Pediatric C-Spine Injuries

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Pediatric C-Spine Injuries Powered By Docstoc
					Pediatric C-Spine Injuries



       Harold K. Simon, MD, MBA
       Professor, Emory Department of Pediatrics & Emergency Medicine
                   Objectives

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Immobilization Techniques
•   Clinical versus radiograph clearance
•   CT versus Plain Films
•   Interpreting the cervical spine radiograph
    – Cases
Inspiration Yet Reality
                   Objectives

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Immobilization Techniques
•   Clinical versus radiograph clearance
•   CT versus Plain Films
•   Interpreting the cervical spine radiograph
    – Cases
                  Epidemiology : Age

•   Mean age is 8-9 years old, 2:1 male to female
•   < 8 years old mainly, ligamentous injuries
•   > 8 years old mainly fractures
•   Infants under 1 year old with Cervical Spine
    Injuries are rare
                 Epidemiology : Mechanism

• 67% occur with motor vehicle collision
  – 33% occupant
  – 23% bicyclist vs. auto
  – 11% pedestrian vs. auto
• 30% occur with falls and sports injuries
• < 3% occur with gunshot wounds
                               Epidemiology :
                               Associated Injuries
Of 45 children with Cervical Spine Injuries

Pulmonary Contusion                                             10
Femur Fracture                                                  8
Hemoperitoneum                                                  6
Tibial Fracture                                                 5
Arm Fracture                                                    4
Rib Fracture                                                    3
Splenic Laceration                                              3
Ruptured Kidney                                                 2
Pelvis Fracture                                                 2
Clavicle fracture, pneumothorax,                                1 each
   hemothorax, flail chest, liver laceration,
   bowel wall edema, limb amputation

Note: 40% of children with cervical spine injury have no trauma to an other body part
Orestein et al.
                   Objectives

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Immobilization Techniques
•   Clinical versus radiograph clearance
•   CT versus Plain Films
•   Interpreting the cervical spine radiograph
    – Cases
                  Anatomy : Pediatric
                  versus Adult
• Proportionally larger and heavier head
• Weaker and underdeveloped neck musculature
• Higher center of gravity
  – Pediatric : C2-C3
  – Adult: lower cervical vertebrae
• Greater elasticity and laxity of ligaments in
  children
• More horizontal orientation of facet joints
                Anatomy : Pediatric
                versus Adult
• Relatively wedged anterior vertebral bodies
• Biomechanical and anatomic difference begin to
  disappear around 8-10 years old, but are not
  fully gone until 15-17 years old
                  Anatomy : Implications

• Ligamentous laxity
  – Allows the spine to absorb and cushion traumatic
    forces, thus protecting the bones and spinal cord
  – More cervical distraction injuries, as well as
    hyperflexion-extension injuries in rapid deceleration
    accidents (high energy injuries)
  – Children may have spinal cord injury in the absence
    of radiographic abnormality (SCIWORA)
                     Objectives

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Immobilization Techniques
•   Clinical versus radiograph clearance
•   CT versus Plain Films
•   Interpreting the cervical spine radiograph
     – Cases
                Question

• 28 month old male
• Fell from shopping cart, landed on head
• Arrives in C-collar

• Primary survey is normal
• Patient is crying and uncooperative

• How would you clear his cervical spine?
                                 Which Trauma Patients
                                 Should Be Immobilized
Severe or high risk mechanism of injury,      Yes   Immobilize, radiographic evaluation
    instability, or inability to assess
                       No
Altered level of consciousness, altered       Yes   Immobilize, radiographic evaluation
    alertness, or inebriated
                       No
                                              Yes   Immobilize, radiographic evaluation
Neurologic abnormality at any time post-
  injury
                   No
Complaints of neck pain                       Yes   Immobilize, radiographic evaluation
                    No
                                              Yes   Immobilize, radiographic evaluation
Cervical spine tenderness (or other painful
   injuries which might mask neck pain
                    No
                                              Yes   Immobilize, radiographic evaluation
Limited or painful neck motion
                     No
Clinical evaluation without radiographs
                     Immobilization Techniques

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Immobilization Techniques
•   Clinical versus radiograph clearance
•   CT versus Plain Films
•   Interpreting the cervical spine radiograph
     – Cases
                    Immobilization Techniques


   Cervical collars - soft foam, firm foam, and rigid plastic
   Sandbags/foam cushions/towels/tape
   Backboards/Kendricks extrication device/Extriboard
   Combinations usually used in the pre-hospital setting
              Immobilization Techniques

Pediatric patients have disproportionally large
heads that actually cause neck flexion on a rigid
backboard. Padding under the shoulders and back,
or a recessed area for the head is recommended to
keep the patient in the neutral position.
               Immobilization Techniques

   Pediatric backboards with recessed head areas
 Pre-hospital: Usea rigid or firm foam collar in
combination with other padding, on a rigid
backboard, with tape to provide the best initial
immobilization
                   Immobilization Techniques


 Never attempt to straighten a cervical deformity when
immobilizing a child!
Cervicalcollar alone DOES NOT provide full
immobilization if moving about uncontrollably!
    It may however be an option for a totally cooperative
    patient not moving about and for lower risk situations.
    Only   mobilization necessary for most in-hospital
    situations
                             Immobilization Techniques


                               Flexion Extension Rotation Lateral
Pediatric Control                    35°   45°      80°      16°
Infant Control                       35°    38°     >90°      40°




Range of neck motion in mannequins
                                                   Pitfalls of Pediatric Immobilization:




                                                    Degrees of Motion Allowed From Neutral Position in Mannequin Models
Collar                              Flexion   Extension   Rotation     Lateral      Summed Score*             (%) ±
Infant
   Infant car seat, padding, tape
           With foam collar         8         12           2°          3°           25                        (64)
   Head Brace                       35        38           4°          1°           78                        (205)
           With Foam Collar         11        19           2°          2°           34                        (87)
   Half-Spine board, tape           1          1           4°          6°           12                        (23)
           With Foam Collar         1          1           2°          4°            8                        (17)
    Kendrick Extriction             12        10           19 °        9°            50                       (92)
           With Foam Collar         1          1            4°         1°             7                       (11)
                                          Pitfalls of Pediatric
                                          Immobilization:
Child Control
Head Immobilizer
  Foam cushions to spine board           11            18           26 °           3°          58                    (122)
             With Vertebrace             10            14            1°            1°          26                    (66)
Head Brace                               16            12                2°        1°          31                    (82)
              With Flex-Support          7              9                5°        2°          23                    (58)
Kendricks Extrication                    6              8                4°        2°          20                    (53)
              With Flex-Support          4              3                1°        2°          10                    (31)
Extriboard Disposable
Extrication device                       9              7                5°        4°          24                    (73)
               With Vertebrace           3              2                2°        1°           8                    (20)
Half-Spine board & tape                  10             1                4°         7°         22                    (79)
              With Flex-Support & Tape   2              3                1°         2°          8                    (26)
Full-Spine board & Tape                  4             12                5°         3°         24                    (63)
              Tape, Beanbag & Flex-Sup   10             9                3°         2°         24                    (66)
              Tape, Beanbag 5             5             0°               1°       11                  (31)

* Summed score, arithmatic sum of degrees of motion in each direction.    Degrees of motion allowed
                                                                                                         In each direction
±Summed of score, arithmatic sum of percentage of control motion.                 Control
                     Objectives

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Immobilization Techniques
•   Clinical versus radiograph clearance
•   CT versus Plain Films
•   Interpreting the cervical spine radiograph
     – Cases
                  NEXUS

• National Emergency Medicine X-ray Utilization Study

• 23 Center National Cooperative Study
• Viccellio P, Simon HK, Pressman B, Shah M, Mower W,
  Hoffman J, for the NEXUS Group. A Prospective
  Multicenter Study of Cervical Spine Injury in Children.
  Pediatrics August 2001;108: e20
                   NEXUS : Study Definitions

Low Risk Patient

Those with none of the following criteria:
  – Midline cervical tenderness
  – Focal neurologic deficits
  – Altered level of alertness
  – Evidence of intoxication
  – Distracting painful injury
                    NEXUS : Study Results


• 34,069 patients enrolled
  – 3,065 Pediatric Patients
     • (9%) were < 18 yrs
     • 603 (19.7%) were “Low-risk”
                             NEXUS : Study Results

         Age distribution in years - All Nexus Patients
         1000

         800
Number




         600

         400

         200

           0
                0       12        24        36        48        60        72        84        96
                    6        18        30        42        54        66        78        90        102
                             NEXUS : Study Results

         Age distribution in years - All Nexus Patients
         1000
                                        N = 34,069
         800
Number




         600
                n = 3,065                              n = 31,004

         400

         200

           0
                0       12        24        36        48        60        72        84        96
                    6        18        30        42        54        66        78        90        102
                                       NEXUS : Study Results

                          Age Distribution of Pediatric Patients
                          600
# of patients




                                      N = 3,065
                500

                400

                300

                200

                100

                 0
                      0     1   2 3   4   5   6 7      8   9 10 11 12 13 14 15 16 17
                                                  Age distribution in years
                                        NEXUS : Study Results

                           Age Distribution of Pediatric Patients
                           600
# of patients




                                       N = 3,065
                500
                    <2 y.o.,
                400 n = 88

                300

                200

                100

                  0
                       0     1   2 3   4   5   6 7      8   9 10 11 12 13 14 15 16 17
                                                   Age distribution in years
                                        NEXUS : Study Results

                           Age Distribution of Pediatric Patients
                           600
# of patients




                                       N = 3,065
                500
                    <2 y.o.,           2-8 y.o.,
                400 n = 88             n = 817

                300

                200

                100

                  0
                       0     1   2 3   4   5       6 7   8   9 10 11 12 13 14 15 16 17
                                                   Age distribution in years
                                        NEXUS : Study Results

                           Age Distribution of Pediatric Patients
                           600
# of patients




                                       N = 3,065
                500
                    <2 y.o.,           2-8 y.o.,                 9-17 y.o.,
                400 n = 88             n = 817                   n = 2160

                300

                200

                100

                  0
                       0     1   2 3   4   5       6 7   8   9 10 11 12 13 14 15 16 17
                                                   Age distribution in years
                  NEXUS : Study Results


• Of 3,065 children enrolled, 30 had c-spine injuries
  (0.98%)
• All children with c-spine injuries were prospectively
  classified as being in the “high-risk” group
• No child from the “low-risk” group had a c-spine
  injury
               NEXUS : Study Results

  Of the 30 children with c-spine injuries

Clinical Features    +         -         N/A
Tenderness           21        4         5
Neuro deficits       8         19        3
Altered LOC          6         21        3
Intoxication         0         27        3
Distracting injury   11        17        2
               NEXUS : Study Results

  Of the 30 children with c-spine injuries

Clinical Features    +         -         N/A
Tenderness           21        4         5
Neuro deficits       8         19        3
Altered LOC          6         21        3
Intoxication         0         27        3
Distracting injury   11        17        2
               NEXUS : Study Results

  Of the 30 children with c-spine injuries

Clinical Features    +         -         N/A
Tenderness           21        4         5
Neuro deficits       8         19        3
Altered LOC          6         21        3
Intoxication         0         27        3
Distracting injury   11        17        2
               NEXUS : Study Results

  Of the 30 children with c-spine injuries

Clinical Features    +         -         N/A
Tenderness           21        4         5
Neuro deficits       8         19        3
Altered LOC          6         21        3
Intoxication         0         27        3
Distracting injury   11        17        2
               NEXUS : Study Results

  Of the 30 children with c-spine injuries

Clinical Features    +         -         N/A
Tenderness           21        4         5
Neuro deficits       8         19        3
Altered LOC          6         21        3
Intoxication         0         27        3
Distracting injury   11        17        2
               NEXUS : Study Results

  Of the 30 children with c-spine injuries

Clinical Features    +         -         N/A
Tenderness           21        4         5
Neuro deficits       8         19        3
Altered LOC          6         21        3
Intoxication         0         27        3
Distracting injury   11        17        2
                NEXUS : Study Results

Of the 3,035 children without c-spine injuries

Clinical Features     +        -         N/A
Tenderness            1179     1333      523
Neuro deficits        176      2611      248
Altered LOC           520      2326      189
Intoxication          110      2730      195
Distracting injury    878      1915      242
                                   NEXUS : Study Results
Age   Sex   Fracture type
2     F     C2 type III odontoid fracture
3     M     Occipital condyle fracture
6     M     Cranio-cervical dissociation
8     M     C1 & C2, fractures
9     M     C4 flexion tear drop fracture
11    M     Cranio-cervical dissociation
11    F     C7 burst fracture
11    M     C5 body fracture
11    M     C1 lateral mass fracture
12    F     C2 spinous process fracture
13    M     C6 spinous process fracture
14    M     C7 wedge compression
14    F     C4 - C5 subluxation, C5 - C6 subluxation, C5 body and,posterior element fractures, C4-6 cord contusion
16    F     C7 compression fracture
16    F     C6 - C7 fracture
16    M     C6 burst fracture and bilateral laminar fractures, C7 body fractures
16    M     C5 burst fracture and bilateral laminar fractures; C5 – C6 subluxation
16    M     C5 body fracture; C5-6 sublux
16    M     C5 & C6 trabecular fractures, C3 - C7 interspinous ligament injury
16    M     C6 facet fracture; C6 compression fracture; C5 – C6 interfacetal dislocation; C5 – C6 cord contusion
16    M     C1 posterior arch fracture
16    M     C4 compression fracture; C3 – C4 subluxation; C3 – C4 cord contusion
16    F     C4 burst fracture; C4-C5 subluxation; C4-C5 cord contusion
17    M     C7 spinous process fracture
17    F     C7 body fracture
17    M     C6 - C7 facet and capsular injury
17    M     C5 laminar fracture, C6 body fracture, C5 – C6 nterfacetal dislocation, C5 – C6 cord contusion
                          NEXUS : Study Results

                  Pediatric versus Adult
Item of interest                   Age <18yrs   Age ≥18yrs
Total # of cases                   3,065        31,004
# with c-spine injury              30           788
Injury Rate                        0.98%        2.54%
“Missed injuries”                  0            8
(all negative criteria)

# of cases with all (-) criteria   20%          12%
              NEXUS : Study Results

Take Home
 – No c-spine injuries occurred in children
   prospectively identified at “low-risk”
 – NEXUS decision instrument could have safely
   reduced c-spine imaging by nearly 20%
 – Limited data on under 2 years old
                   NEXUS : Study Definitions

Low Risk Patient

Those with none of the following criteria:
  – Midline cervical tenderness
  – Focal neurologic deficits
  – Altered level of alertness
  – Evidence of intoxication
  – Distracting painful injury
Canadian c-spine
algorithm
                     Objectives

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Immobilization Techniques
•   Clinical versus radiograph clearance
•   CT versus Plain Films
•   Interpreting the cervical spine radiograph
     – Cases
                  Helical CT vs Plain
                  Films
• Advantages
  – CT is more sensitive for detecting C-Spine Injuries
    than plain film
  – Depending on age may save time
• Disadvantages
  – Radiation
  – Cost
  – May increase time if sedation required
                   Helical CT vs Plain
                   Films
• Randomized trial
• 136 children 0-14yr
• Increased radiation in HCT group
• No reduction in the amount of sedation or LOS in the
  HCT group
• 34% crossover from assigned group secondary to
  perceived advantages


     Adelgais KM, Grossman D, et al. Academic Emerg Med
     March 2004
                                   Helical CT vs Plain
                                   Films

Outcome                     Helical CT (n=97)   Plain Film (n=39)
Mean ED time (min)          243 (CI 143, 343)   174 (CI 154,194)
Mean Radiation time (min)   89 (CI 60, 118)     88 (CI 76, 99)
Radiographic cost
          total RVU         17.3 (CI 15, 19)    10.7 (CI 8.5, 12.9)
          Total $           657 (CI 570, 737)   407 (CI 323, 494)
          C-Spine RVU       5.9 (CI 5.8, 6.1)   1.8 (CI 1.4, 2.2)
          C-Spine $         224 (CI 220, 232)   68 (CI 53, 84)
          Rad dose (nRem)   432 (CI 340, 465)   127 (CI 117, 138)
                                   Helical CT vs Plain
                                   Films

Outcome                     Helical CT (n=97)   Plain Film (n=39)
Mean ED time (min)          243 (CI 143, 343)   174 (CI 154,194)
Mean Radiation time (min)   89 (CI 60, 118)     88 (CI 76, 99)
Radiographic cost
          total RVU         17.3 (CI 15, 19)    10.7 (CI 8.5, 12.9)
          Total $           657 (CI 570, 737)   407 (CI 323, 494)
          C-Spine RVU       5.9 (CI 5.8, 6.1)   1.8 (CI 1.4, 2.2)
          C-Spine $         224 (CI 220, 232)   68 (CI 53, 84)
          Rad dose (nRem)   432 (CI 340, 465)   127 (CI 117, 138)
                                   Helical CT vs Plain
                                   Films

Outcome                     Helical CT (n=97)   Plain Film (n=39)
Mean ED time (min)          243 (CI 143, 343)   174 (CI 154,194)
Mean Radiation time (min)   89 (CI 60, 118)     88 (CI 76, 99)
Radiographic cost
          total RVU         17.3 (CI 15, 19)    10.7 (CI 8.5, 12.9)
          Total $           657 (CI 570, 737)   407 (CI 323, 494)
          C-Spine RVU       5.9 (CI 5.8, 6.1)   1.8 (CI 1.4, 2.2)
          C-Spine $         224 (CI 220, 232)   68 (CI 53, 84)
          Rad dose (nRem)   432 (CI 340, 465)   127 (CI 117, 138)
                                   Helical CT vs Plain
                                   Films

Outcome                     Helical CT (n=97)   Plain Film (n=39)
Mean ED time (min)          243 (CI 143, 343)   174 (CI 154,194)
Mean Radiation time (min)   89 (CI 60, 118)     88 (CI 76, 99)
Radiographic cost
          total RVU         17.3 (CI 15, 19)    10.7 (CI 8.5, 12.9)
          Total $           657 (CI 570, 737)   407 (CI 323, 494)
          C-Spine RVU       5.9 (CI 5.8, 6.1)   1.8 (CI 1.4, 2.2)
          C-Spine $         224 (CI 220, 232)   68 (CI 53, 84)
          Rad dose (nRem)   432 (CI 340, 465)   127 (CI 117, 138)
                                   Helical CT vs Plain
                                   Films

Outcome                     Helical CT (n=97)   Plain Film (n=39)
Mean ED time (min)          243 (CI 143, 343)   174 (CI 154,194)
Mean Radiation time (min)   89 (CI 60, 118)     88 (CI 76, 99)
Radiographic cost
          total RVU         17.3 (CI 15, 19)    10.7 (CI 8.5, 12.9)
          Total $           657 (CI 570, 737)   407 (CI 323, 494)
          C-Spine RVU       5.9 (CI 5.8, 6.1)   1.8 (CI 1.4, 2.2)
          C-Spine $         224 (CI 220, 232)   68 (CI 53, 84)
          Rad dose (nRem)   432 (CI 340, 465)   127 (CI 117, 138)
                                   Helical CT vs Plain
                                   Films

Outcome                     Helical CT (n=97)   Plain Film (n=39)
Mean ED time (min)          243 (CI 143, 343)   174 (CI 154,194)
Mean Radiation time (min)   89 (CI 60, 118)     88 (CI 76, 99)
Radiographic cost
          total RVU         17.3 (CI 15, 19)    10.7 (CI 8.5, 12.9)
          Total $           657 (CI 570, 737)   407 (CI 323, 494)
          C-Spine RVU       5.9 (CI 5.8, 6.1)   1.8 (CI 1.4, 2.2)
          C-Spine $         224 (CI 220, 232)   68 (CI 53, 84)
          Rad dose (nRem)   432 (CI 340, 465)   127 (CI 117, 138)
                       Objectives

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Clinical versus radiograph clearance
    – NEXUS Study
    – Canadian Rules
• CT versus Plain Films
• Interpreting the cervical spine radiograph
    – Cases
               C-Spine Radiograph

• Lateral film
• Anteroposterior film
• Open-mouth odontoid view
                            C-Spine Radiograph

• Lateral Film
   – Most injuries picked up with lateral film >80%
   – Odontoid view utility questionable in small children

• Basic Information
   – Jefferson Fracture – axial compression
       • Burst of C1 ring
   – Hangman Fracture – hyperextension, then flexion
       • C2 pedicle fracture
   – Physiologic dislocation
       • Usually under 16 years of age
       • Anteriorly displacement of C2 on C3
                    C-Spine Radiograph

Focus on the lateral neck
  1.   Film adequacy
  2.   C-spine alignment and curves
  3.   Inter-vertebral spaces: discs and joints
  4.   Pre-vertebral space
  5.   Pre-dental space
                     Brief anatomic review

C1                 C2                   C3
“Atlas”                          Dens
                   “Axis”




 C4           C5            C6          C7




          Bodies
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies
    and 1 thoracic body
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies,
    and 1 thoracic body
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies,
    and 1 thoracic body
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies,
    and 1 thoracic body
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies,
    and 1 thoracic body
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies,
    and 1 thoracic body
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies,
    and 1 thoracic body
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies,
    and 1 thoracic body
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Adequacy
  – Visualize entire cervical
    spine
  – Count 7 cervical bodies,
    and 1 thoracic body
               Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Alignment
• C-Spine Curves
                  Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Alignment
• C-Spine Curves
  – Anterior Vertebral Bodies
                  Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Alignment
• C-Spine Curves
  – Anterior Vertebral Bodies
  – Anterior Spinal Canal
                  Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Alignment
• C-Spine Curves
  – Anterior Vertebral Bodies
  – Anterior Spinal Canal
  – Posterior Spinal Canal
                    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Alignment
• C-Spine Curves
  –   Anterior Vertebral Bodies
  –   Anterior Spinal Canal
  –   Posterior Spinal Canal
  –   Spinous Process Tips
                 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Inter-vertebral spaces
  – Disc spaces
  – Cartiledge
  – Apophyseal joints
                Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Pre-vertebral space
                 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Pre-vertebral space
  – Space between vertebral
    bodies and air column
                 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Pre-vertebral space
  – Space between vertebral
    bodies and air column
                     Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Pre-vertebral space
  – Space between vertebral
    bodies and air column
  – Must measure space
    above the glottis
  – Normal size
     • ~1/2 to 2/3 of adjacent
       vertebral body
  – Can be abnormal if
     • non-inspiratory film
     • Intubated
  – Often normal in C-Spine
    injuries
             Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Pre-Dental Space
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Pre-Dental Space
  – Space between Dens
    of C2 and anterior,
    interior side of C1 ring
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Pre-Dental Space
  – Space between Dens
    of C2 and anterior,
    interior side of C1 ring
                        Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Pre-Dental Space
  – Space between Dens
    of C2 and anterior,
    interior side of C1 ring
  – Must be less than or
    equal to 5 mm
  – Cause of increased
    space
     • transverse ligament injury
     • burst fracture of C1
                       Objectives

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Clinical versus radiograph clearance
    – NEXUS Study
    – Canadian Rules
• CT versus Plain Films
• Interpreting the cervical spine radiograph
    – Cases
                Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                   Case 1

4 year old female, restrained, back seat
High speed, head on, car versus tree
Eye witnesses noted the passengers’ heads violently
  snapped forward
The driver died at the scene

C-spine immobilized
Minimally responsive
Intubated
Ng-tube placed
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
                                 Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Fracture at base of dens with anterior displacement
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                      Case 1

• The greater elasticity and laxity of ligaments in
  children allow for more hyper flexion and
  extension injuries
     • Children with hypoplasia of dens, ie: Trisomy 21
     • Children with rheumatoid arthritis, are at higher risk for
       atlanto-axial dislocation
                  Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                     Case 2

18 month old female, unrestrained, front seat
Sitting in babysitter’s lap, babysitter died at scene

C-spine ‘immobilized’ by gauze strapped with tape over
  child’s head
Alert and awake
Severe respiratory distress, with decreased breath
  sounds on right chest
No movement of lower extremities
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
                     Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Distraction injury
               Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                  Case 2

• C-spine injuries in children are rare
• Up to 40% of children with c-spine injury have
  trauma to another body part
• Must learn to properly immobilize the c-spine
               Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                  Case 3

A 4 year old child, fell from shopping cart, no loc
Fever, sore throat, strep positive yesterday
Not tolerating liquids or solid food

Temperature=104
Alert, awake and talking with hoarse voice
Drooling, mild increased work of breathing
He complains of neck pain
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
          Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




                     Glottis
Abscess
              Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                 Case 3

• The pre-vertebral space can be enlarged with a
  hematoma post c-spine trauma or general
  edema
                  Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                     Case 4

5 year old male, sitting in seatbelt, front seat
Airbag deployed

C-spine immobilized
Alert and awake
Numerous abrasions to face, neck and left shoulder and
  arm
Left arm limp and without sensation
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
                   Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




Ruptured Transverse Ligament
            Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental




C2 - Axis
             Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                v




C1 - Atlas
           Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental



                        ANTERIOR




ANTERIOR               POSTERIOR
           Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental



                        ANTERIOR




ANTERIOR               POSTERIOR
           Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental



                        ANTERIOR




ANTERIOR               POSTERIOR
           Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental



                        ANTERIOR




ANTERIOR               POSTERIOR
           Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental



                        ANTERIOR




ANTERIOR               POSTERIOR
               Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


                  Case 4

• The safest place for any aged child is the back
  seat
  – Air bags can be lethal to children
  – AAP Recommends: Children ages 12 and younger
    should ride in the back seat
• Must wear seat belts
                   Summary

•   Epidemiology
•   Anatomy: Pediatric versus Adult
•   Who should be immobilized
•   Immobilization Techniques
•   Clinical versus radiograph clearance
•   CT versus Plain Films
•   Interpreted the cervical spine radiograph

				
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