Pediatric emergency medicine trisk 3578 3578
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Current Evidence
Cervical spine injuries are uncommon in children, occurring in an estimated 1% to
2% of patients with multiple trauma. The majority of injuries are a result of blunt
forces. Motor vehicle crashes are the most common mechanism across all age
groups, with the highest risk injuries occurring in children who are unrestrained in
high-speed collisions (head-on or roll-over) or ejected from the vehicle. Other
mechanisms include sports-related injuries for children older than 8 years of age
and falls for children younger than 8 years of age. For sports-related injuries,
accidents with axial loading mechanisms and those that occurred during diving
and football are associated with poorer neurologic outcomes. Nonaccidental
trauma should also be considered in younger children.
It is estimated that 5% of all spinal injuries occur in children younger than 16
years. However, approximately 72% of spinal injuries in children younger than 8
years occur in the cervical region. Certain pre-existing conditions (Down,
Maroteaux–Lamy, Morquio, Grisel, and Klippel–Feil syndromes; achondroplasia;
congenital cervical stenosis; Chiari malformation; rheumatoid disease; and acute
soft tissue or bony infection or infiltration) may result in a cervical spine more
predisposed to injury with minor or more significant trauma. Neurologic sequela
may also occur in pediatric patients undergoing spinal manipulation for
therapeutic purposes. Neonatal spinal injury may result from birth-associated
trauma and is reported in approximately 1 in 60,000 births. These patients often
have a history of forceps use during delivery or abnormal head presentation
causing neck hyperextension and may exhibit examination findings of weakness,
flaccid quadriplegia, spinal shock, and apnea. These birth-related injuries carry
high morbidity and mortality. CT or MRI is the preferred imaging modality.
The pediatric cervical spine and its evaluation differ in several ways from that
of the adult cervical spine. The fulcrum of the cervical spine of an infant is at
approximately C2–C3 and reaches C3–C4 by 5 to 6 years of age. At about 8 to 10
years of age, the fulcrum (C5–C6) and other characteristics of the cervical spine
approximate that of an adult. The higher fulcrum of a young child’s spine in
combination with a relatively larger head, weaker neck muscles, and poor
protective reflexes accounts for 74% to 78% of injuries in younger children
involving the upper cervical spine (occiput–C2).
Older children and adults have injuries that more often (53%) involve the
subaxial cervical spine (C3–C7). Neurologic disability can occur from cervical
lesions at all levels, but high cervical cord injuries are more likely to be fatal than
are lower cervical cord injuries due to respiratory compromise.
