Pediatric Cervical Spine Trauma When Is Cross-sectional Imaging ...
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Pediatric Cervical Spine TraumaPediatric Cervical Spine Trauma
When Is CrossWhen Is Cross--sectional sectional Imaging NeededImaging Needed??
Susan D. John, M.D.
RSNA 2013
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Spine Fractures in ChildrenSpine Fractures in Children • Uncommon – 1-3% of pediatric trauma
patients • 60-80% spine fxs in children involve C-spine,
especially those <8 yrs of age • Combined injuries common
– >60% with C spine injury have head injury, neurologic deficit
– 0.2% with head injury have C spine injury • Causes
– MVC, auto-ped, falls, sports – Birth trauma (breech delivery) – Non-accidental trauma
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Pediatric Spine DifferencesPediatric Spine Differences
• Fractures are rare • Clinical assessment challenging • Immobilization can be difficult • Ossification incomplete
– Normal variants common • Mild normal laxity can be present
– Injuries can occur without fracture
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ObjectivesObjectives • Plan safe and effective imaging protocols for
C-spine injuries in infants and children • Understand mechanisms and patterns of
pediatric cervical spine injuries • Recognize anatomical variations and subtle
injuries that benefit from cross-sectional imaging.
www.uth.tmc.edu/radiology
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What percentage of patients in your What percentage of patients in your practice are practice are < < 15 15 years of ageyears of age??
1) 80 - 100% 2) 50 – 79% 3) 25 – 49% 4) 5 – 25% 5) < 5%
1
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When Is CWhen Is C--spine Imaging Neededspine Imaging Needed?? • NEXUS (National Emergency X-ray Utilization) study
– Children evaluated as part of large, multi-age study (9% of all patients)
– Criteria • Midline cervical tenderness • Altered mental alertness • Evidence of intoxication • Neurologic abnormality • Painful distracting injury
– Only 30 injuries in 3065 patients <18 yrs (0.98%) • 4 younger than 9 yrs
– Decision rule predicted 100%, but not directly applicable to children
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Radiographic EvaluationRadiographic Evaluation • Lateral view most valuable
– Should include C7-T1 disc space – 65 – 87% accuracy
• AP view usually obtained, but of questionable value
• Odontoid view difficult to obtain in children <5 years
– Not needed under age of 9 • Flexion/extension views
– Not used in acute injuries – May be helpful for FU of ligamentous injury
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Radiographs for CRadiographs for C--spine Injury in spine Injury in ChildrenChildren
• Useful for those familiar with the differences of the immature spine – Incomplete development – Normal degree of laxity – Challenges of obtaining good quality
images – Congenital anomalies
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Which of the following CWhich of the following C--spine spine radiograph findings can be normal radiograph findings can be normal
in childrenin children??
1) Atlantodental distance of 6 mm 2) Anterior tilting of the dens 3) 4 mm anterior displacement of C2 on C3 4) Basion to dens distance of 15 mm 5) Anterior wedging of the C3 vertebral body
2
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Which of the following CWhich of the following C--spine spine radiograph findings can be normal radiograph findings can be normal
in childrenin children??
1) Atlantodental distance of 6 mm 2) Anterior tilting of the dens 3) 4 mm anterior displacement of C2 on C3 4) Basion to dens distance of 15 mm 5) Anterior wedging of the C3 vertebral body
2
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Precervical Soft Tissue ThicknessPrecervical Soft Tissue Thickness Can be misleading on radiographs
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Normal Neurocentral Synchondrosis (gone by age 8)
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Dens TiltingDens Tilting
• Posterior often normal
• Beware of anterior or lateral tilt
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Physiologic Physiologic Hypermobility in Hypermobility in Young ChildrenYoung Children
• Ligamentous laxity leads to misleading appearances on XR –Pseudosubluxation –Increased interspinous distance –Increased dens-to-C1 distance
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Wide Wide Interspinous Interspinous
DistanceDistance
• Can be as wide as 10-12 mm
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Physiologic Physiologic SubluxationSubluxation
• 1-2 mm • Normal
spinolaminar line
• Caveat – Apophyseal
joints intact
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Pseudosubluxation occurs in Pseudosubluxation occurs in 1919% % of of normal children between normal children between 1 1 –– 7 7 yrs ageyrs age
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Normal VNormal V--shaped shaped
apophyseal apophyseal joints joints ((mildmild))
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Anterior Anterior Atlantodental Atlantodental
DistanceDistance
• May be as wide as 4-5 mm
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Change in atlantodens interval of Change in atlantodens interval of 22mm is mm is normalnormal, , with maximum of with maximum of 5 5 mmmm
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Normal Mild Lateral Motion Normal Mild Lateral Motion
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CC11 AnomaliesAnomalies
• Common • Vary from absent
posterior arch to hairline defects
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Congenital Congenital Defects of Defects of
CC11
• Stable as long as dens is normal
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Clues to Clues to Congenital Congenital
DefectsDefects
• Tapering or rounding of margins
• Hypertrophy of anterior arch
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Patterns of InjuryPatterns of Injury • Infantile (before head control)
– Birth injuries (traction, torsion) – Shaking – Stretching may lead to vertebral artery injury
• Young juvenile (head control-8 yrs) – Usually above C4 – Fulcrum at C2-3 – Incomplete development of vertebra
complicates assessment
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Patterns of InjuryPatterns of Injury
• Old juvenile (greater than 8 yrs age) – More like adults – Midcervical more common – Most ossification centers fused
• Except for os terminale, ring apophyses, spinous and transverse processes
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What initial cervical spine screening What initial cervical spine screening exam is used at your facility for exam is used at your facility for
children with GCS children with GCS > > 88??
1) None 2) C-spine radiographs 3) C-spine CT 4) C-spine CT if non-verbal 5) MRI
3
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Spine CT in ChildrenSpine CT in Children • Use has increased
– Higher in teenagers, at non-Level I Trauma centers Mannix, Acad Emerg Med. 2011 September ; 18(9): 905–911
• Concerns about radiation dose in children – Dose to thyroid 90-200 X that of multiple xrays
Excess risk for thyroid CA 2X higher in 0-4 yr olds Jiminez, Pediatr Radiol 2008; 38:635-644 – Adolescents with spine injury get more studies
and have cumulative effective dose 3X that of children Lemburg, AJR 2010; 195:1411
• Osseous injuries usually visible on XRs – 4/147 with CT showed abnormality, all seen on
lateral Xray Hernandez, Emerg Radiol 2004 Feb; 10(4):176-8
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Are Radiographs An Adequate Are Radiographs An Adequate Screening ExamScreening Exam??
• Nigrovic, PECARN C-spine study group. Pediatr Emerg Care 2012; 28(5):426-432
• Multicenter study of 206 children <16 yrs age –168/186 injuries identified on radiographs –Sensitivity 90% –Missed 15 fractures and 3 isolated ligamentous injuries
• Factors showing higher risk: –Abnormal mental status –Endotracheal intubation –Focal neurologic deficits
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When Is CT WorthwhileWhen Is CT Worthwhile?? • Consequences of a missed cervical injury can be
devastating – Error rates (included CT) – false + and -
• 8 yrs or less – 24% (4/17) • 9 yrs or greater – 15% (3/20) • Occiput – C2 most common sites • Failure to recognize normal anatomy, normal variants
Avellino, Childs Nerv Sys (2005) 21:122-127.
• Ages < 10 years – Should be restricted to problem solving when radiographs are inconclusive – Natl. Institute of Health and Clinical Excellence(U.K.) –
• GCS 8 or less • Strong clinical suspicion with normal XR
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CC11 SynchondrosesSynchondroses
Anterior archAnterior arch:: Ossifies by Ossifies by 11 yearyear Fuses by age Fuses by age 77
CC2 2 SynchondrosesSynchondroses
Injuries can occur at synchondroses, so be wary of asymmetrical widening
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Unilateral Absence of CUnilateral Absence of C11
C1-2 anomalies are common, difficult to assess on radiographs
1/3 develop tortocollis and symptoms after birth
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Jefferson FractureJefferson Fracture
• Uncommon in children
• Falls on head, diving accidents
• Often not visible on radiographs
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MRI for Pediatric CMRI for Pediatric C--spine Injuryspine Injury • Highly sensitive for soft tissue injury
– Sensitivity 100%, NPV 75%, PPV 100% – Relevance of subtle findings not established
Henry,Childs Nerv Syst (2013) 29:1333–1338
• Decreases time to clearance and cost • Cost effective in certain patients
– Obtunded or non-verbal with severe mechanism of injury
– Equivocal radiographs – Neurologic findings with normal XRs – Inability to clear spine within 72 hours Frank, Spine 2002; 27(11): 1176-1179
• Important in patients with unstable injuries
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CC--spine MRI Protocolsspine MRI Protocols
• Axial – T2 gradient echo – T1
• Sagittal – T1 – STIR or T2 fat sat
• Coronal – STIR
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Dens AnomaliesDens Anomalies
Swischuk, Imaging of the Cervical Spine in Children
Prone to instability in some patients
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Os OdontoideumOs Odontoideum • Os is often fused to anteror arch of C1 or to
basion • Posterior atlantodental interval more
important than AADI
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Controlled flexion/extension under fluoroscopy
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Cinical Implications Cinical Implications of Os Odontoideumof Os Odontoideum • Pain • Myelopathy –varies
from transient to paralysis
• Asymptomatic – Cases of sudden
injury after minor trauma
• MRI evaluates cord atrophy
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Odontoid FracturesOdontoid Fractures • Most common pediatric cervical
fracture • Most occur through basilar
synchondrosis – Fuses at 5-7 yrs, but remains
partially visible until 11 • Heal with halo immobilization
(6-8 weeks)
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Type II Dens FracturesType II Dens Fractures Displacement can be subtle on radiographs
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Fracture at Neurocentral Fracture at Neurocentral SynchondrosisSynchondrosis
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Fracture at CFracture at C22 SynchondrosisSynchondrosis
• Anterior tilt • Anterior offset
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FractureFracture--Subluxation at CSubluxation at C2 2 may may resemble physiologic laxityresemble physiologic laxity
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AtlantoAtlanto--occipital dissociationoccipital dissociation::
1) Is more common in adults than children. 2) Is fatal in 90% of patients. 3) Can manifest as asymmetry of the AO joint. 4) Cannot be diagnosed reliably with radiographs or CT.
4
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AtlantoAtlanto--occipital dissociationoccipital dissociation::
1) Is more common in adults than children. 2) Is fatal in 90% of patients. 3) Can manifest as asymmetry of the AO joint. 4) Cannot be diagnosed reliably with radiographs or CT.
4
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Atlantoccipital DislocationAtlantoccipital Dislocation
• More common in children than adults –Small condyles –More horizontal orientation
• High velocity trauma • Survival improving, but
neurological deficits are common
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Basion Basion –– dens dens distancedistance
Should be 12 mm or less
Powers ratioPowers ratio
Should be less than 1
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Atlantoccipital DissociationAtlantoccipital Dissociation
• CT allows more accurate measurement of dens-basion distance
• Soft tissue injuries visible when severe
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Retroclival HematomaRetroclival Hematoma • Rare injury • Elevated
tectorial membrane
• Associated with CC ligamentous injuries
• May be treated conservatively if patient asymptomatic
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Condyle Condyle –– CC1 1 IntervalInterval • Highest sensitivity and specificity for AOD • 4-5 mm or greater – abnormal • Asymmetry, offset
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6 6 yr old in MVCyr old in MVC
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Transverse Ligament Transverse Ligament Injury with AvulsionInjury with Avulsion
Isolated Ligamentous Injuries
• Rare • Avulsed fragments difficult to see
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CC11--22 Ligamentous InjuriesLigamentous Injuries
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Cervical Instability Cervical Instability –– Trisomy Trisomy 2121 • Due to ligamentous laxity • Can occur at multiple
levels • C1-2 instability –
14-17% • C1 hypoplasia (posterior)-
26% • <10% have signs of
cervical myelopathy • CT or MRI not usually
needed
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SCIWORA InjurySCIWORA Injury
• Incidence 6 -20% • Normal ligamentous laxity
allows excess motion without bone injury
• Most common at C5-8 • Spinal column can withstand
2 in. of distract ion (infants) – cord and vessels only .25 in.
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Pediatric Cervical Injuries without FracturePediatric Cervical Injuries without Fracture
• Children under 8 yrs age – More severe injuries – Upper spine more
common • 52% - delayed
paraplegia (up to 4 days)
• Susceptible to reinjury - occult instability?
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Cervical Epidural HematomaCervical Epidural Hematoma
• May result from shearing forces without spine fracture
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Anderson, J Neurosurg Pediatr 2010; 5:292.
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Spine Injuries in Spine Injuries in ChildrenChildren • CT best for questionable fractures on
radiographs, neurologic symptoms • Mild laxity is normal
– MRI may help identify subtle instability or injuries
• Anomalies – CT for better anatomical definition – MRI for effects on spinal cord
• More cross-sectional imaging may be warranted in infants with NAT