Neck and Cervical Spine Trauma

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Chapter 59 Neck and Cervical Spine Trauma

Howard Kadish, MD

1 What are the differences in neck anatomy between children and adults?

Compared with adults, children have a larger head and mandible and a shorter neck in proportion to the rest of their body. These differences protect the child’s anterior neck at the time of injury; the head, neck, and face absorb the major force of impact. In infants and young children, the larynx is not only smaller in overall size but also has smaller relative dimensions compared with adults. In children, the arytenoids are larger, the epiglottis has an omega shape, and the larynx has a funnel shape, which is narrowest in the subglottis. In adults, the narrowest point of the trachea is located at the level of C7, whereas in children it is at the cricoid cartilage (C3). These anatomic differences, along with the ringlike cricoid cartilage, result in a narrowed laryngeal inlet. Adolescents and adults can tolerate up to 50% narrowing of the airway without obvious respiratory distress. Infants and children experience significant respiratory embarrassment with this degree of restriction.

3 How should I manage a patient with a blunt or penetrating neck injury?

The goals of management should follow trauma guidelines, with strict adherence to airway, breathing, and circulation. After the airway is assessed and breathing stabilized, control any hemorrhage and maintain good cervical spine precautions rapidly. Stabilize all penetrating objects in the neck but keep them in place until they can be removed under surgical care in the operating room. Obtain routine trauma laboratory studies, including type and cross-match of blood for packed red blood cells. Minimal radiographic evaluation includes cervical spine films and chest radiograph.

4 How should the airway and breathing be managed in a child with neck injury?

Give all patients supplemental oxygen and treat them as if they were considered to have cervical spine injury until proved otherwise. Therefore, any airway manipulation should include cervical spine stabilization. Elective endotracheal intubation is not recommended unless back-up measures, such as a surgical airway or fiberoptic intubation equipment, are available. Attempted placement of an endotracheal tube through an already injured airway may cause a small mucosal laceration to progress to complete transection. In cases of laryngotracheal separation, the transected ends of the trachea may separate by as much as 8 cm. Successful passage of an endotracheal tube across this distance is difficult and may delay or preclude airway control. Trauma to the airway also may produce a blind path and inability to pass an endotracheal tube successfully. In the unstable airway, blind nasotracheal intubation is not recommended. If orotracheal intubation needs to be performed emergently, back-up measures, such as surgical and anesthesia consultation, fiberoptic bronchoscopy, cricothyrotomy, and tracheostomy, should be available in case complications occur.

6 How common are cervical spine injuries in children?

Cervical spine injuries are rare, occurring in only 1–2% of pediatric patients with injuries due to blunt trauma. Unfortunately, a cervical spine injury can result in permanent disability or death. Therefore, patients with suspicious mechanisms of injury at least should be evaluated for cervical spine injury.

7 Which methods are helpful to immobilize a patient with suspected cervical spine injury?

Soft cervical collars offer no stability to a potentially unstable cervical spine. Even hard collars (Philadelphia, Stifneck) allow a significant amount of motion. A Philadelphia collar allows approximately 60% of cervical flexion and rotation. Patients with a suspected cervical spine fracture should be placed in a hard cervical collar and immobilized on a hard spine board. Even with adequate immobilization on a spine board, the patient may be able to flex or extend the neck approximately 20%.

8 What are the major differences between pediatric and adult cervical spines?

Upper cervical spine fractures are more common in younger pediatric patients because they have relatively large heads, weak neck muscles, and higher fulcrums. The large amount of cartilage in the pediatric cervical spine makes identification of radiographic injuries difficult, and the retropharyngeal space may change with crying or respiratory patterns. Pediatric patients also may present with pseudosubluxation rather than actual subluxation of C3 over C4 and C2 over C3.

9 What is the NEXUS?

The National Emergency X-Radiography Utilization Study (NEXUS) is a multicenter, prospective, observational study of emergency department (ED) patients with blunt trauma for whom cervical spine imaging is ordered. The results of the study suggested that patients with an abnormal neurologic examination, depressed or altered level of consciousness, distracting or painful injury (femur fracture), intoxication, or midline cervical tenderness should be evaluated for a possible cervical spine injury. Patients without these findings have a low risk for cervical spine injury and may not need radiographic imaging.

Hoffman JR, Mower WR, Wolfson AB, et al: Validity of a set of criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Study Group. N Engl J Med 343:94–99, 2000.

10 What is the Canadian C-spine rule?

The Canadian C-spine rule was developed from a prospective cohort study in Canada evaluating patients with head or neck trauma. If there is a high-risk factor (dangerous mechanism, paresthesias) then radiography should be performed. A low-risk factor (simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness) would allow for the clinician to assess the patient’s range of motion. If the patient is able to actively rotate his or her neck 45° to the left and right, then cervical spine radiography may not be needed.

Stiell IG, Wells GA, Vandemheen KL: The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 286:1841–1848, 2001.

11 What type of cervical spine radiographs should I order for a child with suspected neck injury?

A lateral cervical spine view misses approximately 20% of cervical spine injuries. At a minimum, three views—lateral, anteroposterior, and odontoid—should be ordered. The three views miss approximately 3–6% of cervical spine injuries. Therefore, if a patient is still symptomatic, further imaging tests, such as oblique views, flexion/extension, or cervical spine computed tomography, should be performed.

12 When a cervical spine injury is suspected, when should computed tomography (CT) or magnetic resonance imaging of the cervical spine be ordered?

Magnetic resonance imaging is not ideal for identifying bony fractures and should be used when trying to evaluate a patient for an acute ligamentous or a spinal cord injury. CT identifies fractures, but is not ideal for evaluation of the spinal cord or ligaments. CT is useful in the secondary evaluation of a possible cervical spine fracture when plain radiographs are difficult to obtain or to interpret or are noted to be abnormal. Given the low incidence of pediatric cervical spine injuries and the increased radiation exposure with CT, it is not recommended to use CT as a primary radiographic evaluation in patients with a possible cervical spine fracture.

13 What is the best way to read cervical spine radiographs?

A systematic approach using the ABCS method should be used:

A = Alignment (Four lines are assessed: the anterior vertebral bodies, posterior vertebral bodies, spinolaminal line, and spinous process tips.)

B = Bones (Evaluate for fractures.)

C = Cartilage (Because cartilage is radiolucent on cervical spine radiographs, the intervertebral space, where cartilage is present, should be evaluated. Compression or widening of the intervertebral space may indicate a cartilage disruption.)

S = Soft tissues (Because a child’s spinal column contains a significant amount of cartilage, prevertebral soft tissue swelling may be the only clue to cartilage or ligament injury. The prevertebral space at C2 or C3 should not be greater than half the width of the adjacent vertebral body. Abnormal swelling of the prevertebral space may be due to blood or edema.)

KEY POINTS: NECK AND CERVICAL SPINE TRAUMA

1 Cervical spine injuries occur in only 1–2% of pediatric patients

2 Any pediatric trauma patient with an altered mental status, abnormal neurologic examination, point tenderness of the cervical spine, or pain with rotation should be evaluated radiographically.

3 One view is no view—at a minimum, patients with suspected cervical spine injury should undergo lateral, anteroposterior, and odontoid radiography.

4 The administration of high-dose steroids is controversial in spinal cord injury and should be preceded by consultation with a neurosurgeon.

5 When in doubt, immobilize, obtain imaging studies, and consult neurosurgery.

14 What is a pseudosubluxation of C2 on C3? How do you differentiate it from an anterior subluxation of C2 on C3?

Pseudosubluxation, which is a normal variant, is caused by ligamentous laxity and can be seen in patients up to 16 years of age, whereas anterior subluxation of C2 on C3 is usually caused by a hyperextension injury and possible spinal cord injury. Swischuk’s “posterior cervical line” is helpful in distinguishing a pseudosubluxation from a more serious fracture. A line is drawn from the cortex of the spinous process of C1 to the cortex of the spinous process of C3. The line should not be greater than 2.0 mm anterior to the cortex of the spinous process of C2. If it is, then a fracture should be suspected and further imaging should be undertaken.

Swischuk L: Emergency Radiology of the Acutely Ill or Injured Child, 3rd ed. Baltimore, Williams & Wilkins, 1994.

15 What is a Jefferson fracture?

A Jefferson fracture is a burst fracture of C1 secondary to an axial load, such as a diving injury. Patients may present with severe neck pain, especially with rotation. Although patients rarely have neurologic symptoms because the fracture burst outward, the Jefferson fracture is unstable and needs to be immobilized immediately. The odontoid view may show the lateral masses offset or overriding the vertebral body of C2. This fracture can be confused with a pseudo-Jefferson fracture. Children’s lateral masses of C1 grow faster than the vertebral body of C2; often the lateral masses override C2 either unilaterally or bilaterally. If you are in doubt, CT of the cervical spine at C1 and C2 is helpful in making the diagnosis.

16 Why should patients with Down syndrome receive cervical spine radiographs before participating in sports?

Approximately 15% of patients with Down syndrome have atlantoaxial subluxation. Atlantoaxial subluxation occurs because ligament instability or a fractured dens allows movement between C1 and C2. It has been associated with minor trauma in patients with connective tissue disorders, arthritis, pharyngitis, and Down syndrome. The lateral cervical spine radiograph shows a widening of the preodontoid space. A normal preodontoid space should be < 3 mm in adults and < 5 mm in children. Neurologic symptoms may be seen if the preodontoid space is 7–10 mm.

Elliot S, Morton R, Whitelaw R: Atlantoaxial instability and abnormalities of the odontoid in Down’s syndrome. Arch Dis Child 63:1484–1489, 1988.

17 What is SCIWORA?

SCIWORA is an abbreviation for spinal cord injury without radiographic abnormality. It usually is seen in children younger than 8 years because of the increased amount of cartilage and elastic nature of the younger child’s spinal column. The child may present with an abnormal neurologic examination caused by vascular or ligamentous injury and no evidence of a fracture on radiography or CT.

18 Describe the appropriate treatment of a child with a spinal cord injury

Adherence to the ABCs of trauma management should be the first priority. Children may present with hypotension, bradycardia, and warm or flushed peripheral extremities (spinal shock) because of the loss of sympathetic input. They need fluid resuscitation and inotropic support (dopamine). A common mistake is to treat patients with spinal shock as if they have hypovolemic shock and to overload them with fluids. If the child is not improving after aggressive fluid resuscitation, spinal shock should be considered part of the differential diagnosis.

19 Why is the administration of steroids in pediatric spinal cord injuries controversial?

Experts in emergency medicine and neurosurgery have recently questioned the potential benefit of steroids for a traumatic cervical spine injury. Children younger than 13 years of age were excluded in the studies, and some experts feel the potential risks of steroids are greater then the potential neurologic benefits. Consultation with neurosurgery and trauma surgery should occur prior to starting steroids.

Qian T, Campagnolo D, Kirshblum S: High-dose methylprednisolone may do more harm for spinal cord injury. Med Hypotheses 55:452–453, 2000.

Short DJ, El Masry WS, Jones PW: High dose methylprednisolone in the management of acute spinal cord injury: A systematic review from a clinical perspective. Spinal Cord 38:273–286, 2000.

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