Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center

Evaluation of traumatic spinal injuries: a pediatric perspective

PURPOSE

The aim of the present study is to provide information about pediatric patients with spinal trauma.

METHODS

A single-center retrospective chart review was carried out. Children who arrived at the pediatric emergency department due to trauma and those with spinal pathology confirmed by radiological assessment were included. Demographics, mechanisms of trauma, clinical findings, radiological investigations, applied treatments, hospital stay and prognosis were recorded.

RESULTS

A total of 105 patients [59 (56.2%) boys; mean age: 12.9 ± 3.8 years (mean ± SD)] were included. The most common age group was that of 14-18 years (58.1%). The three most common trauma mechanisms were road traffic collisions (RTCs) (60.0%), falls (32.4%), and diving into water (2.9%). A fracture of the spine was detected in 97.1% patients, vertebral dislocation in 10.7%, and spinal cord injury in 16.3%. Of the patients, 36.9% were admitted to the ward and 18.4% to the pediatric intensive care unit; 17.1% were discharged with severe complications and 2.9% cases resulted in death. While 34.3% of the patients had a clinically isolated spine injury, the remaining cases entailed an injury to at least one other body part; the most common associated injuries were to the head (39.8%), abdomen (36.1%), and external areas (28.0%).

CONCLUSION

Spinal trauma was found to have occurred mostly in adolescent males, and the majority of those cases were due to RTCs. Data on the incidence and demographic factors of pediatric spinal trauma are crucial in furthering preventive measures, allowing for the identification of at-risk populations and treatment modalities.

Factors Associated With Tracheostomy in Ventilated Pediatric Trauma Patients. A National Trauma Database Study

PURPOSE

The purpose of the study was to find the factors that were associated with tracheostomy procedures in ventilated pediatric trauma patients.

METHODS

The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017 through 2019 was accessed for the study. All patients <18 years old and who were on mechanical ventilation for more than 96 hours were included in the study. Multiple logistic regression analysis was performed to find the factors that were associated with a tracheostomy.

RESULTS

Out of 2653 patients, 1907 (71.88%) patients underwent tracheostomy. The patients who underwent tracheostomy had a lower median [IQR] of Glasgow Coma Scale (GCS) (3 [3-8] vs 5 [3-10], P < .001) and had a higher proportion of severe spine injury (On Abbreviated Injury Scale [AIS]≥3) (11.6% vs 8.8%, P = .044) when compared with patients who did not have tracheostomy. Lower GCS scores and severe spine injury were associated with higher odds of tracheostomy, with all P values <.05. Higher proportion of tracheostomy procedures were performed at level I pediatric trauma centers as compared to non-designated pediatric centers (odds ratio [95% CI]: 1.848 [1.524-2.242], P < .001).

CONCLUSION

A lower GCS score, severe spine injury and highest level trauma centers were associated with a tracheostomy.

Differential screen and treatment of sternocleidomastoid syndrome versus eagle syndrome: a case report

BACKGROUND/PURPOSE

Differential screening is a complex process in chronic pain conditions. There is significant uncertainty that surrounds the pathophysiology of many chronic pain syndromes that may lead to misdiagnosis and treatment failures. Such differential screening is even more challenging where there is regional overlapping from surrounding tissues. This case report chronicles the differential screening and treatment of a patient with sternocleidomastoid syndrome (SCMS) originally diagnosed as Eagle's syndrome (ES).

CASE DESCRIPTION

A 55-year-old woman, referred to a physical therapist (PT) by an ear, nose and throat (ENT) physician with the diagnosis of ES. The patient complained of yearlong left-sided otalgia, blurred vision, excessive lacrimation, dysphagia, hyperesthesia on the left side of the face, unilateral temporal headaches, and both left mandibular and anterior neck pain.

OUTCOMES

The PT examination revealed the patient did not exhibit hallmark findings for clinical confirmation of ES and instead demonstrated multiple signs consistent with SCMS.

DISCUSSION

Manual therapy techniques and therapeutic exercises resolved the patient's year-long chronic symptoms within 6 sessions.

The Spine is the Tree of Life: A Systematic Review and Meta-Analysis of the Radiographic Findings Related to Spinal Injuries in Athletes

This review article explores spinal injuries in athletes participating in various sporting activities. It also highlights the various mechanisms of injuries that contribute to spinal injuries in each sport. Electronic databases such as PubMed, Cochrane Library, Web of Science, Embase, MEDLINE Ovid, and Google Scholar were searched for articles from 2000 to 2022 on spine injuries in sports and radiological studies discussing the various injury patterns among athletes. Studies were scoured in accordance with the inclusion criteria, and relevant data such as the number of participants, sporting activities, spine injuries, and outcomes were retrieved. Fifteen articles that met the inclusion criteria were included in the study. Cervical spine injuries are common in athletes who participate in contact sports such as football. Similarly, athletes in collision sports such as football, rugby, and hockey are likely to suffer stingers due to traction and compression injuries. Players engaged in such as soccer, baseball, and swimming, are likely to suffer from spondylolysis. Soccer players are more prone to multiple lesions compared to athletes in sports such as baseball because the sport involves training exercises such as jogging and running without kicking any ball. In swimmers, spondylolysis is common in breaststroke and butterfly styles since they involve repeated flexion and hyperextension of the lumbar spine. CT is essential for diagnosing spondylolysis as it demonstrates the lesions more accurately. Ice hockey is associated with a significant incidence of cervical spine injuries, mostly due to players being constantly checked/pushed from behind. Spine injuries are common in elite athletes across several sports. About 10% of spinal injuries in the United States result from sports activities. In diagnosing spine injuries, imaging modalities such as MRI, CT, or plain radiographs are essential. From a radiologist's perspective, these tests help immensely in deciding which treatment is required for a particular athlete or how the injury can be optimally managed. Achieving recovery from a specific spine injury usually depends on the kind of injury and the rehabilitation process the athletes undergo before returning to play.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

Minimally Invasive Techniques in the Surgical Management of Traumatic Pediatric Thoracolumbar Fractures

BACKGROUND

Thoracolumbar (TL) fractures are uncommon in children. While surgical treatment is recommended for unstable TL fractures, there is no consensus on appropriate surgical treatment. We present a case series of pediatric patients with traumatic TL fractures treated with minimally invasive techniques. We discuss our early experience and technical challenges with navigation and robotic-assisted fixation.

METHODS

A retrospective review of a prospectively maintained trauma database from February 2018 to February 2023 of all pediatric patients (<18 years old) undergoing percutaneous fixation for unstable TL fractures was performed. Minimally invasive techniques included fluoroscopy and/or navigation-guided or robotic-assisted surgery. Clinical course, radiographic findings, and technical challenges were reviewed.

RESULTS

A cohort of 12 patients (age range, 4-17 years) with 6 (50%) Chance fractures, 2 (16%) pars fractures, 2 (16%) pedicle fracture, 1 (8%) burst fracture, and 1 (8%) other fracture were identified. Nine patients had fractures involving the lumbar spine, and the remaining 3 had thoracic fractures. In all cases, percutaneous pedicle screws were placed above and below the fracture with the use of neuronavigation or robotic-assisted navigation (n = 2). Blood loss was <30 mL for single-level fractures and instrumented fusion. Two patients had hardware-related complications. At follow-up (mean 9.67 months after surgery), patients were doing well clinically, and most imaging showed stable alignment.

CONCLUSIONS

Our early experience shows that short segment instrumentation through a minimally invasive approach is a safe and effective surgical option for young pediatric patients with good clinical outcomes and favorable radiographic postoperative finding.

Nationwide emergency department visits for pediatric traumatic spinal cord injury in the United States, 2016-2020

Introduction

Traumatic spinal cord injury (tSCI) is a debilitating neurological condition resulting in lifelong disability for many individuals. The primary objectives of our study were to describe national trends in incident emergency department (ED) visits for tSCI among children (less than 21 years) in the United States, and to determine the proportion of visits that resulted in immediate hospitalization each year, including stratified by age and sex. Secondary objectives were to examine associations between select characteristics and hospitalization following tSCI, as well as to assess sports-related tSCIs over time, including by individual sport and geographic region.

Methods

We used the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample to identify ED visits among children between January 2016 and December 2020 for incident tSCI. Diagnosis codes were used to identify tSCI and sports-related injury etiologies. Census Bureau data were used to approximate annual rates of pediatric ED visits for tSCI per 100,000 children. Unconditional logistic regression modeling assessed whether select factors were associated with hospital admission.

Results

We found that the annual ED visit rate for tSCI remained relatively stable between 2016 and 2020, with approximately 2,200 new all-cause pediatric ED visits for tSCI annually. Roughly 70% of ED visits for tSCI resulted in hospitalization; most ED visits for tSCI were by older children (15-20 years) and males, who were also more often admitted to the hospital. Notable secondary findings included: (a) compared with older children (15-20 years), younger children (10-14 years) were less likely to be hospitalized immediately following an ED visit for tSCI; (b) patient sex and race were not associated with hospital admission; and (c) American tackle football was the leading cause of sports-related ED visits for tSCI among children. Our findings also suggest that the proportion of sports-related tSCI ED visits may have increased in recent years.

Discussion

Future research should further examine trends in the underlying etiologies of pediatric tSCI, while assessing the effectiveness of new and existing interventions aimed at tSCI prevention.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

A Pediatric Cervical Spine Clearance Guideline Leads to Fewer Unnecessary Computed Tomography Scans and Decreased Radiation Exposure

OBJECTIVES

Physical examination and computed tomography (CT) are useful to rule out cervical spine injury (CSI). Computed tomography scans increase lifetime cancer risk in children from radiation exposure. Most CSI in children occur between the occiput and C4. We developed a cervical spine (C-spine) clearance guideline to reduce unnecessary CTs and radiation exposure in pediatric trauma patients.

METHODS

A pediatric C-spine clearance guideline was implemented in September 2018 at our Level 2 Pediatric Trauma Center. Guidance included CT of C1 to C4 to scan only high-yield regions versus the entire C-spine and decrease radiation dose. A retrospective cohort study was conducted comparing preguideline and postguideline of all pediatric trauma patients younger than 8 years screened for CSI from July 2017 to December 2020. Primary endpoints included the following: number of full C-spine and C1 to C4 CT scans and radiation dose. Secondary endpoints were CSI rate and missed CSI. Results were compared using χ 2 and Wilcoxon rank-sum test with P < 0.05 significant.

RESULTS

The review identified 726 patients: 273 preguideline and 453 postguideline. A similar rate of total C-spine CTs were done in both groups (23.1% vs 23.4%, P = 0.92). Full C-spine CTs were more common preguideline (22.7% vs 11.9%, P < 0.001), whereas C1 to C4 CT scans were more common post-guideline (11.5% vs 0.4%, P < 0.001). Magnetic resonance imaging utilization and CSIs identified were similar in both groups. The average radiation dose was lower postguideline (114 vs 265 mGy·cm -1 ; P < 0.001). There were no missed CSI.

CONCLUSIONS

A pediatric C-spine clearance guideline led to increasing CT of C1 to C4 over full C-spine imaging, reducing the radiation dose in children.

LEVEL OF EVIDENCE

Level IV, therapeutic.

Surgical Treatment for Displaced Odontoid Synchondrosis Fracture: A Retrospective Case Series Study

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Odontoid synchondrosis fracture is rare, and there is a paucity of literature on its surgical treatments. This case series study analyzed patients treated with C1 to C2 internal fixation with or without anterior atlantoaxial release and discussed the clinical effectiveness of the procedure.

METHODS

Data were retrospectively collected from a single-center cohort of patients who had undergone surgical treatments for displaced odontoid synchondrosis fracture. The operation time and blood loss volume were recorded. Neurological function was assessed and classified using the Frankel grades. The odontoid process tilting angle (OPTA) was used to evaluate fracture reduction. Fusion duration and complications were also analyzed.

RESULTS

Seven patients (1 boy and 6 girls) were included in the analysis. Three patients underwent anterior release and posterior fixation surgery, and the other 4 underwent posterior-only surgery. The fixation segment was C1 to C2. The average follow-up period was 34.7 ± 8.5 months. The average operation time was 145.7 ± 45.3 min, with an average blood loss volume of 95.7 ± 33.3 mL. The OPTA was corrected from 41.9° ± 11.1° preoperative to 2.4° ± 3.2° at the final follow-up (P < .05). The preoperative Frankel grade of 1 patient was grade C, of 2 patients was grade D, and of 4 patients was grade E. The neurological function of the patients in grade C and grade D recovered to grade E at the final follow-up. None of the patients developed a complication. All the patients achieved odontoid fracture healing.

CONCLUSIONS

Posterior C1 to C2 internal fixation with or without anterior atlantoaxial release is a safe and effective method for treating young children with displaced odontoid synchondrosis fracture.

Pediatric spinal injuries- current concepts

Spinal injuries in children contribute to the highest mortality and morbidity among all pediatric injuries. Fortunately, these injuries are a rare clinical entity but pose a difficulty in diagnosis due to challenges in neurological evaluation of a child and varied radiological presentation. Anatomical and biomechanical aspects of developing musculoskeletal system, relative plasticity of the pediatric spine make children vulnerable to spine injuries. Though motor vehicle collisions are common, children also suffer non-accidental trauma, falls and sports injuries. More chances of cervical spine involvement, higher susceptibility of spinal cord to tensile forces and associated multisystem injuries result in devastating consequences in children compared to adults. Injuries like SCIWORA, vertebral apophyseal injuries, birth-related spinal cord injuries are more specific injuries in pediatric age group. A vigilant clinical, neurological and radiological evaluation is mandatory in all children with suspected spinal injuries. Normal radiological features like ossification centers, pseudosubluxation and physiological vertebral wedging should be carefully noted as they could be misinterpreted as injuries. While CT scans help in better understanding of the fracture pattern, Magnetic Resonance Imaging in children is beneficial especially in detecting SCIWORA and other soft tissue injuries. Management principles of these pediatric spinal injuries are similar to adults. Literature evidences support conservative management in injuries like SCIWORA, unless there is an ongoing spinal cord compression. As in adults, the role of high dose methylprednisolone is still controversial in pediatric spinal cord injuries. Stable spinal injuries can be managed conservatively using orthosis or halo. Instrumentation by both anterior and posterior techniques has been described, but it is challenging due to smaller anatomy and poor implant purchase. In addition to pedicle screw instrumentation, wiring techniques are very beneficial especially in younger children.

Concomitant Cervical Spine Injuries in Pediatric Maxillofacial Trauma: An 11 Year Review of the National Trauma Data Bank

PURPOSE

Craniofacial trauma with concomitant cervical fractures (CCFs) is responsible for significant morbidity and mortality in the pediatric population. We aim to characterize its incidence, injury patterns, outcomes, and risk factors, along with identifying any association between mandible fractures and cervical injuries via the National Trauma Databank.

METHODS

A retrospective cohort study was performed using National Trauma Databank records between 2007 and 2017 to identify patients equal or under the age of 18 years hospitalized for maxillofacial trauma and with recorded cervical injury. Variables of interest include age, gender, race/ethnicity, trauma type (blunt vs penetrating), Injury Severity Score, area involved, mechanism of injury, comorbid conditions, inpatient complications, and discharge disposition. Retrospective cohorts were separated by CCF status. Univariate, bivariate, and multivariable regression analysis was utilized, with P-value <.05 considered statistically significant.

RESULTS

A total of 32,952 patients were included in the study, with the majority being White (60.8%), male (68.2%), and between the ages of 13 and 18 years (65%). Of these, 8.2% experienced CCF. Most common mechanisms of injury were motor vehicle trauma (32.6%), interpersonal violence (18.8%), and falls (13.5%). Univariate analysis revealed patients with CCF were significantly older (15.2 vs 12.9; P < .001), more likely to be motor vehicle occupants (46.6 vs 31.9%; P < .001), and suffer polyfacial fractures (62.6 vs 60.7%; P < .001). Longer length of stay (9.4 vs 3.6 days; P < .001) and significantly higher inpatient complications such as deep vein thrombosis, pulmonary embolism, unplanned intubation, severe sepsis, pressure ulcer, ventilator-associated pneumonia, and unplanned return to operating room were observed in the CCF cohort. Female gender (1.5 [1.37 to 1.64; 95% confidence interval {CI}] P < .001) and higher Injury Severity Score (1.12 [1.11 to 1.11; 95% CI] P < .001) were associated with significantly higher odds on multivariable analysis. The presence of a mandible fracture was not associated with increased CCF on multivariate analysis (1.06 [0.92 to 1.22; 95% CI] P = .36).

CONCLUSIONS

There are statistically significant differences in demographics, outcomes, and injury patterns in maxillofacial patients with CCF that may help guide treatment. No association between mandible fractures and cervical trauma was identified.

Clinical characteristics and treatment of spinal cord injury in children and adolescents

Pediatric and adult spinal cord injuries (SCI) are distinct entities. Children and adolescents with SCI must suffer from lifelong disabilities, which is a heavy burden on patients, their families and the society. There are differences in Chinese and foreign literature reports on the incidence, injury mechanism and prognosis of SCI in children and adolescents. In addition to traumatic injuries such as car accidents and falls, the proportion of sports injuries is increasing. The most common sports injury is the backbend during dance practice. Compared with adults, children and adolescents are considered to have a greater potential for neurological improvement. The pathogenesis and treatment of pediatric SCI remains unclear. The mainstream view is that the mechanism of nerve damage in pediatric SCI include flexion, hyperextension, longitudinal distraction and ischemia. We also discuss the advantages and disadvantages of drugs such as methylprednisolone in the treatment of pediatric SCI and the indications and timing of surgery. In addition, the complications of pediatric SCI are also worthy of attention. New imaging techniques such as diffusion tensor imaging and diffusion tensor tractography may be used for diagnosis and assessment of prognosis. This article reviews the epidemiology, pathogenesis, imaging, clinical characteristics, treatment and complications of SCI in children and adolescents. Although current treatment cannot completely restore neurological function, patient quality of life can be enhanced. Continued developments and advances in the research of SCI may eventually provide a cure for children and adolescents with this kind of injury.

Establishing an Australian pediatric spinal cord disorder register using consumer, health professional, and researcher perspectives

CONTEXT/OBJECTIVE

Pediatric spinal cord disorders (SCD) are rare, and epidemiological data available to support treatment are lacking. The implementation of a national data register tailored to this population would greatly assist clinicians and therapists in guiding clinical practice. This study gathered perspectives surrounding a prospective national pediatric spinal cord disorder register.

DESIGN

Survey and modified Delphi technique.

SETTING

Australia.

PARTICIPANTS

SCD consumers, health professionals, and researchers.

INTERVENTIONS

None.

OUTCOME MEASURES

None.

RESULTS

Purposive sampling recruited 6 consumers and 52 health professionals and researchers working in the field of SCD to participate. The consumer survey contained items including demographic information, general and pediatric-specific SCD health issues, and questions regarding activity and participation. The modified Delphi survey required health professionals and researchers to identify which "collection items" and "administrative features" should be included in a national SCD register for both clinical and research purposes. Seventeen essential and nine optional items, two outcome measures, data collection methods, consumer access, definition of "pediatric," and use of International Data Standards were included in the consensus for a minimum dataset.

CONCLUSION

This study developed a minimum dataset that could inform an Australian register for pediatric SCD. A register linking to an adult database is recommended to ensure coverage across the lifespan. While items for a minimum dataset have been recommended, this dataset is large. Review and refinement of this list are recommended to ensure the register is not overly time-consuming for practical use.

Prevertebral Soft Tissue Thickness of the Cervical Spine in Children: An Insensitive but Specific Aid in the Diagnosis of Occult Trauma

BACKGROUND

The purpose of this study was to investigate the sensitivity and specificity of current cervical prevertebral soft tissue swelling (PVST) values in a cohort of children with known cervical fractures or dislocations.

METHODS

Forty two children (average age 11.9, range 1.4 to 17.0 y) with documented cervical spine injury and 61 children (average age 11.9, range 0.5 to 17.9 y) with cervical pain but no injury were reviewed (January 2004 to December 2015). PVST was measured on lateral cervical radiographs at C2, C3, and C6. Patients were stratified by age (0 to 2 y, 3 to 6 y, 7 to 10 y, 11 to 15 y, and 16 y and above). The Wilcoxon rank sum test was used to compare PVST measurements at each spine level across injury and noninjury cohorts. Sensitivity and specificity were estimated to assess the ability of abnormal reference values to detect when a true injury was present. In addition, positive predictive value and negative predictive value were also estimated.

RESULTS

The majority of c-spine injuries (31/42; 76%) involved bony fracture and 57% (24/42) were treated with a collar or brace. Comparison of PVST measurement found no difference at C2 ( P =0.07), C3 ( P =0.07), or at C6 ( P =0.99) across injury and non-injury cohorts. Sensitivity was poor at single-level measures for C2 (26%), C3 (31%), and C6 (24%), while specificity was relatively high (92%, 87%, and 79%, respectively). When an increased value at either C2 or C3 indicated injury, sensitivity increased to 36%, and when an increased measurement at just one of the 3 measured levels indicated injury, the sensitivity increased to 48%, while the specificity decreased to 72%. While retropharyngeal measures were more likely to detect injury than retrotracheal, C6 alone was increased in 5 of the 20 injury patients.

CONCLUSIONS

PVST measurements exhibit poor sensitivity but good specificity as indicators for the diagnosis of occult cervical trauma in children. Negative values do not exclude injury; positive values suggest further evaluation.

LEVELS OF EVIDENCE

Level III.

A Retrospective Look at a Cervical Spine Clearance Protocol in Pediatric Trauma Patients at a Level-1 Trauma Center

BACKGROUND

Adult studies have demonstrated the efficacy of written protocols for clearance of the cervical spine. However, less than half of recently surveyed pediatric trauma centers report using a documented protocol. Little data exists on such protocols in pediatric populations, but interest remains because of potential reductions in radiation exposure, time to clearance, hospital stay, and specialist referral. However, missed injury can have devastating consequences. The purpose of this study is to examine the efficacy in detecting injury of an implemented cervical spine clearance protocol at a level-1 pediatric trauma hospital.

METHODS

A retrospective review was performed on pediatric patients presenting as activated traumas to the emergency department of a single level-1 pediatric trauma hospital between May 2010 and October 2018. This institution has utilized a written cervical spine clearance protocol throughout this time. Presence of cervical spine injury, documented clearance, cervical spine imaging, and follow-up documentation were reviewed for any missed injuries.

RESULTS

There were no missed cervical spine injuries. Five-hundred sixty-three clinically significant cervical spine injuries were identified, representing 16.5% of patients. Of these, 96 were fractures, dislocations, or ligamentous injuries, representing 2.8% of all patients. Most cervical spine clearances were performed by trauma surgery. Advanced imaging of the cervical spine was ordered for 43.2% of patients overall and trended down over time.

CONCLUSION

Documented cervical spine clearance protocols are effective for detection of significant injury in pediatric trauma patients. This study suggests these protocols minimize risk of missed injury and may prevent unnecessary radiation exposure, delayed clearance, prolonged hospitalization, or unnecessary specialist referral.

CLINICAL RELEVANCE

Utilization of a standard written protocol for cervical spine clearance likely prevents missed injury and helps to minimize radiation exposure in pediatric populations. Further research is needed on evaluation and management of pediatric cervical spine trauma.

Complex Pathophysiology of Abusive Head Trauma with Poor Neurological Outcome in Infants

Abusive head trauma (AHT) in infants, especially acute subdural hematoma, has an extremely poor outcome. The most decisive and important finding is the appearance of a widespread low-density area on head computed tomography. This phenomenon was traditionally thought to be caused by cerebral ischemia. However, many other pathophysiological abnormalities have been found to be intricately involved. Recent studies have found that status epilepticus and hyperperfusion injures are the major causes. Another serious problem associated with AHT is cardiopulmonary arrest (CPA). Many infants are reported to visit to the hospital with CPA, and its pathophysiology has not been fully elucidated. This paper examines the background of these pathological conditions and associated factors and elucidate the pathophysiological mechanisms resulting in poor outcomes in AHT. In addition to the intensity of assault on the head, the peculiar pathophysiological characteristics in infants, as well as the social background specific to child abuse, are found to be associated with poor outcome.

Biomechanical Analysis of Cervical Motion With a Pediatric Immobilization and Extrication Device

OBJECTIVE

To determine the motions produced during pediatric extrication when using a system of motion estriction and extrication.

METHODS

Simulation-based biomechanical analysis study conducted with inertial sensors to measure motion produced in the cervical spine of a pediatric simulator during extrication from a vehicle.

RESULTS

The mean of the movements was 3.5° (SD ±1.35°). The mean time was 4 minutes 1 second (SD, ±45.09 seconds). The mean rotation toward the right was 3.34° (SD ±3.52°) and toward the left 2.62° (SD ±2.26°). The mean for lateralization was 6.24° (SD ±3.20°) toward the right and 2.50° (DE ±2.76°) toward the left. The mean for flexion was 2.36° (SD ±2.10°) and for extension 4.21° (SD ±2.15°).

CONCLUSIONS

The device analyzed allows for the extrication of the pediatric patient with high levels of motion restriction of the spinal column with the Pediatric Immobilization and Extrication System.

Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel

OBJECTIVES

The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel.

METHODS

A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol.

RESULTS

The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful.

CONCLUSIONS

Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.

Spine Fractures in Children and Adolescents—Frequency, Causes, Diagnostics, Therapy and Outcome—A STROBE-Compliant Retrospective Study at a Level 1 Trauma Centre in Central Europe

The aim of this study was to present the frequencies and characteristics of paediatric spine fractures, focusing on injury mechanisms, diagnostics, management, and outcomes. This retrospective, epidemiological study evaluated all patients aged 0 to 18 years with spine fractures that were treated at a level 1 trauma centre between January 2002 and December 2019. The study population included 144 patients (mean age 14.5 ± 3.7 years; 40.3% female and 59.7% male), with a total of 269 fractures. Common injury mechanisms included fall from height injuries (45.8%), with an increasing prevalence of sport incidents (29.9%) and a decreasing prevalence of road incidents (20.8%). The most common localisation was the thoracic spine (43.1%), followed by the lumbar spine (38.2%), and the cervical spine (11.8%). Initially, 5.6% of patients had neurological deficits, which remained postoperatively in 4.2% of patients. Most (75.0%) of the patients were treated conservatively, although 25.0% were treated surgically. A small proportion, 3.5%, of patients presented postoperative complications. The present study emphasises the rarity of spinal fractures in children and adolescents and shows that cervical spine fractures are more frequent in older children, occurring with a higher rate in sport incidents. Over the last few years, a decrease in road incidents and an increase in sport incidents in paediatric spine fractures has been observed.

Distinguishing Pseudosubluxation From True Injury: A Case of C2-3 and C3-4 Subluxation in a Pediatric Patient

A 6-year-old girl presented with a one-week history of neck pain after a trampoline accident. Cervical radiographs interpreted as pseudosubluxation of C2 on C3. CT demonstrated the reversal of lordosis with anterolisthesis of C2-C3 and C3-C4. Ten weeks after two months of halo traction, radiographs demonstrated anatomic alignment and maintained disk heights. This case highlights the similarities of pseudosubluxation and true injury, emphasizing the need for high index of suspicion in this population and a successful treatment of subluxation using a halo construct.

Operative Treatment of Cervical Spine Injuries Sustained in Youth Sports

BACKGROUND

Little data exists on surgical outcomes of sports-related cervical spine injuries (CSI) sustained in children and adolescent athletes. This study reviewed demographics, injury characteristics, management, and operative outcomes of severe CSI encountered in youth sports.

METHODS

Children below 18 years with operative sports-related CSI at a Level 1 pediatric trauma center were reviewed (2004 to 2019). All patients underwent morden cervical spine instrumentation and fusion. Clinical, radiographic, and surgical characteristics were analyzed.

RESULTS

A total of 3231 patients (mean, 11.3±4.6 y) with neck pain were evaluated for CSI. Sports/recreational activities were the most common etiology in 1358 cases (42.0%). Twenty-nine patients (2.1%) with sports-related CSI (mean age, 14.5 y; range, 6.4 to 17.8 y) required surgical intervention. Twenty-five were males (86%). Operative CSI occurred in football (n=8), wrestling (n=7), gymnastics (n=5), diving (n=4), trampoline (n=2), hockey (n=1), snowboarding (n=1), and biking (n=1). Mechanisms were 27 hyperflexion/axial loading (93%) and 2 hyperextension injuries (7%). Most were cervical fractures (79%) and subaxial injuries (79%). Seven patients (24%) sustained spinal cord injury (SCI) and 3 patients (10%) cord contusion or myelomalacia without neurological deficits. The risk of SCI increased with age (P=0.03). Postoperatively, 2 SCI patients (29%) improved 1 American Spinal Injury Association Impairment Scale Grade and 1 (14%) improved 2 American Spinal Injury Association Impairment Scale Grades. Increased complications developed in SCI than non-SCI cases (mean, 2.0 vs. 0.1 complications; P=0.02). Bony fusion occurred in 26/28 patients (93%) after a median of 7.2 months (interquartile range, 6 to 15 mo). Ten patients (34%) returned to their baseline sport and 9 (31%) to lower-level activities.

CONCLUSIONS

The incidence of sports-related CSI requiring surgery is low with differences in age/sex, sport, and injury patterns. Older males with hyperflexion/axial loading injuries in contact sports were at greatest risk of SCI, complications, and permanent disability. Prevention campaigns, education on proper tackling techniques, and neck strength training are required in sports at high risk of hyperflexion/axial loading injury.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

American football is the youth sporting activity most commonly associated with acute vertebral fractures

OBJECTIVES

Athletics confer cardiovascular fitness and improved cognitive processing in pediatric populations. However, one risk of sports participation is acute vertebral fracture, an injury with significant morbidity. It is currently unknown which sports represent the highest risk of acute vertebral fracture in pediatric populations. This study seeks to identify the youth sporting activities most commonly associated with acute vertebral fractures presenting to United States (U.S.) emergency departments (EDs).

METHODS

This cross-sectional, retrospective study queries the National Electronic Injury Surveillance System database to report national weighted estimates and demographic characteristics of pediatric patients with acute vertebral fractures presenting to U.S. EDs.

RESULTS

The mean annual incidence of estimated acute vertebral fractures over the study period was 1,672 (C.I. 1,217-2,126). From 2000-2001 (N = 4,030; C.I. 2,934-5,125) to 2016-2017 (N = 2,559; C.I. 1,681-3,438), there was no significant change in the estimated rate of sports-related acute vertebral fractures in pediatric patients (p = 0.09). American football was identified as the sport most frequently associated with acute vertebral fractures (23.4%; C.I. 17.6-29.3%). We found no appreciable change in the rate of football-related acute vertebral fractures over time, with 48.2% (C.I. 37.3-59.0%) occurring from 2000 to 2008 and 51.8% (C.I. 41.0-62.7%) from 2009 to 2017.

CONCLUSIONS

While sports-related acute vertebral fractures remain rare injuries in pediatric populations, we identify youth football as the sport associated with the highest risk of such injuries. Despite decreasing football participation rates over our study period, the annual incidence of football-associated acute vertebral fractures has not exhibited a proportional decline. Our findings raise concern that the relative risk of acute vertebral fracture associated with youth football has not significantly decreased over time. Elimination of dangerous tackling technique, improvement in helmet fit and technology, and availability of on-site medical care may contribute to decreased estimates in the future.

Cervical Spine Injury in Children and Adolescents

Complaints related to the neck are common following mild pediatric trauma. Although significant cervical spine injuries are most often seen and evaluated in the emergency room or inpatient setting, the primary care provider is faced with the evaluation of lower acuity complaints. We provide a review to assist with the efficient evaluation of these patients to facilitate decisions regarding return to play, the need for imaging, and need for referral to subspecialty providers.

Pediatric Cervical Spine Clearance and Immobilization Practice Among Prehospital Emergency Medical Providers: A Statewide Survey

OBJECTIVES

Pediatric cervical spine injuries are rare but potentially life threatening. Although published guidelines for assessment of such injuries exist, there is less uniformity in its implementation in out-of-hospital settings. Our purpose was to assess the knowledge and practice patterns for pediatric cervical spine immobilization among prehospital emergency medical services (EMS) providers in Arizona.

METHODS

A cross-sectional web-based survey was conducted (October-December 2018), using an electronic mailing list of certified EMS providers (ground and air) in Arizona. A 20-question structured web-based survey was developed and deployed.

RESULTS

One hundred eight EMS stations were contacted with the survey. Sixty-eight providers responded; majority were emergency medical paramedics (73.1%). Most of the stations surveyed did not have a pediatric trauma center (66.2%). When treating children younger than 3 years, half of the respondents stated they did not know of a specific cervical spine clearance criterion; 59.3% felt that cervical spine immobilization was required "sometimes," and 40.0% were unaware of the state's EMS pediatric cervical spine clearance algorithm; 93.9% of EMS providers felt that an age-based algorithm for cervical spine clearance in children would be useful.

CONCLUSIONS

In this statewide survey involving prehospital EMS providers, we found that pediatric cervical spine clearance and immobilization practices, even within a specific geographic location, remain inconsistent.

Neck Trauma: Cervical Spine, Seatbelt Sign, and Penetrating Palate Injuries

Pediatric cervical spine, blunt cerebrovascular, and penetrating palate injuries are rare but potentially life-threatening injuries that demand immediate stabilization and treatment. Balancing the risk of a missed injury with radiation exposure and the need for sedation is critical in evaluating children for these injuries. Unfortunately, effective clinical decision tools used in adult trauma cannot be uniformly applied to children. Careful risk stratification based on history, mechanism and examination is imperative to evaluate these injuries judiciously in the pediatric population. This article presents a review of the most up-to-date literature on pediatric neck trauma.

Cervical Pediatric Spine Trauma Managed With Open Spinal Fixation and Instrumentation and a Review of the Literature

Cervical spine injuries in the pediatric population are rare. Most injuries to the cervical spinal cord and vertebral column can be managed nonoperatively; however, surgical management may be required in certain clinical scenarios. A posterior surgical approach has been previously preferred; however, the utilization of anterior spinal fixation and instrumentation has been limited. We present a small case series of patients presenting with a traumatic cervical spine injury and detail the feasibility of craniocervical junction (CVJ) and subaxial spinal fixation in the pediatric population.

We report four cases involving pediatric patients, all of whom presented with cervical spine injuries necessitating operative intervention using a combination of the anterior and posterior operative approaches. All four patients recovered well, did not require surgical revision, and were neurologically intact at the last follow-up. 

Therefore, we conclude that spinal arthrodesis is a safe, effective way to manage spinal injuries in the cervical spine following traumatic injury.

Sports-related Cervical Spine Fracture and Spinal Cord Injury: A Review of Nationwide Pediatric Trends

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Assess trends in sports-related cervical spine trauma using a pediatric inpatient database.

SUMMARY OF BACKGROUND DATA

Injuries sustained from sports participation may include cervical spine trauma such as fractures and spinal cord injury (SCI). Large database studies analyzing sports-related cervical trauma in the pediatric population are currently lacking.

METHODS

The Kid Inpatient Database was queried for patients with external causes of injury secondary to sports-related activities from 2003 to 2012. Patients were further grouped for cervical spine injury (CSI) type, including C1-4 and C5-7 fracture with/without spinal cord injury (SCI), dislocation, and SCI without radiographic abnormality (SCIWORA). Patients were grouped by age into children (4-9), pre-adolescents (Pre, 10-13), and adolescents (14-17). Kruskall-Wallis tests with post-hoc Mann-Whitney U's identified differences in CSI type across age groups and sport type. Logistic regression found predictors of TBI and specific cervical injuries.

RESULTS

A total of 38,539 patients were identified (12.76 years, 24.5% F). Adolescents had the highest rate of sports injuries per year (P < 0.001). Adolescents had the highest rate of any type of CSI, including C1-4 and C5-7 fracture with and without SCI, dislocation, and SCIWORA (all P < 0.001). Adolescence increased odds for C1-4 fracture w/o SCI 3.18×, C1-4 fx w/ SCI by 7.57×, C5-7 fx w/o SCI 4.11×, C5-7 w/SCI 3.63×, cervical dislocation 1.7×, and cervical SCIWORA 2.75×, all P < 0.05. Football injuries rose from 5.83% in 2009 to 9.14% in 2012 (P < 0.001), and were associated with more SCIWORA (1.6% vs. 1.0%, P = 0.012), and football injuries increased odds of SCI by 1.56×. Concurrent TBI was highest in adolescents at 58.4% (pre: 26.6%, child: 4.9%, P < 0.001), and SCIWORA was a significant predictor for concurrent TBI across all sports (odds ratio: 2.35 [1.77-3.11], P < 0.001).

CONCLUSION

Adolescent athletes had the highest rates of upper/lower cervical fracture, dislocation, and SCIWORA. Adolescence and SCIWORA were significant predictors of concurrent TBI across sports. The increased prevalence of CSI with age sheds light on the growing concern for youth sports played at a competitive level, and supports recently updated regulations aimed at decreasing youth athletic injuries.

LEVEL OF EVIDENCE

3.

The 100 Most-Cited Papers in Traumatic Injury of the Spine

Background

Traumatic injury to the spine can be a complex diagnostic and therapeutic entity often with devastating consequences. Outside of the isolated vertebral column injury costs; annual costs associated with spinal cord injury (SCI) are estimated to exceed $9.7 billion.

Objective

To identify the 100 most-cited articles on spine trauma.

Methods

The Thomson Reuters Web of Science citation indexing service was queried. The articles were sorted by times cited in descending order. Two independent reviewers reviewed the article titles and abstracts to identify the top 100 most-cited articles.

Results

The top 100 articles were found to be cited between 108 (articles #99-100) and 1595 times (article #1). The most-cited basic science article was cited 340 times (#12 on the top 100 list). The oldest article on the top 100 list was from 1953 and most recent from 2012. The number of patients, when applicable, in a study ranged from 9 (article #34) to 34,069 (article #5). Top 100 articles were published in 41 different journals with a wide range of specialities and fields most commonly multidisciplinary. Basic science research encompassed 34 of the 100 articles on the list.

Conclusions

We present the 100 most-cited articles in spinal trauma with emphases on important contributions from both basic science and clinical research across a wide range of authors, specialties, patient populations, and countries. Recognizing some of the most important contributions in the field of spinal trauma may provide insight and guide future work.

Hand Reconstruction in Children with Spinal Cord Injury

Comprehensive programs for children who sustain traumatic spinal cord injury should incorporate optimizing hand and upper extremity function along with the other traditional pillars of rehabilitation. Children's smaller anatomy, open growth plates, and future skeletal growth, combined with the age-related psychosocial impact of these injuries, require protocols suited to these age-related issues. There is a role for surgical reconstruction, as is the case for adults with traumatic tetraplegia, and surgical outcomes are equally beneficial and long lasting. Strict adherence to surgical indications, and surgical strategies and protocols that incorporate their age-related challenges, are the keys to successful management.

Complete Atlantoaxial Dislocation After Odontoid Synchondrosis Fracture: A 2-Year Follow-up Study: A Case Report

CASE

Spine injuries are rare in children, but when they do occur, the synchondrosis of C2 may be involved. A 5-year-old boy presented to our clinic complaining of neck pain for 6 weeks, which started after wrestling with peers. He had slight upper extremity weakness, clonus, and diminished reflexes. Imaging, including computed tomography and magnetic resonance imaging scans, showed a fracture dislocation through the synchondrosis of the odontoid. The patient was initially treated with admission to the hospital, awake halo placement, and gradual traction over a few days. Subsequently, he was taken for transoral reduction and posterior instrumented fusion of C1-C3 using a combination of sublaminar suture, screws, and rods. Most recently, he was doing well over 2 years later, with no residual neurologic symptoms.

CONCLUSIONS

The case presented demonstrates one option for an otherwise nonreducible odontoid synchondrosis fracture with complete atlantoaxial dislocation: transoral reduction and open posterior instrumentation. This proved to be a practical technique and provided a good clinical result in this case. These injuries are rare, but when they do occur, the examination can be surprisingly subtle given the severity of the injury. Plain films should be scrutinized carefully and advanced imaging obtained when necessary to confirm the diagnosis.

Does prehospital spinal immobilization influence in hospital decision to obtain imaging after trauma?

IMPORTANCE

This study highlights the unnecessarily high suspicion for cervical spine injury among study providers and shows that cervical CT scans were more likely in patients who arrived to the emergency department wearing a cervical collar, even when clinically cleared for suspicion of cervical spine injury by the emergency department provider.

OBJECTIVE

To determine if patients with a cervical collar were more likely to undergo cervical spine imaging than those who arrived to the emergency department without a collar.

DESIGN

Adult trauma patients at a level 1 trauma center over 4 months (n = 1,438) were stratified by acuity (1,2, or 3), mechanism, and known injury cephalad to clavicles, defined as pain, wounds, or hematomas. Cervical spine imaging findings were recorded.

RESULTS

975 patients (67.8%) had cervical CT scans. Twenty-six (1.81%) sustained a fracture or ligamentous injury, all with known injury cephalad to clavicles. 161 (11.2%) patients without injury cephalad to clavicles all had a negative cervical CT. Category 1 patients with gunshot wounds with injury cephalad to clavicles were more likely to have CT if they arrived with a collar versus without (66.7% vs 14.3%, p = 0.027). Category 2 and 3 patients with injury cephalad to clavicles after motor vehicle collision (MVC) (88.2% vs 69.6%, p = 0.011), low energy falls (88.3% vs 59.4%, p < 0.0001), and assault (86.0% vs 37.1%, p < 0.0001) underwent cervical CT more frequently if they arrived wearing a collar. Category 2 and 3 trauma patients without injury cephalad to clavicles were also more likely to undergo CT when wearing a collar after MVC (66.3% vs 21.4%, p = 0.001), low energy fall (81.8% vs 35.3%, p = 0.016), and pedestrian vs MVC (55.6% vs 12.5%, p = 0.04).

CONCLUSION

Certain trauma patients were more likely to undergo cervical CT if they arrived wearing a cervical collar. No conscious patients without complaints proximal to the clavicles had cervical injury.

Trends in pediatric cervical spine injuries in the United States in a 10-year period

BACKGROUND

Cervical spine fractures (CSFs) are potentially devastating injuries in pediatric population. Fortunately, these injuries are uncommon in pediatric patients. The purpose of this study was to determine the epidemiology, the risk factors, mechanisms of injury and to identify possible strategies for prevention. In addition, the aim of the current study was to compare CSF sustained in 2003 to CSF sustained in 2008 and 2013 so as to recognize the trend of pediatric CSFs in the United States.

METHODS

The National Electronic Injury Surveillance System was queried for CSF sustained in pediatric population up to 16 years of age for years 2003, 2008, and 2013. Outcomes of interest were patient characteristics (age and sex), causes of CSF, and mechanism of injury.

RESULTS

Eighty pediatric patients with CSF were identified. The average age was 10.5 years. Boys sustained significantly more CSF than girls. Statistically significant more CSF were occurred in children of 10-16 years than in children up to 9 years. Sports or recreational activities and home-related accidents were the predominant causes of CSF. Mechanisms of injury were age-related, with younger children sustaining CSF as a result of home-related accidents while adolescents commonly injured during sporting or recreational activities. In contrast to current data in literature, motor vehicle accidents were not a major cause of CSF. Comparing the years 2003, 2008, and 2013, statistically significant differences in the incidence of CSF were not found.

CONCLUSIONS

Our study confirms previous findings that adolescents who sustain CSF have higher incidence of sport or recreation-related accidents than younger patients who sustain commonly home-related accidents as a consequence of insufficient parental supervision. The perception that motor vehicle accidents comprise major cause of CSF appears not to be true.

Pediatric Spinal Traumas

INTRODUCTION

Although childhood trauma is a major cause of morbidity and mortality, the incidence of spinal trauma is significantly lower in children than in adults. Existing studies on pediatric spinal trauma (PST) largely concern cervical trauma because of its frequency of incidence. We aimed to obtain more information by examining all types of spinal trauma, and evaluating factors such as age, trauma type, injury type, and American Spinal Injury Association score and comparing them with data from the literature.

METHODS

We retrospectively reviewed 30 pediatric trauma patients with spinal pathology confirmed by spinal imaging.

RESULTS

The mean age was 166.4 months. Mean age for each mechanism of injury was: 142.7 months for a simple fall, 149.0 months for injury involving a foreign object, 163.5 months for a fall from a height, and 181.6 months for traffic accidents. There was no statistically significant difference in mean age for different mechanisms of injury (p = 0.372). The levels of the spinal injuries were: lumbar 53.3% (16), thoracic 26.6% (8), and cervical 20.0% (6). Mean age for each level of spinal injury was 113.3 months for the cervical area, 172.2 months for the thoracic area, and 183.3 months for the lumbar area. Mean age was found to be statistically significant (p = 0.000).

DISCUSSION

PST is uncommon and the type of trauma and the spinal level affected varies with age. Cervical trauma predominates at younger ages, but adult-like traumas begin to occur with increasing age. It should be considered that the risk of developing neurological deficits is higher in pediatric patients than in adults, and the risk of multisystem injury is also high.

Morbidity after traumatic spinal injury in pediatric and adolescent sports-related trauma

OBJECTIVE

Sports injuries present a considerable risk of debilitating spinal injury. Here, the authors sought to profile the epidemiology and clinical risk of traumatic spinal injuries (TSIs) in pediatric sports injuries.

METHODS

The authors conducted a retrospective cohort analysis of pediatric patients who had experienced a sports-related TSI, including spinal fractures and spinal cord injuries, encoded in the National Trauma Data Bank in the period from 2011 to 2014.

RESULTS

Included in the analysis were 1723 cases of pediatric sports-related TSI, which represented 3.7% of all pediatric sports-related trauma. The majority of patients with TSI were male (81%), and the median age was 15 years (IQR 13-16 years). TSIs arose most often from cycling accidents (47%) and contact sports (28%). The most frequently fractured regions were the thoracic (30%) and cervical (27%) spine. Among patients with spinal cord involvement (SCI), the cervical spine was involved in 60% of cases.The average length of stay for TSIs was 2 days (IQR 1-5 days), and 32% of the patients required ICU-level care. Relative to other sports-related trauma, TSIs without SCI were associated with an increased adjusted mean length of stay by 1.8 days (95% CI 1.6-2.0 days), as well as the need for ICU-level care (adjusted odds ratio [aOR] 1.6, 95% CI 1.3-1.9). Also relative to other sports-related trauma, TSIs with SCI had an increased length of stay by 2.1 days (95% CI 1.8-2.6 days) and the need for ICU-level care (aOR 3.6, 95% CI 2.6-4.8).TSIs without SCI were associated with discharge to or with rehabilitative services (aOR 1.7, 95% CI 1.5-2.0), as were TSIs with SCI (aOR 4.0, 95% CI 3.2-4.9), both relative to other sports-related trauma. Among the patients with TSIs, predictors of the need for rehabilitation at discharge were having a laminectomy or fusion, concomitant lower-extremity injury, head injury, and thoracic injury. Although TSIs affected 4% of the study cohort, these injuries were present in 8% of patients discharged to or with rehabilitation services and in 17% of those who died in the hospital.

CONCLUSIONS

Traumatic sports-related spinal injuries cause significant morbidity in the pediatric population, especially if the spinal cord is involved. The majority of TSI cases arose from cycling and contact sports accidents, underscoring the need for improving education and safety in these activities.

Halo Fixator and Halo Traction - Value for the Treatment of Spinal Disorders in Childhood

The application of the Halo fixateur in case of spinal pathologies in childhood is a standardized technique. The halo fixateur may be used for treatment of injuries of the cervical spine, for additional stabilization following extended surgery at the cervical spine and their transitional regions as well as to achieve preoperative reduction in case of severe and rigid deformity. These indications are, referred to the early age, rare. However, the successful use of the Halo fixateur presumes a certain familiarity with the device and experiences regarding the underlying diseases to minimize related risks and to avoid possible complications. In this article the use and specific features regarding the application of the halo fixateur in childhood based on presented cases and the literature will be discussed.

[Development and first application testing of a new protocol for preclinical spinal immobilization in children : Assessment of indications based on the E.M.S. IMMO Protocol Pediatric]

BACKGROUND

To protect the spine from secondary damage, spinal immobilization is a standard procedure in prehospital trauma management. Immobilization protocols aim to support emergency medicine personnel in quick decision making but predominantly focus on the adult spine; however, trauma mechanisms and injury patterns in adults differ from those in children and applying adult prehospital immobilization protocols to pediatric patients may be insufficient. Adequate protocols for children with spinal injuries are currently unavailable.

OBJECTIVE

The aim of this study was (i) to develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) to perform a first analysis of the quality of results if the protocol is used by emergency personnel.

MATERIAL AND METHODS

Based on a structured literature search a new immobilization protocol was developed. Analysis of the quality of results was performed by a questionnaire containing four case scenarios in order to assess correct decision making. The decision about spinal immobilization was made without and with the utilization of the protocol.

RESULTS

The E.M.S. IMMO Protocol Pediatric was developed based on the literature. The analysis of the quality of results was performed involving 39 emergency medicine providers. It could be shown that if the E.M.S. IMMO Protocol Pediatric was used, the correct type of immobilization was chosen more frequently. A total of 38 out of 39 participants evaluated the protocol as helpful.

CONCLUSION

The E.M.S. IMMO Protocol Pediatric provides decision-making support whether pediatric spine immobilization is indicated with respect to the cardiopulmonary status of the patient. In a first analysis, the E.M.S. IMMO Protocol Pediatric improves decision making by emergency medical care providers.

Radiologic Imaging in Trauma Patients with Cervical Spine Immobilization at a Pediatric Trauma Center

BACKGROUND

Pediatric trauma patients with cervical spine (CS) immobilization using a cervical collar often require procedural sedation (PS) for radiologic imaging. The limited ability to perform airway maneuvers while CS immobilized with a cervical collar is a concern for emergency department (ED) staff providing PS.

OBJECTIVE

To describe the use of PS and analgesia for radiologic imaging acquisition in pediatric trauma patients with CS immobilization.

METHODS

Retrospective medical record review of all trauma patients with CS immobilization at a high-volume pediatric trauma center was performed. Patient demographics, imaging modality, PS success, sedative and analgesia medications, and adverse events were analyzed. Patients intubated prior to arrival to the ED were excluded.

RESULTS

A total of 1417 patients with 1898 imaging encounters met our inclusion criteria. A total of 398 patients required more than one radiographic imaging procedure. The median age was 8 years (range 3.8-12.75 years). Computed tomography of the head was used in 974 of the 1898 patients (51.3%). A total of 956 of the 1898 patients (50.4%) required sedatives or analgesics for their radiographic imaging, with 875 (91.5%) requiring a single sedative or analgesic agent, and 81 (8.5%) requiring more than one medication. Airway obstruction was the most common adverse event, occurring in 5 of 956 patients (0.3%). All imaging procedures were successfully completed.

CONCLUSION

Only 50% of CS immobilized, nonintubated patients required a single sedative or analgesic medication for their radiologic imaging. Procedural success was high, with few adverse events.

C2-3 Fracture Dislocation and Bilateral Vertebral Artery Occlusion Without Neurological Injury: A Case Report

A 27-year-old female involved a motor vehicle collision as the restrained driver presented to the ER with agonal breathing and a Glasgow Coma Scale (GCS) of 3. Radiographic imaging demonstrated C2-3 craniocaudal dislocation, bilateral C2 comminuted pedicle fractures extending through the transverse foramina, complete bilateral vertebral artery occlusion, and negative signs of stroke with MRI. After halo immobilization, surgical stabilization, and medical treatment the patient was discharged and at her six-month follow up she was without neurological deficit.

Surgical Management of Pediatric Spine Trauma: 12 Years of Experience

OBJECTIVE

Spine trauma management in children varies from one team to another, and to date, no clear consensus has been reached. The goal of this study was to describe the epidemiology of spine trauma in children and evaluate the timing and techniques of surgery when it was required.

METHODS

A retrospective review of all patients admitted to our pediatric trauma center for spine traumas that required surgical management, between 2005 and 2016, was performed. All patients were followed with clinical and radiologic examination to evaluate the quality of fusion and realignment.

RESULTS

Seventy-three children, with a mean age of 14.1 years, were admitted. Spinal injuries were more common in the teenage group (14-18 years). The predominant etiology of spine injuries was motor vehicle collision (36%). The spinal level of injury varied according to the age group: young children presented more cervical traumas (P < 0.01), while teenagers presented more lumbar traumas. There were more fractures alone in the teenage group (P < 0.005), while there were more luxations alone in the school-age group (P < 0.05). Median timing for surgical intervention in patients with neurologic deficits was 1 day. Patients with posterior wall recession >5 mm underwent surgical management quicker than patients with no posterior wall recession (P < 0.03). At follow-up, out of the 37 patients with initial neurologic deficits, 14 had improved (38%).

CONCLUSIONS

Diskoligament maturation is an essential concept in spine traumas in children, as well as in surgical management. Surgical procedures should be carried out as soon as possible when patients present with neurologic deficits. At the thoracolumbar junction, a 2-level up-and-down fixation is recommended.

Spine Injuries in Child Abuse

BACKGROUND

Although rare, spinal injuries associated with abuse can have potentially devastating implications in the pediatric population. We analyzed the association of pediatric spine injury in abused children and determined the anatomic level of the spine affected, while also focusing on patient demographics, length of stay, and total hospital charges compared with spine patients without a diagnosis of abuse.

METHODS

A retrospective review of the Kids' Inpatient Database was conducted from 2000 to 2012 to identify pediatric patients (below 18 y) who sustained vertebral column fractures or spinal cord injuries. Patients with a documented diagnosis of abuse were identified using ICD-9-CM diagnosis codes. Our statistical models consisted of multivariate linear regressions that were adjusted for age, race, and sex.

RESULTS

There were 22,192 pediatric patients with a diagnosis of spinal cord or vertebral column injury during the study period, 116 (0.5%) of whom also had a documented diagnosis of abuse. The most common type of abuse was physical (75.9%). Compared with nonabused patients, abused patients were more likely to be below 2 years of age (OR=133.4; 95% CI, 89.5-198.8), female (OR=1.67; 95% CI, 1.16-2.41), and nonwhite (black: OR=3.86; 95% CI, 2.31-6.45; Hispanic: OR=2.86; 95% CI, 1.68-4.86; other: OR=2.33; 95% CI, 1.11-4.86). Abused patients also presented with an increased risk of thoracic (OR=2.57; 95% CI, 1.67-3.97) and lumbar (OR=1.67; 95% CI, 1.03-2.72) vertebral column fractures and had a multivariate-adjusted mean length of stay that was 62.2% longer (P<0.001) and mean total charges that were 52.9% higher (P<0.001) compared with nonabused patients. Furthermore, 19.7% of all pediatric spine patients under 2 years of age admitted during the study period belonged to the abused cohort.

CONCLUSIONS

Spine injuries are rare but can be found in the pediatric population. With an additional documented diagnosis of abuse, these injuries affect younger patients in the thoracolumbar region of the spine, and lead to longer lengths of stay and higher hospital costs when compared with nonabused patients. Because of these findings, physicians should maintain a higher level of suspicion of abuse in patients with spine injuries, especially patients under 2 years of age.

LEVEL OF EVIDENCE

Level III evidence-a case-control study.

Pediatric Spine Emergencies

Acute onset of neurological signs and symptoms referable to the spine including difficulty walking, bowel and bladder dysfunction, and paresthesias in the extremities may be manifestations of pediatric spine emergency. Trauma is the most common etiology for a pediatric spinal emergency. Because a history of trauma is often available, the role of imaging involves detection of spinal injuries. Other pathologies such as infection, inflammation, vascular, and neoplasms may lead to pediatric spinal emergencies that also require imaging for assistance in determining the etiology and appropriate management.

Fatal atlantoaxial dislocation due to an odontoid synchondrosis fracture in a child with chromosome 9 abnormality: A case report

A 5-year-old boy with a chromosome-9 abnormality and multiple external and visceral malformations was found in cardiopulmonary arrest during a regular visit to the hospital; he did not respond to cardiopulmonary resuscitation and died. An odontoid process fracture and calcification and fibrosis of the muscles around the superior cervical vertebra were observed during the autopsy. Postmortem computed tomography revealed an anterior dislocation of the atlas; odontoid synchondrosis fracture; and delayed, incomplete bony fusion of the odontoid process relative to his age. The cause of his death was a superior spinal cord injury. The tissue surrounding the upper cervical spine presented with myositis ossificans, suggesting a prior injury. He experienced a minor traffic accident 3 months before his death. It was concluded that the odontoid synchondrosis fracture occurred during the accident based on the incomplete bony fusion and atlantoaxial instability, which were consistent with the findings of myositis ossificans. Delayed fatal dislocation may then have occurred under the influence of a minor external force. Odontoid process abnormalities and atlantoaxial instability are common in patients with trisomy 21 and other congenital diseases; however, the condition's association with chromosome-9 abnormalities has not been reported. In children with various chromosomal abnormalities, periodic assessment of instability and morphology of the cervical spine, and a lowered examination threshold for the children at risk, could prove useful in the prevention injuries leading to fatality, and provide additional information to rule out abuse.

Pediatric Injuries Treated at a Level 1 Trauma Center After an F5 Tornado

BACKGROUND

On May 22, 2011, an F5 tornado ripped through the city of Joplin, Mo, resulting in over 150 fatalities and over 750 injuries. Pediatric trauma centers in the region needed to be prepared to receive patients. Little data exist on the types of patients who are received at pediatric trauma centers after disasters such as tornados.

OBJECTIVE

The purpose of this study is to describe the patients received at the nearest level 1 pediatric trauma center after the tornado.

METHODS

Cases were identified through the trauma registry. Data regarding patient demographics, past medical history, characteristics of injury, treatment received, and outcomes were obtained retrospectively from medical records.

RESULTS

A total of 10 patients were received at the pediatric trauma center. Traumatic brain injury was the most common diagnosis followed by orthopedic and maxillofacial injuries. Seven patients required surgical procedures in the operating room, but only 1 patient required surgery within the first 24 hours of arrival. Eight patients were intubated and were in the pediatric intensive care unit. The average length of stay in the hospital was 19.4 days with a range of 14 hours to 94 days.

CONCLUSIONS

Immediately after a significant tornado in the referral region, pediatric trauma centers need to prepare to receive patients. Head injuries will likely be common, and pediatric trauma centers will likely receive multiple intubated patients. Knowledge of injuries received and resources needed can better prepare these trauma centers for future devastating tornadoes.

Cervical Spine Injuries in Children Associated With Sports and Recreational Activities

OBJECTIVE

The aim of this study was to ascertain potential factors associated with cervical spine injuries in children injured during sports and recreational activities.

METHODS

This is a secondary analysis of a multicenter retrospective case-control study involving children younger than 16 years who presented to emergency departments after blunt trauma and underwent cervical spine radiography. Cases had cervical spine injury from sports or recreational activities (n = 179). Comparison groups sustained (1) cervical spine injury from other mechanisms (n = 361) or (2) other injuries from sports and recreational activities but were free of cervical spine injury (n = 180).

RESULTS

For children with sport and recreational activity-related cervical spine injuries, common injury patterns were subaxial (49%) and fractures (56%). These children were at increased odds of spinal cord injury without radiographic abnormalities compared with children with cervical spine injuries from other mechanisms (25% vs 6%). Children with sport and recreational activity-related trauma had increased odds of cervical spine injury if they had focal neurologic findings (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.5-9.4), had complaints of neck pain (OR, 3.1; 95% CI, 1.9-5.0), were injured diving (OR, 43.5; 95% CI, 5.9-321.3), or sustained axial loading impacts (OR, 2.2; 95% CI, 1.3-3.5). Football (22%), diving (20%), and bicycle crashes (11%) were the leading activities associated with cervical spine injury.

CONCLUSIONS

In children injured during sports and recreational activities, focal neurologic findings, neck pain, axial loading impacts, and the possibility of spinal cord injury without radiographic abnormality should guide the diagnostic evaluation for potential cervical spine injuries. Certain activities have a considerable frequency of cervical spine injury, which may benefit from activity-specific preventive measures.