Pediatric Cervical Spine Injuries: A Rare But Challenging Entity

[Pediatric Upper Cervical Spine Injuries: a Systematic Review]

PURPOSE OF THE STUDY

The study aimed to systematically review the available literature focusing on upper cervical spine injuries in children, namely the age and sex of patients, epidemiology of injuries, classifications used, diagnosis and treatment methods, neurologic deficit, concomitant injuries, and potential complications.

MATERIAL AND METHODS

The systematic review was elaborated in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The studies assessing pediatric upper cervical spine injuries were searched for in the MEDLINE database in September 2023. The studies included were published between 1991 and 2022.

RESULTS

A total of 1354 studies were found through the database search. Subsequently, 53 articles were excluded as duplicates and 1217 due to irrelevant title or abstract. The full text of 84 studies was reviewed. Sixty-nine manuscripts failed to meet the predefined criteria. In the end, the systematic review was based on 15 studies. In the cohort of paediatric patients with upper cervical spine injuries, the girls accounted for 51.1% and boys for 48.9%. X-ray (64.9%) and CT (56.2%) were the most commonly used imaging for diagnosis, with MRI (51.5%) being the least used diagnostic method. Surgical procedure was opted for in treating more than a quarter of cases (27.6%). Most of the surviving patients were neurologically intact (69.2%), a fairly large number of patients (14.4%) died. The most common concomitant injury was craniocerebral trauma (39%) and the most common treatment complication was the instrumentation failure (11.3%).

DISCUSSION

Upper cervical spine injuries are rare in children and represent a relatively heterogeneous group. The literature on this topic is mostly inconsistent. Currently, there is just a few studies dealing with pediatric upper cervical spine injuries as a whole; more often the papers focus on a single type of injury. Inconsistencies also occur in defining the age limit for the pediatric spine and in defining the upper cervical spine. For these reasons, comparing the results of individual studies can be difficult.

CONCLUSIONS

The mean age of pediatric patients with upper cervical spine injuries was 6.7 years, with a slight predominance of girls. The most common cause of injury was traffic accidents. X-ray and CT were the most commonly used diagnostic methods and surgical therapy was opted for in treating more than a quarter of cases. More than two-thirds of the surviving patients were neurologically intact. Instrumentation failure was the most common treatment complication and craniocerebral trauma was the most common concomitant injury.

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

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

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.

CONCLUSION

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 neck pain of a 10-year-old child with cervical spinal tumor evaluated and managed in direct access physical therapy: a case report

INTRODUCTION

Differential diagnosis of pediatric neck pain requires age-appropriate communication and assessment tools. Recognizing these age-related nuances is critical, emphasizing the role of physical therapists in assessing and managing pediatric patients while ruling out severe pathologies.

CASE DESCRIPTION

A 10-year-old male presented to physical therapy with a five-week history of increasing neck pain. A thorough history and segmental cervical examination considering the patient's age and development, led to patient referral to the emergency department. This case underscores the significance of comprehensive evaluation in pediatric neck pain management.

OUTCOMES

The patient was diagnosed with Langerhans Cell Histiocytosis (LCH). LCH primarily affects children and is treated with chemotherapy. Chemotherapy reduced the tumor, revealing C2 vertebral body damage. The patient underwent C1-C3 fusion surgery, a standard procedure for atlanto-occipital region stabilization in children. The patient was advised to restrict motion for 6 months while monitoring for tumor growth.

DISCUSSION-CONCLUSION

Pediatric neck cancer presents diagnostic challenges due to varied symptoms, but research highlights specific indicators to assist with differential diagnosis. This case emphasizes the need to recognize the complexities of pediatric neck pain and perform a thorough age-appropriate evaluation.

New clinical decision tool to assist physical therapists with joint mobilization application to the pediatric population

Joint mobilizations are well-established and extensively researched treatment modality for adults. However, it remains largely unexplored in the pediatric population. Physical therapists hesitate to perform joint mobilization on children because of lack of knowledge, concern for the developing skeletal system, and the paucity of research on the topic. The aim of this article is to present a decision tool created for a continuing education course with the purpose to instruct pediatric therapists in the safe and effective use of joint mobilizations in children. It is based on the pediatric paradigm of developmental and functional assessment to best address the concerns and preferences of physical therapists (PTs). To advance research in pediatric joint mobilization, PTs should listen to the concerns of pediatric therapists and respond to those concerns with effective, evidence-supported training. This decision tree will serve as a resource for the education of pediatric therapists in the safe and effective use of joint mobilizations.

Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study

OBJECTIVES

The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy.

MATERIALS AND METHODS

Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years).

RESULTS

A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92).

CONCLUSIONS

The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically.

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.

Comprehensive treatment algorithm for atlanto-axial rotatory fixation (AARF) in children

BACKGROUND

Atlanto-axial rotatory fixation (AARF) is an uncommon condition in children presenting with torticollis. Many studies have elaborated on the diagnostic sequence of AARF. However, there is no consensus for the algorithm of management of AARF.

METHODS

This study proposes to provide a comprehensive step-by-step guideline which aims to achieve and retain anatomic reduction of the atlanto-axial joint (AAJ). We recommend a 'therapeutic crescendo': closed reduction and immobilization in a rigid cervical collar (step I). In cases of re-dislocation, a second attempt of closed reduction and immobilization in a Halo-jacket (step II). Cases of recurrent dislocations due to persistent instability require open reduction and internal fixation. We present a new surgical technique of transverse suture transfixation (TSF) of C1/C2 (step III). Alternatively, a dorsal stabilization of C1/C2 is indicated after open reduction (step IV). 13 patients with radiologically confirmed AARF were included in this study. These patients were treated as per the above mentioned algorithm. All these patients were serially evaluated with a minimum follow-up of 1 year.

RESULTS

Clinical data of 10/13 patients were available for follow-up evaluation at mean 4.6 years after the onset of symptoms. Two patients were managed surgically. We recorded good clinical results in all patients treated according to the algorithm.

CONCLUSIONS

AARF is a subacute pediatric emergency. Reduction and maintenance of joint congruency of the AAJ are the treatment goals. The comprehensive therapeutic algorithm presented in this study is applicable in patients with AARF to achieve excellent long-term results.

LEVEL OF EVIDENCE

IV, Retrospective cohort study.

TRIAL REGISTRATION NUMBER

Clinical Trial Registry University of RegensburgZ-2014-0453-4. Registered 01 December 2014.

Pediatric Cervical Spine Injuries and SCIWORA: WFNS Spine Committee Recommendations

Cervical trauma in children have variations from the adults mainly due to anatomic differences. An optimal diagnostic and treatment strategy is critical, particularly when there is a lack of standardized protocols for the management of such cases. This review paper examines the diagnostic and treatment options of pediatric cervical trauma and Spinal Cord Injury Without Radiographic Abnormality (SCIWORA). A literature search for the last 10 years were conducted using key words. Case reports, experimental studies, papers other than English language were excluded. Up-to-date information on pediatric cervical trauma and SCIWORA were reviewed and statements were produced to reach a consensus in 2 separate consensus meeting of WFNS Spine Committee. The statements were voted and reached a consensus using Delphi method. This review reflects different aspects of contemporary pediatric cervical trauma decision-making and treatment, and SCIWORA. The mainstay of SCIWORA treatment is nonsurgical with immobilization, avoidance of risky activities. Prognosis generally depends on the initial neurological status and magnetic resonance imaging. Due to a significant discrepancy in the literature on diagnostic and management, future randomized controlled trials are needed to aid in generating standardized protocols.

Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre

PURPOSE

Cervical spine injury after blunt trauma in children is rare but can have severe consequences. Clear protocols for diagnostic workup are, therefore, needed, but currently not available. As a step in developing such a protocol, we determined the incidence of cervical spine injury and the degree of protocol adherence at our level 2 trauma centre.

METHODS

We analysed data from all patients aged < 16 years suspected of cervical spine injury after blunt trauma who had presented to our hospital during two periods: January 2010 to June 2012, and January 2017 to June 2019. In the intervening period, the imaging protocol for diagnostic workup was updated. Outcomes were the incidence of cervical spine injury and protocol adherence in terms of the indication for imaging and the type of imaging.

RESULTS

We included 170 children in the first study period and 83 in the second. One patient was diagnosed with cervical spine injury. Protocol adherence regarding the indication for imaging was > 80% in both periods. Adherence regarding the imaging type decreased over time, with 45.8% of the patients receiving a primary CT scan in the second study period versus 2.9% in the first.

CONCLUSION

Radiographic imaging is frequently performed when clearing the paediatric cervical spine, although cervical spine injury is rare. Particularly CT scan usage has wrongly been emerging over time. Stricter adherence to current protocols could limit overuse of radiographic imaging, but ultimately there is a need for an accurate rule predicting which children really are at risk of injury.

Pediatric dens anatomy and its implications for fracture treatment: an anatomical and radiological study

PURPOSE

Separation of C2 growth plates and dens fractures are the most common types of injuries to the axis (C2) in children. Operative treatment of these injuries with the use of direct osteosynthesis requires a profound knowledge of detailed anatomy and dimensions of the axis. The main issue addressed by the study was the age at which the size of the dens is adequate at all levels to accommodate two screws, and the size of the posterior dens angulation angle (PDAA) in a healthy child in individual age periods.

METHODS

Dimensions and angles of the dens and C2 in individual age categories in both boys and girls were measured in a series of 203 CT scans of individuals 0-18 years old and on anatomical specimens (42 samples). In addition, 5 histological series of this region from the fetal period were reviewed.

RESULTS

Dimensions of the dens gradually increase with age, with a considerable acceleration during growth spurt periods that are different in boys and girls. PDAA is markedly changing with age; in the fetal period, the dens shows a slight anterior angulation which gradually transforms into posterior angulation, as early as between 4 and 6 years of age. The screw insertion angle changes accordingly.

CONCLUSION

During growth, there occur changes in PDAA that should be respected in evaluation of transformation of anterior into posterior angulation, as shown by imaging methods. Dens dimensions theoretically allow insertion of two 3.5 mm screws as early as from the age of 1 year.

Management of cervical spine trauma in children

PURPOSE

Paediatric cervical spine injuries are fortunately a rare entity. However, they do have the potential for devastating neurological sequelae with lifelong impact on the patient and their family. Thus, management ought to be exceptional from the initial evaluation at the scene of the injury, through to definitive management and rehabilitation.

METHODS

We set out to review cervical spine injuries in children and advise on current best practice with regards to management.

RESULTS

Epidemiology, initial management at the scene of injury, radiological findings and pitfalls of cervical spine trauma are outlined. Strategies for conservative and surgical management are detailed depending on the pattern of injury. The management of spinal cord injuries without radiological abnormality (SCIWORA) and cranio-cervical arterial injuries is also reviewed.

CONCLUSIONS

Due to a paucity of evidence in these rare conditions, expert opinion is necessary to guide best practice management and to ensure the best chance of a good outcome for the injured child.

Transoral Closed Reduction of Fixed Atlanto-Axial Rotatory-Subluxation (AARS) in Childhood and Adolescence

Atlanto-axial rotatory-subluxation (AARS) is the most common pediatric cervical spine injury. Patients usually present with contralateral rotation and inclination of the upper cervical spine after minor trauma, or associated with an infection of the upper respiratory tract. According to the authors, initial management of patients with acute and chronic AARS type I-II should comprise closed reduction and immobilization with a cervical collar or a Halo-Body-Jacket. Surgical options of open reduction or C1/2 fusion should be restricted to irreducible or recurrent subluxations. This paper reviews the detailed technique of transoral closed reduction of AARS, as well as the preoperative and postoperative considerations.

Pediatric spinal cord injury without radiographic abnormality in the era of advanced imaging

PURPOSE OF REVIEW

The current review describes the current evidence on pediatric spinal cord injury without radiographic abnormality (SCIWORA) with attention to the definition, epidemiology, and clinical presentation of the condition, as well as common MRI findings, management strategies, and outcomes.

RECENT FINDINGS

Recent literature demonstrates that with more widespread MRI use, our understanding of SCIWORA has improved. The new literature, although still limited, provides a more granular conceptualization of patterns of injury as well as potential prognostic stratification of patients based on MRI findings. Through case studies and national database analyses, researchers have further defined the epidemiology and outcomes of SCIWORA.

SUMMARY

Although SCIWORA occurs infrequently, thus making robust research a challenge, maintaining a high suspicion in the appropriate clinical setting ought to prompt acquisition of advanced imaging. For patients with persisting neurologic symptoms after trauma, despite negative plain films and cervical spine computed tomography, MRI can be helpful diagnostically as well as prognostically. Once SCIWORA is diagnosed, patients are treated nonoperatively with hard collar immobilization and physical therapy.