Pediatric emergency medicine trisk 904
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FIGURE 112.29 Examples of cervical compression injuries. A: Teardrop fracture. This patient
sustained a whiplash injury with resultant flexion injury. A typical flexion teardrop fracture is
demonstrated at 1 . An increased interspinous distance and an associated avulsion fracture of the
posterior elements of C5 are demonstrated at 2 . B: Anterior C6 vertebral wedge fracture (arrow
). C: Burst fracture of C4 vertebral body (arrow ). (A : Reprinted with permission from
Swischuk L. Emergency Radiology of the Acutely Ill or Injured Child . 2nd ed. Baltimore, MD:
Williams & Wilkins; 1986:674.)
Vertebral Compression Injuries
Vertebral compression injuries are most frequently caused by axial loading and
hyperflexion. They are suggested by isolated anterior wedging, teardrop fractures,
or burst vertebral bodies ( Fig. 112.29 ). The vertebral bodies should be regular,
cuboid, and consistent between adjacent cervical levels ( Fig. 112.29 ). A
flexion/rotation stress can lead to anterior subluxation of one vertebral body on
another with facet dislocation (“locked” or “jumped” facet) ( Fig. 112.30 ). If the
anterior displacement is less than 50% of the vertebral body width, it is consistent
with a unilateral facet dislocation ( Fig. 112.30 ). More than a 50% anterior
subluxation suggests a bilateral facet dislocation ( Fig. 112.30 ). These injuries are
often accompanied by widened interspinous and interlaminar spaces, anterior soft
tissue swelling, and a narrowed disc space.
Spinal Cord Injury Without Radiographic Abnormality
SCIWORA was initially described as occurring in up to 67% of all children with
cervical cord injuries ( Fig. 112.31 ), and up to 25% of cervical cord injuries in
children younger than 8 years. SCIWORA has been described as mainly occurring
in children younger than 8 years who present with, or develop symptoms
consistent with, cervical cord injuries without any radiographic or tomographic
evidence of bony abnormality. Some authors have recently suggested that the
diagnosis of SCIWORA be applied only to those patients who also do not have
abnormal MRI findings. The original characterization of this syndrome occurred
during a period when MRI was less available and it is important to note there are
distinct differences between patients with and without MRI findings in the setting
of persistent neurologic abnormalities. Regardless, this type of injury is not often
seen in children older than 8 years because the forces necessary to injure the
spinal cord also cause persistent spinal column abnormalities. In older children,
sports-related injuries have been found to have a higher association with
SCIWORA (OR 3.5) as compared to those injured by other mechanisms. The
young child’s elastic spinal column, ligamentous laxity, horizontal facets, and
underdeveloped spinous processes allow the spine to deform beyond physiologic
extremes, injuring the cord, and then reducing spontaneously without any
persistent (radiographic) evidence of bone injury. The causes of the neurologic
compromise can include segmental spinal instability, vascular injury (occlusion,
spasm, and infarction), ligamentous injury, disc impingement, or incomplete
neuronal destruction. A subset of patients has initial transient neurologic
symptoms as previously described, temporarily recover, and then return, on
average, 1 day later with neurologic abnormalities. Therefore, hospitalization,
immobilization, and further radiographic evaluation (MRI) for this group of
patients may be optimal. Neurosurgical consultation is recommended if the history
suggests a SCIWORA-type injury in a child younger than 8 years.
FIGURE 112.30 Unilateral facet dislocation. C4 is offset anteriorly on C5 less than 50% of the
width of the vertebral body. Arrows denote the offset of vertebral body and apophyseal joints.
The disc space between C4 and C5 is narrowed. Note that the distance between the posterior
cortex of the apophyseal joint facet and the anterior cortex of the spinous process tip is wider
below the level of dislocation than above the level (stars ). Anterior vertebral offset of more than
50% would denote a bilateral facet dislocation. (Reprinted with permission from Swischuk L.
Emergency Radiology of the Acutely Ill or Injured Child . 2nd ed. Baltimore, MD: Williams &
Wilkins; 1986:697.)
FIGURE 112.31 Magnetic resonance imaging (MRI) of a SCIWORA patient. Accompanying
cervical spine radiographs were normal. The MRI demonstrates an area of cord contusion in the
midcervical area (arrows ). This patient had physical evidence of a central cord syndrome.
(Reprinted with permission from Swischuk L. Emergency Radiology of the Acutely Ill or Injured
Child . 2nd ed. Baltimore, MD: Williams & Wilkins; 1986:710.)
Torticollis (Wry Neck)
Torticollis is a common complaint in the pediatric ED. The clinician should
always inquire about traumatic events because an underlying bone injury may be
present. Often, however, torticollis is caused by spasm of the sternocleidomastoid
(SCM) muscle. In the patient with muscular torticollis, their chin points toward
the unaffected side, while SCM spasm occurs on the affected side. This condition
is different from rotary subluxation. Rotary subluxation is a cervical spine injury
that is often misdiagnosed or undiagnosed because of difficulty in interpreting a
