What a Pain in the Neck: C-spine Management in Pediatric Trauma

Cases:

Case 1: 1 yo M, rear facing restrained in car seat in low speed MVC. Was found on scene appropriately restrained and awake Airbags deployed but car driveable from scene. Alert and crying. No other notable exam findings. Brought in by EMS with c-collar.

Case 2: 16 yo M snowboarding accident. + LOC on scene. GCS currently 14. +Femur swelling and pain. Brought in by EMS with c-collar and backboard. Has midline c-spine tenderness on exam.

Epidemiology and Causes of C-Spine Injuries in Pediatric Patients:

- < 2% of pediatric trauma patients have clinically significant c-spine injuries (CSIs)

- CSIs in children are typically seen in those with other significant blunt trauma or dangerous mechanism

- MVCs are the most common cause of CSIs in children from birth to age 8

- MVCs and sports are the most common causes of CSIs in children over age 8

- Injuries may result from flexion/extension forces, vertical compression/axial load, rotational forces, or a combination mechanism.

Anatomic Considerations in the Pediatric Population:

- The anatomic c-spine fulcrum in pediatric patients less than age 8 years is between C2-C3

- By age 8, the fulcrum moves down to C5-C6, similar to adults

- There are other important differences between the pediatric c-spine and the adult c-spine:

Paraspinous muscles are underdeveloped
There is increased elasticity of facet joint ligaments
The facet joints are shallow
The vertebrae are incompletely ossified
There is high water content and elasticity of the intervertebral discs
The relatively large head in comparison to the neck and trunk results in increased flexion/extension forces on the cervical spine

- All of these differences contribute to patterns of injury, which include higher level c-spine injuries in children <8 (occiput to C3) and spinal cord injuries without radiographic abnormalities (SCIWORA) in children >8.

When should you suspect c-spine injury?

- Severely injured or have high risk injuries

Multisystem trauma
Serious head injury

- Pain or neurologic symptoms at any time after trauma

Immediately after or resolved

- In children with predisposition to c-spine injuries

Trisomy 21 (atlantoaxial instability)
Prior history of c-spine injury or abnormalities
Some metabolic syndrome

NEXUS Criteria in Pediatrics:

- 3065 patients (9% of NEXUS study) were < 18yo

- 30 had CSI (0.98%)

NONE were < 2 years old and only 4 were < 9 years old

- Assessed the validity of the following 5 criteria:

Absence of tenderness at the posterior midline
Absence of focal neuro deficit
Normal level of alertness
No evidence of intoxication
Absence of clinically apparent distraction

- 100% (87.8%-100%) sensitivity for pediatrics but only 19.9% (18.5%-21.3%) specific

NOT powered for children < 9 years old
May lead to unnecessary imaging given the low specificity

Canadian C-Spine Rule in Pediatrics:

- Study EXCLUDED patients < 16 years old

- Included adults >16 years old with a GCS of 15 who are clinically stable in whom there is concern for c-spine injury

- Highly sensitive but also results in false positives

- May be able applicable to adolescents but this initial study did not apply to young children

- May also may result in unnecessary imaging

Figure 1: The Canadian C-Spine Rule (CCR)

Factors Associated with CSI in Children after Blunt Trauma:

(Leonard et al. Annals of Emergency Medicine. 2011.)

- Case-Control Study of Pediatric Patients < 16 years old

- 8 Factors Associated with CSI:

AMS
Focal neurologic findings
Neck pain
Torticollis
Substantial torso injury
Conditions predisposing to CSI
Diving
High risk MVC

- Having 1+ factors was 98% sensitive and 26% specific for CSI

Clinically Clearing Reliable Pediatric Patients:

- For the patient who is awake and alert, follow the algorithm as listed below (based on components of NEXUS and CCR)

- For infants, assess for loss of consciousness, neurologic deficits, and distracting injuries

If no apparent injury, remove immobilization in protected environment
Observe for spontaneous movement of the neck
Most young children will “clinically clear” themselves!

Figure 2: From Evaluation of Cervical Spine Injuries in Children and Adolescents.

Hasbro Trauma Handbook Imaging Guidelines (For Our Providers):

- Hasbro/Rhode Island Hospital (RIH) has guidelines that are approved by radiology, emergency medicine, and spine, which can be found in the Hasbro Trauma Handbook. Please refer to this and use it to guide your workup and management.

Figure 3: Hasbro Children's Hospital C-Spine Guidelines

Clearing Unreliable Pediatric Patients:

- Patients who are unreliable cannot be clinically cleared

- See guidelines below that include elements of NEXUS and CCR and that are consistent with Hasbro/RIH guidelines

Figure 4: From Evaluation of Cervical Spine Injuries in Children and Adolescents. UptoDate.com

Hasbro Guidelines for Management of Pediatric Cervical Spine Injuries:

- This protocol has been approved by emergency medicine, orthopedics, and neurosurgery, and can be found on the Pediatric Emergency Intranet. Please refer to this protocol to guide your disposition for patients

Back to our Cases:

Case 1: 1 y/o M, rear facing restrained in car seat in low speed MVC. Was found on scene appropriately restrained and awake. Airbags deployed but car drivable from scene. Alert and crying. No other notable exam findings. Brought in by EMS with c-collar.

- Try taking off c-collar and monitor. If refusing to move neck or seems to be in pain after removal of c-collar, replace collar and obtain imaging. Otherwise, clinically clear.

Case 2: 16 yo M snowboarding accident. +LOC on scene. GCS currently 14. +Femur swelling and pain. Brought in by EMS with c-collar and backboard. Seems to have midline c-spine tenderness on exam.

- You would be unable to clinically clear based on his AMS and distracting injuries. Per protocol, you could consider plain films or CT scan of the neck as initial imaging. If obtaining head CT, consider obtaining neck CT limited to 1 level below the area of tenderness, otherwise start with plain films.

Key Points:

- C-spine injuries in kids are rare

- Kids < 8 yo : C2-C3, Kids > 8 yo C5-C6

- Try to clinically clear if appropriate

- Generally can start with lateral neck +/- AP film, and odontoid view in older kids

- Consider CT if persistent pain or symptoms despite negative plain films or if there is a high risk mechanism

- Consider limited CT to C3 in younger children, especially if getting a head CT

- For patients with normal imaging and normal neuro exam but persistent neck pain: follow protocol on the pediatric emergency intranet!

Editor: Robyn Wing, MD

References:

Caviness, AC. Evaluation of Cervical spine injuries in children and adolescents. UpToDate.com. Accessed 2/8/2016. http://www.uptodate.com/contents/evaluation-of-cervical-spine-injuries-in-children-and-adolescents?source=search_result&search=cervical+spine+injuries&selectedTitle=1~119

Dorney, K et al. Outcomes of pediatric patients with persistent midline cervical spine tenderness and negative imaging result after trauma. J Trauma Acute Care Surg. 2015;79(5):822-827

Hoffman J et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEJM. 2000;343(2):94-99

Leonard, JR et al. Factors associated with cervical spine injury in children after blunt trauma. Annals of Emergency Medicine. 2011;58(2):145-155

Leonard, JR et al. Cervical Spine Injury Patterns in Children. Pediatrics. 2014;133(5):1179-1188

AC Caviness. Evaluation of Cervical Spine Injuries in Children and Adolescents. Up To Date. Accessed February 5, 2016.

Stielle et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA 2001;285(15(:1841-1848

Tat ST et al. Imaging, Clearance, and Controversies in Pediatric Cervical Spine Trauma. Pediatric Emergency Care. 2014;30(12):911-915