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Cervical spine trauma in the injured child: A tragic injury with potential for salvageable functional outcome
Cervical Spine Trauma in the Injured Child: A Tragic Injury With Potential for Salvageable Functional Outcome By David A. Partrick, Denis D. Bensard, Ernest E. Moore, Casey M. Calkins, and Frederick M. Karrer Denver, Colorado
Background/Purpose: Cervical spine injuries are uncommon in children, and, therefore, presumptive immobilization and diagnosis remain controversial. The purpose of this study was to review the author’s experience with cervical spine injuries in children to determine the incidence, injury mechanism, pattern of injury, and subsequent functional outcome. Methods: Fifty-two children over a 6-year period (1994 to 1999) with a cervical spine injury secondary to blunt trauma were identified (1.3% incidence). The functional independent measure (FIM) was assessed at the time of discharge in each of 3 categories: communication, feeding, and locomotion. Results: Mean age of the study children was 10.7 ⫾ 0.7 years. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanism of injury included motor vehicle crash (52%), falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents
C
ERVICAL SPINE INJURIES are uncommon in the pediatric age group.1-3 This clinical bias almost certainly influences whether children’s cervical spines are immobilized aggressively at the injury scene by paramedics and in the emergency department by physicians. Furthermore, some investigators have concluded that routine cervical spine radiographs in injured children are low yield, and that these studies should be done only if indicated by symptoms referable to the neck.4 Some argue that the cervical spine does not need to be immobilized in children ⱕ 3 years old. Others propose that all children admitted with a significant mechanism should be immobilized until the cervical spine can be cleared both clinically and radiographically because many children with cervical spine fractures present with no neck pain or tenderness.5,6 Unfortunately, when these tragic injuries are overlooked, they frequently result in death of the patient or lifelong disability.7 To clarify the need for cervical spine immobilization and radiographic clearance in children, we reviewed our experience with documented pediatric cervical spine injuries to determine the incidence, injury mechanism, pattern of injury, and subsequent outcome of these potentially devastating injuries. MATERIALS AND METHODS
Patients All patients less than 18 years of age admitted to the trauma service at The Children’s Hospital (TCH) of Denver or Denver Health Medical Center (DHMC) with a radiographically documented cervical spine injury over a 6-year period (1994 through 1999) were identified by the
(8%), and motorcycle crashes (4%). Seven patients died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlantooccipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries. FIM scores were recorded for 18 patients. Seventeen communicated independently, 14 fed themselves independently, and 12 had independent locomotive function.
Conclusions: Cervical spine injuries occur in children across a spectrum of ages. Although atlanto-occipital dislocation is a highly lethal event, children with C1 to C7 injuries have a high likelihood of reasonable independent functioning. J Pediatr Surg 35:1571-1575. Copyright © 2000 by W.B. Saunders Company. INDEX WORDS: Trauma, cervical, spine, rehabilitation, atlanto-occipital dislocation, immobilization.
trauma registry at each institution. Children with a penetrating mechanism of injury were excluded as were children with spinal cord injury without radiographic abnormality. The medical records were reviewed to confirm details of the cervical spine injury as well as the patient’s outcome. The data recorded includes age, gender, injury severity score (ISS), injury mechanism, admitting diagnoses, and arrival and discharge dates. For patients treated at the rehabilitation unit in TCH, the functional independent measure (FIM) score was assessed for each child at the time of discharge in each of 3 categories: communication, feeding, and locomotion. FIM is regarded as a standard indicator of disability and handicap for trauma registries and outcome studies.8,9 Rehabilitation physicians give patients a score in each category mentioned above. Children are determined to be either completely independent, partially dependent, or totally dependent on the help and assistance of a caregiver. The Children’s Hospital functions as a designated regional pediatric trauma center for the city of Denver and the state of Colorado. DHMC functions as a level I regional trauma center with pediatric commitment for the same encatchment area. At TCH, injured patients are evaluated in the emergency department by a senior general surgery resident (postgraduate year 4) or pediatric surgery fellow (postgraduate year ⱖ 6) along with an attending emergency medicine physician. At DHMC, injured patients also are evaluated initially in the emergency depart-
From the Division of Pediatric Surgery, The Children’s Hospital, and the Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, Denver, CO. Presented at the 33rd Annual Meeting of the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, May 15-19, 2000. Address reprint requests to David A. Partrick, MD, The Children’s Hospital, 1950 Ogden St, B-323, Denver, CO 80218. Copyright © 2000 by W.B. Saunders Company 0022-3468/00/3511-0010$03.00/0 doi:10.1053/jpsu.2000.18313
Journal of Pediatric Surgery, Vol 35, No 11 (November), 2000: pp 1571-1575
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ment by a senior general surgical resident from the same residency program as those rotating at TCH (postgraduate year ⱖ 4) along with a senior emergency medicine resident (postgraduate year 3) and an attending emergency medicine physician. Twenty-four– hour attending adult and pediatric surgery coverage is available within 15 minutes and is provided by 5 adult and 3 pediatric academic trauma surgeons. Adult and pediatric neurosurgery coverage also is available at each hospital, and all patients with suspected cervical spine injury are evaluated by a senior neurosurgery resident in the emergency department in consultation with the attending neurosurgeon on call. All pediatric trauma patients evaluated by the surgical service are admitted to the trauma service and remain in the hospital for at least 24 hours of observation. At both institutions, children are admitted to the pediatric intensive care unit (ICU) step-down unit, or pediatric ward (depending on the severity of injury), and pediatric consultation is available and provided by in-house pediatric residents, attending physicians, intensivists, and neonatologists. Pediatric anesthesiologists also are available 24 hours a day for children requiring emergent surgery. In every case, the trauma surgical service remains the primary care team of these patients throughout their acute hospital stay.
RESULTS
The study population consisted of 52 children who had sustained cervical spine injury documented by physical examination and radiographic studies over the 6-year period ending December 1999. Twenty-nine of the patients were boys (56%), and they had a mean injury severity score of 22.5 ⫾ 2.9. Mean age of the children sustaining cervical spine injuries was 10.7 ⫾ 0.7 years with a wide range from 8 months old to 17 years old. Their age distribution is depicted in Fig 1. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanisms of injury for the patient population are depicted in Fig 2. The majority of these injuries were sustained from a motor vehicle crash (27 of 52, 52%) with the remaining being the result of falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents (8%), or motorcycle crashes (4%).
Fig 1. Age distribution of the 52-patient study population. Ages are depicted as an inclusive range. Percentage of total population is in parentheses above the histogram.
Fig 2. Mechanisms of injury for the 52-patient study population. The number of patients in each group are included in parentheses.
These injured children stayed in the acute hospital setting a mean of 7.2 ⫾ 1.3 days, and 7 of them died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlanto-occipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries to the cervical spine. As depicted in Fig 3, high cervical spine injuries resulted in significant mortality rate, with atlanto-occipital dislocations experiencing the highest mortality rate of 60%. Lower levels of cervical spine injury resulted in progressively decreased mortality rate. These cervical spine injuries were then analyzed further according to the corresponding age group of the patients (Table 1). Boys were at increased risk of cervical spine injury during the infant and toddler years, whereas injuries in girls became progressively more common in the adolescent and teenage age groups. Three fourths of the children aged 0 to 4 years sustained injuries to the upper (C1 to C3) cervical spine compared with only one fourth in the lower
Fig 3. The number of children with cervical spine injuries depicted according to the anatomic level of injury. Mortality rate also is depicted as the black histogram with the mortality rate above.
CERVICAL SPINE TRAUMA
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Table 1. Summary of Cervical Spine Injuries by Age Group Age Group (n)
Mean Age (yr)
Male (%)
0-4 yr (8) 5-9 yr (14) 10-14 yr (13) 15-18 yr (17)
1.9 ⫹ 0.4 7.0 ⫹ 0.3 12.8 ⫹ 0.4 16.3 ⫹ 0.2
6 (75) 9 (64) 7 (54) 7 (41)
A-O (%)
0 4 (29) 0 1 (5)
C1-C3 (%)
C4-C7 (%)
Mortality Rate (%)
6 (75) 8 (57) 9 (64) 5 (29)
2 (25) 0 4 (31) 11 (58)
0 4 (29) 1 (7) 2 (11)
Abbreviations: A-O, atlanto-occipital dislocation; C1 to C3, injury to cervical spine vertebrae 1, 2, or 3; C4 to C7, injury to cervical spine vertebrae 4, 5, 6, or 7.
cervical spine (C4 to C7), and there was no associated mortality. Atlanto-occipital dislocation injuries were most common in the 5- to 9-year-old children with the remaining injuries all in the upper cervical spine. There also were 2 cervical spine ligamentous injuries in the 5 to 9 year olds. This vulnerable age group had the highest mortality rate of 29% (2 A-O dislocations and 2 C1 to C3 injuries). In the 10 to 14 year olds, lower cervical spine injuries became more frequent, but upper cervical spine injuries still predominated (36% v 64%, respectively). There was 1 death associated with a C1 to C3 injury in this group. The lower cervical spine becomes the primary area of injury in the 15- to 18-year-old teenage group, although 37% of injuries still involved the upper cervical spine, and 1 15-year-old girl had an atlanto-occipital dislocation. Two of these older children died (one with A-O dislocation and one with a C4 to C7 injury) yielding a mortality rate of 11%. FIM scores were recorded for 18 of the 23 children with cervical spine injuries from TCH. These are reported along with the associated level of injury in Table 2. One surviving patient with atlanto-occipital dislocation had a remarkable recovery leading to independent functioning in all 3 categories of communication, feeding, and locomotion. Two others had at least partial or total dependence on caregivers as might be expected with this severe an injury. Those with C1 to C3 and C4 to C7 injuries as well as the 2 with ligamentous injuries fared better with the majority attaining independent status in all 3 categories. Overall, 17 patients with cervical spine injuries communicated independently, 14 fed themselves independently, and 12 had independent locomotive function.
DISCUSSION
There are substantial differences between children and adults in the clinical presentation as well as anatomy, diagnosis, and functional outcome for cervical spine injuries, especially for very young children.10 Previous investigators have documented that cervical spine injuries are uncommon in the pediatric trauma population.1-3 It is estimated that only 10% of spinal cord injuries occur in children.11,12 Because these injuries are rare, the most appropriate and cost-effective means of safely immobilizing a child’s cervical spine remains controversial.13 Although some recommend cervical spine immobilization before transport for all significantly injured children or any child injured by certain mechanisms (ie, motor vehicle accidents, falls),1,3,5,13,14 others propose that routine cervical spine radiographs are low yield, and, consequently, only comatose children or those with symptoms referable to the neck require aggressive radiologic workup.4 We reviewed our experience at 2 urban trauma centers that treat injured children, 1 regional pediatric trauma center and 1 level 1 trauma center with pediatric commitment, to help delineate this controversy. Furthermore, we wanted to document the functional recovery of children who sustain these tragic cervical spine injuries. Our data show cervical spine injuries occur in children across a wide spectrum of ages with 15% of injuries occurring in children less than 5 years of age. Although certainly less common, cervical spine injuries were documented in 4 children less than 2 years of age (8% of the patient population). Young children also are reported to be much more vulnerable to upper cervical spine injuries rather than lower.4,15-17 This was confirmed in our study where atlanto-occipital dislocation and injuries to C1 to
Table 2. Functional Independent Measures for Patients With Cervical Spine Injury Communication Level of Injury
Indep
A-O Dislocation C1-C3 C4-C7 Ligamentous injury
2 8 5 2
Partial
Feeding
Locomotion
Total
Indep
Partial
Total
Indep
Partial
Total
1
1 7 4 2
1 1
1
1 6 3 2
1 1 1
1 1 1
1
Abbreviations: A-O, atlanto-occipital dislocation; C1 to C3, injury to cervical spine vertebrae 1, 2, or 3; C4 to C7, injury to cervical spine vertebrae 4, 5, 6, or 7; Indep, independent functioning; Partial, partial dependence; Total, total dependence.
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C3 were definitely more common in children less than 10 years of age. Interestingly, atlanto-occipital dislocation was not seen in any child less than 5 years old, but was most frequent in the 5 to 9 year old age group (29% of injuries). Children older than 14 years experienced increasingly more injuries to the lower cervical spine, C4 to C7, and correspondingly fewer to the upper cervical spine. Adolescents and teenagers had a pattern of cervical spine injury more similar to those injuries seen in the adult trauma population. These differences in injury patterns may be explained partially by specific variances in pediatric anatomy. Until the age of 10 years, the head of a child is larger in relation to the body than a teenager’s or an adult’s. Furthermore, the umbilicus is the center point of stature and children have a relatively short neck with poor cervical musculature. These anatomic differences predispose children to a very high incidence of head injuries and can also help explain why upper cervical spine injuries predominate in the younger children. Furthermore, the pediatric spine has increased elasticity of the joint capsules and ligaments, shallow and horizontally oriented facet joints, anterior wedging of the vertebral bodies, and poorly developed uncinate processes.18 These properties allow increased ligamentous flexibility and elasticity of the immature spine, thus, permitting extreme ranges of flexion and extension. The spinal cord actually can be completely disrupted in young children without any apparent disruption of the vertebral elements, an injury referred to as SCIWORA (spinal cord injury without radiographic abnormality).19 Although not analyzed in this study group, 5 children over this same study time period sustained spinal cord injuries consistent with SCIWORA. If added to the current study population, SCIWORA would account for 9% of all cervical spinal cord injuries. The overall mortality rate in our series of pediatric patients was 13%. Atlanto-occipital dislocation certainly
is a highly lethal injury, resulting in 60% mortality rate. Traditionally, atlanto-occipital dislocation has been considered a rare and often fatal injury, yet recently reported survivors from this type of an injury have been reported.7,20 In addition to mortality statistics, we recorded the functional independent measure (FIM) at time of patient discharge to more thoroughly describe the clinical outcome of these injured children. FIM is regarded as a standard indicator of disability and handicap for trauma registries and outcome studies.8,9 Although these data were only available for 18 of the 23 children at TCH, significant levels of independent functioning was obtained by the majority of children with cervical spine injuries. Seventeen of these 23 communicated independently, 14 fed themselves independently, and 12 had independent locomotive function. This includes 1 patient with atlanto-occipital dislocation who achieved independent functioning in all 3 categories. Moreover, children with cervical spine injuries from C1 to C3 and from C4 to C7 have a high likelihood of return to reasonable independent functioning. Cervical spine injuries thus occur in children across a spectrum of ages, including very young infants, and can occur in any anatomic location from the atlantis to C7. The suspicion for such injuries needs to be high to avoid further spinal cord injury. Any child with a significant mechanism, distracting injury, or abnormality on neurologic evaluation or physical examination of the neck needs to be immobilized aggressively for protection from further injury and interrogated radiographically to clear the cervical spine.21 The potential exists, with appropriate rehabilitation, for many of these tragically injured children to sustain a significant level of independent functioning. Cervical spine injuries are devastating to children and require extensive multidisciplinary treatment for optimal outcome.
REFERENCES 1. Givens TG, Polley KA, Smith GF, et al: Pediatric cervical spine injury: A three-year experience. J Trauma 41:310-314, 1996 2. Etzwiler LS, Smith ER, Lelyveld S: Cervical spine injuries. Pediatr Emerg Care 12:233-235, 1996 3. Manary MJ, Jaffe DM: Cervical spine injuries in children. Pediatr Ann 25:423-428, 1996 4. Lally KP, Senac M, Hardin WD, et al: Utility of the cervical spine radiograph in pediatric trauma. Am J Surg 158:540-542, 1989 5. Dietrich AM, Ginn-Pease ME, Bartkowski HM, et al: Pediatric cervical spine fractures: Predominantly subtle presentation. J Pediatr Surg 26:995-1000, 1991 6. Baker C, Kadish H, Schunk JE: Evaluation of pediatric cervical spine injuries. Am J Emerg Med 17:230-234, 1999 7. Shamoun JM, Riddick L, Powell RW: Atlanto-occipital subluxation/dislocation: A “survivable” injury in children. Am Surg 65:317320, 1999 8. Hall KM, Cohen ME, Wright J, et al: Characteristics of the
functional independence measure in traumatic spinal cord injury. Arch Phys Med Rehab 80:1471-1476, 1999 9. Currens JAB: Evaluation of disability and handicap following injury. Injury 31:99-106, 2000 10. Luerssen TG: Central nervous system injuries, in O’Neill JA, Rowe MI, Grosfeld JL, et al (eds): Pediatric Surgery. St Louis, MO, Mosby, 1998, pp 330-332 11. Kewalramani LS, Tori JA: Spinal cord trauma in children: Neurologic patterns, radiologic features and pathomechanics of injury. Spine 5:11-18, 1980 12. Ruge JR, Sinson GP, McLone DG, et al: Pediatric spinal injury: The very young. J Neurosurg 68:25-30, 1988 13. Curran C, Dietrich AM, Bowman MJ, et al: Pediatric cervicalspine immobilization: Achieving neutral position? J Trauma 39:729732, 1995 14. Orenstein JB, Klein BL, Ochsenschlager DW: Delayed diagnosis of pediatric cervical spine injury. Pediatrics 89:1185-1188, 1992
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15. Apple JS, Kirks DR, Merten DF, et al: Cervical spine fractures and dislocations in children. Pediatr Radiol 17:45-49, 1987 16. Lui TN, Lee ST, Wong CW, et al: C1-C2 fracture-dislocations in children and adolescents. J Trauma 40:408-411, 1996 17. Finch GD, Barnes MJ: Major cervical spine injuries in children and adolescents. J Pediatr Orthop 18:811-814, 1998 18. Bailey DK: The normal cervical spine in infants and children. Radiology 59:712-716, 1952
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19. Kriss VM, Kriss TC: SCIWORA (spinal cord injury without radiographic abnormality) in infants and children. Clin Pediatr 35:119124, 1996 20. Ferrera PC, Bartfield JM: Traumatic atlanto-occipital dislocation: A potentially survivable injury. Am J Emerg Med 14:291-296, 1996 21. Grasso SN, Keller MS: Diagnostic imaging in pediatric trauma. Curr Opin Pediatr 10:299-302, 1998
Background/Purpose: Cervical spine injuries are uncommon in children, and, therefore, presumptive immobilization and diagnosis remain controversial. The purpose of this study was to review the author’s experience with cervical spine injuries in children to determine the incidence, injury mechanism, pattern of injury, and subsequent functional outcome. Methods: Fifty-two children over a 6-year period (1994 to 1999) with a cervical spine injury secondary to blunt trauma were identified (1.3% incidence). The functional independent measure (FIM) was assessed at the time of discharge in each of 3 categories: communication, feeding, and locomotion. Results: Mean age of the study children was 10.7 ⫾ 0.7 years. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanism of injury included motor vehicle crash (52%), falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents
C
ERVICAL SPINE INJURIES are uncommon in the pediatric age group.1-3 This clinical bias almost certainly influences whether children’s cervical spines are immobilized aggressively at the injury scene by paramedics and in the emergency department by physicians. Furthermore, some investigators have concluded that routine cervical spine radiographs in injured children are low yield, and that these studies should be done only if indicated by symptoms referable to the neck.4 Some argue that the cervical spine does not need to be immobilized in children ⱕ 3 years old. Others propose that all children admitted with a significant mechanism should be immobilized until the cervical spine can be cleared both clinically and radiographically because many children with cervical spine fractures present with no neck pain or tenderness.5,6 Unfortunately, when these tragic injuries are overlooked, they frequently result in death of the patient or lifelong disability.7 To clarify the need for cervical spine immobilization and radiographic clearance in children, we reviewed our experience with documented pediatric cervical spine injuries to determine the incidence, injury mechanism, pattern of injury, and subsequent outcome of these potentially devastating injuries. MATERIALS AND METHODS
Patients All patients less than 18 years of age admitted to the trauma service at The Children’s Hospital (TCH) of Denver or Denver Health Medical Center (DHMC) with a radiographically documented cervical spine injury over a 6-year period (1994 through 1999) were identified by the
(8%), and motorcycle crashes (4%). Seven patients died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlantooccipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries. FIM scores were recorded for 18 patients. Seventeen communicated independently, 14 fed themselves independently, and 12 had independent locomotive function.
Conclusions: Cervical spine injuries occur in children across a spectrum of ages. Although atlanto-occipital dislocation is a highly lethal event, children with C1 to C7 injuries have a high likelihood of reasonable independent functioning. J Pediatr Surg 35:1571-1575. Copyright © 2000 by W.B. Saunders Company. INDEX WORDS: Trauma, cervical, spine, rehabilitation, atlanto-occipital dislocation, immobilization.
trauma registry at each institution. Children with a penetrating mechanism of injury were excluded as were children with spinal cord injury without radiographic abnormality. The medical records were reviewed to confirm details of the cervical spine injury as well as the patient’s outcome. The data recorded includes age, gender, injury severity score (ISS), injury mechanism, admitting diagnoses, and arrival and discharge dates. For patients treated at the rehabilitation unit in TCH, the functional independent measure (FIM) score was assessed for each child at the time of discharge in each of 3 categories: communication, feeding, and locomotion. FIM is regarded as a standard indicator of disability and handicap for trauma registries and outcome studies.8,9 Rehabilitation physicians give patients a score in each category mentioned above. Children are determined to be either completely independent, partially dependent, or totally dependent on the help and assistance of a caregiver. The Children’s Hospital functions as a designated regional pediatric trauma center for the city of Denver and the state of Colorado. DHMC functions as a level I regional trauma center with pediatric commitment for the same encatchment area. At TCH, injured patients are evaluated in the emergency department by a senior general surgery resident (postgraduate year 4) or pediatric surgery fellow (postgraduate year ⱖ 6) along with an attending emergency medicine physician. At DHMC, injured patients also are evaluated initially in the emergency depart-
From the Division of Pediatric Surgery, The Children’s Hospital, and the Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, Denver, CO. Presented at the 33rd Annual Meeting of the Pacific Association of Pediatric Surgeons, Las Vegas, Nevada, May 15-19, 2000. Address reprint requests to David A. Partrick, MD, The Children’s Hospital, 1950 Ogden St, B-323, Denver, CO 80218. Copyright © 2000 by W.B. Saunders Company 0022-3468/00/3511-0010$03.00/0 doi:10.1053/jpsu.2000.18313
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ment by a senior general surgical resident from the same residency program as those rotating at TCH (postgraduate year ⱖ 4) along with a senior emergency medicine resident (postgraduate year 3) and an attending emergency medicine physician. Twenty-four– hour attending adult and pediatric surgery coverage is available within 15 minutes and is provided by 5 adult and 3 pediatric academic trauma surgeons. Adult and pediatric neurosurgery coverage also is available at each hospital, and all patients with suspected cervical spine injury are evaluated by a senior neurosurgery resident in the emergency department in consultation with the attending neurosurgeon on call. All pediatric trauma patients evaluated by the surgical service are admitted to the trauma service and remain in the hospital for at least 24 hours of observation. At both institutions, children are admitted to the pediatric intensive care unit (ICU) step-down unit, or pediatric ward (depending on the severity of injury), and pediatric consultation is available and provided by in-house pediatric residents, attending physicians, intensivists, and neonatologists. Pediatric anesthesiologists also are available 24 hours a day for children requiring emergent surgery. In every case, the trauma surgical service remains the primary care team of these patients throughout their acute hospital stay.
RESULTS
The study population consisted of 52 children who had sustained cervical spine injury documented by physical examination and radiographic studies over the 6-year period ending December 1999. Twenty-nine of the patients were boys (56%), and they had a mean injury severity score of 22.5 ⫾ 2.9. Mean age of the children sustaining cervical spine injuries was 10.7 ⫾ 0.7 years with a wide range from 8 months old to 17 years old. Their age distribution is depicted in Fig 1. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanisms of injury for the patient population are depicted in Fig 2. The majority of these injuries were sustained from a motor vehicle crash (27 of 52, 52%) with the remaining being the result of falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents (8%), or motorcycle crashes (4%).
Fig 1. Age distribution of the 52-patient study population. Ages are depicted as an inclusive range. Percentage of total population is in parentheses above the histogram.
Fig 2. Mechanisms of injury for the 52-patient study population. The number of patients in each group are included in parentheses.
These injured children stayed in the acute hospital setting a mean of 7.2 ⫾ 1.3 days, and 7 of them died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlanto-occipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries to the cervical spine. As depicted in Fig 3, high cervical spine injuries resulted in significant mortality rate, with atlanto-occipital dislocations experiencing the highest mortality rate of 60%. Lower levels of cervical spine injury resulted in progressively decreased mortality rate. These cervical spine injuries were then analyzed further according to the corresponding age group of the patients (Table 1). Boys were at increased risk of cervical spine injury during the infant and toddler years, whereas injuries in girls became progressively more common in the adolescent and teenage age groups. Three fourths of the children aged 0 to 4 years sustained injuries to the upper (C1 to C3) cervical spine compared with only one fourth in the lower
Fig 3. The number of children with cervical spine injuries depicted according to the anatomic level of injury. Mortality rate also is depicted as the black histogram with the mortality rate above.
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Table 1. Summary of Cervical Spine Injuries by Age Group Age Group (n)
Mean Age (yr)
Male (%)
0-4 yr (8) 5-9 yr (14) 10-14 yr (13) 15-18 yr (17)
1.9 ⫹ 0.4 7.0 ⫹ 0.3 12.8 ⫹ 0.4 16.3 ⫹ 0.2
6 (75) 9 (64) 7 (54) 7 (41)
A-O (%)
0 4 (29) 0 1 (5)
C1-C3 (%)
C4-C7 (%)
Mortality Rate (%)
6 (75) 8 (57) 9 (64) 5 (29)
2 (25) 0 4 (31) 11 (58)
0 4 (29) 1 (7) 2 (11)
Abbreviations: A-O, atlanto-occipital dislocation; C1 to C3, injury to cervical spine vertebrae 1, 2, or 3; C4 to C7, injury to cervical spine vertebrae 4, 5, 6, or 7.
cervical spine (C4 to C7), and there was no associated mortality. Atlanto-occipital dislocation injuries were most common in the 5- to 9-year-old children with the remaining injuries all in the upper cervical spine. There also were 2 cervical spine ligamentous injuries in the 5 to 9 year olds. This vulnerable age group had the highest mortality rate of 29% (2 A-O dislocations and 2 C1 to C3 injuries). In the 10 to 14 year olds, lower cervical spine injuries became more frequent, but upper cervical spine injuries still predominated (36% v 64%, respectively). There was 1 death associated with a C1 to C3 injury in this group. The lower cervical spine becomes the primary area of injury in the 15- to 18-year-old teenage group, although 37% of injuries still involved the upper cervical spine, and 1 15-year-old girl had an atlanto-occipital dislocation. Two of these older children died (one with A-O dislocation and one with a C4 to C7 injury) yielding a mortality rate of 11%. FIM scores were recorded for 18 of the 23 children with cervical spine injuries from TCH. These are reported along with the associated level of injury in Table 2. One surviving patient with atlanto-occipital dislocation had a remarkable recovery leading to independent functioning in all 3 categories of communication, feeding, and locomotion. Two others had at least partial or total dependence on caregivers as might be expected with this severe an injury. Those with C1 to C3 and C4 to C7 injuries as well as the 2 with ligamentous injuries fared better with the majority attaining independent status in all 3 categories. Overall, 17 patients with cervical spine injuries communicated independently, 14 fed themselves independently, and 12 had independent locomotive function.
DISCUSSION
There are substantial differences between children and adults in the clinical presentation as well as anatomy, diagnosis, and functional outcome for cervical spine injuries, especially for very young children.10 Previous investigators have documented that cervical spine injuries are uncommon in the pediatric trauma population.1-3 It is estimated that only 10% of spinal cord injuries occur in children.11,12 Because these injuries are rare, the most appropriate and cost-effective means of safely immobilizing a child’s cervical spine remains controversial.13 Although some recommend cervical spine immobilization before transport for all significantly injured children or any child injured by certain mechanisms (ie, motor vehicle accidents, falls),1,3,5,13,14 others propose that routine cervical spine radiographs are low yield, and, consequently, only comatose children or those with symptoms referable to the neck require aggressive radiologic workup.4 We reviewed our experience at 2 urban trauma centers that treat injured children, 1 regional pediatric trauma center and 1 level 1 trauma center with pediatric commitment, to help delineate this controversy. Furthermore, we wanted to document the functional recovery of children who sustain these tragic cervical spine injuries. Our data show cervical spine injuries occur in children across a wide spectrum of ages with 15% of injuries occurring in children less than 5 years of age. Although certainly less common, cervical spine injuries were documented in 4 children less than 2 years of age (8% of the patient population). Young children also are reported to be much more vulnerable to upper cervical spine injuries rather than lower.4,15-17 This was confirmed in our study where atlanto-occipital dislocation and injuries to C1 to
Table 2. Functional Independent Measures for Patients With Cervical Spine Injury Communication Level of Injury
Indep
A-O Dislocation C1-C3 C4-C7 Ligamentous injury
2 8 5 2
Partial
Feeding
Locomotion
Total
Indep
Partial
Total
Indep
Partial
Total
1
1 7 4 2
1 1
1
1 6 3 2
1 1 1
1 1 1
1
Abbreviations: A-O, atlanto-occipital dislocation; C1 to C3, injury to cervical spine vertebrae 1, 2, or 3; C4 to C7, injury to cervical spine vertebrae 4, 5, 6, or 7; Indep, independent functioning; Partial, partial dependence; Total, total dependence.
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C3 were definitely more common in children less than 10 years of age. Interestingly, atlanto-occipital dislocation was not seen in any child less than 5 years old, but was most frequent in the 5 to 9 year old age group (29% of injuries). Children older than 14 years experienced increasingly more injuries to the lower cervical spine, C4 to C7, and correspondingly fewer to the upper cervical spine. Adolescents and teenagers had a pattern of cervical spine injury more similar to those injuries seen in the adult trauma population. These differences in injury patterns may be explained partially by specific variances in pediatric anatomy. Until the age of 10 years, the head of a child is larger in relation to the body than a teenager’s or an adult’s. Furthermore, the umbilicus is the center point of stature and children have a relatively short neck with poor cervical musculature. These anatomic differences predispose children to a very high incidence of head injuries and can also help explain why upper cervical spine injuries predominate in the younger children. Furthermore, the pediatric spine has increased elasticity of the joint capsules and ligaments, shallow and horizontally oriented facet joints, anterior wedging of the vertebral bodies, and poorly developed uncinate processes.18 These properties allow increased ligamentous flexibility and elasticity of the immature spine, thus, permitting extreme ranges of flexion and extension. The spinal cord actually can be completely disrupted in young children without any apparent disruption of the vertebral elements, an injury referred to as SCIWORA (spinal cord injury without radiographic abnormality).19 Although not analyzed in this study group, 5 children over this same study time period sustained spinal cord injuries consistent with SCIWORA. If added to the current study population, SCIWORA would account for 9% of all cervical spinal cord injuries. The overall mortality rate in our series of pediatric patients was 13%. Atlanto-occipital dislocation certainly
is a highly lethal injury, resulting in 60% mortality rate. Traditionally, atlanto-occipital dislocation has been considered a rare and often fatal injury, yet recently reported survivors from this type of an injury have been reported.7,20 In addition to mortality statistics, we recorded the functional independent measure (FIM) at time of patient discharge to more thoroughly describe the clinical outcome of these injured children. FIM is regarded as a standard indicator of disability and handicap for trauma registries and outcome studies.8,9 Although these data were only available for 18 of the 23 children at TCH, significant levels of independent functioning was obtained by the majority of children with cervical spine injuries. Seventeen of these 23 communicated independently, 14 fed themselves independently, and 12 had independent locomotive function. This includes 1 patient with atlanto-occipital dislocation who achieved independent functioning in all 3 categories. Moreover, children with cervical spine injuries from C1 to C3 and from C4 to C7 have a high likelihood of return to reasonable independent functioning. Cervical spine injuries thus occur in children across a spectrum of ages, including very young infants, and can occur in any anatomic location from the atlantis to C7. The suspicion for such injuries needs to be high to avoid further spinal cord injury. Any child with a significant mechanism, distracting injury, or abnormality on neurologic evaluation or physical examination of the neck needs to be immobilized aggressively for protection from further injury and interrogated radiographically to clear the cervical spine.21 The potential exists, with appropriate rehabilitation, for many of these tragically injured children to sustain a significant level of independent functioning. Cervical spine injuries are devastating to children and require extensive multidisciplinary treatment for optimal outcome.
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functional independence measure in traumatic spinal cord injury. Arch Phys Med Rehab 80:1471-1476, 1999 9. Currens JAB: Evaluation of disability and handicap following injury. Injury 31:99-106, 2000 10. Luerssen TG: Central nervous system injuries, in O’Neill JA, Rowe MI, Grosfeld JL, et al (eds): Pediatric Surgery. St Louis, MO, Mosby, 1998, pp 330-332 11. Kewalramani LS, Tori JA: Spinal cord trauma in children: Neurologic patterns, radiologic features and pathomechanics of injury. Spine 5:11-18, 1980 12. Ruge JR, Sinson GP, McLone DG, et al: Pediatric spinal injury: The very young. J Neurosurg 68:25-30, 1988 13. Curran C, Dietrich AM, Bowman MJ, et al: Pediatric cervicalspine immobilization: Achieving neutral position? J Trauma 39:729732, 1995 14. Orenstein JB, Klein BL, Ochsenschlager DW: Delayed diagnosis of pediatric cervical spine injury. Pediatrics 89:1185-1188, 1992
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15. Apple JS, Kirks DR, Merten DF, et al: Cervical spine fractures and dislocations in children. Pediatr Radiol 17:45-49, 1987 16. Lui TN, Lee ST, Wong CW, et al: C1-C2 fracture-dislocations in children and adolescents. J Trauma 40:408-411, 1996 17. Finch GD, Barnes MJ: Major cervical spine injuries in children and adolescents. J Pediatr Orthop 18:811-814, 1998 18. Bailey DK: The normal cervical spine in infants and children. Radiology 59:712-716, 1952
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19. Kriss VM, Kriss TC: SCIWORA (spinal cord injury without radiographic abnormality) in infants and children. Clin Pediatr 35:119124, 1996 20. Ferrera PC, Bartfield JM: Traumatic atlanto-occipital dislocation: A potentially survivable injury. Am J Emerg Med 14:291-296, 1996 21. Grasso SN, Keller MS: Diagnostic imaging in pediatric trauma. Curr Opin Pediatr 10:299-302, 1998