Management of Pediatric Cervical Spine and Spinal Cord Injuries

Objectives In children with TBI, to describe cervical spine imaging practice, to assess for recent changes in imaging practice, and to determine if cervical spine CT is being used in children at low risk for cervical spine injury. Methods The setting was children’s hospitals participating in the Pediatric Health Information System database, January, 2001 to June, 2011. Participants were children (age < 18 years) with TBI who were evaluated in the Emergency Department, admitted to the hospital, and received a head CT scan on the day of admission. The primary outcome measures were cervical spine imaging studies. This study was exempted from IRB review. Results 30,112 children met study criteria. Overall, 52% (15,687/30,112) received cervical spine imaging. Use of cervical spine radiographs alone decreased between 2001 (47%) and 2011 (23%), annual decrease 2.2% (95% confidence interval [CI] 1.1–3.3%), largely replaced by increased use of CT, with or without radiographs (8.6% in 2001, 19.5% in 2011, annual increase 0.9%, 95% CI 0.1–1.8%). 2,545 children received a cervical spine CT despite being discharged alive from the hospital in < 72 hours, and 1,655 of those had a low-risk mechanism of injury. Conclusions The adoption of CT clearance of the cervical spine in adults appears to have influenced the care of children with TBI, despite concerns about radiation exposure.

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“…A 2013 update to that guideline recommends plain radiographs or computed tomography (CT) in such patients. (12)…”

Section: Introductionmentioning

confidence: 99%

Cervical Spine Imaging in Hospitalized Children With Traumatic Brain Injury

Bennett

Bratton

Riva-Cambrin

et al. 2015

Pediatric Emergency Care

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“…Nonoperative management of OCDI includes placement of a halo [20], Minerva cast, rigid cervical collar, and other modalities [21]. Although postoperative approaches for adjunctive external immobilization in pediatric OCDI has been described [22], there is a dearth of literature on nonoperative management as a primary treatment option.…”

Section: Discussionmentioning

confidence: 99%

“…Typically, unless frank AOD is seen on imaging, patients without neurological deficits may be treated conservatively [21, 26]. Furthermore, patients without focal neurological defects at presentation rarely go on to experience severe neurological decline [27].…”

Section: Discussionmentioning

confidence: 99%

Traumatic Occipitocervical Distraction Injuries in Children: A Systematic Review

et al. 2019

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Background: Occipitocervical distraction injuries (OCDI) in children occur on a wide spectrum of severity, and decisions about treatment suffer from a lack of rigorous guidelines and significant inter-institutional variability. While clear cases of frank atlanto-occipital dislocation (AOD) are treated with surgical stabilization, the approach for less severe cases of OCDI is not standardized. These patients require a careful assessment of both radiographic and clinical criteria, as part of a complex risk-benefit analysis, to establish whether occipitocervical fusion (OCF) is indicated. Here, we performed a systematic review of the literature that describes traumatic OCDI in children < 18 years of age. Summary: We performed a systematic review, according to PRISMA guidelines, of children < 18 years of age presenting with traumatic etiologies of OCDI. We searched PubMed to identify papers congruent with these criteria. Exclusion criteria included (1) reports on atraumatic causes of OCDI and (2) studies with insufficient clinical and radiographic details on individual patients. We identified 16 reports describing a total of 144 patients treated for pediatric traumatic OCDI. Based on the synthesis of these findings and the collective experience of the authors, we present the demographic, clinical, and radiographic factors that underlie OC instability, which we hope will serve as components of a grading system in the future. We considered various clinical and radiographic findings including: (1) the mechanism of injury, (2) the patient’s age, (3) CT/CT angiography of head and neck findings and parameters, (4) MRI findings, and (5) neurological exam, for the purpose of determining the severity of the OCDI and offering treatment guidelines based on the summative risk of underlying OC instability. Key Messages: OCDI is a potentially devastating injury, especially in children. Although missing the diagnosis can have potentially catastrophic consequences, reverting to surgical fixation in less severe cases can subject children to unnecessary operative risk and permanently reduce their range of motion. After reviewing all the available reports of pediatric traumatic OCDI in the neurosurgical literature, we propose an outline of clinical and radiographic factors influencing underlying OC instability that could be incorporated into a grading scale to guide treatment. We hope this study stimulates discussion on the standardization of treatment for pediatric OCDI.

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“…When considering perioperative complications, many authors also recommend conservative management in patients with Down syndrome and for asymptomatic patients with AAI [21,22]. However, there are many complications with prolonged nonoperative management including pin-site infection, pin loosening, recurrent subluxation and a high nonunion rate [18,23]. Hence, many authors recommend that the rigid collar be used first, followed by head-halter traction for 3-4 weeks.…”

Section: Discussionmentioning

confidence: 99%

“…Hence, many authors recommend that the rigid collar be used first, followed by head-halter traction for 3-4 weeks. If the reduction cannot be maintained by these methods, surgery should then be performed [18,23] (as we also practice). …”

Section: Discussionmentioning

confidence: 99%

Clinical Application of a Revised Screw Technique via the C1 Posterior Arch and Lateral Mass in the Pediatric Population

Tan

et al. 2013

Pediatr Neurosurg

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Objective: Pediatric patients with insufficient height (≤4 mm) of the C1 posterior arch may restrict atlas screw placement via the posterior arch and lateral mass (PALM). For these patients, we modified this technique, called the ‘pedicle exposure technique' (PET). We aimed to analyze the clinical feasibility and safety of the PET in the pediatric population. Methods: Twenty pediatric patients with atlantoaxial instability (AAI) were enrolled in this study. The average C1 posterior arch was 3.1 (2.5-3.9) mm on CT scan. All patients underwent the C1 PET and C2 pedicle screw fixation. The imaging was performed to evaluate the accuracy of screw placement and bony fusion. Results: Forty screws were inserted via C1 PALM using the PET. Venous plexus bleeding occurred in 1 patient and the internal wall of the C1 lateral mass was perforated in 1 patient. There were no perioperative neurological deficits or vertebral artery injury. Follow-up was performed in all 20 cases over a period ranging from 6 to 80 months. Bony union was seen within 3-6 months. At the final follow-up visit, 14 patients had experienced an improvement, while 6 had complete resolution of their neck pain. Myelopathy symptoms were improved in 9 patients with spinal compression. Conclusion: The PET is an effective alternative for pediatric AAI when the height of the C1 posterior arch is <4 mm. Because of the higher screw entry point through the C1 posterior arch, there is effective biomechanical stability and less irritation of the venous plexus and C2 nerve root.

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Management of Pediatric Cervical Spine and Spinal Cord Injuries

Cited by 86 publications

References 92 publications

Cervical Spine Imaging in Hospitalized Children With Traumatic Brain Injury

Cervical Spine Imaging in Hospitalized Children With Traumatic Brain Injury

Traumatic Occipitocervical Distraction Injuries in Children: A Systematic Review

Clinical Application of a Revised Screw Technique via the C1 Posterior Arch and Lateral Mass in the Pediatric Population

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