Pediatric emergency medicine trisk 906
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FIGURE 112.33 Rotary subluxation of C1 and C2. A: Grossly normal lateral neck radiograph
in an 8-year-old child with rotary subluxation. B: Grossly normal open-mouth (odontoid)
radiograph in an 8-year-old child with rotary subluxation. C: Computed tomographic (CT) scan
demonstrating marked rotary subluxation of C1 clockwise around dens. Actual measurement
was 22 degrees of rotation. D–G: CT evidence of fixed rotary subluxation in a 6-year-old child.
D: Lateral radiograph demonstrating mild increased distance of predental space. E: Axial CT
scan demonstrating asymmetry between right and left sides and increased distance between dens
and patient’s left side of C1 (star noted on E–G ) (asymmetry between right and left sides). F:
Axial CT scan with patient’s head turned to the right, demonstrating asymmetry between the
dens and ring of C1. G: Axial CT scan with patient’s head turned to the left, demonstrating fixed
asymmetry between the dens and the ring of C1.
Spinal Cord Syndromes
Several specific spinal cord syndromes may be encountered in the ED ( Fig.
112.34 ). A spinal cord concussion (transient traumatic paresis or paralysis)
involves neurologic symptoms that completely resolve over a short period. This
condition can occur with or without associated fracture or dislocation. A complete
cord transection (either mechanical or physiologic) results in immediate and
permanent loss of all neurologic functions distal to that level ( Fig. 112.34 ). The
anterior cord syndrome results from the loss of neurologic function in those areas
supplied by the anterior spinal artery ( Fig. 112.34 ). Motor function is lost below
the level of the lesion. Touch and proprioceptive functions, carried by the dorsal
(posterior) columns, are preserved. The posterior cord syndrome is rare ( Fig.
112.34 ). It involves the loss of proprioceptive functions, deep pressure, and pain
and vibratory sense, with preservation of motor and temperature sensation. This
can occur with direct posterior cord trauma or posterior spinal artery involvement.
The Brown-Séquard syndrome (hemisection of the cord) involves contralateral
loss of pain and temperature sensation with ipsilateral motor findings (weakness
or paralysis) below the lesion ( Fig. 112.34 ). The central cord syndrome signifies
an injury that is most severe in the center of the cord and less so toward the
periphery ( Fig. 112.34 ). The resultant physical examination demonstrates motor
strength that is more severely depressed in the arms than in the legs. These
designations may be useful in suggesting prognosis. Approximately two-thirds of
those patients with central cord syndrome and one-third of those with the BrownSéquard syndrome recover. Complete transections and anterior cord syndrome
usually signify nonreversible lesions. Patients with posterior cord syndrome
usually recover but may demonstrate some degree of ataxia.
FIGURE 112.34 Graphic illustrations of a normal cervical spinal cord and specific postinjury
syndromes. A: Brown-Séquard syndrome. B: Central cord syndrome. C: Anterior artery
syndrome. D: Complete transection.
The os odontoideum is an abnormality that may be the result of an occult
flexion injury with subsequent incomplete healing and bone resorption ( Fig.
112.35 ). It may also represent an overgrowth of the ossiculum terminale, often
associated with a hypoplastic dens. This leads to a risk of increased mobility and
cord injury at the C1–C2 level and may require surgical stabilization. This
condition can be confused with a fracture at the base of the odontoid. The
ossiculum terminale is a small ossicle at the tip of the dens ( Fig. 112.36 ). It is
seen in most children, fusing with the rest of the dens by adolescence. This ossicle
can be large and associated with a hypoplastic dens, as previously described.
FIGURE 112.35 Example of os odontoideum. Note the hypoplastic dens and overgrown
ossiculum terminale or ossiculum odontoideum (O ). The arrow indicates posterior
displacement, attesting to instability of the lesions. (Reprinted with permission from Swischuk
L. Emergency Radiology of the Acutely Ill or Injured Child . 2nd ed. Baltimore, MD: Williams
& Wilkins; 1986:717.)
Spinal epidural hematomas are also seen in the pediatric population. These
hematomas are venous bleeds that compress the adjacent spinal cord and present
hours or days after a sometimes minor traumatic event, with ascending neurologic
symptoms as the bleed progresses. An MRI scan can be helpful in evaluating
these patients ( Fig. 112.37 ). Rapid evaluation and surgical decompression are
mandatory.
Treatment of children with suspected cervical spine injuries may involve basic
and advanced life-support measures, initiation and/or maintenance of
immobilization, and neurosurgical or orthopedic consultation. Airway support for
patients with traumatic quadriplegia should be anticipated because they will
develop respiratory failure as their respiratory muscles fatigue. Children may
present in spinal shock (hypotension, bradycardia, peripheral flush) from the loss
