Clinical Review of Cervical Spine Injuries in Children PAULHENRYS, M.D.,* E. DENNISLYNE,M.D.,* CHARLES LIFTON,M.D.**
AND
GINO SALCICCIOLI, M.D.**
Certain constitutional peculiarities of children such as hypermobility1 and horizontal position of the facets,* as well as normal variations previously reported by Cattell and Filtzer4 may impair our radiological interpretation and evaluation of such injuries. Wackenheimlo described 5 radiological signs which have helped differentiate traumatic lesions in the upper cervical region from congenital anomalies or other variations: 1. Condyloatlantal diastasis - when one side is twice the width of the other, definite abnormality is diagnosed. 2. Increase of the axis foramen diameter. Normally the anteroposterior diameter of the atlas is 1-3mm greater than the axis. Reversal is abnormal. 3. Transverse dislocation of the cervicooccipital joint manifested by loss of symmetry of the atlanto-occipitalatlantoaxial joint. 4. A functional block of the atlantooccipital or atlantoaxial joint creating a constant relationship either with the atlanto-occipital or atlantoaxial joint with flexion, extension, or neutral position of the neck. 5. Differentiation of an odontoid fracture from an 0s odontoid, with a congenital anomaly showing evidence of reduction only with flexion and a fracture of base showing reduction usually with extension.
Cervical spine injuries have often constituted difficult diagnostic and treatment problems in orthopedics. Although the increase of industrial and automobile accidents has made the problem more familiar, it represents a challenging differential diagnosis when the patient is a child. From 1953 to 1973 1,299 traumatic lesions of the vertebral spine were seen and treated at Henry Ford Hospital, Detroit, Michigan. Table 1 shows their topographic distribution. Among the 63 1 cervical lesions, only 12 patients were under 15 years of age ( 1.9% ), though the average orthopedic cases load shows a normal general population mix age wise. A search of the medical records at Children’s Hospital, Detroit revealed no more than 5 cases during the years 1970-1973 and a recent case of a 1974 admission to the Henry Ford Hospital was added to this review to bring the total to 18 patients. Table 2 represents sex and age distribution with a preponderance of males and an increase in frequency with chronological age. This low incidence of cervical spine injuries in children before age 15 was surprising and perhaps is partially explained by the fact that this age group is less at risk to industrial and automobile accidents.
* Henry Ford Hospital 2799 West Grand Boulevard, Detroit Michigan 48202. **Wayne State University, Detroit, Michigan. Received: January 7, 1976. I72
Number 129 November-December, 1977
TABLE 1. Topography
Childhood Spine lniuries
Topographic Distribution Number
%
TABLE 2. Sex
I73
Age and Sex Distribution Cases
%
13
72.2%
5
27.8%
Cervical
63 1
48.2%
Males
Thoracic
422
33. %
Females
Lumbar
195
15. %
Total
41
3. %
Age
0.8% 100. %
0-2y
2
11.1%
3-5y
6
33.3%
6- 15y
10
55.6%
Sacral Coccygeal Total
10 1299
The mechanisms and intensities of injuries often are identical to the adult ones. Table 3 shows their etiological distribution. Age seems to be of importance. From birth to 2 years injuries to the cervical spine are very rare. Obstetrical complications constitute the principle cause. Warrick11 in 1919 referred to 2 cases in 130 deliveries, Capon3 in 1922 4 cases in 80 deliveries, and Potter9 in 1940 2 cases in 2,000 newborn autopsies. Two obstetrical injuries were registered in this series. From 3-5 years falls and automobile accidents were found to be the main causes. Six such cases are included in the present series. Hubbard7 reported in his series one case of a battered child in this age group. From the ages of 6-15 automobile accidents and athletic trauma are the most frequent causes. Ten such cases are recorded in this series and represent more than one-half the cases. Higher incidence of bony injuries in this age group may also reflect the fact that cervical spine at this age begins to acquire the adult feature of reduced flexibility. If it is true that the mechanisms of injury may be identical to adult ones it is not so for the topographic distribution. In this series 16 of 18 patients sustained injuries in the CI.4area while in the adult a greater involvement is usually seen at the level of C4.i.2
The neurological evaluation (Table 4 ) is of primary importance since damage to the spinal cord is the main complication. Seven out of 18 cases of this report suffered neuro-
18
Cases
loo.
%
%
logical injuries. Two were newborn, one with a fracture dislocation of G-, with an immediate quadriplegia and death at age one month and the other, fracture dislocation at C:+, with root avulsion resulting in permanent Erb's palsy of the left arm; 2 fracture dislocations of C:$., area with immediate quadriplegia secondary to diving injury and automobile accident respectively; 2 subluxations of C, on C2 with decerebration; and one subluxation of C, on C2 with transient paresthesia of the left arm secondary to a football injury. A good assessment of the general condition of the patient should be performed to rule out other systemic injuries. The associated injuries in this series shown on Table 5 represent the expected head trauma but not the diffuse trauma anticipated. It is also of interest to note that only 5 of 18 patients were felt by the surgeons to require operative treatment with one superficial wound infecTABLE 3. Auto
Etiologic Distribution
accident
Fall Athletic Obstetrical Total
18
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Clinical Orthopaedicr and Related Research
Henry, et al.
TABLE 4. Neurological Complications Case I
No grasp, no moro, no patellar jerk,
quadriparesis, death Case 2
Permanent palsy left arm secondary to brachial plexus injury
Case 7
Decerebration
Case 13 Spastic cerebral palsy Case 14 Transient paresis left arm Quadriplegia Case 18 Quadriplegia Case 16
tion and one infected halo pin (Table 6). Table 7 summarizes etiology, type of injuries, as well as neurological complications and treatment. FRACTURE OF T H E ODONTOID Fracture of the odontoid often offers the most difficult differential diagnosis in children since fusion of the whole odontoid process with the body occurs late ( 12-14 years of age). It is obvious that before 15 years the basilar odontoid epiphyseal plate,4 as well as anomalies of the odontoid process,sl hypoplasia and angulation,6 all can account for uncertainty in evaluation of a cervical spine injury in children. In this series 4 fractures of the odontoid were found, TABLE 5 . Associated Injuries Case 1
Cerebral trauma
Case 3
Cerebral concussion
Case 6
Ruptured spleen, liver laceration, superficial lacerat,ion of the abdomen
Case 7
Superficial laceration of the left parietal eminence
Case I 1
Laceration of thc forehead and right parietal area
Case 15
Fracture dislocation T;-T,)
TABLE 6. Complications of Treatment Case 3
Infected halo pin site
Case 16 Persistent subluxation C,-C, Case 18 Surgical superficial wound infection
all at the base, uncomplicated and treated in traction followed by Minerva jacket with satisfactory results. DISLOCATION In dislocation, defined as complete disruption of normal contact between articular surfaces, it should be appreciated that the posterior ligament is the main stabilizing factor. This series registered only one patient, a 7-year-old negro male, who fell off a swing and sustained a dislocation of C1 on C, with no X-ray evidence of fracture and no neurological deficit. Conservative treatment with Minerva jacket in reduced position failed and the patient underwent fusion of C1 on C, 3 months after the original injury with satisfactory result. FRACTURE-DISLOCATION This condition usually results from severe violence and accounts for the most severe neurological complications. This series showed that among 6 patients with fracture dislocation 5 developed neurological complications and one resulted in death. Three of 6 patients in this category underwent surgical fusion. Neurological lesions in these children demand special attention. Every effort should be directed to preventing contractures as well as avoiding pneumonia and urinary tract complications. SUBLUXATION AND PSEUDOSUBLUX ATION Differentiation of a traumatic from an inflammatory subluxation constitutes a major diagnostic problem. Subluxation may be de-
obst.
Auto Ac.
F
M
F
M
M
3 wk.
3 Yr.
3 yr.
3% yr
4 yr.
4 yr.
5 yr.
6 yr.
7 yr.
8 yr.
10 yr.
11 yr.
11 yr.
13 yr.
13 yr.
14 yr.
14 yr.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
M
M
M
M
F
F
M
M
M
F
M
M
obst.
F
1 day
1
Ci
Fxldisloc. C, on C7 Fx/disloc. CR on C , Fx/disloc. C1 on C, Fx base odontoid Fx of Lamina
Type of Injury
Ath. Diving
Auto Ac.
Auto Ac.
Fx Base odontoid Fx/disloc. CR on C ,
Fx base odontoid Auto Ac. Sublux. C1 on C2 Fx base Fall odontoid Auto Ac. Sublux Ci on C, Disloc. C1 Fall on C2 Auto Ac. Fx/disloc. C2 on C:( Sublux C1 Ath. Wrestling on C2 Sublux C1 Fall on C, Sublux C1 Ath. on C2 Ft. Ball Auto Ac. Fx pars articularis C, Auto Ac. Fx/disloc. C, on C,
Fall
Fall
Cairse
Sex
Age
No.
Quad
None
Quad
Paresis left arm None
Spasticity
None
None
None
None
None
Decerebration
None
None
None
None
Erb's Palsy
Quad
Neuro
Early
TABLE 7.
Quad
None
Quad
None
Spasticity
Pinch right hand None
None
None
Spastic cerebral palsy None
None
None
None
None
Quad
Lote Neuro
Sign out
CRU tongs Fusion C1 C2 Minerva Halter Decornp. Fusion C 2 C c Minerva
FXTZ-T, Halter-Minerva
Minerva-Fusion Minerva Halter-Minerva Collar Halter, Tongs Collar Fusion C1Cz Minerva Soft collar
Halter-soft collar
38
16
4
3
48
6
6
12
18
8
37
Tongs-Minerva Collar Halter-Minerva
1
3
12
1%
1 '42
6
Mongolism
Inf. Pins
Death
Other Follow-up Complications Month
Minerva-Collar
Closed reduction Minerva Closed reduction soft collar CRU tong Halo fusion OX2 Halter, Minerva Collar Halter-Brace
Treatment
176
Clinical Orthopaedics and Related Research
Henrys, et al.
fined as a mild shift of one vertebral body on the subjacent or superjacent one such that anteroposterior diameter of the spinal canal is altered. On the anteroposterior X-ray study subluxation would be defined as a change of the obliquity of the zygapophyseal joint facets with a coexistent change in the position of the spinous process. It is of interest that 5 cases of lateral subluxation were observed in this series. All cases were documented initially on X-ray and posttreatment to demonstrate this change. It is possible, especially considering 3 of 5 patients sustained neurological injury, that some were complete dislocations with spontaneous reduction but this was impossible to determine from a retrospective study. CONCLUSIONS Although the mechanisms of injury to the cervical spine may be the same in adults as in children, it is obvious that we cannot base our clinical judgment and appreciation upon our experience with the adult population. A study of the orthopedic literature on cervical spine injuries reveals a disproportionately small number of children. Distribution of injuries to the cervical spine in children showed a major difference in this series. Sixteen of 18 lesions were found in the CI-C4areas while in the adult a greater involvement is usually seen at the level of
crc,.
Normal variations, specifically at the C2Cn level, and anomalies of the odontoid process are not uncommon and must be differentiated. Use of specific X-rays such as laminograms may be helpful. Intelligent correlation of Wackenheim’slO 5 signs and the patient’s symptoms helped establish an accurate diagnosis. In case of doubt, it is safest to over treat initially. The vertebral compression injuries very common in adults were not found in this series. Neurological damage is the most disabling complication and occurred in 7 of 18 patients.
Despite extensive progress and rehabilitation. management of a growing paraplegic or quadriplegic child remains laborious and challenging.
SUMMARY Clinical presentation is made of 18 cervical fractures occurring in children age 15 and under. Seven of 18 patients sustained neurological complications. The incidence of childhood cervical spine injury increases with age. Sixteen of 18 lesions were found in the C! through C4 area in contrast to a greater involvement in adults in levels of C , through Ci. Although normal variations and anomalies are frequent in cervical spines in children, over treatment, at least initially, is recommended in all cases in which the diagnosis is in doubt. REFERENCES I . Bailey, D. K.: The normal cervical spine in infants and children, Radiology 59:712,1952. 2. Bohlman, H. H.: Personal Communications. 3. Capon, N. B.: lntracranial traumata in the newborn, J. Obstet. Gynaecol. Br. Emp. 572. 1922. 4. Cattell, H. S. and Filtzcr, D. L.: Pseudosubluxation and other normal variations in th: cervical spine in children, J. Bone Joint Surg. 47A: 1295, 1965. 5 . Dunlap, J. P., Morris, M. and Thompson, R. G.: Cervical spine injuries in children, J. Bone Joint Surg. 40A:681, 1958. 6. Garber, J. N.: Abnormalities of the atlas and axis vertebra congenital and traumatic, J. Bone Joint Surg. 46:1782, 1964. 7. Hubbard, D. D.: Injuries of the spine in children and adolescents. Clin. Orthop. 100:56. 1974. 8. Nicholson, J. T.: Symposium Sur les Lesions Traumatiques de la Colonne Cervicale; Aspects Radiologiques chez L’ Enfant: Rev. Chir. Orthop. 50, 5, 715, 1964. 9. Potter, E. L.: Fetal and Neonatal Deaths ( A Statistical Analysis of 2,000 Autopsies), JAMA 12,996, 1940. 10. Wackenheirn, M. A.: Cinq signes radiologiques originaux concernant la traumatolgic de las region cervico-occipitale Lowain Med. 91 :421,1972. 11. Warwick, M.: cerebral hemorrhage of the newborn, Am. J. Med. Sci. 95:158, 1919.