PEDIATRIC CERVICAL SPINE DEFORMITY - · PDF filePEDIATRIC CERVICAL SPINE ... • 82% OF ALL...

PEDIATRIC CERVICAL SPINE PEDIATRIC CERVICAL SPINE DEFORMITYDEFORMITY
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DEVELOPMENTDEVELOPMENT
EACH VERTEBRAE DEVELOP FROM THE EACH VERTEBRAE DEVELOP FROM THE CAUDAL AND CRANIAL CAUDAL AND CRANIAL OF 2 OF 2 SCLEROTOMES SCLEROTOMES C1 and C2 primitive C1 and C2 primitive centrumcentrum fuse to form fuse to form
odontoidodontoid processprocess
ATLASATLAS Body ossifies at 6Body ossifies at 6--24 24 mosmos Arch closure (final canal diameter) at 6Arch closure (final canal diameter) at 6--7 7 yoyo
Further growth by Further growth by periostealperiosteal appositional growth appositional growth only (external, no canal change)only (external, no canal change)

AXISAXIS ODONTOIDODONTOID
2 PRIMARY OSSIFICATION CENTERS2 PRIMARY OSSIFICATION CENTERS Coalesce by 3 Coalesce by 3 mosmos Separated from C2 by Separated from C2 by dentocentraldentocentral synchondrosissynchondrosis
Gradually closes Gradually closes btwnbtwn 33--6yo6yo TIP BECOMES AN APOPHYSIS TIP BECOMES AN APOPHYSIS
ChondrumChondrum terminaleterminale Begins ossifying 5Begins ossifying 5--8yo8yo Fuses at 10Fuses at 10--13yo 13yo
NEURAL ARCHES CLOSED BY 6NEURAL ARCHES CLOSED BY 6--7 YRS7 YRS Similar to atlas, no increase in canal size after this pointSimilar to atlas, no increase in canal size after this point

C 3C 3--77 3 OSSIF. CTRS @ BIRTH3 OSSIF. CTRS @ BIRTH
1 BODY, 2 ARCHES1 BODY, 2 ARCHES POST SYNCHONDROSIS POST SYNCHONDROSIS
CLOSES @ 2 YRSCLOSES @ 2 YRS
FACETS START FACETS START HORIZONTAL , BECOME HORIZONTAL , BECOME VERTICAL WITH GROWTHVERTICAL WITH GROWTH

C 3C 3--77 BODY GROWTHBODY GROWTH
VERTICAL VERTICAL ENCHONDRAL OSSIFICATIONENCHONDRAL OSSIFICATION CIRCUMFERENTIAL CIRCUMFERENTIAL PERIOSTEAL APPOSITIONPERIOSTEAL APPOSITION

RADIOGRAPHIC PARAMETERSRADIOGRAPHIC PARAMETERS
WHAT IS PATHOLOGIC IN AN ADULT CAN WHAT IS PATHOLOGIC IN AN ADULT CAN BE NORMAL IN A GROWING CHILDBE NORMAL IN A GROWING CHILD ADIADI SACSAC PSEUDOSUBLUXATION C 1PSEUDOSUBLUXATION C 1--22 OSOS--ODONTOIDIUMODONTOIDIUM GROWTH CENTERS ARE NOT FRACTURESGROWTH CENTERS ARE NOT FRACTURES

ADI (ATLANTOADI (ATLANTO--DENS DENS INTERVAL)INTERVAL) Measure on lateral Measure on lateral
flex/ext films, flex/ext films, voluntary motion in voluntary motion in awake patientawake patient ANT ASPECT OF DENS ANT ASPECT OF DENS
TO THE POST ASPECT TO THE POST ASPECT OF THE ANT RING OF OF THE ANT RING OF THE ATLAS ON BOTH THE ATLAS ON BOTH FILMSFILMS
NL: < 5mm kids, NL: < 5mm kids,

Anterior arch of atlas can override Anterior arch of atlas can override odontoidodontoid on extension in 20% of kidson extension in 20% of kids
Why ADI increase in kids?Why ADI increase in kids? ligamentousligamentous laxitylaxity cartilage component of dens and atlascartilage component of dens and atlas

SAC (SPACE AVAILABLE FOR THE CORD)SAC (SPACE AVAILABLE FOR THE CORD) POST ASPECT OF DENS TO ANT ASPECT OF POST POST ASPECT OF DENS TO ANT ASPECT OF POST
RING OF ATLASRING OF ATLAS >13 mm in adults and teens>13 mm in adults and teens Need at least the diameter of the Need at least the diameter of the odontoidodontoid availableavailable

SACSAC SteelSteels rule of thirdss rule of thirds
1/3 cord1/3 cord 1/3 1/3 odontoidodontoid 1/3 space available (1/3 space available (safe zonesafe zone))
ATTENUATION OF TRANSVERSE ATLANTAL ATTENUATION OF TRANSVERSE ATLANTAL LIG LEAVES ONLY THE ALAR LIG (i.e. LIG LEAVES ONLY THE ALAR LIG (i.e. TRISOMY)TRISOMY) ALAR LIG ALONE CANNOT PROTECT FROM SCI ALAR LIG ALONE CANNOT PROTECT FROM SCI
WITH EVEN MILD TRAUMAWITH EVEN MILD TRAUMA

COMMON NORMAL VARIANTSCOMMON NORMAL VARIANTS
Absence of cervical Absence of cervical lordosislordosis Mimics splinting of injuryMimics splinting of injury
PseudosubluxationPseudosubluxation C1 multiple ossification centers/ C1 multiple ossification centers/ spinaspina bifidabifida
Can mimic Can mimic fxfx Look for Look for smootsmoot cortical margins cortical margins Lack Lack hematomahematoma on CTon CT
SpinaSpina bifida bifida occultaocculta C2 C2 dentocentraldentocentral synchondrosissynchondrosis
CLOSES BY 11 YEARSCLOSES BY 11 YEARS
Anterior wedging of C3 seen in 7%Anterior wedging of C3 seen in 7%

PSEUDOSUBLUXATIONPSEUDOSUBLUXATION
ANT DISPLACE OF C2 ON C3ANT DISPLACE OF C2 ON C3 C 3C 3--4 less common4 less common 9% of kids 19% of kids 1--7yo7yo Posterior line of Posterior line of SwischukSwischuk
Line from ant aspect of C1 posterior Line from ant aspect of C1 posterior arch to same on C3arch to same on C3
Should be within 1mm of same of C2Should be within 1mm of same of C2 >2mm= pathologic>2mm= pathologic
CAUSESCAUSES HorizantalHorizantal facetsfacets
Esp. in upper Esp. in upper
RELATIVE HEAD SIZERELATIVE HEAD SIZE LIG LAXITYLIG LAXITY

ANT DISPLACE OF C2 ON C3ANT DISPLACE OF C2 ON C3 CAUSESCAUSES
Horizontal facetsHorizontal facets Esp. in upper C spineEsp. in upper C spine Change from 30deg to 70deg Change from 30deg to 70deg
during growthduring growth
Large relative head sizeLarge relative head size General General ligamentousligamentous laxitylaxity
Treatment Treatment Do nothingDo nothing

OS ODONTOIDIUMOS ODONTOIDIUM
TIP OF ODONTOID IS DIVIDEDTIP OF ODONTOID IS DIVIDED Apical segment lacks basilar supportApical segment lacks basilar support
VERY RAREVERY RARE XX--RAY RAY oval oval ossicleossicle, smooth margins, smooth margins CAUSES ?CAUSES ?
Old Old fxfx nonnon--unionunion MRIMRIss have shown cord changes have shown cord changes c/wc/w traumatrauma
AVNAVN Congenital anomalyCongenital anomaly

SYMPTOMSSYMPTOMS NECK PAINNECK PAIN VERT ART OCLUSION (C1VERT ART OCLUSION (C1--2 MOTION)2 MOTION)
SYNCOPE, VERTIGO, N/V, VISUAL DEFECITSSYNCOPE, VERTIGO, N/V, VISUAL DEFECITS NEURO SXS (RARE)NEURO SXS (RARE)
Posterior translation of Posterior translation of osos into cordinto cord Transient paresis, Transient paresis, myelopathymyelopathy, paralysis, paralysis SUDDEN DEATHSUDDEN DEATH

TREATMENTTREATMENT SURGERY (C1SURGERY (C1--2 PSA, INST, HALO)2 PSA, INST, HALO)
ADI > 10 mmADI > 10 mm SAC SAC

TORTICOLLISTORTICOLLIS
Combined head tilt and Combined head tilt and rotatoryrotatory deformitydeformity Indicates C1Indicates C1--2 problem2 problem
50% rotation in C50% rotation in C--spine at this jointspine at this joint
Large differential diagnosisLarge differential diagnosis Osseous vs. Osseous vs. nonosseousnonosseous

TORTICOLLISTORTICOLLIS
DIFFERENTIAL DIAGNOSESDIFFERENTIAL DIAGNOSES MUSCULAR (82%)MUSCULAR (82%) ATLANTOATLANTO--AXIAL ROTATORY SUBLUXATIONAXIAL ROTATORY SUBLUXATION CNS LESIONCNS LESION BIRTH TRAUMABIRTH TRAUMA CONGENITAL SPINE DEFORMITYCONGENITAL SPINE DEFORMITY
KLIPPELKLIPPEL--FEILFEIL OCCIPITOOCCIPITO--CERVICAL SYNOSTOSISCERVICAL SYNOSTOSIS GOLDENHAR SYNDGOLDENHAR SYND HEMIATLASHEMIATLAS
BASILAR IMPRESSIONBASILAR IMPRESSION ODONTOID ANOMALY (OS ODONTOIDIUM)ODONTOID ANOMALY (OS ODONTOIDIUM)

CONGENITAL MUSCULAR CONGENITAL MUSCULAR TORTICOLLISTORTICOLLIS
82% OF ALL TORTICOLIS82% OF ALL TORTICOLIS 75% right sided75% right sided 88--20% also have DDH20% also have DDH
CONGENITAL CONSTRICTION OF SCMCONGENITAL CONSTRICTION OF SCM HEAD TILT WITH ROTATION OPPOSITE HEAD TILT WITH ROTATION OPPOSITE
TILTTILT FAMILIAL COMPONENTFAMILIAL COMPONENT

CONGENITAL MUSCULAR CONGENITAL MUSCULAR TORTICOLLISTORTICOLLIS CAUSE UNKNOWNCAUSE UNKNOWN
INTRAUTERINE SCM INTRAUTERINE SCM COMPARTMENT SYNDROME FROM COMPARTMENT SYNDROME FROM NECK COMPRESSIONNECK COMPRESSION SCM VENUS OCLUSION ON SCM VENUS OCLUSION ON
HISTOPATHOLOGYHISTOPATHOLOGY MYOFIBROSIS MYOFIBROSIS CONTRACTIONCONTRACTION
NEUROLOGICNEUROLOGIC Spinal accessory N. injurySpinal accessory N. injury
FETAL POSITIONFETAL POSITION EMBRYOLOGICEMBRYOLOGIC BIRTH TRAUMABIRTH TRAUMA

PLAGYCEPHALYPLAGYCEPHALY Flattening of head on side of contractureFlattening of head on side of contracture Due to sleeping position (prone in U.S.)Due to sleeping position (prone in U.S.) Untreated: eye/ear levels become unequalUntreated: eye/ear levels become unequal
XX-- RAYSRAYS Always normal in congenital muscular Always normal in congenital muscular torticollistorticollis Check hipsCheck hips
RARELY A TREATABLE NEUROLOGIC CAUSERARELY A TREATABLE NEUROLOGIC CAUSE SYRINX, SPINAL CORD TUMOR, CHIARI, POST FOSSA SYRINX, SPINAL CORD TUMOR, CHIARI, POST FOSSA
TUMOR, OCULAR PATHOLOGY (involuntary head tilt)TUMOR, OCULAR PATHOLOGY (involuntary head tilt)

TREATMENTTREATMENT 90% RESOLVE WITHOUT SURGERY90% RESOLVE WITHOUT SURGERY
STRETCHING, PTSTRETCHING, PT Crib toy modificationCrib toy modification
After 1yo, stretching usually unsuccessfulAfter 1yo, stretching usually unsuccessful SURGERY: GOOD RESULTS UP TO 12 YO SURGERY: GOOD RESULTS UP TO 12 YO

PEDIATRIC CERVICAL SPINE DEFORMITY - · PDF filePEDIATRIC CERVICAL SPINE ... • 82% OF ALL...

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