":02" /> | ||
The immature spine is hypermobile because of [[Ligament Sprain|ligamentous]] laxity, shallow and angled facet joints, underdeveloped spinous processes, and physiologic anterior wedging of [[Cervical Vertebrae|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<ref name=":02" />. 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.<ref name=":02" /> | The immature spine is hypermobile because of [[Ligament Sprain|ligamentous]] laxity, shallow and angled facet joints, underdeveloped spinous processes, and physiologic anterior wedging of [[Cervical Vertebrae|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<ref name=":02" />. 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.<ref name=":02" /> | ||
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<ref name=":22" />. 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<ref name=":02" />. Injury patterns in children, once they have reached the age of 12, more closely resemble those of adults<ref name=":22" />. | 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<ref name=":22" />. 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<ref name=":02" />. Injury patterns in children, once they have reached the age of 12, more closely resemble those of adults<ref name=":22" />. | ||
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|Jefferson]] fracture.”<ref name=":02">Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, Brown JH, Diamond AS, Black K, Singh S. [http://pubs.rsna.org/doi/full/10.1148/rg.233025121 Pediatric cervical spine: normal anatomy, variants, and trauma]. Radiographics. 2003 May;23(3):539-60.</ref> | 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|Jefferson]] fracture.”<ref name=":02">Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, Brown JH, Diamond AS, Black K, Singh S. [http://pubs.rsna.org/doi/full/10.1148/rg.233025121 Pediatric cervical spine: normal anatomy, variants, and trauma]. Radiographics. 2003 May;23(3):539-60.</ref> | ||
==Injuries== | ==Injuries== | ||
Although CSI is uncommon in children, accounting for only 1–2% of paediatric trauma<ref name=":12">Booth TN. [http://www.ajronline.org/doi/full/10.2214/AJR.11.8150 Cervical spine evaluation in pediatric trauma]. American Journal of Roentgenology. 2012 May;198(5):W417-25.</ref>, the clinical implications of failure to correctly diagnose CSI are significant. [[Spinal Injury|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%<ref name=":12" /><ref name=":22" />. | Although CSI is uncommon in children, accounting for only 1–2% of paediatric trauma<ref name=":12">Booth TN. [http://www.ajronline.org/doi/full/10.2214/AJR.11.8150 Cervical spine evaluation in pediatric trauma]. American Journal of Roentgenology. 2012 May;198(5):W417-25.</ref>, the clinical implications of failure to correctly diagnose CSI are significant. [[Spinal Injury|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%<ref name=":12" /><ref name=":22" />. | ||
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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<ref name=":22" />. 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<ref name=":12" /><ref name=":22" />. | 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<ref name=":22" />. 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<ref name=":12" /><ref name=":22" />. | ||
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<ref name=":02" />. Younger children have a relatively higher fulcrum with a larger head, predisposing to occipital cervical | 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<ref name=":02" />. 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<ref name=":12" />. Unfused synchondroses, especially at the level of the [[Odontoid process|dens]], are susceptible to trauma and notoriously difficult to diagnose<ref name=":12" />. 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<ref name=":02" />. | ||
=== Neurological Injury === | === 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 | * 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 management of pediatric spinal trauma is with an interprofessional team. | ||
* The outlook of children is | * 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.<ref name=":0" /> | ||
=== Imaging === | === Imaging === | ||
The interpretation of cervical spine images can be challenging even for the most experienced radiologist. [[X-Rays|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. <ref>Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, Brown JH, Diamond AS, Black K, Singh S. [https://pubs.rsna.org/doi/full/10.1148/rg.233025121 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)</ref> | The interpretation of cervical spine images can be challenging even for the most experienced radiologist. [[X-Rays|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. <ref>Lustrin ES, Karakas SP, Ortiz AO, Cinnamon J, Castillo M, Vaheesan K, Brown JH, Diamond AS, Black K, Singh S. [https://pubs.rsna.org/doi/full/10.1148/rg.233025121 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)</ref> | ||
Spinal cord injuries without radiologic abnormalities (SCIWORA)<ref>Szwedowski D, Walecki J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4262055/ Spinal cord injury without radiographic abnormality (SCIWORA)–clinical and radiological aspects.] Polish journal of radiology. 2014;79:461.</ref> 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<ref name=":22" />. SCIWORA was also frequently associated with sports<ref name=":22" />.{{#ev:youtube|64WGW8sY37c}} | Spinal cord injuries without radiologic abnormalities (SCIWORA)<ref>Szwedowski D, Walecki J. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4262055/ Spinal cord injury without radiographic abnormality (SCIWORA)–clinical and radiological aspects.] Polish journal of radiology. 2014;79:461.</ref> 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<ref name=":22" />. SCIWORA was also frequently associated with sports<ref name=":22" />. | ||
=== Overview === | |||
This 10 minute video, below, is a good summary of paediatric cervical spine injury. | |||
{{#ev:youtube|64WGW8sY37c|300}}<ref>Nabil Ebraheim. Pediatric Cervical Spine Injuries - Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=64WGW8sY37c [last accessed 31/10/2021]</ref> | |||
==References== | ==References== | ||
<references /> | <references /> | ||
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[[Category:Paediatrics]] | [[Category:Paediatrics]] | ||
[[Category:Paediatrics - Conditions]] | [[Category:Paediatrics - Conditions]] | ||
[[Category:Conditions]] | |||
[[Category:Cervical Spine]] | |||
[[Category:Cervical Spine - Conditions]] | |||
Latest revision as of 11:31, 15 November 2023
Original Editor - Rachael Lowe Top Contributors - Rachael Lowe, Lucinda hampton, Kim Jackson, Admin, Simisola Ajeyalemi, George Prudden, Rucha Gadgil, Nikhil Benhur Abburi and Jess Bell
Introduction[edit | edit source]
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[edit | edit source]
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[edit | edit source]
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[edit | edit source]
- 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[edit | edit source]
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[edit | edit source]
This 10 minute video, below, is a good summary of paediatric cervical spine injury.
References[edit | edit source]
- ↑ 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.
- ↑ 2.0 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)
- ↑ 3.0 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.
- ↑ 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.
- ↑ 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.
- ↑ Forrester-Gale, G and Paneris, I. The Cervical Spine. Chapter 9.1 in: Jull et al (Editors). Greive's Modern Musculoskeletal Physiotherapy. Elsevier, 2015.
- ↑ 7.0 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.
- ↑ 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)
- ↑ Szwedowski D, Walecki J. Spinal cord injury without radiographic abnormality (SCIWORA)–clinical and radiological aspects. Polish journal of radiology. 2014;79:461.
- ↑ Nabil Ebraheim. Pediatric Cervical Spine Injuries - Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=64WGW8sY37c [last accessed 31/10/2021]
