Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

Abstract

The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.

Keywords: Anatomical features; Clinical Decision Rules; Pediatrics; anatomy; cervical vertebrae; pediatric cervical spine injuries; spinal cord injuries; spinal cord injury without radiological anomaly.

Flowchart 1

Flowchart depicting study methodology

Figure 1

Diagrammatic representation of lateral cervical spine radiograph showing a comparison between pediatric and adult cervical vertebral bodies. Open ossification centers, physiological wedging of immature vertebral bodies and horizontally oriented facet joints enhance flexibility of the spine and augment risk for dislocation injury or growth plate fractures

Figure 2

Diagrammatic representation of anteroposterior radiograph depicting open synchondrosis between dens and C2 body. This anatomical peculiarity should not be confused for an odontoid fracture

Figure 3

Diagrammatic representation of the relative size of head of a child in comparison with body size. This peculiarity of pediatric spine fixes the fulcrum of cervical motion at C2/C3 in younger patients and predispose them to high levels of cervical injury

Figure 4

(a) Diagrammatic representation of lateral cervical spine radiograph showing C2–C3 pseudosubluxation (normal relationship of the upper cervical spine determined using Swischuk's Line). (b) Lateral cervical spine radiograph showing C2–C3 pseudosubluxation

Figure 5

Diagrammatic representation of lateral cervical spine radiograph showing standard four curvilinear alignment lines: Anterior vertebral body line (1), posterior vertebral body line (2), spinolaminar line (3) and tips of spinous process (4). Any disruption of these lines should lead to suspicion of a possible fracture and need for further imaging

Figure 6

Diagrammatic representation of lateral cervical spine radiographs showing (a) Basion-dens interval. (b) Powers ratio: b/a. (c) Atlantooccipital joint not exceeding 5 mm. (d) C1–C2 interspinous distance

Figure 7

Computerized tomography scan showing (a) mid-sagittal section, (b) coronal section (c) axial section. Showing specific points: A: Anterior arch of atlas, B: Basion, D: Dens, S: Synchondrosis, O: Opisthion, L: Lateral Mass of Atlas, AX: Vertebral body of atlas, OC: Occipital condyle

Figure 8

Magnetic resonance imaging showing (a) mid-sagittal T2W image (b) axial section. i: Prevertebral soft tissue, ii: Retro vertebral soft tissue, iii: Spinal cord morphology, iv: Space available for cord