29 Special Considerations in Pediatric Cervical Spine Injury
Introduction
Spine trauma in the pediatric population is a relatively uncommon occurrence (1–2% of all pediatric fractures 1 ), but has been observed more frequently with improvements in emergency care, transport services, and trauma life support. 2 Children differ from their adult counterparts with regard to spine anatomy, physiology, and body proportions:
Ligaments and joints can stretch and expand considerably without tearing
Facet joints are shallow and horizontally oriented
Vertebral bodies are wedged anteriorly
Uncinate processes, which limit rotation, do not form until age 10
Disproportionately larger head in conjunction with weaker and incompletely developed muscular and ligamentous supporting structures
These unique differences result in a spine that is more malleable than that of an adult. Pediatric cervical spinal injuries follow a predictable pattern related to the child’s age. Spinal injuries in children younger than 8–10 years of age are more likely to involve the upper cervical spine, from the occiput to the third cervical vertebra. Most injuries in this age group are ligamentous axis-atlanto-occipital dislocations or spinal cord injuries without radiographic abnormality (SCIWORA). Children older than 8–10 years of age are more vulnerable to cervical spine injuries involving the lower segments (C3–C7); the pattern of injury in this group is similar to the adult population. 3 , 4
Spinal cord injury (SCI) is a rare occurrence in the pediatric population and accounts for less than 4% of the total annual incidence of SCI (National Spinal Cord Injury Statistical Center, 2004). Neurologic recovery in children with SCI tends to be better than in adults. 5 SCI occurring before the adolescent growth spurt is a great risk factor for the development of posttraumatic scoliosis. 5
Indications
Pediatric cervical spine injuries can be divided into injuries that affect the upper cervical spine (occiput–C2) and those that affect the subaxial spine (C3–C7). Below is a list of the injuries that are more commonly encountered in children. As stated previously, older children will have a physiologically developed adult spine, and thus, the spine injuries are similar to those seen in adults. There is a myriad of congenital cervical anomalies that may cause or place a child at risk for spinal cord injury.
A detailed review of these entities is beyond the scope of this chapter.
Upper cervical spine injuries
Atlanto-occipital dislocation (AOD)
Atlantoaxial dislocation (AAD)
Atlantoaxial rotatory subluxation (AARS)
Translational atlantoaxial subluxation (TAAS)
Odontoid fractures, including synchondrosis fractures
Traumatic spondylolisthesis of the axis (i.e., hangman’s fracture)
Pure ligamentous/soft tissue injury (previously known as SCIWORA)
Combination of the above pathologies
Lower cervical spine injuries
Pure ligamentous/soft tissue injury (previously known as SCIWORA)
Osseous anterior and/or posterior column injuries (e.g., compression and burst fractures, laminar/pedicle/facet fractures)
Spinal cord disruption
Biomechanical instability resulting from any of the above injuries may provide an indication for operative intervention.
The appropriate surgical approach is dictated by the specific injury:
Occipitocervical arthrodesis
Atlanto-occipital dislocations, atlas fractures, congenital occipitocervical anomalies
Atlantoaxial arthrodesis
Atlas fractures, odontoid fractures, traumatic C1–C2 ligamentous disruptions, and congenital atlantoaxial instability
Subaxial cervical posterior arthrodesis
Posterior ligamentous disruption, unilateral and bilateral facet dislocations, burst fractures, and spondylolisthesis
Anterior cervical approach
An anterior approach is rarely indicated (except possibly for decompression of a burst fracture) before the age of 12. Thereafter, children assume a more “adult” spine and become more susceptible to adult-type injuries.
Preoperative Considerations
Field and Emergency Room Management
Field management follows the basic principles of the Advanced Trauma Life Support (ATLS). Airway, breathing, and circulation (ABCs) must be addressed. Because of a relatively larger head size, the cervical spine will be flexed when the child is placed supine on a standard horizontal backboard. 6 A recessed head backboard, or elevation of the trunk by approximately 25 mm, must be considered primarily in children aged less than 8 years of age with suspected neck injury ( Fig. 29.1a, b ). 6 , 7 Once the child arrives in the emergency room, the ABCs must be repeated, and disability and exposure should be added. In patients presenting with hypotension in the presence of bradycardia, neurogenic shock must be differentiated from hypovolemic shock. If a spinal cord injury is present, management should proceed with vasopressors and modest fluid resuscitation. Neurologic impairment should focus the emergency team on a possible head or spine injury or both.
Radiographic Imaging
After a careful neurologic evaluation, cervical spinal imaging should be obtained. Plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) may be considered. Once a spine injury is detected, clearance and imaging of all spine segments should be undertaken, considering a significant prevalence of noncontiguous fractures. 4 , 8
Some variants of the normal anatomy or congenital anomalies may be misinterpreted as traumatic injury. 9 , 10 An anterolisthesis of C2–C3 is a very common finding and could be misdiagnosed as a ligamentous injury when, most of the time, it is a physiologic pseudosubluxation caused by the hyperflexibility of the immature cervical spine. A synchondrosis between the odontoid and the body of C2—which may persist until a child is 12 years of age—may be misinterpreted as an odontoid fracture. Furthermore, a persistent neurocentral synchondrosis of C2 can be misdiagnosed as a hangman’s fracture. The atlantodental interval (ADI) in the child spine is greater than in the adult, but should not exceed 5 mm; this limit is because of the thicker child cartilage that does not appear in radiographs. Any persisting doubt with standard radiographs should be further evaluated with CT and MR.
Preoperative imaging ( Fig. 29.2a–c ).
Medication
Steroid administration in the setting of a spinal cord injury is still controversial and should be based on the institutional protocol. A recent systematic review of the literature found no evidence supporting the use of neuroprotective interventions for the treatment of spinal cord injury in children, including hypothermia and steroids. 7 Furthermore, all studies that have evaluated steroids in spinal cord injury have specifically targeted the adult population.
Surgical Timing
The optimal timing for surgical decompression and fixation is also controversial. A recent systematic review states that early surgical decompression (i.e., in less than 72 hours) may improve neurologic outcomes—especially in the setting of incomplete SCI and when performed in less than 24 hours. 11 While this review suggests early decompression may benefit the general SCI population, neurologic recovery seems to be better in the pediatric population than in adults.
Operative Management
Successful intraoperative management of the child with a cervical spine injury depends on a team approach with the spinal surgeon, pediatric trauma surgeon, anesthesiologist, and surgical and radiology technicians.
Anesthesia
In cervical spine injuries with gross instability, the neck must be maintained in a neutral position throughout the procedure; intubation may be challenging. In-line fiberoptic intubation should be considered, followed by induction of general anesthesia. Care to prevent both subluxation and distraction is imperative when intubating, turning, or transferring. Preoperatively, antibiotics are administered at least 30 minutes before the procedure; the authors prefer vancomycin and cefazolin. If neuromonitoring (e.g., motor-evoked potentials [MEPs] and somatosensory-evoked potentials [SSEPs]) is used, the anesthesia team should be alert that alterations in anesthetic depth can affect the ability to obtain useful signals; the use of bispectral index (BIS) monitoring can minimize this effect. It is imperative that the anesthesiologist avoid hypotension and hypovolemia during surgery.
Positioning
Anterior Cervical Approach
Supine position
Pad or towel roll between scapulas for slight neck extension
Stabilize head with a chin or forehead strap
Neck in neutral position or rotated to contralateral surgical approach site
Pull both arms together caudally and tape them on the shoulders for better fluoroscopic view of the cervical spine
Use intraoperative fluoroscopy to mark the correct level on the skin
Some surgeons advocate a left-sided approach because of the lower rates of recurrent laryngeal nerve injuries 12
∘ Longitudinal incision provides a greater exposure (usually when three or more levels are exposed) whereas a transverse incision heals with better cosmesis
Care must be taken not to distract the injured spine with either manipulation or inadvertent elevation of the head of bed when the patient is in Mayfield fixation.
Posterior Cervical Approach
Prone position
Use chest rolls (or a spine table for older children) and a three-pinion skull clamp or Gardner-Wells tongs in neutral position
Strap arms down at the patient’s side
Slight reverse Trendelenburg positioning allows for better exposure, if the patient does not distract
Pad all bony prominences and apply tight straps over the patient
The critical period during which the spine is at greatest risk is the transfer to prone position; a tightly applied rigid collar or halo may be used to reduce this risk.
Occipitocervical Arthrodesis
Indications
Atlanto-occipital dislocations, atlas fractures, congenital occipitocervical anomalies.
Atlantoaxial Arthrodesis
Indications
Atlas fractures, odontoid fracture, traumatic C1-C2 ligamentous disruptions, and congenital atlantoaxial instability.
Subaxial Cervical Posterior Arthrodesis
Indications
Posterior ligamentous disruption, unilateral and bilateral facet dislocations, burst fractures, and spondylolisthesis.
Operative Procedure
Occipitocervical Arthrodesis with Contoured Rod and Segmental Wire
Positioning and Preparation (Fig. 29.3)
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