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P E D I AT R I C Emergency Medicine Practice An Evidence-Based Approach To PEDIATRIC Emergency Medicine s ebmedicine.net Emergency Evaluation Of The Pediatric Cervical Spine The Friday night shift brings a variety of traumatic injuries. First, a 15year-old football player tackled the opposing quarterback while leading with his helmet. At the end of the play, he could not stand and stated his arms were tingling and both his legs were numb. Next, a 3-year-old fell down a flight of stairs after tripping on a toy. She is alert and crying but will not allow anyone other than her parents near her. Finally, an 8-year-old is brought in as a trauma alert, following a motor vehicle crash where another passenger was killed at the scene. This boy is unresponsive and is being bag-mask ventilated by the emergency response team. Each of these children arrives to the emergency department with a cervical-spine-immobilizing collar in place. Despite very different mechanisms, each will require a complete cervical spine evaluation. What is required to safely remove the collar? Could any of these children be clinically cleared? What radiographic studies are indicated? When is expert consultation required? W hile cervical spine injuries (CSIs) in children are relatively rare, acute care providers are often called upon to assess pediatric patients for CSI as part of an overall trauma evaluation. The developing cervical spine has unique anatomic and biomechanical features that impact injury patterns and outcomes. Certain genetic and metabolic anomalies can also predispose patients to additional harm. Prompt stabilization at the scene and accurate diagnostic evaluation in the emergency department (ED) are imperative; not recognizing a CSI can prove disastrous. Several developmental anatomic and radiographic findings can simulate injury and make radiographic clearance of the cervical spine more challenging in children. Simple management algorithms that can be used to treat adults are not AAP Sponsor Michael J. Gerardi, MD, FAAP, FACEP Martin I. Herman, MD, FAAP FACEP Clinical Assistant Professor, Professor of Pediatrics, UT Medicine, University of Medicine College of Medicine, Assistant and Dentistry of New Jersey; Director of Emergency Services, Director, Pediatric Emergency Lebonheur Children’s Medical Medicine, Children’s Medical Center, Memphis, TN Center, Atlantic Health System; Department of Emergency Editorial Board Medicine, Morristown Memorial Jeffrey R. Avner, MD, FAAP Hospital, Morristown, NJ Professor of Clinical Pediatrics and Chief of Pediatric Emergency Ran D. Goldman, MD Associate Professor, Department Medicine, Albert Einstein College of Pediatrics, University of Toronto; of Medicine, Children’s Hospital at Division of Pediatric Emergency Montefiore, Bronx, NY Medicine and Clinical Pharmacology T. Kent Denmark, MD, FAAP, and Toxicology, The Hospital for Sick FACEP Children, Toronto, ON Residency Director, Pediatric Mark A. Hostetler, MD, MPH Emergency Medicine; Assistant Assistant Professor, Department Professor of Emergency Medicine of Pediatrics; Chief, Section of and Pediatrics, Loma Linda Emergency Medicine; Medical University Medical Center and Director, Pediatric Emergency Children’s Hospital, Loma Linda, CA Department, The University of Chicago, Pritzker School of Medicine, Chicago, IL Alson S. Inaba, MD, FAAP, PALS-NF Pediatric Emergency Medicine Attending Physician, Kapiolani Medical Center for Women & Children; Associate Professor of Pediatrics, University of Hawaii John A. Burns, School of Medicine, Honolulu, HI; Pediatric Advanced Life Support National Faculty Representative, American Heart Association, Hawaii and Pacific Island Region Andy Jagoda, MD, FACEP Professor and Vice-Chair of Academic Affairs, Department of Emergency Medicine, Mount Sinai School of Medicine; Medical Director, Mount Sinai Hospital, New York, NY Tommy Y. Kim, MD, FAAP Attending Physician, Pediatric Emergency Department; Assistant July 2008 Volume 5, Number 7 Authors Julie A. Haizlip, MD, RPh Assistant Professor, Department of Pediatrics, Division of Pediatric Critical Care, University of Virginia Children’s Hospital, Charlottesville, VA Patricia D. Scherrer, MD Assistant Professor, Department of Pediatrics, Division of Pediatric Critical Care, University of Virginia Children’s Hospital, Charlottesville, VA Peer Reviewers Lisa Freeman-Grossheim, MD, FAAM Assistant Professor, Department of Emergency Medicine, University of Texas Medical School at Houston, Houston, TX Paula J. Whiteman, MD, FACEP, FAAP Medical Director, Pediatric Emergency Medicine, EncinoTarzana Regional Medical Center; Attending Physician, Ruth and Harry Roman Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA CME Objectives Upon completing this article, you should be able to: 1. Identify the epidemiology, mechanisms of injury, and specific types of pediatric cervical spine injuries. 2. Assess the unique anatomic, developmental, and functional aspects of the pediatric cervical spine. 3. Evaluate the radiological imaging modalities and management algorithms available for evaluating the pediatric patient with a cervical spine injury and discuss their advantages and limitations. 4. Recognize and summarize special circumstances and diagnoses that increase the risk of cervical spine injury in the pediatric patient. Date of original release: July 1, 2008 Date of most recent review: June 10, 2008 Termination date: July 1, 2011 Time to complete activity: 4 hours Medium: Print and Online Method of participation: Print or online answer form and evaluation Prior to beginning this activity, see “Physician CME Information” on the back page. Professor of Emergency Medicine and Pediatrics, Loma Linda Medical Center and Children’s Hospital, Loma Linda, CA Gary R. Strange, MD, MA, FACEP Professor and Head, Department of Emergency Medicine, University of Illinois, Chicago, IL Brent R. King, MD, FACEP, FAAP, Adam Vella, MD, FAAP FAAEM Assistant Professor of Emergency Professor of Emergency Medicine Medicine, Pediatric EM Fellowship and Pediatrics; Chairman, Director, Mount Sinai School of Department of Emergency Medicine, Medicine, New York The University of Texas Houston Michael Witt, MD, MPH, FAAP Medical School, Houston, TX Attending Physician, Division of Robert Luten, MD Emergency Medicine, Children’s Professor, Pediatrics and Hospital Boston; Instructor of Emergency Medicine, University of Pediatrics, Harvard Medical School, Florida, Jacksonville, FL Boston, MA Ghazala Q. Sharieff, MD, FAAP, Research Editor FACEP, FAAEM Christopher Strother, MD Associate Clinical Professor, Children’s Hospital and Health Center/ Fellow, Pediatric Emergency Medicine, Mt. Sinai School of University of California, San Diego; Medicine; Chair, AAP Section on Director of Pediatric Emergency Residents, New York, NY Medicine, California Emergency Physicians, San Diego, CA Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Mount Sinai School of Medicine and Pediatric Emergency Medicine Practice. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Haizlip, Dr. Scherrer, Dr. Freeman-Grossheim, and Dr. Whiteman report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: Pediatric Emergency Medicine Practice does not accept any commercial support. readily applicable to children because of the unique patterns of injury. Because failure to recognize a CSI can prove to be disastrous, prompt stabilization at the scene and accurate diagnostic evaluation in the emergency department are imperative. Critical Appraisal Of The Literature The variability in defining and therefore categorizing pediatric CSIs results in difficulty synthesizing the available literature about these injuries. The inclusion or exclusion of older teenagers can skew the patterns and types of injuries that are reported from a study population. Data collected from emergency room records and trauma registries may miss the most serious of injuries that occur in patients who expire at the scene of an accident. Also, diagnosis codes used to query databases must be uniform to allow meaningful comparisons. Most of the current recommendations for the management of pediatric CSIs are based on class II and class III studies with primarily adult patient populations. While there have been a number of recent retrospective analyses of the mechanisms and types of CSIs sustained by children, there is still a relative paucity of rigorous randomized controlled trials concerning the emergency evaluation and management of the pediatric cervical spine. ED practitioners must therefore make clinical judgments regarding the management of Table 1. Radiographic Development Of The Pediatric Cervical Spine Age Developmental Change 6 months Body of C1 not visible; all synchondroses open 1 year Body of C1 now visible 3 years Synchondroses of posteriorly located spinous processes fuse 3-6 years Neurocentral synchondroses fuse; synchondrosis between odontoid and body of C2 fuses; summit ossification center appears at superior aspect of odontoid; anterior wedging of vertebral bodies resolve 8 years Pseudosubluxation and widening of predental space resolve; spine assumes a more lordotic appearance Puberty Secondary ossification centers appear at the tips of the spinous processes; superior and inferior epiphyseal rings appear; summit ossification center of odontoid fuses 25 years Secondary ossification centers at tips of spinous processes fuse; superior and inferior epiphyseal rings fuse to the main body Reprinted with permission from Fesmire FM, Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med. 1989;7:133-142. Pediatric Emergency Medicine Practice © 2008 acute pediatric CSIs by synthesizing the unique developmental aspects of such injuries in children with the available management data from adults. Anatomy And Development Of The Pediatric Cervical Spine The major structures of the cervical spine that provide support and protect from injury include the bony vertebrae, the multiple ligaments, the intervertebral discs, the facet and interfacet joints, and the neck musculature. Bonadio’s two-part review article from 1993 provides a thorough overview of the subject.17-18 Table 1 describes the age related radiographic development of the pediatric cervical spine.24 The pediatric cervical spine is in a constant state of functional development from birth through adolescence. Infants and toddlers have a higher axis of movement, with torque and acceleration stress occurring higher in the cervical spine, secondary to their relatively large head size and relatively weak neck musculature and ligamentous support. The fulcrum of cervical motion is much lower, in the C5 to C6 region, in adolescents and adults. With increasing age, the relative head to neck and body size decreases, and the strength of the neck muscles increases. The combination of maturation of the interspinous ligaments and ossification of the vertebral bodies lowers the axis of movement. In younger children, physiologic anterior wedging of the upper cervical spine causes this area to be more susceptible to anterior dislocation by allowing for forward vertebral movement and displacement. The articulating facet joints in children are oriented more horizontally than in adolescents and adults, predisposing the upper cervical spine in particular to increased instability. Also, the posterior joint capsules and cartilaginous end plates are much more elastic than those found in adults.1,24,25 This laxity of the architecture of the cervical spine decreases the likelihood of vertebral fracture in association with trauma; however, it increases the possibility of other injuries, including subluxation and spinal cord injury without radiographic abnormality (SCIWORA).26 Epidemiology CSIs in children comprise approximately 5% of all CSIs. While only 30%-40% of adult vertebral injury occurs in the cervical region, 60%-80% of pediatric spinal injuries are CSIs. A recent review of the Kids’ Inpatient Database found the overall incidence of pediatric CSI in the U.S. to be 1.99 cases per 100,000 children, with a peak age of incidence of 14 years.4,5 Male children comprise 60%-75% of those injured.1,4-7 In a multicenter evaluation of 3065 pediatric blunt July 2008 • EBMedicine.net trauma victims by the National Emergency X-Radiography Utilization Study (NEXUS) group, 30 children sustained a CSI; none of these children were below the age of 2 years, and only 4 of them were younger than 9 years of age.8 Similarly, a 5 year review of the National Pediatric Trauma Registry demonstrated that an average of 81 CSIs per year were reported in patients from birth to 20 years of age and that fewer than 8 of these per year occurred in children under the age of 2 years.1 and/or muscular injuries. Dislocations and distractions have approximate combined incidences of 25%44%, but both are much more common in younger children.1,6,10,27,28 Younger patients are more susceptible to growth plate fractures, particularly at the synchondrosis between the odontoid and vertebral body of C2.27 Vertebral body and arch fractures are more common in older children. Occult injuries, including those involving vertebral growth centers, ligaments, muscles, intervertebral discs, and/or the spinal cord, account for 40%-70% of all pediatric CSIs.29 Injuries in younger children more often involve the upper cervical spine, C1 and C2, due to the higher axis of movement. From the ages of 8 to 12, either upper or lower cervical cord injury may be seen. In teenagers, the pattern of CSI more closely resembles that of adults with the lower cervical spine, C3 to C7, more commonly affected.1,3,6,9,10,28,30,31 However, the previous age generalizations that have been made in the literature can be dangerously misleading. In a 2001 review of pediatric CSIs at a level 1 pediatric trauma center, Brown et al found that, of the 28 patients who presented with a sports related injury, 75% involved the upper cervical region (C1 to C4), even though the mean age of this patient group was 13.8 years.5 Similarly, 10 of the 20 children below 8 years of age cared for at the Children’s Hospital of Alabama over a 36 month period were found to have CSIs below C4.25 Occipitoatlantal and atlantoaxial injuries are perhaps the most common CSIs in young children. Because of the high axis of motion, the young child’s cervical spine is more susceptible to injuries related to the inherent lack of bony stability in the occipital to C2 region. The paired alar ligaments extend from the tip of the odontoid to the occipital condyle.32 The tectorial membrane is a cephalad extension of the posterior longitudinal ligament that extends to the ventral surface of the foramen magnum. These 2 structures are the primary stabilizers of the cranium on the cervical spine, as there is no significant ligamentous support between the occiput and the atlas.33 Ligamentous or soft tissue disruptions are frequent in young children since the supporting muscular structures are underdeveloped and the ligaments are more lax. Such injuries are often immediately fatal or result in subsequent death from hypoxic ischemic encephalopathy secondary to cardiorespiratory arrest from brain stem injury.34 Figure 1 illustrates the lateral plain radiograph of one unfortunate child with this type of injury.28 In a review of 227 pediatric CSIs occurring between 1976 and 1992, Nitecki et al reported 19 fatalities (8.4%), 11 of which were associated with atlantoaxial fracture or dislocation. All of these children suffered cardiorespiratory collapse and died soon after the injury.31 In a 13-year retrospective review from Canada, occipitoatlantal dislocation Etiology The etiologies of pediatric CSI are diverse. Motor vehicle accidents (MVAs), falls, and sports injuries are the predominant causes. The most common mechanism of injury is motor vehicle related, representing 44%-56% of the total injuries.1, 4, 5, 9 Data from the National Pediatric Trauma Registry and from the National Trauma Data Bank show that over 65% of children who sustain a CSI in an MVA were not wearing a seat belt at the time of the injury.1,4 Inappropriate use of available restraint systems can also be associated with MVA-related CSI.10 While children of all ages have similar rates of CSI related to MVA injury, children under the age of 10 are more likely to sustain CSIs from falls and pedestrian accidents. In contrast, children above age 10 have a higher incidence of sports and bicycle related injuries.1 Alcohol and drug abuse are involved in 30% of older pediatric CSI cases.4 Sports activities most commonly associated with pediatric CSI include diving, football, gymnastics, and hockey. Most pediatric CSIs occur with football since participation rates in this sport are much higher.12 A recent review of catastrophic CSIs in football players found that the total number of quadriplegic events in high school and college players is approximately 6 per year.13 Axial loading of the cervical spine is the major etiologic factor in sports related CSIs; in football, this type of injury most often results from spear tackling.14,15 Submersion and diving injuries are more likely to be associated with CSI in children over 15 years of age because of the higher incidence of risk taking behaviors and high speed watercraft use.16 Although unusual, child abuse is another unfortunate cause of pediatric CSI. While most reports in the literature detail only isolated cases of CSI associated with shaken impact syndrome, Brown et al reported a 3% incidence of child-abuse-related CSI at a level 1 pediatric trauma center.5 Mechanisms And Types Of Injury The most common types of CSIs are fractures, with an approximate incidence of 56% of total pediatric CSIs. Fractures are commonly associated with ligamentous EBMedicine.net • July 2008 Pediatric Emergency Medicine Practice © 2008 and/or atlantoaxial fracture with subluxation was found at autopsy in 15% of fatal pediatric spine injuries; more than 80% of these children died at the accident scene.35 Bohn et al described 19 children with a mean age of 6.3 years who were found at the scene of MVAs and presented to the ED with absent vital signs or profound hypotension without clear etiology.36 All of these patients subsequently died, and 16 of them were later found by autopsy to have suffered injury to the high cervical spine and cord. In more recent years, prehospital care has improved, and more children with occipitoatlantal and atlantoaxial injuries are now surviving.21,32-33 In a review of children under 10 years of age who underwent cervical MRI for evaluation of traumatic injury, Sun et al found 20 of these patients, with a mean age of 3.5 years, demonstrated a number of different injuries in the atlantoaxial region, including spinal cord injuries with atlantoaxial dislocation/distraction, intraspinal hemorrhage, and ligamentous injuries.37 Only 2 of these children suffered bony injuries. One child became brain dead at the scene Figure 1. Occipitoatlantal Dissociation Lateral plain film of a 7-year-old boy who was struck by an automobile and sustained an occipitoatlantal dissociation. He died shortly after presentation, and autopsy revealed complete transaction of the spinal cord. Reprinted with permission from McGrory BJ, Klassen RA, Chao EYS, et al. Acute fractures and dislocations of the cervical spine in children and adolescents. J Bone Joint Surg Am. 1993;75:988-995. Pediatric Emergency Medicine Practice © 2008 of the accident from anoxia; the rest demonstrated a spectrum of motor deficits ranging from mild limb weakness to quadriplegia. The authors of this study noted that many of the ligamentous and tectorial injuries, and their resulting instability, would not have been diagnosed without MRI evaluation. Deployment of passenger airbags has recently been identified as a causative factor in craniocervical junction injuries in younger children involved in MVAs. More than 30 children who were improperly restrained or were in rear facing safety seats in the front seat of the vehicle have been killed in MVAs involving airbag deployment.38 Giguère, Saveika, and others have reported fatalities due to occipitoatlantal dissociation in children who were appropriately restrained but were in the front seat of the vehicle.38-39 The Centers for Disease Control have identified at least 8 airbag-related deaths in low speed crashes where the children might have otherwise survived; the cause of death in these children was significant closed head injury.40 The National Highway Traffic Safety Administration now recommends that all children younger than 13 years ride in the rear seat of motor vehicles. If a rear seat is not available, the passenger airbag should be turned off (a feature available in many newer vehicles) or the child should be placed as far back as possible from the airbag. Since 1997, changes in the Federal Motor Vehicle Safety Standards have allowed the redesign of frontal airbags to reduce the force with which they deploy, and a recent cross sectional study demonstrated a decrease in overall risk of injury to front seat pediatric passengers with these second-generation airbags.41 In older children, atlantoaxial injuries are more likely to be associated with bony fractures. Odontoid fractures are the most common CSI in pediatric patients.42 Along with its accompanying ligamentous support, the odontoid is the primary stabilizer of atlantoaxial articulation.43 In a review of 22 patients with atlantoaxial injury, Lui et al reported that 8 of the 12 children with odontoid fractures were over 13 years of age and that 7 of the 10 dislocations without fracture occurred in children under 13 years.43 Most patients with odontoid fractures present with minimal associated neurological deficits because the larger diameter of the spinal canal at the C1 level allows for displacement without compromise of the spinal cord.44 There are 3 characteristic types of odontoid fractures: avulsion fracture of the tip, fracture through the base of the odontoid, and fracture through the vertebral body of C2.17 If the transverse ligament remains intact, the odontoid is displaced anteriorly from its normal position, and there is resultant atlantoaxial instability in all planes of motion. Less common odontoid fractures can be seen in younger children, often occurring at the synchondrosis between the odontoid and the body of C2.45 Atlantoaxial injury has a lower incidence of neuroJuly 2008 • EBMedicine.net logical dysfunction in the presence of a fractured odontoid than with an intact odontoid because if the odontoid is intact, the force of injury has more likely been displaced to the spinal cord.46 Os odontoideum represents a failure of the odontoid to fuse with the body of C2. While the etiology of this finding as either posttraumatic or congenital continues to be debated in the literature, most authors now suspect that this finding occurs after a previously undiagnosed odontoid fracture.47 In a prospective evaluation of 35 symptomatic patients who were found to have os odontoideum, the traumatic episode preceded discovery of the lesion by an average of 3.5 years.48 Radiography demonstrates a radiolucent oval or a round ossicle with a smooth cortical bony border.34,49 Lack of stability in this region predisposes patients to atlantoaxial instability and further injury, potentially from even minor trauma.42,50 In patients with underlying atlantoaxial instability, os odontoideum may be a consequence of the hypermobility rather than its cause.51 Jefferson fractures, usually occurring through the anterior and posterior arches of the ring of C1, are typically caused by axial loading injury. Most often, the child lands directly on his or her head.52 With this mechanism, force is transmitted from compression on the skull through the lateral occipital condyles to the lateral masses of C1.34,53 The degree of fracture spread is typically controlled by stretch of the transverse ligament.52 If the transverse ligament is disrupted as well, these injuries are quite unstable and carry a high incidence of mortality.34 The classically described hangman’s fracture occurs secondary to a hyperextension mechanism and is extremely unusual in children. Bilateral fractures of the pars interarticularis of the axis lead to anterior subluxation of C2 on C3 and an unstable injury.34 Typically this injury is not associated with resultant neurological impairment.20 Physiologic pseudosubluxation in children can be confused with hangman’s fracture, as will be discussed in differential diagnoses. Subaxial CSIs are more often seen in adolescent patients. Common patterns of injury include fracture-dislocations, burst fractures, simple compression fractures, and facet dislocation.20 These types of injuries are similar to those found in adults and can be found at other levels of the vertebral column. The incidence of injury to the cervical spine at multiple levels reported in the literature ranges from 7% to 22%.5,10,30 Concomitant fractures in the upper cervical spine can occur at any age, although they are better described in adolescent and adult patients.54 Frequently combined injuries include dens fracture, fracture of the posterior arch of C1, bipedicular fracture of the axis, Jefferson fracture, or fracture of the superior articular process of C2. Mazur et EBMedicine.net • July 2008 al reported the case of an unfortunate 5-year-old boy who suffered a combined Jefferson and odontoid fracture after falling on his head when his fourwheeler rolled over.52 Multiple fractures of the lower cervical spine are well described in older children. Dogan et al found that 18% of subaxial CSIs involve more than one level.30 Injury to multiple segments, with obvious injury at one level and more subtle pathology at another, may easily be underestimated in pediatric CSIs.55 Neurological disability that results from CSIs in children is relatively uncommon. In a review of 10 years of data collected in the National Pediatric Trauma Registry, Patel et al found that only one-third of pediatric patients with CSIs had neurological deficits, and half of those patients had no initial evidence of radiographic abnormality.6 Less than 10% of children demonstrated a complete cord injury. Dogan et al reported that of 51 patients with subaxial injuries, 64% were neurologically intact on admission, 16% had incomplete neurological injuries, and 14% had a complete spinal cord injury.30 Cervical spine dislocations are associated with a much higher incidence of mortality and neurological dysfunction. Although only 19% of the 103 pediatric patients with CSIs suffered a cervical spine dislocation in the group studied by Brown et al, this group had a mortality rate of 40%, in part related to the high degree of association with severe traumatic brain injury (TBI).5 SCIWORA was initially described by Pang and Wilberger in 1982 and is a phenomenon that is considerably more common in pediatric patients than adults.56 SCIWORA is defined as “spinal cord injury without observable abnormality on conventional radiographs or computed tomography (CT) images.” Cervical SCIWORA comprises 15%-38% of all pediatric CSIs in reviews based in the US.1,5,9,10,57,58 In 2004, Pang reviewed the literature since 1969 for all children from birth to 17 years of age with SCIWORA type injuries and found the mean incidence to be 34.8%.26 The exact incidence does seem to depend on the strictness with which the definition of SCIWORA is applied. Because of the increased laxity of the cervical spine’s supporting structures in younger children, a traumatic event can lead to distortion or contusion of the spinal cord without vertebral fracture; during the trauma, the vertebrae are transiently displaced but return to their normal configuration and alignment. The child’s vertebral column allows for up to 2 cm of stretch, but less than 0.25 cm of stretching to the spinal cord can be associated with distortion and injury.59 The elasticity of the spine is inversely proportional to age; therefore, the risk of occult cord injury is greatest in the youngest children.57 Other mechanisms that may result in SCIWORA include ligamentous bulging, reversible subluxation, indirect transmis Pediatric Emergency Medicine Practice © 2008 sion of kinetic injury to the spinal cord, or vascular or ischemic phenomena.58,60 SCIWORA can result from trauma that leads to hyperextension, hyperflexion, longitudinal distraction, rotation, or axial loading.18,61 While this type of injury, particularly in the upper cervical region, is much more common in younger patients, SCIWORA is also seen in older pediatric patients, particularly in association with sports related injuries.5 When patients with SCIWORA have been studied by MRI, most have demonstrated abnormalities of the spinal cord, most commonly swelling with occlusion of the subarachnoid space.44 Thus, the more frequent use of MRI to evaluate CSIs does challenge the semantics of the term SCIWORA.62 With the accumulation of MRI data in pediatric CSI, any and all of the ligamentous and soft tissue supporting structures have been demonstrated to potentially be involved. Children with SCIWORA present with a variety of neurological syndromes. Mild partial cord syndromes are just as common as complete cord transections.26 Unfortunately, even in the absence of further trauma, a small subset of children with SCIWORA do not have paralysis initially but instead have a latent period of 30 minutes to as long as 4 days. In a group of 15 patients with delayed neurological deterioration, once sensorimotor paralysis began, it progressed inexorably, and 2 of the children ultimately progressed to complete cord transaction.63 This progression may reflect ongoing ischemia with infarction of the spinal cord.60 The incidence of delayed onset SCIWORA may be decreasing in association with more conservative immobilization practices for pediatric patients.26 Recurrent SCIWORA can occur if the spine is not adequately immobilized, either from improper stabilization or from an inadequate duration of time. A recent meta-analysis found an overall incidence of recurrent pediatric SCIWORA to be 17% in the available literature.58 CSIs related to child abuse are most commonly SCIWORA type injuries. Hadley et al found that, in 6 patients on whom autopsy was performed who had presented with classic findings of non-accidental trauma from shaking (profound neurological impairment, seizures, retinal hemorrhages, and intracranial subarachnoid and/or subdural hemorrhages), 5 also had injuries at the cervicomedullary junction consisting of subdural or epidural hematomas of the cervical spinal cord with proximal spinal cord contusions.64 MRI findings in the subset of child abuse patients evaluated by Brown et al included diffuse edema and hemorrhage of the cervical spinal cord.5 Abuse can also be associated with hangman’s fracture secondary to the hyperflexion and hyperextension that occurs with shaking. While fortunately not a common injury, several case reports have described infants with hangman’s fracture secondary to abuse.65,66 Rooks et al described 2 twins who sustained fracture-dislocation injuries of the cervical Pediatric Emergency Medicine Practice © 2008 spine along with numerous other fractures in the axial and appendicular skeleton.67 Atlantoaxial rotary subluxation is also relatively unique to children. When rotation exceeds 40°-45°, the anterior facet of C1 becomes locked on the facet of C2, so children can present with either limited rotation of the neck or complete fixation.19,53 Although associated with trauma in up to 70% of patients, other causes can include recent upper respiratory infection or inflammation from recent surgery.21,68 The inciting traumatic event can often be minor, such as with falls and low speed MVAs. Recently, several cases of atlantoaxial subluxation and fixation have been reported from trampoline use.69 The classic presentation is the “cock robin” position, where the child’s chin is rotated to one side and the head is flexed to the other side. Traumatic subluxation can occur from rupture of the transverse ligament, but this injury is unusual in children because the odontoid usually fails before the transverse ligament.18 Fortunately, the cervical canal is at its widest at this level, so subluxation does not often result in spinal cord impingement.34 Atlantoaxial rotary subluxation, even when associated with fixation, is only rarely associated with any neurological deficits.70 Differential Diagnosis Several normal anatomic variants can be seen in radiographic evaluation of the pediatric cervical spine and can lead to diagnostic confusion. Absent Lordosis While absence of lordosis on a lateral view of the cervical spine in adults is concerning for possible ligamentous injury, this finding is frequent in children and does not necessarily suggest injury. Anterior Vertebral Wedging Ossification of the subaxial vertebral bodies is more advanced at the dorsal aspect and progresses anteriorly with age. Incomplete ossification creates the radiographic appearance of anterior wedging of the vertebral bodies.71 A similar appearance would suggest compression fractures in adults. Pseudosubluxation Most commonly seen between C2 and C3, pseudosubluxation occurs in children secondary to ligamentous laxity. In a classic study evaluating flexion and extensions radiographs in healthy children, Cattell and Filtzer demonstrated that 32 of 70 children (46%) studied under the age of 8 years had 3 or more millimeters of anteroposterior movement of C2 on C3.72 Anterior displacement of C3 on C4 was also seen in 14% of this population. The posterior cervical line devised by Swischuk can help to evaluate for July 2008 • EBMedicine.net fracture or subluxation.73 A line that is drawn down from the anterior spinous process of C1 to C3 should come within 1.5 mm of the anterior spinous process of C2 in the absence of injury. In pathologic dislocation of C2 on C3, the posterior cervical line misses the posterior arch of C2 by 2 mm or more. From a practical standpoint, radiographic subluxation should reduce with extension; patients who have a true traumatic subluxation typically cannot be reduced by extension due to pain and muscle spasm.23 An abnormal posterior cervical line measurement is often indicative of a hangman’s fracture at C2.53 from C3 through C7 fuse between 3 and 6 years of age.74 The posterior synchondroses between each vertebral body and the 2 supporting pedicles fuse within the first 2 years. Also, both the synchondrosis between the body of the atlas and the odontoid and the neurocentral synchondrosis between the body of the atlas and the neural arch fuse by 4 to 6 years of age. Prior to fusion, the appearance of these synchondroses can be mistaken for fracture. Similarly, the secondary ossification center within the odontoid appears between 3 and 6 years of age and fuses by age 12. This V-shaped epiphyseal area of the odontoid can also be confused with a traumatic fracture. Secondary ossification centers can be seen at the tips of the transverse and spinous processes of Pseudo-Jefferson Fracture The lateral masses of the odontoid can be developmentally displaced up to 4 mm in up to 90% of children under 2 years of age.74 As a result, the radiographic appearance, with pseudospread of the atlas on the axis, resembles that of a true Jefferson fracture in older children and adults.53 Figure 2a. Young Child Positioned On A Standard Adult Backboard Atlantoaxial Widening While a distance greater than 2.5 mm between C1 and C2 in adults is strictly considered to be abnormal, infants and small children may have an intervertebral distance of greater than 3 mm without underlying injury.74 Younger patients, especially infants, are much more likely to have physiologic atlantoaxial widening. This finding can be accentuated in young children with Down syndrome due to underlying ligamentous laxity. Because the occiput of the child is more prominent and the head is larger relative to the body as compared to an adult, the neck becomes flexed and the cervical spine does not assume a neutral alignment. Figure 2b. Young Child Positioned On A Standard Adult Backboard With Padding Widened Predental Space The study by Cattell was also the first to report that widening of the predental space or an increase in the distance between the odontoid process and the anterior arch of the atlas can be a normal radiologic variant.72 While a distance of greater than 3 mm of predental space can be associated with a torn transverse ligament, the same increase in distance in children likely represents developmental laxity of this ligament and not injury.24 Young child positioned on a backboard with a double thickness mattress pad that raises the chest relative to the head allowing for neutral positioning of the cervical spine. Widened Prevertebral Space Figure 2c. Young Child Positioned On A Modified Backboard Widening of the prevertebral soft tissue space can occur from injury associated edema and hemorrhage. Measurement of this space is standardized in the adult patient, but in children the size of this space can be markedly influenced by the position of the neck at the time films are obtained. Also, an increase in width can be seen in association with breath holding or forced expiration with crying.71 Therefore, defining normal values for the width of this space in the pediatric patient remains challenging. Young child positioned on a modified backboard with a recessed area for the occiput that again allows for neutral positioning of the cervical spine. Reprinted with permission from Herzenberg JE, Hensinger RN, Dedrick DK, et al. Emergency transport and positioning of young children who have an injury of the cervical spine. J Bone Joint Surg. 1989; 71:15-22. Synchondroses The neurocentral synchondroses between each vertebral body and the neural arch ossification centers EBMedicine.net • July 2008 Pediatric Emergency Medicine Practice © 2008 C3 through C7; although well described, these can persist into adulthood and can simulate fractures.15 In general, epiphyseal plates are smooth and regular and occur in predictable locations as compared to the radiographic appearance of fractures.53 Prehospital Care The primary goal of preadmission management of the pediatric cervical spine is to “first do no harm.” The key to preventing further injury is immobilization of the cervical spine.75 Although it can be very difficult to place an injured or frightened child in an appropriate cervical collar, all reasonable attempts should be made to provide adequate immobilization. When appropriately sized and applied, semirigid cervical collars provide approximately 60%70% limitation of movement. However, providers should be aware that attempting to manipulate and immobilize the cervical spine forcefully could lead to additional injury. Spine boards with stabilizing sand bags or blocks and tape can provide additional immobilization. However, consideration of a child’s physical habitus is paramount to proper positioning. Snyder et al determined that a child’s head achieves 50% of its post-natal growth by the age of 18 months. In contrast, the chest circumference of a child does not reach 50% of its post-natal growth until the age of 8 years.76 As a result of this growth dissymmetry, a child’s head is disproportionately large. Positioning young children in the supine position can lead to unrecognized flexion or anterior displacement of the cervical spine (Figure 2A).77 This cervical flexion can exacerbate unstable cervical spine injuries. Herzenberg et al suggested that using padding to elevate the torso (Figure 2B) or using a modified backboard with an occipital recess (Figure 2C) can prevent this problem by bringing the cervical spine back into a neutral position.77 Subsequent articles have supported the assertion that current spine immobilization techniques are inadequate to assure neutral positioning of the pediatric cervical spine.78-80 Nypaver and Treloar demonstrated that padding under the thorax can be sufficient to correct flexion of a child’s cervical spine while supine; however, there was significant variability in the height of padding required (5-41 mm).78 Curran et al found that 61% of children transported with spinal immobilization had greater than 5 degrees of kyphosis or lordosis by lateral cervical spine radiograph and more than 30% had greater than 10 degrees of flexion. In this study, investigators found that children older than 12 years most frequently had excessive cervical spine angulation with standard immobilization techniques. However, since none of the subjects of their study had spinal injury, they could not assess the associated clinical impact.79 Pediatric Emergency Medicine Practice © 2008 ED Evaluation When faced with a pediatric patient with a traumatic injury, the clinician should first determine if the mechanism of the injury is one that could produce a CSI. Whereas it is unlikely that a child who has fallen off a bike into a bush would have sufficient impact to injure the cervical spine, a child who was jumping a ramp and fell from a bike might. For this reason, the emergency physician must try to obtain the most accurate description of the injury as possible, either from the patient or an eyewitness. Unfortunately, traumatic injuries are often not witnessed and the child may be amnestic of the event or too distressed to answer questions. In these cases, one must assume there was a possible mechanism for injury and fully evaluate the cervical spine. “Clearing” the cervical spine involves evaluating the bony and ligamentous structures of the neck. Clearance indicates that there are no injuries present that could lead to instability of the spine which could lead to cervical cord or nerve root injury in the absence of intervention. In 2002, the Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons (AANS) performed a comprehensive literature review with a goal of producing evidence-based guidelines for the evaluation and management of pediatric cervical spine and spinal cord injuries. Despite the plethora of articles addressing the issue of the pediatric cervical spine, the authors concluded that there was insufficient evidence to support a diagnostic standard.75 In the ideal situation, a trained clinician can clear the cervical spine clinically by physical examination. The NEXUS study determined that imaging of the cervical spine following blunt trauma could be avoided in the absence of 5 clinical criteria (Table 2).81 The validation of these criteria included pediatric patients (2.5% of 34,069 patients were < 8 years old and 1.3% of 818 patients with documented CSI were ≤ 8 years old). Subsequently, Viccellio and the NEXUS group published prospective observational data from 3065 children varying in age from 0 to 18 years to validate the use of NEXUS criteria in children.8 The authors found the NEXUS criteria correct- Table 2. NEXUS Criteria For Radiographic Evaluation Of The Cervical Spine Following Blunt Trauma81 1. Midline cervical tenderness 2. Focal neurologic deficits 3. Altered level of consciousness 4. Evidence of intoxication 5. Painful distracting injury July 2008 • EBMedicine.net ly identified all children at high risk for injury. However, given the low incidence of injury (30 patients, 0.98%), the confidence interval for the sensitivity of the instrument remained wide (88%-100%).8 Nonetheless, this study will likely serve as the definitive study on the validity of the NEXUS tool in children, given that a prospective study to address the question authoritatively would require more than 80,000 children based on the low incidence of CSI in children.8 Of note, the study authors point out that children under the age of 2 were underrepresented and recommend that caution be observed when applying the NEXUS criteria to this population.8 However, other authors suggest that preverbal children should automatically be considered high-risk.75,82 One of the greatest controversies associated with the NEXUS criteria is the determination of what constitutes a painful distracting injury. This question is important because high CSIs, such as those to which young children are predisposed, have been shown to be correlated with increased incidence of other orthopedic injuries.83 In the original article, Hoffman et al defined a distracting injury as one that “could potentially distract the patient from a cervical spine injury.” To address the question of what injuries are potentially distracting, Hefferman et al studied a series of 406 adult trauma patients. They determined that only 7 patients with cervical spine injury failed to report cervical pain. Each of these 7 patients had an upper torso injury. They concluded that isolated lower torso injury did not distract adult patients from accurate reporting of cervical pain.84 It is unknown whether this data would be applicable to pediatric patients. A clinician must also consider that a careful neurological exam can be limited by pain or deformity in the region of a significant injury. In 2003, Stiell et al published the Canadian C-spine Rule (CCR) and found that their algorithm was significantly more sensitive and specific in identifying adult patients at low risk for cervical spine injury and had fewer missed injuries than the NEXUS criteria.85 Using the CCR, any patient under the age of 65 years without a dangerous mechanism or paresthesias may be initially evaluated clinically. It is considered safe to evaluate the patient’s range of motion without radiographs if the patient was involved in a simple rear-end motor vehicle collision, is sitting upright, has been ambulatory, did not have immediate neck pain, or does not have midline tenderness. At that point, if the patient is able to actively rotate the neck 45˚ to the left and right, no radiographs are required to achieve clinical cervical spine clearance.85 While the data to support use of this algorithm in adults is compelling, no children under the age of 16 were evaluated in this study, and to our knowledge, no further studies to evaluate this tool in children have been performed. EBMedicine.net • July 2008 There have been attempts to derive a clinical decision tool specifically for the evaluation of the pediatric cervical spine. Based on a retrospective chart review, Jaffe et al proposed an 8 variable screening tool to determine which children required radiographic evaluation.86 Neck pain, neck tenderness, abnormal reflexes, abnormal strength, and abnormal sensation were each statistically associated with CSI. Additional criteria included a history of neck trauma, limitation of neck mobility, and abnormal mental status. Screening with these 8 criteria produced a sensitivity of 98% and a specificity of 54%. This tool was believed to minimize unnecessary radiographs and time spent in cervical immobilization. The authors cautioned widespread application of this algorithm until it can be further studied, since this tool failed to identify a 2-year-old with an odontoid fracture and dislocation.86 Radiographs can be avoided if an alert and cooperative child will allow an appropriate examination. First, a complete neurological assessment including evaluation of sensory and motor function and reflexes should be done. Any new neurological abnormality in a child with a history of recent trauma should increase the index of suspicion for a CSI. Most children with SCIWORA present with some transient neurological findings, including weakness or paresthesias. If the neurological examination is normal, the clinician should then visually inspect the neck for deformity, abrasions, and bruising. Inspection is followed by gentle palpation of the cervical spine in a neutral position for tenderness, deformity, or muscular spasm. If the patient is pain-free, the collar may be removed. The patient is then instructed to move his neck through the range of motion (flexion, extension, and lateral rotation.)23,87 If the patient remains pain-free, the cervical spine is clinically cleared. In many circumstances, however, an alert child is too scared, too uncomfortable, or too young to complete an adequately informative examination. In this case, or if the child has an altered mental status, additional evaluation must be undertaken. Diagnostic Studies The only diagnostic studies relevant to the clearance of the pediatric cervical spine are radiological imaging. Multiple imaging modalities are available. Plain Films Anteroposterior (AP), cross table lateral, and odontoid films comprise the standard three-view evaluation of the cervical spine. Lateral radiographs must fully image from C1 to the C7/T1 junction.23,87 Downward traction on the arms may be required to obtain full visualization of the cervicothoracic junction. Alternately, a swimmer’s Pediatric Emergency Medicine Practice © 2008 view may be used. Oblique radiographs may be useful to review detail of pedicles and facet joints.23 Detailed discussion of the interpretation of these films has been previously published23 and is beyond the scope of this article. One of two guidelines recommended by the AANS in their 2002 review of the management of pediatric cervical spine and spinal cord injuries was that AP and lateral cervical spine x-rays be obtained in children who have experienced trauma and do not meet NEXUS criteria.75 The omission of the odontoid film from this recommendation is significant since this has been an area of some controversy. Odontoid films are difficult to obtain and often inadequate in children less than 8 years of age.19,88,89 Young children may not be able or willing to open their mouths sufficiently to obtain this film. In a retrospective review of 51 children with CSI, Buhs et al found that the odontoid view was omitted in 33% of evaluations and not helpful in 63%. Only one patient in this series had an injury identified by odontoid view that would not have been seen on other views.88 Similarly, Swischuk et al found in a survey of pediatric radiologists that, while 64% of the group attempted an odontoid view in children less than 5 years of age, 70% of those that tried stopped if the first attempt was unsuccessful. Respondents to this survey reported having missed a total of 46 injuries on lateral cervical spine films that were identified by odontoid view over the course of a cumulative nearly 7000 practice years.89 While plain films have reasonable sensitivity for bony injury,88 it is generally accepted that they are unreliable for the identification of most pediatric soft tissue injuries.29 motion on physical examination, cross sectional imaging with CT or MRI is of greater utility.91 Computed Tomography (CT) In acute spinal trauma in adults, CT scanning of the cervical spine has been demonstrated to be more sensitive in detecting fractures than plain films and more time efficient.92,93 With multidetector CT, images are rapidly obtained and may be reconstructed to provide three-dimensional images.92 In adult patients, CT has a reported sensitivity for cervical spinal fracture between 90% and 99% and a specificity of 72%-89%.92 This is far superior to the sensitivity of 39%-94% and variable specificity reported for plain films.92 In the pediatric population, however, the increased sensitivity of CT for the detection of fractures and malalignment has not been demonstrated.94,95 In one retrospective review of the radiologic evaluation of 606 children less than 5 years of age, 147 children had CT scans performed. Of those, only 4 (2.7%) had significant findings of fracture, dislocation, or instability and each of those injuries had been identified on the initial plain film evaluation.95 While Keenan et al found that utilizing CT for evaluation of the pediatric cervical spine in children with head trauma decreased the number of plain radiographs required at a relatively equivalent cost, those children evaluated by CT were exposed to a higher effective dose of radiation.96 Adelgais and colleagues further demonstrated that the use of helical CT for the evaluation of the traumatic pediatric cervical spine increased health care costs, increased radiation exposure by a factor of 3.4, and did not diminish either emergency department length of stay or sedative medication requirement when compared to plain films.94 The concerns of increased radiation exposure have limited the routine use of CT for evaluation of the pediatric cervical spine. While CT accounts for only 5% of all radiographic imaging, CT examinations account for 40%-67% of all medically based radiation exposure.97 One report demonstrated that compared with plain radiography, helical CT of the pediatric cervical spine increased the mean radiation dose by 50%.94 Furthermore, Rybicki and others found a 10-fold increase in skin radiation and 14-fold increase in thyroid radiation when cervical spine CT was compared to a 4- or 5-view radiographic evaluation of the cervical spine.98 This is of particular significance in children less than 5 years old, for whom it has been stated that glandular tissues (such as thyroid and gonadal tissues) are at greater risk for the development of radiation induced malignancy.97 In circumstances when the benefits of the use of CT is thought to outweigh the radiation risks, individual settings should be based on the size of the child and the regions of the body to be scanned.97 Flexion-Extension Radiographs Flexion-extension cervical radiographs are used as an adjunct to standard three-view evaluation (AP, lateral, and odontoid).90 Indications have included evaluation for ligamentous injury when 3-view evaluation is suggestive of possible injury, evaluation of abnormal physical examination findings when three-view evaluation is normal, and clinical concern for SCIWORA.90 Flexion views may be of particular use in revealing transverse ligament rupture associated with C1/C2 injuries in children or posterior ligamentous complex instability associated with hyperflexion injuries.90 Flexion-extension films may be limited in the acute setting by muscular spasm.90 In a prospective study to assess the utility of flexion-extension radiographs in adult patients with blunt trauma, Insko et al found that when patients could produce adequate cervical flexion and extension, there were no missed injuries. However, they found that 30% of studies were inadequate due to limited range of motion. The investigators concluded that in patients with limited Pediatric Emergency Medicine Practice © 2008 10 July 2008 • EBMedicine.net While CT can clearly be of benefit in evaluation of bony injury, a prospective series of 1577 patients confirmed that CT is not an effective imaging technique for evaluation of ligamentous injury. This series demonstrated that the sensitivity of CT in identifying ligamentous injury was 32% and the negative predictive value was 78% when compared to MRI.99 For this reason, a negative CT scan result is not sufficient to clear the C-spine in the obtunded patient.100 22 of 25 obtunded, intubated, or uncooperative children were able to have their cervical spines cleared by MRI. The remaining 3 children were found to have significant injuries. Final diagnosis after MRI differed from the preliminary diagnoses made by plain films and/or CT in 25 (34%) patients.29 Figures 4 and 5 demonstrate 2 cases of pediatric cervical spine injury in which MRI demonstrated abnormal findings not fully appreciated on plain film or CT. In a retrospective review, Keiper et al demonstrated that MRI studies performed within 48 hours Magnetic Resonance Imaging (MRI) MRI is emerging as an integral tool for the evaluation and management of a child with a potential CSI that cannot be cleared clinically. While flexion and extension views are optimal to determine functional stability of the cervical spine, these films require an alert, cooperative patient with a normal neurological examination. Pediatric patients are rarely able to adequately cooperate with this process, and since they must be alert, anxiolytic medications cannot be used. Since ligaments and cervical soft tissues can be imaged directly with MRI, these images can be used as a surrogate for the determination of stability.92 Trauma to the spinal cord and surrounding tissue results in hemorrhage or edema. These anatomic disruptions are represented by increased water content of tissues that can be detected by MRI.101 MRI has a unique ability to evaluate soft issue pathology and is, therefore, of significant value in direct evaluation of the spinal cord, discs, and ligamentous structures.92 The T2-weighted MRI in Figure 3 demonstrates soft tissue and spinal cord injury that would not be evident on other imaging modalities.20 The level of anatomic detail obtainable has made MRI a desirable modality for evaluation of the atlantooccipital and cervicothoracic regions.101 Bone edema may also be detected on short TI inversion recovery (STIR) and fat-saturated T2 images. This finding can aid in determination of the acuity of bony injury.92 However, compared to CT, MRI is much less sensitive (46%-71%) in identification of osseous injury.101 Flynn et al prospectively studied the use of MRI for evaluation of the cervical spine in pediatric trauma patients.29 Indications for obtaining an MRI included: 1) an obtunded or non-verbal child with a mechanism of injury that could be consistent with CSI, 2) equivocal plain films, 3) neurological symptoms without radiographic findings, and 4) an inability to clear the cervical spine by other diagnostic means within 3 days following injury. Based on these criteria, 74 children obtained cervical spine MRI evaluation. Results from this study showed that MRI revealed injury not seen on plain films in 23% of children (ligamentous injury, muscle injury, and 1 C1 lateral mass fracture). Ten children with equivocal plain films and 3 with concern for odontoid fracture on CT were able to be cleared after MRI. Additionally, EBMedicine.net • July 2008 Figure 3. Child With Spinal Cord Transection T2 weighted magnetic resonance image of a child who sustained cord transection and extensive posterior soft tissue injury. Reprinted with permission from Reilly CW. Pediatric spine trauma. J Bone Joint Surg Am 2007; 89:98-107. 11 Pediatric Emergency Medicine Practice © 2008 of injury provided information that ultimately altered therapy.102 In their study, 6 of 52 patients were found to have unstable injuries, 4 of which required operative intervention. In each of these 4 cases, MRI demonstrated more extensive ligamentous injury than was appreciated by CT, and in each case, the extent of posterior fusion was extended. This study also demonstrated that none of the 36 children with normal MRI findings developed delayed instability or symptoms.102 In SCIWORA, extra-axial compressive lesions are rarely detected and therefore, MRI rarely affects acute management. Nonetheless, MRI is valuable for prognostic information. Major cord hemorrhage (>50% of transverse area or cord discontinuity) predicts complete lesions. Minor cord hemorrhage is associated with good recovery but long term defects. Normal MRI findings suggest complete recovery independent of presenting symptoms.100 Given that it may take up to 4 hours to detect traumatic cord Figure 4. Figure 5. This series of images demonstrates findings on plain film, CT and MRI for an 18 month old. Plain film and CT depict a complete fracture through the base of the dens with anterior dislocation and angulation. MRI also demonstrates disruption of the anterior and posterior longitudinal ligaments, edema of prevertebral tissue and posterior paraspinal musculature, and an epidural hematoma at C6-7. Images courtesy of Julie Matsumoto, MD. Pediatric Emergency Medicine Practice © 2008 This series of images from a 10 year old illustrates very subtle findings on plain film and CT with significant abnormality visualized on MRI. The lateral cervical spine film shows no evidence of gross malalignment but minimal narrowing of the C3-C4 intervertebral disc space. CT demonstrates mild asymmetry of the lateral space between C1 and C2 (anterior view) and inferior and anterior fractures at the base of C6 (lateral view). MRI reveals a near complete transection of the spinal cord at the C1C2 level with distraction injury of the atlantooccipital and atlantoaxial joints. Images courtesy of Julie Matsumoto, MD. 12 July 2008 • EBMedicine.net Clinical Pathway For Evaluation Of The Pediatric Cervical Spine Awake and alert child with possible CSI Is child: > 3 years old, AND cooperative, AND with no developmental delay AND with no high risk mechanism? Is child: < 3 years of age, OR uncooperative, OR developmentally delayed, OR with high risk mechanism? NO Yes Yes Are you ordering a head CT? Does child meet NEXUS criteria? Yes NO NO Order AP and lateral c-spine. Order odontoid if child is > 9 years of age. If odontoid is insufficient, order CT of occiput to C2. Is child > 9 years of age? Yes NO Order CT of cervical spine. Order AP and lateral c-spine and CT occiput to C2. Are test abnormal or is there pain on exam? Is CT abnormal or is there pain on exam? NO NO Yes Patient is normal AND meets NEXUS criteria. Yes Yes Cervical spine is cleared. Order expert consultation. EBMedicine.net • July 2008 13 Pediatric Emergency Medicine Practice © 2008 edema, delaying the MRI scan may be reasonable. Based on the above information, it seems that MRI is nearly the ideal imaging modality for the evaluation of the pediatric cervical spine. MRI images can provide diagnostic and prognostic information and there is evidence to suggest the information obtained alters therapy. Additionally, Frank et al demonstrated that utilizing MRI in obtunded or mechanically ventilated patients allowed cervical spine clearance approximately 2 days earlier. This was associated with non-significant decrease in ICU and hospital lengths of stay and an estimated cost savings of $7700.100 However, the majority of studies done to compare the utility and sensitivity of MRI are not referenced to a true “gold standard.” Frequently, findings on MRI have been empirically accepted to be most reliable. There have been few studies that have attempted to correlate MRI findings with operative or pathologic findings.104 Yet when directly compared to intra-operative findings, there is some evidence to suggest that MRI may overestimate the degree of injury and there is variable sensitivity for detection of injury (45% for posterior osseous structures, 71% for the anterior longitudinal ligament, 100% for intraspinous soft tissues and vertebral body injuries).104 Nevertheless, given the potentially devastating injury that can result from missing a cervical spine injury, it is preferable to overestimate an injury than to miss one. MRI does have some other distinct disadvantages. First, MRI is not as readily available as plain radiography or CT. The acquisition of MRI images is time consuming. Patients with metallic devices such as pacemakers or embedded metallic fragments cannot be safely placed in the MRI scanner. Many intracranial pressure monitors are MRI incompatible. It is difficult to manage mechanically ventilated or critically ill patients in the scanner since specific MRI compatible ventilators must be used and medication pumps cannot be in close proximity to the scanners. Additionally and of significant importance, the majority of conscious children require sedation to tolerate the study. To be performed safely, this procedural sedation requires a trained clinician to remain with the child for the duration of the MRI and until the child wakes.105,106 For these reasons, despite the considerable imaging advantages, MRI may not be a practical consideration for use in the emergency department. Treatment A child with concern for CSI should not be discharged from the emergency department unless the injury has been ruled out or a specific injury has been identified and no acute intervention is required.23 If a CSI is excluded, no specific therapy is warranted, with the possible exception of mild analgesics for trauma associated pain. In the event that an injury is identified, expert consultation with either orthopedics or neurosurgery is indicated. Even if no acute intervention is required, outpatient follow-up will be necessary. More significant injuries may require transfer of the patient to a tertiary or quaternary care center for immediate evaluation by a spine specialist. Discussions of the surgical management of an unstable CSI can be found in the AANS Guidelines for the Management of Pediatric Cervical Spine and Spinal Cord Injuries.75 However, their review found insufficient evidence to support the development of treatment standards or guidelines.75 Primary indications for operative intervention include cervical instability and need for decompression of an incomplete CSI. Determining the ideal timing for intervention can be controversial.107 Despite the fact that pharmacological therapy for spinal cord injury in children has not been addressed in the literature,75 high dose methylprednisilone may be considered when there is evidence Cost- And Time-Effective Strategies 1. Clinically clear the cervical spine when possible. Avoiding radiographic studies saves not only their cost, but also time in the emergency room. 2. Don’t waste a lot of time or effort on getting the odontoid view. Successful attempts to obtain this view are rare in children under the age of 9 years. 3. If ordering a head CT, consider extending it to include the cervical spine from the occiput to C2. This eliminates the need for an odontoid and guarantees adequate visualization of the area most prone to injury in the small child. Pediatric Emergency Medicine Practice © 2008 4. If the patient has cervical pain or an abnormality on plain film, consult an expert early. An orthopedic surgeon or neurosurgeon may have preferences about which further studies will be done. This can prevent redundant or unnecessary imaging. 5. REMEMBER: The cost of a missed injury is far greater than the cost of additional imaging. During the time period from 1997 to 2000, the average hospital bill for a pediatric CSI patient was $57,280, and the average length of hospital stay was 13.47 days.4 14 July 2008 • EBMedicine.net of spinal cord injury with neurological deficits. A bolus of 30 milligrams per kilogram of body weight is given over 15 minutes followed by infusion of 5.4 milligrams per kilogram of body weight per hour for 23 hours.107 We believe that this intervention should be done in consultation with the neurosurgeon or orthopedic surgeon who will be assuming care for the patient. ties including occipitoatlantal instability, odontoid hypoplasia, os odontoideum, hypoplasia of the posterior arch of C1, and spondylolisthesis of the midcervical vertebrae.2 While children with Down syndrome are advised not to participate in contact sports or other activities that could lead to acute hyperflexion or hyperextension of the neck if they have any radiographic evidence of atlantoaxial instability, several reports have failed to demonstrate an increase in incidence of neurological injury in children who were allowed to fully participate in all activities.111,112 More often, patients present with a stable decline in neurological function that has occurred over months to years. The most common constellation of symptoms at presentation for neurological compromise from atlantoaxial instability in children with Down Syndrome includes easy fatigability, difficulties in walking, abnormal gait, neck pain, limited neck mobility, torticollis or head tilt, incoordination and clumsiness, sensory deficits, spasticity, hyperreflexia, clonus, extensor plantar reflexes, and other upper motor neuron and posterior column signs and symptoms.113 While children with Down syndrome can present with catastrophic injury to the spinal cord, nearly all of them have experienced weeks to years of precedingly less severe neurological abnormalities. Klippel-Feil syndrome is classically characterized by a low hairline, short neck, and oc- Special Circumstances Pediatric patients with certain genetic or metabolic syndromes are at increased risk of CSI. Children with Down syndrome have a variably reported incidence of atlantoaxial instability secondary to congenital ligamentous laxity. When defined as hypermobility, up to 60% of Down syndrome children have some degree of increased laxity.71 Only 1%-2% of individuals with laxity go on to develop spinal cord compression.51,108 The American Academy of Pediatrics (AAP) currently recommends that plain films be obtained at 3-5 years of age to look for evidence of atlantoaxial instability or subluxation.109 However, these screening films can be unreliable, so all children with Down syndrome who present for care in the ED should be managed as if they are vulnerable, especially during the course of anesthesia or neck manipulation.108,110 These children are also at risk for a variety of other cervical spine abnormali- Key Points l l l l l Although CSIs are rare in children, they comprise 60%-80% of all pediatric spinal traumas, with most common etiologies including MVAs, sports activities, and falls. The developing pediatric cervical spine demonstrates unique anatomic and functional characteristics, including multiple ossification centers, an initially weak and elastic ligamentous support system, a higher axis of movement, and anterior wedging of the upper cervical vertebrae, all of which predispose it to unique patterns of injury. As in adults, fractures are the most common pediatric CSIs, but dislocations and distractions, especially of the occipitoaxial region, are much more common in children. SCIWORA is a relatively unique phenomenon in children, with a higher incidence of initial and subsequent neurological abnormalities. A multitude of normal anatomic variants on radiographic evaluation of the pediatric cervical spine increases the complexity of evaluation and diagnosis. EBMedicine.net • July 2008 15 l l l l l Appropriate prehospital stabilization of the cervical spine is critical in the prevention of subsequent injury. Clearing the cervical spine of a child by physical examination alone requires that the child be awake and alert, of an appropriate developmental level, free from distracting injury, and cooperative with a complete neurological examination. Of the available radiographic evaluation methods, plain films and CT scans are reasonably sensitive at identifying bony injury but lack the ability to identify ligamentous injury; therefore, MRI has become the gold standard for evaluation of the child who cannot be cleared clinically. Children with Down syndrome, Klippel-Feil syndrome, skeletal dysplasias, mucopolysaccharidoses, and other genetic and metabolic syndromes have an increased risk of CSIs, most notably atlantoaxial instability. All practitioners who care for pediatric patients should encourage proper restraint and seating systems in motor vehicles and should counsel children and families about prevention of CSIs. Pediatric Emergency Medicine Practice © 2008 Risk Management Pitfalls For Cervical Spine Injuries 1. “I didn’t think she needed a cervical collar because she was up and walking around at the scene of the accident.” It is safer to provide cervical spine immobilization until the history can be reviewed, the child can be examined thoroughly, and the appropriate radiographic evaluations can be performed. 2. “They didn’t have a pediatric backboard in the ambulance, and they forgot to put anything under him. Since he’s already secured on the adult board, we’ll just leave him on it.” Immobilization on an adult backboard with no adjustment to allow for the proportionately greater head and occiput size keeps the cervical spine of a child from being positioned in neutral alignment. The resulting position, with the neck flexed and the chin tucked, can lead to upper airway obstruction. 3. “She said her neck didn’t hurt, so I thought it was OK to take her out of the collar.” Remember that children will often tell you whatever you want to hear, partly to please you and partly because they don’t want to wear a cervical collar! This is especially true if the child is scared or overwhelmed by the situation. Also, the impact of other distracting injuries can be more challenging to sort out in young children. It is most prudent to leave the collar in place until other injuries have been cared for and the child can be reassured by a more familiar face. 4. “I’m pretty sure that line on the x-ray is just a growth plate. He seems just fine, and the likelihood of a kid his age having a cervical spine fracture is really low anyway.” Ouch. While it is true that the incidence of CSIs in children is quite low and that children do have a number of growth plate findings on x-ray that can be confused with fracture, children DO get cervical spine fractures and often are neurologically intact with minimal complaints. Unless your radiologist is confident that what you’re seeing is a growth plate, further evaluation is definitely in order. 5. “The x-ray tech has had it! He has tried but he simply cannot get this little girl to hold still and open her mouth for the odontoid view.” Odontoid views are notoriously challenging to obtain in younger children and they often provide inadequate views anyway. Rather than struggling with a frightened or frustrated child, consider another method of evaluation. 6. “The patient you sent over for flexion and extension films is crying because he says his neck hurts too much to bend. What do you want us to do?” Stop! The quality of flexion and extension films will be limited by this child’s inability to bend his Pediatric Emergency Medicine Practice © 2008 7. 8. 9. 10. 16 neck. More importantly, first do no harm. Forcing a child with an unrecognized subluxation or instability through a broad range of motion could precipitate neurological abnormalities. “I’m worried that I’ll miss a fracture in a pediatric patient, so just to be on the safe side, I get a CT on every child with a possible mechanism for a CSI.” Although CT scanning is still an important adjunct in the evaluation of pediatric patients for CSI, it should not be employed haphazardly. Increased sensitivity when using CT for fracture detection in younger children has not been borne out thus far in literature. The increase in total radiation exposure, combined with the fact that CT is not particularly effective at diagnosing ligamentous injury, should be a deterrent for over-use of CT. “Her cervical spine CT was normal, and so were her bedside plain films. I know she’s unconscious so I can’t clinically clear her, but the plastic surgeon really wants her collar off so she can sew her up. It should be fine to leave the collar off once they’re done.” Again, ouch. You’ve failed to get adequate clearance on this child who may be at risk for ligamentous injury or a SCIWORA. While the collar can certainly be loosened or removed in order for other diagnostic or therapeutic procedures to be performed, in line stability should be provided at all times. Once those procedures are completed, put the collar back on! “I know he’s a child with Down syndrome, but his screening plain films were read as OK a few months ago. That means his cervical spine is stable and I should be fine to intubate him, right?” Wrong. Most children with Down syndrome have some degree of atlantoaxial hypermobility, and screening films that look for atlantoaxial subluxation in this population can be unreliable. These children should be managed as if they are at risk for instability and potential cord compression, and the technique of stabilization with intubation or any other manipulation of the head and neck should be managed accordingly. “All of her films were clear and she seems fine, so I told her parents they didn’t have anything to worry about.” The risk of occult injury with a normal physical examination and normal plain films is admittedly quite low. However, there have been case reports of children with SCIWORA who have presented with neurological deficits up to 4 days later that were not present on their initial examination. Always review concerning signs and symptoms with families as well as specific instructions on where and how to return for care. July 2008 • EBMedicine.net cipitoatlantal fusion.44 Estimated to occur in 1 in every 40,000 births, this syndrome is considered to be a congenital malformation of proper cervical segmentation that results in a fusion of 2 or more cervical vertebrae.114 In the majority of patients, the congenital fusions occur in the upper cervical spine.115 A wide range of other anomalies can occur in association with this diagnosis, including renal anomalies, congenital heart disease, impaired hearing, and limb malformations. In the upper cervical spine, instability and hypermobility in the region above the fusion can result in neurological abnormalities from cord or nerve root impingement.116 Hypermobility of the cervical spine below the region of fusion can lead to degenerative disc disease. Cord transection from fracture-dislocation above or below the fused spinal segments may be observed.117 Because the cervical spine of children with Klippel-Feil syndrome is unable to compensate for excessive flexion, extension, or lateral bending through the fused segments, seemingly minor traumatic events in these children can result in a fracture of the fused area and subsequent neurological devastation.118 Therefore, ED practitioners should pay careful attention to positioning and management of these children to avoid iatrogenic injury. Klippel-Feil syndrome is also associated with an increased incidence of os odontoideum.34 The osteochondrodysplasias include a wide variety of skeletal, genetic, and metabolic anomalies that can be associated with cervical spine disorders. These heritable disorders are characterized by intrinsic abnormalities of bone and cartilage growth and remodeling.115 Upper cervical spinal stenosis and atlantoaxial instability can occur with many of these disorders.119 Achondroplasia is associated with cervical spine stenosis especially at the cervicomedullary junction at the foramen magnum.15 These children have a significantly higher risk of spinal cord injury resulting from hyperextension and hyperflexion. Patients with one of the many variants of mucopolysaccharidoses, a group of metabolic skeletal dysplasias, can demonstrate odontoid hypoplasia and atlantoaxial subluxation and instability.119 With any of these disorders, the possibility of iatrogenic injury associated with anesthetic preparation and airway positioning, as well as with any other manipulation of the head and neck region, must always be considered. For children with achondroplasia, uncontrolled neck movement (as may occur during the process of endotracheal intubation) can lead to spinal cord compression secondary to constriction of the foramen magnum.120 there is no clear consensus. While there is no national standard, it has been shown that an organized, consistent approach is of benefit. In a prospective single center study at a level 1 trauma center, implementation of a standard protocol for evaluation of the pediatric cervical spine led to a significant increase in the proportion of children whose cervical spines were cleared by non-neurosurgical personnel with no late injuries identified.124 Clinical algorithms for the evaluation of CSI should be designed to maximize the sensitivity because missing even a small number of true CSIs could have tragic ramifications.86 However, emergency physicians should be mindful that children differ from adults in anatomy, mechanisms of injury, and patterns of injury, and as such, it is inappropriate to simply apply cervical spine imaging protocols for adults to pediatric patients.29 121-124 Disposition The ultimate disposition of the pediatric patient with a demonstrable CSI is often inpatient management. For the patient whose cervical spine has been cleared in the ED, subsequent disposition often depends on the severity of other associated injuries. Because of the possibility of SCIWORA, all patients who are discharged from the ED with any history of a potential mechanism of trauma to the cervical spine should receive detailed written follow-up instructions. These instructions should review symptoms and signs relative to CSI, including numbness, paresthesias, paresis, and shock-like sensations in the extremities and should include clear instructions for where, when, and how families can seek subsequent care. The decision regarding return to play for the pediatric athlete can be complex and should be considered in light of the presenting injury and other associated findings.15 Typically, recommendations regarding return to play are delayed until the athlete has no neurological symptoms and has regained pre-injury strength, especially in the neck musculature.125 While assessment scales that attempt to establish objective guidelines for return to play do exist in the literature, application of these grading systems in the ED in the immediate post-injury period in adults have undergone no evidence-based evaluation. No grading scales exist that are specific for pediatric patients. Prognosis Overall mortality rates in pediatric patients with CSI are between 15% and 30%.1,3,9 Neurological status at the time of presentation to the ED clearly defines the likely outcome. Non-survivors most often have evidence of devastating neurological injury at the time of initial evaluation. Often, these are patients who are unresponsive and apneic at the scene of the accident but who survive to reach Controversies/Cutting Edge While many algorithms for the approach to imaging the pediatric cervical spine have been published,87, EBMedicine.net • July 2008 17 Pediatric Emergency Medicine Practice © 2008 the ED because of rapid prehospital ventilatory support.7 Dietrich et al found that the level of injury was above C3 in 88% of children who did not ultimately survive and that 88% of children exhibited distraction of vertebral bodies.7 Pediatric CSI mortality is highly correlated with the presence of severe TBI. Overall, 30%-60% of pediatric CSIs occur in association with head injury.9,27 In a review of National Pediatric Trauma Registry data from 1994 to 1999, 93% of pediatric CSI deaths were associated with severe TBI.1 Glasgow Coma Score (GCS) has been evaluated as a predictor of pediatric CSI outcome based on 1997 and 2000 National Trauma Data Bank documentation.4 In this retrospective review of pediatric patients who presented with CSIs, a GCS of 3 upon arrival to the emergency department was associated with a mortality of greater than 40%. For patients with a GCS of 4 or higher, the survival rate was 99%. Children who suffer cervical dislocations have an extremely low incidence of neurological sequelae. More than 80% of children with cervical spine fractures from 1994 to 1999 are free of lasting neurological impairment.1 During that same time period, only 4.4% of children with CSIs demonstrated complete cord lesions. Follow up of 102 pediatric CSI patients by Eleraky et al found that all patients who were neurologically intact at the time of injury remained so and that 83% of patients with some degree of neurological impairment recovered completely.9 Similarly, Orenstein et al found that 79% of children had no residual motor or sensory impairment.27 Even patients who present with initial cardiopulmonary compromise and quadriplegia can have complete recovery of neurological function, as was the case for a 4-yearold girl in Japan who presented for care following a C2-C3 fracture-dislocation.126 SCIWORA syndromes in particular seem to have some lasting degree of neurological dysfunction. Of 19 patients who presented with complete cord deficits with SCIWORA type injuries, only 1 demonstrated any significant neurological recovery.62 However, 95% of patients in the same review who did not sustain a complete injury made a full recovery. ride rear facing in a convertible seat or in an infant seat approved for higher weights until at least 1 year of age.127 The rear facing position for infants helps to distribute the force of acute deceleration over the entire back and pelvis and into the shell of the car seat.27 Placing an infant in the forward facing position markedly increases the risk for cervical distraction injury. There are many reported cases of restrained children younger than 12 months of age who suffer CSIs who were prematurely placed in forward facing car seats. Moreover, there have been several cases of children above the age of 1 year who died from CSIs when restrained in the forward facing position as is recommended.128 There are no current cases in the literature reporting catastrophic CSI for any child restrained properly in a rear-facing seat. A forward facing seat, a combination seat, or a belt-positioning booster seat should be used when a child outgrows a convertible safety seat but is too small to use the vehicle’s safety belts.127 Typically, children are restrained in a forward facing child safety seat until they are 4 years of age and weigh 40 pounds. At that time, a child should be transitioned to a belt-positioning booster seat until the seat belt fits properly (approximately 80 pounds and 57 inches in height, typically at least 8 years of age).129 A number of studies in the literature have demonstrated a reduction in CSIs, and other injuries in general, with booster seat use as compared to seatbelt use in children.130-134 Unfortunately, 62% of children aged 4-8 years remain inappropriately restrained in adult seat belts.129 Customized restraint systems are available for children with special health care needs.135 Children and adolescents who participate in sports activities should wear proper fitting protective gear. Spear tackling in football remains the primary mechanism of CSI leading to quadriplegia. While it is an illegal form of tackling, players should receive education on safe techniques to avoid this potentially catastrophic move. In other sports, children should be taught to avoid “head first” maneuvers. Neck conditioning exercises to strengthen muscular and ligamentous support structures may provide additional protection and are a typical part of conditioning regimens in contact sports. Given the nearly 100,000 injuries that occur on trampolines each year, the AAP has recommended that trampolines should not be used at home, in schools, or on playgrounds.136 Adolescents have the highest incidence of CSIs in the pediatric age group as a whole. Although some of these injuries may be difficult to prevent, many are associated with the combination of motor vehicles, excessive rates of speed, lack of seatbelt use, and substance use. Adolescents should be counseled at any available opportunity about the dramatic increase in CSI with risk taking behaviors Prevention The association of pediatric CSI incidence and lack of seat belt use offers just one of many reasons for anticipatory guidance regarding motor vehicle safety and age appropriate restraints at any encounter with children, teenagers, and their families. Restraint systems should be age and weight appropriate as recommended by the AAP. Children should be over the age of 1 year and should weigh at least 20 pounds before they are turned to a face forward position in a motor vehicle. Infants who weigh more than 20 pounds before 1 year of age should Pediatric Emergency Medicine Practice © 2008 18 July 2008 • EBMedicine.net as well as the significant danger of combining them with drug and alcohol use. reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference. Summary Evaluation of a child with a potential CSI is a relatively frequent procedure in the emergency department. To do this properly, the emergency physician must have a complete understanding of the factors that make children unique. The developmental anatomy of the cervical spine impacts the mechanism of injury and predisposes children to higher-level fractures and injuries that are not readily apparent on standard imaging. The incidence of injury is incredibly low but the ramifications of a missed injury are significant and could be life altering for the patient and his family. A standardized approach to children at risk for CSI can assist emergency physicians in their evaluation and determining the need for expert consultation. 1. 2. 3. 4. 5. Case Conclusions 6. Each of the three patients had a mechanism of injury that required cervical spine evaluation. Neurosurgery was consulted to see the 15 year-old football player. A cervical spine CT demonstrated no bony injury. An urgent MRI demonstrated soft tissue and spinal cord edema. Cervical spine immobilization was continued, and he was admitted for neurological monitoring. At the time he was transported to his room, the tingling in his arms was subsiding, but his lower extremity deficits persisted. After some time, the three year old became less distressed and more active. Despite her cervical collar, she was playful and walked to the soda machine with her mom. At that point she cooperated with a physical exam, during which she had no neck tenderness and she demonstrated a full active range of motion. Her cervical spine was cleared clinically and she was discharged to home. The 8 year old was admitted to the Pediatric Intensive Care Unit, where an intracranial pressure monitor revealed severe intracranial hypertension. Despite no obvious bony abnormality on plain films, his clinical course prevented MRI evaluation for ligamentous injury within 72 hours of his accident. Therefore, he remained in a cervical collar at the time of transfer to a rehabilitation facility. He was scheduled to follow up with Orthopedics for further evaluation in 6 weeks. 7. *8. 9. 10. 11. 12. 13. 14. 15. References 16. Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each EBMedicine.net • July 2008 *17. *18. 19. 19 Kokoska ER, Keller MS, Rallo MC, et al. Characteristics of pediatric cervical spine injuries. J Pediatr Surg. 2001; 36:100-105. (Retrospective review of National Pediatric Trauma Registry; 408 patients 0-20 years) Hall DE, Boydston W. Pediatric neck injuries. Pediatr Rev. 1999; 20:13-20. (Review) Platzer P, Jaindl M, Thalhammer G, et al. Cervical spine injuries in pediatric patients. J Trauma. 2007; 62:389-396. (Retrospective review; 56 patients 0-16 years) Vitale MG, Goss JM, Matsumoto H, et al. Epidemiology of pediatric spinal cord injury in the United States. J Pediatr Orthop. 2006; 26:745-749. (Retrospective review of Kid’s Inpatient Database and National Trauma Data Bank; 2909 patients 0-18 years) Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg. 2001; 36:1107-1114. (Retrospective trauma registry review; 103 patients 0-19 years) Patel JC, Tepas III JJ, Mollitt DL, et al. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001; 36:373-376. (Retrospective review of National Pediatric Trauma Registry; 1098 patients 0-19 years) Dietrich AM, Ginn-Pease ME, Bartkowski HM, et al. Pediatric cervical spine fractures: predominantly subtle presentation. J Pediatr Surg. 1991; 26:995-1000. (Retrospective review; 50 patients 2-18 years) Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001; 108:E20. (Prospective evaluation of radiographic examination criteria; 3065 blunt trauma patients 0-18 years) Eleraky MA, Theodore N, Adams M, et al. Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg. 2000; 92:12-17. (Retrospective review; 102 patients 0-16 years) Zuckerbraun BS, Morrison K, Gaines B, et al. Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices. J Pediatr Surg. 2004; 39:483486. (Retrospective review; 94 patients 0-18 years) Martin BW, Dykes E, Lecky FE. Patterns and risks in spinal trauma. Arch Dis Child. 2004; 89:860-865. (Retrospective review of UK Trauma Audit & Research Network Database; 19538 trauma patients 0-16 years, 301 with CSI) Cantu RC, Mueller FO. Catastrophic football injuries: 1977-1998. Neurosurgery. 2000; 47:673-677. (Retrospective review; 118 fatalities, 200 nonfatal injuries, pediatric and adult population) Boden BP, Tacchetti RL, Cantu RC, et al. Catastrophic cervical spine injuries in high school and college football players. Am J Sports Med. 2006; 34:1223-1232. (Retrospective review; 196 high school and college football players) Torg JS, Guille JT, Jaffe S. Injuries to the cervical spine in American football players. J Bone Joint Surg Am. 2002; 84:112-122. (Review) Jagannathan J, Dumont AS, Prevedello DM, et al. Cervical spine injuries in pediatric athletes: mechanisms and management. Neurosurg Focus. 2006; 21:E6. (Review) Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma. 2001; 51:658-662. (Retrospective review; 2244 pediatric and adult patients, 11 CSIs) Bonadio WA. Cervical spine trauma in children: Part I. General concepts, normal anatomy, radiographic evaluation. Am J Emerg Med. 1993; 11:158-165. (Review) Bonadio WA. Cervical spine trauma in children: Part II. Mechanisms and manifestations of injury, therapeutic considerations. Am J Emerg Med. 1993; 11:256-278. (Review) Menezes AH. Craniovertebral junction anomalies: diagnosis and Pediatric Emergency Medicine Practice © 2008 management. Semin Pediatr Neurol. 1997; 4:209-223. (Review) 20. Reilly CW. Pediatric spine trauma. J Bone Joint Surg Am. 2007; 89:98-107. (Review) 21. d’Amato C. Pediatric spinal trauma. Clin Orthop. 2005; (432):3440. (Review) 22. Woods WA. Pediatric cervical spine injuries: avoiding potential disaster. Trauma Reports. 2003; 4:1-12. (Review) *23. Dormans JP. Evaluation of children with suspected cervical spine injury. J Bone Joint Surg Am. 2002; 84:124-132. (Review) 24. Fesmire FM, Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med. 1989; 7:133142. (Review) 25. Givens TG, Polley KA, Smith GF, et al. Pediatric cervical spine injury: a three-year experience. J *26. Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery. 2004; 55:1325-1343. (Systematic review and discussion) 27. Orenstein JB, Klein BL, Gotschall, CS. Age and outcome in pediatric cervical spine injury: 11-year experience. Pediatr Emerg Care. 1994; 10:132-137. (Retrospective review; 73 patients 0-18 years) 28. McGrory BJ, Klassen RA, Chao EYS, et al. Acute fractures and dislocations of the cervical spine in children and adolescents. J Bone Joint Surg Am. 1993; 75:988-995. (Retrospective review; 143 patients 0-15 years) 29. Flynn JM, Closkey RF, Mahboubi S, et al. Role of magnetic resonance imaging in the assessment of pediatric cervical spine injuries. J Pediatr Orthop. 2002; 22:573-577. (Retrospective review; 237 patients 0-18 years, 74 evaluated by MRI) 30. Dogan S, Safavi-Abbasi S, Theodore N, et al. Pediatric subaxial cervical spine injuries: origins, management, and outcome in 51 patients. Neurosurg Focus. 2006; 20:E1. (Retrospective review; 51 patients 0-16 years) 31. Nitecki S, Moir CR. Predictive factors of the outcome of traumatic cervical spine fracture in children. J Pediatr Surg. 1994; 29:1409-1411. (Retrospective review; 227 patients 0-17 years) 32. Salinsky JP, Scuderi GJ, Crawford AH. Occipito-atlanto-axial dissociation in a child with preservation of life: a case report and review of the literature. Pediatr Neurosurg. 2007; 43:137-141. (Case report and discussion) 33. Violas P, Ropars M, Doumbouya N, et al. Case reports: atlantooccipital and atlantoaxial traumatic dislocation in a child who survived. Clin Orthop. 2006; (446):286-290. (Case report and discussion) 34. Roche C, Carty H. Spinal trauma in children. Pediatr Radiol. 2001; 31:677-700. (Review) 35. Hamilton MG, Myles ST. Pediatric spinal injury: review of 61 deaths. J Neurosurg. 1992; 77:705-708. (Retrospective review; 61 patients 0-17 years) 36. Bohn D, Armstrong D, Becker L, et al. Cervical spine injuries in children. J Trauma. 1990; 30:463-469. (Retrospective review; 19 patients 2-14 years) 37. Sun PP, Poffenbarger GJ, Durham S, et al. Spectrum of occipitoatlantoaxial injury in young children. J Neurosurg. (Spine 1) 2000; 93:28-39. (Retrospective review; 71 patients 0-10 years) 38. Giguère JF, St-Vil D, Turmel A, et al. Airbags and children: a spectrum of c-spine injuries. J Pediatr Surg. 1998; 33:811-816. (Case reports and discussion) 39. Saveika JA, Thorogood C. Airbag-mediated pediatric atlantooccipital dislocation. Am J Phys Med Rehabil. 2006; 85:1007-1010. (Case report and discussion) 40. Air-bag associated fatal injuries to infants and children riding in front passenger seats – United States. Morbid Mortal Weekly Report. 1995; 44:845-847. (Case reports and discussion) 41. Arbogast KB, Durbin DR, Kallan MJ, et al. Injury risk to restrained children exposed to deployed first- and second-generation air bags in frontal crashes. Arch Pediatr Adolesc Med. 2005; 159:342-246. (Cross sectional study; 1781 children 3-15 years involved in MVAs) 42. Copley LA, Dormans JP. Cervical spine disorders in infants and children. J Am Acad Orthop Surg. 1998; 6:204-214. (Review) 43. Lui TN, Lee ST, Wong CW, et al. C1-C2 fracture-dislocations in children and adolescents. J Trauma. 1996; 40:408-411. (Retrospective review; 22 patients 2-17 years) 44. Manary MJ, Jaffe DM. Cervical spine injuries in children. Pediatr Pediatric Emergency Medicine Practice © 2008 Ann. 1996; 25:423-428. (Review) 45. Odent T, Langlais J, Glorion C, et al. Fractures of the odontoid process: a report of 15 cases in children younger than 6 years. J Pediatr Orthop. 1999; 19:51-54. (Case series; 15 patients 0-6 years) 46. Reynolds R. Pediatric spinal injury. Curr Opin Pediatr. 2000; 12:6771. (Review) 47. Sankar WN, Wills BPD, Dormans JP, et al. Os odontoideum revisited: the case for a multifactorial etiology. Spine. 2006; 31:979-984. (Retrospective review; 16 patients 2-21 years) 48. Fielding JW, Hensinger RN, Hawkins RJ. Os odontoideum. J Bone Joint Surg Am. 1980; 62:376-383. (Prospective evaluation; 35 patients 3-65 years) 49. Epps HR, Salter RB. Orthopedic conditions of the spine and shoulder. Pediatr Clin North Am. 1996; 43:919-931. (Review) 50. Choit RL, Jamieson DH, Reilly CW. Os odontoideum: a significant radiographic finding. Pediatr Radiol. 2005; 35:803-807. (Case reports and discussion) 51. Nader-Sepahi A, Casey ATH, Hayward R, et al. Symptomatic atlantoaxial instability in Down syndrome. J Neurosurg. (Pediatrics 3) 2005; 103:231-237. (Retrospective review; 12 children 2-15 years) 52. Mazur JM, Loveless EA, Cummings RJ. Combined odontoid and Jefferson fractures in a child. Spine. 2002; 27:E197-E199. (Case report) 53. Lustrin ES, Karakas SP, Ortiz AO, et al. Pediatric cervical spine: normal anatomy, variants, and trauma. RadioGraphics. 2003; 23:539-560. (Review) 54. Gleizes V, Jacquot FP, Signoret F, et al. Combined injuries in the upper cervical spine: clinical and epidemiological data over a 14year period. Eur Spine J 2000; 9:386-392. (Retrospective review; 784 adult patients) 55. Hoffman RFG, Weisskopf M, Stockle U, et al. Bisegmental fracture dislocation of the pediatric cervical spine. Spine. 1999; 24:904-907. (Case report and discussion) 56. Pang D, Wilberger JE. Spinal cord injury without radiographic abnormalities in children. J Neurosurg. 1982; 57:114-129. (Retrospective review and discussion; 24 patients 6 months to 16 years) 57. Kriss VM, Kriss TC. SCIWORA (spinal cord injury without radiographic abnormality) in infants and children. Clin Pediatr. 1996; 35:119-124. (Review) 58. Launay F, Leet AI, Sponseller PD. Pediatric spinal cord injury without radiographic abnormality: a meta-analysis. Clin Orthop. 2005; (433):166-170. (Meta-analysis; 353 patients 0-18 years) 59. Rekate HL, Theodore N, Sonntag VKH, et al. Pediatric spine and spinal cord trauma. Child’s Nerv Syst. 1999; 15:743-750. (Review) 60. Dickman CA, Zabramski JM, Rekate HL, et al. Spinal cord injuries in children without radiographic abnormalities. West J Med. 1993; 158:67-68. (Editorial letter) 61. McCall T, Fassett D, Brockmeyer D. Cervical spine trauma in children: a review. Neurosurg Focus. 2006; 20:E5. (Review) 62. Bosch PP, Vogt MT, Ward WT. Pediatric spinal cord injury without radiographic abnormality (SCIWORA). Spine. 2002; 27:2788-2800. (Retrospective review; 189 patients 0-17 years, 170 with cervical level SCIWORA) 63. Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children – the SCIWORA syndrome. J Trauma. 1989; 29:654-664. (Retrospective review; 55 patients 0-16 years) 64. Hadley MN, Sonntag VK, Rekate HL, et al. The infant whiplashshake injury syndrome: a clinical and pathological study. Neurosurgery. 1989; 24:536-540. (Retrospective case series; 13 infants 1-14 months) 65. Kleinman PK, Shelton YA. Hangman’s fracture in an abused infant: imaging features. Pediatr Radiol. 1997; 27:776-777. (Case report) 66. Ranjith RK, Mullett JH, Burke TE. Hangman’s fracture caused by suspected child abuse. A case report. J Pediatr Orthop. 2002; 11:329-332. (Case report) 67. Rooks VJ, Sisler C, Burton B. Cervical spine injury in child abuse: report of two cases. Pediatr Radiol. 1998; 28:193-195. (Case report) 68. Pang D, Li V. Atlantoaxial rotatory fixation: part 3 – a prospective study of the clinical manifestation, diagnosis, management, and outcome of children with atlantoaxial rotatory fixation. Neurosurgery. 2005; 57:954-972. (Prospective evaluation; 50 patients 0-18 years) 20 July 2008 • EBMedicine.net 69. Maranich AM, Hamele M, Fairchok M. Atlanto-axial subluxation: a newly reported trampolining injury. Clin Pediatr. 2006; 45:468-470. (Case reports and discussion) 70. Muniz AE, Belfer RA. Atlantoaxial rotary subluxation in children. Pediatr Emerg Care. 1999; 15:25-29. (Case reports and discussion) 71. Pizzutillo PD. Injury of the cervical spine in young children. Instr Course Lect. 2006; 55:633-639. (Review) 72. Cattell HS, Filtzer DL. Pseudosubluxation and other normal variations in the cervical spine in children. J Bone Joint Surg Am. 1965; 47:1295-1309. (Prospective; 160 children) 73. Swischuk LE. Anterior displacement of C2 in children: physiologic or pathologic? Radiology. 1977; 122:759-763. (Retrospective review; case series and discussion) 74. Kriss VM, Kriss TC. Imaging of the cervical spine in infants. Pediatr Emerg Care. 1997; 13:44-49. (Review) *75. Section on Disorders of the Spine and Peripheral Nerves. American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery. 2002; 50:S85-99. (Practice guidelines) 76. Snyder RG, Schneider LW, Owings CL, et al. Anthropometry of infants, children, and youths to age 18 for product safety design SP-450. Warrendale, Pennsylvania, Society of Automotive Engineers, 1977. (Report) 77. Herzenberg JE, Hensinger RN, Dedrick DK, et al. Emergency transport and positioning of young children who have an injury of the cervical spine. J Bone Joint Surg. 1989; 71:15-22. (Prospective study; 10 patients) 78. Nypaver M, Treloar D. Neutral cervical spine positioning in children. Ann Emerg Med. 1994; 23:208-211. (Prospective study) 79. Curran C, Dietrich AM, Bowman MJ, et al. Pediatric cervicalspine immobilization: achieving neutral position? J Trauma. 1995; 39:729-732. (Prospective study; 118 patients) 80. Treloar DJ, Nypaver M. Angulation of the pediatric cervical spine with and without cervical collar. Pediatr Emerg Care. 1997 Feb; 13:5-8. (Prospective study; 18 patients) *81. Hoffman JR, Mower, WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000; 343:94-99. (Prospective study; 34,069 patients) 82. Laham JL, Cotcamp DH, Gibbons PA, et al. Isolated head injuries versus multiple trauma in pediatric patients: do the same indications for cervical spine evaluation apply? Pediatr Neurosurg. 1994; 21:221-226. (Retrospective review; 268 patients) 83. Cirak B, Ziegfield S, Knight VM, et al. Spinal injuries in Children. J Pediatr Surg. 2004; 39:607-612. (Retrospective review; 406 patients) 84. Heffernan DS, Schermer CR, Lu SW. What defines a distracting injury in cervical spine assessment? J Trauma. 2005; 59:1396-1399. (Prospective study; 406 patients) *85. Stiell IG, Clement CM, McKnight RD, et al. The Canadian CSpine Rule versus the NEXUS Low-Risk Criteria in patients with trauma. N Engl J Med. 2003; 349:2510-2518. (Prospective study; 8,283 patients) 86. Jaffe DM, Binns H, Radkowski MA, et al. Developing a clinical algorithm for early management of cervical spine injury in child trauma victims. Ann Emerg Med. 1987; 16:270-276. (Retrospective; 206 patients) 87. Eubanks JD, Gilmore A, Bess S, et al. Clearing the pediatric cervical spine following injury. J Am Acad Orthop Surg. 2006; 14:552564. (Review) 88. Buhs C, Cullen M, Klein M, et al. The pediatric trauma c-spine: is the “odontoid” view necessary? J Pediatr Surg. 2000; 35:994-997. (Retrospective review; 51 patients) 89. Swischuk LE, John SD, Hendrick EP. Is the open-mouth odontoid view necessary in children under 5 years? Pediatr Radiol. 2000; 30:186-189. (Survey study; 423 respondents) 90. Ralston ME, Chung K, Barnes PD, et al. Role of flexion-extension radiographs in blunt cervical spine injury. Acad Emerg Med. 2001; 8:237-245. (Retrospective review; 129 patients) 91. Insko EK, Gracias VH, Gupta R, et al. Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma. J Trauma. 2002; 53:426-429. (Prospective study; EBMedicine.net • July 2008 106 patients) 92. Bagley LJ. Imaging of spinal trauma. Radiol Clin North Am. 2006; 44:1-12. (Review) 93. Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic clearance of blunt cervical spine injury: plain radiograph or computed tomography scan? J Trauma. 2003; 55:222-227. (Retrospective review, 3018 patients) 94. Adelgeis KM, Grossman DC, Langer SG, et al. Use of helical computed tomography for imaging of the pediatric cervical spine. Acad Emerg Med. 2004; 11:228-236. (Prospective study; 136 patients) 95. Hernandez JA, Chupik C, Swischuk LE. Cervical spine trauma in children under 5 years: productivity of CT. Emerg Radiol. 2004; 10:176-178. (Retrospective review; 606 patients) 96. Keenan HT, Hollingshead MC, Chung CJ, et al. Using CT of the cervical spine for early evaluation of pediatric patients with head trauma. AJR Am Jour Roentgenol. 2001; 177:1405-1409. (Retrospective review; 63 patients) *97. Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics. 2003; 112:951-957. (Review) 98. Rybicki F, Nawfel RD, Judy PF, et al. Skin and thyroid dosimetry in cervical spine screening: two methods for evaluation and a comparison between helical CT and radiographic trauma series. AJR Am Jour Roentgenol. 2002; 179:933-937. (Prospective study; 12 patients) 99. Diaz Jr JJ, Aulino JM, Collier B, et al. The early work-up for isolated ligamentous injury of the cervical spine: does computed tomography have a role? J Trauma. 2005; 59:897-904. (Prospective study; 1577 patients) 100. Frank JB, Lim CK, Flynn JM, et al. The efficacy of magnetic resonance imaging in pediatric cervical spine clearance. Spine. 2002; 27:1176-1179. (Retrospective review; 51 patients) 101. Slucky AV, Potter HG. Use of magnetic resonance imaging in spinal trauma: indications, techniques, and utility. J Am Acad Orthop Surg. 1998; 6:134-145. (Review) 102. Keiper MD, Zimmerman RA, Bilaniuk LT. MRI in the assessment of the supportive soft tissues of the cervical spine in acute trauma in children. Neuroradiology. 1998; 40:359-363. (Retrospective review; 52 children) 103. Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children. Neurosurgery. 1994; 35:406-414. (Prospective study; 18 patients) 104. Goradia D, Linnau KF, Cohen WA, et al. Correlation of MR imaging findings with intraoperative findings after cervical spine trauma. Am J Neuroradiol. 2007: 28:209-215. (Prospective study; 31 patients) 105. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiolgy. 2002; 96:1004-1017. (Practice guidelines) 106. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Engl J Med. 2000; 342:938-945. (Review) 107. Slucky AV, Eismont FJ. Treatment of acute injury of the cervical spine. J Bone Joint Surg. 1994; 76:1882-1896. (Instructional course lecture) 108. Cohen WI. Current dilemmas in Down syndrome clinical care: celiac disease, thyroid disorders, and atlanto-axial instability. Am J Med Genet Part C Semin Med Genet. 2006; 142C:141-148. (Review) 109. Committee on Genetics. American Academy of Pediatrics: health supervision for children with Down syndrome. Pediatrics. 2001; 107:442-449. (Practice guideline) 110. Msall ME, Reese ME, DiGaudio K, et al. Symptomatic atlantoaxial instability associated with medical and rehabilitative procedures in children with Down syndrome. Pediatrics. 1990; 85:447-449. (Case reports and discussion) 111. Cremers MJG, Bol E, de Roos F, et al. Risk of sports activities in children with Down’s syndrome and atlantoaxial instability. Lancet. 1993; 342:511-514. (Prospective study; 400 patients 4-20 years) 112. Davidson RG. Atlantoaxial instability in individuals with Down syndrome: a fresh look at the evidence. Pediatrics. 1988; 81:857- 21 Pediatric Emergency Medicine Practice © 2008 865. (Case reports and discussion) 113. Committee on Sports Medicine and Fitness. American Academy of Pediatrics: atlantoaxial instability in Down syndrome: subject review. Pediatrics. 1995; 96:151-154. (Practice guideline) 114. Shen FH, Samartzis D, Herman J, et al. Radiographic assessment of segmental motion at the atlantoaxial junction in the KlippelFeil patient. Spine. 2006; 31:171-177. (Retrospective review; 33 patients 5-27 years) 115. Herman MJ, Pizzutillo PD. Cervical spine disorders in children. Orthop Clin North Am. 1999; 30:457-466. (Review) 116. Pizzutillo PD, Woods M, Nicholson L, et al. Risk factors in Klippel-Feil syndrome. Spine. 1994; 19:2110-2116. (Retrospective review; 152 patients 6-53 years) 117. Karasick D, Schweitzer ME, Vaccaro AR. The traumatized cervical spine in Klippel-Feil syndrome: imaging features. Am J Roentgenol. 1998; 170:85-88. (Retrospective review; 14 patients 30-87 years) 118. Samartzis D, Lubicky JP, Herman J, et al. Faces of spine care: from the clinic and imaging suite. Klippel-Feil syndrome and associated abnormalities: the necessity for a multidisciplinary approach in patient management. Spine J. 2007; 7:135-137. (Case report and discussion) 119. Lachman RS. The cervical spine in the skeletal dysplasias and associated disorders. Pediatr Radiol. 1997; 27:402-408. (Review) 120. Trotter TL, Hall JG, Committee on Genetics. American Academy of Pediatrics: health supervision for children with achondroplasia. Pediatrics. 2005; 116:771-783. (Practice guideline) 121. Cook BS, Fanta K, Schweer L. Pediatric cervical spine clearance: implications for nursing practice. J Emerg Nurs. 2003; 29:383-6. (Practice guideline) 122. Brohi K, Wilson-Macdonald J. Evaluation of the unstable cervical spine injury: a 6-year experience. J Trauma. 2000; 49:76-80. (Retrospective and prospective data collection; 100 patients) 123. Banit DM, Grau G, Fisher JR. Evaluation of the acute cervical spine: a management algorithm. J Trauma. 2000; 49:450-456. (Retrospective; 4460 patients) 124. Anderson RCE, Scaife ER, Fenton SJ, et al. Cervical spine clearance after trauma in children. J Neurosurg. 2006; 105:361-364. (Prospective with historical control; 937 patients) 125. Ghiselli G, Schaadt G, McAllister DR. On-the-field evaluation of an athlete with a head or neck injury. Clin Sports Med. 2003; 22:445-465. (Review) 126. Sakayama K, Kidani T, Matsuda Y, et al. A child who recovered completely after spinal cord injury complicated by C2-3 fracture dislocation. Spine. 2005; 30:E269-E271. (Case report) 127. Committee on Injury and Poison Prevention. American Academy of Pediatrics: selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics. 2002; 109:550-553. (Practice guideline) 128. Howard A, McKeag AM, Rothman L, et al. Cervical spine injuries in children restrained in forward-facing child restraints: a report of two cases. J Trauma. 2005; 59:1504-1506. (Case reports and discussion) 129. Winston FK, Chen IG, Elliott MR, et al. Recent trends in child restraint practices in the United States. Pediatrics. 2004; 113: e458e464. (Cross sectional study; 10195 children 0-9 years involved in MVAs) 130. Winston FK, Kallan MJ, Elliott MR, et al. Effect of booster seat laws in appropriate restraint use by children 4 to 7 years old involved in crashes. Arch Pediatr Adolesc Med. 2007; 161:270-275. (Cross sectional study; 6102 children 4-7 years involved in MVAs) 131. Elliott MR, Kallan MJ, Durbin DR, et al. Effectiveness of child safety seats vs seat belts in reducing risk for death in children in passenger vehicle crashes. Arch Pediatr Adolesc Med. 2006; 160:617-621. (Cross sectional study; 9246 children 2-6 years involved in MVAs) 132. Durbin DR, Chen I, Smith R, et al. Effects of seating position and appropriate restraint use on the risk of injury to children in motor vehicle crashes. Pediatrics. 2005; 115:e305-e309. (Cross sectional study; 17980 children 0-15years involved in MVAs) 133. Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA. 2003; 289:2835-2840. (Cross sectional study; 4243 Pediatric Emergency Medicine Practice © 2008 children 4-7 years involved in MVAs) 134. Arbogast KB, Durbin DR, Cornejo RA, et al. An evaluation of the effectiveness of forward facing child restraint systems. Accid Anal Prev. 2004; 36:585-589. (Cross sectional study; 1207 children 12-47 months involved in MVAs) 135. Committee on Injury and Poison Prevention. American Academy of Pediatrics: transporting children with special health care needs. Pediatrics. 1999; 104:988-992. (Practice guideline) 136. Committee on Injury and Poison Prevention and Committee on Sports Medicine and Fitness. American Academy of Pediatrics: trampolines at home, school, and recreational centers. Pediatrics. 1999; 103:1053-1056. (Practice guideline) CME Questions 1. Cervical spine injuries represent what percentage of all pediatric spinal injuries in the United States? a. 0-20% b. 20-40% c. 40-60% d. 60-80% e. 80-100% 2. Most common etiologies of pediatric cervical spine injuries include all of the following EXCEPT: a. Motor vehicle accidents b. Falls c. Child abuse associated injuries d. Football related injuries e. Bicycle related injuries 3. Which of the following statements regarding the functional development of the pediatric cervical spine is TRUE? a. All of the bony centers of ossification are fused at birth. b. Infants and toddlers have a lower axis of movement in the cervical spine than do adolescents and adults. c. Physiologic anterior wedging of the upper cervical spine causes this region to be less susceptible to anterior dislocation. d. Each of the cervical vertebrae has 2 centers of ossification. e. The laxity of the entire structure of the cervical spine in younger children decreases the likelihood of fracture secondary to trauma. 4. Cervical spine injuries in younger children are more likely to: a. Occur in the lower region of the cervical spine b. Be associated with a lack of plain film radiographic evidence of injury c. Include vertebral body and arch fractures d. Include a fracture of the odontoid e. Spare the ligaments and soft tissues of the upper cervical spine 22 July 2008 • EBMedicine.net 5. Which of the following statements regarding atlantoaxial rotary subluxation in children is TRUE? a. Children classically present in the “cock robin” position. b. Association of subluxation with trauma is rare. c. The inciting traumatic event must involve a great deal of force to lead to this finding. d. Subluxation frequently results in spinal cord impingement and neurological deficits. e. Atlantoaxial rotary subluxation is more common in adults. 9. Indications for obtaining MRI in the prospective evaluation of cervical spine injury in pediatric trauma by Flynn et al included all of the following EXCEPT: a. Inability to clear the cervical spine by other diagnostic means within 3 days following injury b. An obtunded or nonverbal child with a mechanism of injury that could be consistent with cervical spine injury c. Clinical clearance of the cervical spine and normal CT scan findings d. Neurological symptoms without radiographic findings e. Equivocal plain films 6. Normal radiographic anatomic variants in evaluation of the pediatric cervical spine include all of the following EXCEPT: a. Atlantoaxial widening b. Pseudosubluxation of C2 on C3 c. Anterior vertebral wedging d. Jagged irregular line through a vertebral arch e. Smooth regular line between the body of C1 and the arch 10. Which of the following is an advantage of MRI evaluation of the pediatric cervical spine when compared with other imaging modalities? a. Need for sedation b. Duration of time required for study to be completed c. Ease of use of monitoring equipment in the scanner d. Widespread availability of MRI scanners e. Improved detection of ligamentous injury 7. Prehospital care of the child with a potential injury to the cervical spine should include: a. Stabilization on a adult backboard without modification b. Leaving the cervical collar off if the child is awake and moving around c. Forceful manipulation and immobilization of the cervical spine if necessary d. Stabilizing sand bags or blocks and tape to provide additional immobilization e. Additional padding under the heads of young infants in order to protect the head 11. Common presenting symptoms of neurological compromise from atlantoaxial instability in children with Down syndrome include all of the following EXCEPT: a. Incoordination and clumsiness b. Hyperreflexia c. Changes in speech patterns d. Neck pain or decreased mobility e. Spasticity 12. With regard to appropriate restraint systems for pediatric patients, which of the following statements is FALSE? a. Infants under 1 year of age should be re strained in a rear facing position in the back seat of the car. b. Infants who weigh more than 20 pounds can transition to a forward facing position prior to their first birthday. c. Children should be restrained in a forward facing car seat until they are 4 years of age and weigh 40 pounds. d. Children over the age of 4 years who weigh more than 40 pounds should be restrained in a belt positioning booster seat until the vehicle’s seat belt fits properly. e. All providers who care for children should reinforce the safety benefits of appropriate vehicle restraint systems with children, adolescents, and their families. 8. NEXUS criteria for radiographic evaluation of the cervical spine following blunt trauma include all of the following EXCEPT: a. Altered level of consciousness b. High speed/force mechanism of injury c. Painful distracting injury d. Midline cervical tenderness e. Focal neurological deficits EBMedicine.net • July 2008 23 Pediatric Emergency Medicine Practice © 2008 Physician CME Information Are you prepared to deal with the constantly changing technologies of the 21st century? Date of Original Release: July 1, 2008. Date of most recent review: June 10, 2008. Termination date: July 1, 2011. Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Mount Sinai School of Medicine and Pediatric Emergency Medicine Practice. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 48 AMA PRA Category 1 Credit(s)TM per year. Physicians should only claim credit commensurate with the extent of their participation in the activity. ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category 1 credit per annual subscription. 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Goals & Objectives: Upon completion of this article, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered. Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product. Disclosure of Off- Label Usage: This issue of Pediatric Emergency Medicine Practice discusses no off-label use of any pharmaceutical product. 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For more information or to order, call 1-800-249-5770 or click “Books & Manuals” on the left side of the page at www.empractice.com. Coming In Future Issues: Initial Assessment and Management of Knee, Ankle and Wrist Injuries Acute Appendicitis Accidental Trauma in Infants Heavy Metal Poisoning Class Of Evidence Definitions Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions. 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