pediatric cervical spine injuries daniel a. hirsh, md emory university school of medicine...

Pediatric Cervical Spine Injuries

Daniel A. Hirsh, MD

Emory University School of Medicine

Children’s Healthcare of Atlanta

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Objectives

Epidemiology Anatomy: Pediatric vs Adult Types of injuries Who can be cleared clinically Imaging Choices An approach to clearing a c-spine Lateral Plain Film Cases Wrap Up

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Epidemiology

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Epidemiology: Incidence

Pediatric Spinal Cord Injury (SCI) is rareOf Population: ~1 in 1,000,0001 or 1,000 per year3

Of Fractures: 1-2%, but highest mortality2 Of Trauma: 1-2% 5,6 Of All SCI: Accounts for <10%, <15 years old 1

Likely under-reported3,4

Male : Female 2:1

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Epidemiology: Incidence @ CHOA

*Trauma Registry Patients: All patients that have a Trauma ICD9 code, admitted for greater than 24 hours, or transferred, or admitted to OR or ICU regardless of length of stay.

**Based on ICD-9 Codes

YearTrauma Pts Who Met

Registry Criteria*

C Spine Related

Injuries**

% of Trauma Pts Who Met

Registry Criteria Deaths

C Spine Related Injuries

Resulting in Death**

% of All Trauma Deaths

2005 1521 18 1.2 8 3 37.52006 1535 24 1.6 5 1 20.0

3056 42 1.4 13 4 30.8

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Epidemiology: Age

Most frequent in: 15-24 year age group4

In under 15 year olds, mean age is 8 @ CHOA, mean age 11

7

Epidemiology: Age

Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery 39(3): 483-486.

Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery 36(8): 1107-1114.

8

Epidemiology: Age

Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery 39(3): 483-486.

Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery 36(8): 1107-1114.

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Epidemiology: Age

The younger the child the… • higher the lesion• higher mortality7

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Epidemiology: Age

Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

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Epidemiology: Age

Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

12

Epidemiology: Age

Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

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Epidemiology: Mechanisms

1. Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

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Epidemiology: Mechanisms

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Epidemiology: Mechanisms

Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics 119: e275-283

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Epidemiology: Mechanisms

Vohra. Et al. (2006) “Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic” Pediatrics 119: e275-283

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Epidemiology: Mechanisms

Leonard, M., J. Sproule, et al. (2007). "Paediatric spinal trauma and associated injuries." Injury 38(2): 188-193.

21

Epidemiology: Mechanisms

1. Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

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Epidemiology: Mechanisms

1. Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

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Epidemiology: Mechanisms

1. Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

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Epidemiology: Mechanisms

Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

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Epidemiology: Mechanisms

Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

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Epidemiology: Mechanisms

Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

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Epidemiology: Associated Injuries

Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

~40% of SCI have associated injuries

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Epidemiology: Associated Injuries

Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

~40% of SCI have associated injuries

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Anatomy: Pediatric vs Adult

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\

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37 yo driver lap/shoulder/airbag restrained and her 7 yo son backseat lap/shoulder restrained involved in head on accident. Both in a c-collar. Both have neck pain.

What are this boy’s anatomic disadvantages compared with his mom?

Anatomy: Pediatric vs Adult

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Proportionally larger, heavier head= higher center of gravity:• “..the human head reaches 50% of its adult circumference

by age 18 months, whereas thoracic circumference does not reach this milestone until 8 years of age.”

Weaker and underdeveloped neck musculature Greater elasticity and laxity of ligaments More horizontal orientation of facet joints Fulcrum of Cervical Spine Motion

• Pediatric: C2-C3• Adult: C5-C6

Anatomy: Pediatric vs Adult

33Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following

Injury. 14: 552-564.

Anatomy: Pediatric vs Adult

34Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

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Anatomy: Pediatric vs Adult

Biomechanical and anatomic difference Begins to disappear at 8 years old

Completes at 15-17 years old Literature suggest 2 distinct groups <8 and >=8

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Anatomy: Pediatric vs Adult

Higher prevalence of lesions above C4 More cervical distraction injuries Spinal Cord Injury Without Radiographic Abnormality

(SCIWORA)

37 Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

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Types of Injury

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Types of Injury

Atlanto-occipital injuries• High energy• Typically fatal• More prevalent in young

children than adults

40Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

41Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

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3

4 anterior longitudinal ligament.

42Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

12

3

4 anterior longitudinal ligament.

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Types of Injury

Atlas Fracture• Axial load (like Jefferson

burst fracture in adults)• Open synchondrosis

44Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

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Types of Injury

Traumatic Atlantoaxial Instability• Tear in transverse

ligament• Rare

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Types of Injury

Odontoid fracture• Most common fractures

of cspine in children• Usually through the

subdental synchondrosis in young children

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Types of Injury

Odontoid fracture• Most common fractures

of cspine in children• Usually through the

subdental synchondrosis in young children

48Khanna G et Al (2007) “Imaging of cervical spine injuries of childhood” Skeletal Radiology. 36:477-494

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Types of Injury

Pars interarticularis Fracture of C2• Hangman’s

(hyperextension)• Extremely rare

Distraction Injuries

Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

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Pseudosubluxation

Children have normal physiologic displacement @ C2-3 and C3-4 spaces

Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

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Pseudosubluxation

Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

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Pseudosubluxation

Children have normal physiologic displacement @ C2-3 and C3-4 spaces

Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539

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Types of Injury: SCIWORA

Spinal Cord Injury WithOut Radiographic Abnomality First described in 1980’s before advancements in

MRI Subsequent literature suggest up to 30% all

pediatric cord injuries*

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Types of Injury: SCIWORA

Evolving Definition: Positive neurological findings

weakness, paresthesias, lightening/burning sensation down the spine/extremity or related to neck movement

AND

Xray (-) , CT (-), MRI (+) 6% of SCIOR

Xray (-) , CT (-), MRI (-) 1% of SCI3

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Who can be cleared clinically?

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Which 7 yo can you clinically clear?

1. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck

2. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity.

3. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

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Which 7 yo can you clinically clear?

1. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck

2. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity.

3. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

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Which 7 yo can you clinically clear?

1. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck

2. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Complains of arm pain with a deformity.

3. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver’s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

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Who can be cleared clinically?

National Emergency Medicine XRay Utilization Study (NEXUS) 9

• Prospective• Evaluation of c-spine injury in children• Identify patients at low risk

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NEXUS : Study Definitions

Low Risk Patient

Those with none of the following criteria:• Midline cervical tenderness• Focal neurologic deficits• Altered level of alertness• Evidence of intoxication• Distracting painful injury

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NEXUS : Study Definitions

High Risk Patient

Those with any of the following criteria:• Midline cervical tenderness• Focal neurologic deficits• Altered level of alertness• Evidence of intoxication• Distracting painful injury• Instability or inability to assess

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NEXUS: Study Definitions

Distracting Injury

Significant, painful injury• Skin Large lacerations or heavy bleeding• Soft tissue Crush injuries• Muscle • Bone Any long bone fracture• Vascular structures• Viscera Injury requiring surgical consultation

• Any injury causing acute functional impairment

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NEXUS : Study Results

Of 3,065 children enrolled, 30 had c-spine injuries (0.98%) All 30 were classified as: “high-risk”

No child from the “low-risk” group had a c-spine injury

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NEXUS : Study Results

Value (95% CI)

Sensitivity 100% (87.8 – 100%)

Negative Predictive Value 100% (99.2 – 100%)

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Not so fast…

1. Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

66

Not so fast…

1. Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700

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Ehrlich et al Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients 2009

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Ehrlich et al Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients 2009

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Which 7 yo can you clinically clear?

None of them!Next step…

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How to clinically clear patient with neck pain?

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Imaging choices

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Imaging choices

Plain Film Xrays• Pro: Less radiation than CT. Can be done in trauma bay. Can pick

up most injuries if good technique. Less costly.• Con: Poor technique may lead to repeat shots. Can be difficult to

get odontoid view in a young patient CT Scan Neck

• Pro: Highly sensitive for fracture. • Con: Higher radiation dose to neck. In current facility have to move

patient to another area. More costly.

Issue of initial CT Head and CT Neck versus Ct Head and Plain Film Neck: (Jimenez et al 2008) Plain film first, then CT if needed

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Imaging choices

Flexion and Extension Lateral Xrays• Pro: Can help diagnose ligmentous injury not seen on Xray or CT• Con: Patient must Actively move their head. Muscle spasm often

limits this test• Should not perform Passive Flex/Ex on unconscious patient• If patient has normal static cervical spine radiographs, addition flex-

ext are of questionable use (Dwek, et al Chung 2000)

MRI• Pro: “Gold Standard” (Munchow RD et al 2008) Highly sensitive for

spinal cord injury. Helps with unconscious pts in whom there is high clinical suspicion of C-Spine injury . Visualizes the extradural space and integrity of the ligaments

• Con: Higher cost, time

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An approach to clearing

the c-spine following injury

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Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric

Cervical Spine Following

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Lateral Plain Film

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C-Spine Radiograph

Lateral Plain Film1. Film adequacy

2. C-spine alignment and curves

3. Inter-vertebral spaces: discs and joints

4. Pre-vertebral space

5. Pre-dental space aka atlantodens interval (ADI)

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C-Spine Radiograph

Lateral film Anteroposterior film Open-mouth odontoid view

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Adequacy• Visualize entire cervical

spine• Count 7 cervical bodies and

1 thoracic body

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Adequacy• Visualize entire cervical

spine• Count 7 cervical bodies,

and 1 thoracic body

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Adequacy• Visualize entire cervical

spine• Count 7 cervical bodies,

and 1 thoracic body

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Adequacy• Visualize entire cervical

spine• Count 7 cervical bodies,

and 1 thoracic body

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Alignment C-Spine Curves

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

84

Alignment

C-Spine Curves1. Anterior Vertebral Bodies

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

85

Alignment

C-Spine Curves1. Anterior Vertebral Bodies

2. Anterior Spinal Canal

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

86

Alignment

C-Spine Curves1. Anterior Vertebral Bodies

2. Anterior Spinal Canal

3. Posterior Spinal Canal

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

87

Alignment

C-Spine Curves1. Anterior Vertebral Bodies

2. Anterior Spinal Canal

3. Posterior Spinal Canal

4. Spinous Process Tips

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

88

Inter-vertebral spaces• Disc spaces• Cartiledge• Apophyseal joints

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-vertebral space

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-vertebral space• Space between vertebral

bodies and air column

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-vertebral space• Space between vertebral

bodies and air column

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-vertebral space• Space between vertebral

bodies and air column• Must measure space above

the glottis

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-vertebral space• Space between vertebral

bodies and air column• Must measure space above

the glottis• Normal size

~1/2 to 2/3 of adjacent vertebral body

• Can be abnormal if non-inspiratory film Intubated

• Often normal in C-Spine injuries

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-Dental Space: aka: atlantodens interval (ADI)

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-Dental Space• Space between Dens of C2

and anterior side of C1 ring

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-Dental Space• Space between Dens of

C2 and anterior side of C1 ring

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Pre-Dental Space• Space between Dens of

C2 and anterior side of C1 ring

• Must be less than or equal to 5 mm

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Cases

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Case 1

4 year old female, restrained, back seat High speed, head on car crash – car versus tree Eye witnesses noted the passengers’ heads

violently snapped forward The driver died at the scene

C-spine immobilized Minimally responsive Intubated Ng-tube placed

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

100

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

101

Fracture at pedicle of C2

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Case 2

18 month old female, unrestrained, front seat Car accident Sitting in babysitter’s lap, babysitter died at scene

C-spine ‘immobilized’ by gauze strapped with tape over child’s head

Alert and awake Severe respiratory distress, with decreased

breath sounds on right chest No movement of lower extremities

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

103

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

104Distraction injury

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

105

106

Case 3

A 7 year old child High speed MVC

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

107

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

108

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Prevertebral Bleeding

Glottis

109

Case 4

5 year old male, sitting in seatbelt, front seat 25 mph head-on car crash Airbag deployed

C-spine immobilized Alert and awake Numerous abrasions to face, neck and left

shoulder and arm Left arm limp and without sensation

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

110

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

111

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

Ruptured Transverse Ligament

112C2 - Axis

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

113

v

C1 - Atlas

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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ANTERIOR

POSTERIORANTERIOR

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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ANTERIOR

POSTERIORANTERIOR

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

116

ANTERIOR

ANTERIOR

POSTERIOR

Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental

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Wrap It Up

• Epidemiology• Anatomy: Pediatric vs Adult• Types of injuries• Who can be cleared clinically• Imaging Choices• An approach to the clearing the cspine• Lateral Plain Film• Cases• Wrap Up

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