pediatric cervical spine injuries daniel a. hirsh, md emory university school of medicine...
TRANSCRIPT
Pediatric Cervical Spine Injuries
Daniel A. Hirsh, MD
Emory University School of Medicine
Children’s Healthcare of Atlanta
2
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
3
Epidemiology
4
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
5
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
6
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.
9
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.
11
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.
13
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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16
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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
20
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
22
Epidemiology: Mechanisms
1. Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700
23
Epidemiology: Mechanisms
1. Garton Et Al (2008). “ Detection of Cervical Spine Injury” Neurosurgery 62 (3) 700
24
Epidemiology: Mechanisms
Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.
25
Epidemiology: Mechanisms
Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.
26
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
28
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
30
\
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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
35
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
38
Types of Injury
39
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
12
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.
43
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
45
Types of Injury
Traumatic Atlantoaxial Instability• Tear in transverse
ligament• Rare
46
Types of Injury
Odontoid fracture• Most common fractures
of cspine in children• Usually through the
subdental synchondrosis in young children
47
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
49
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
50
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
51
Pseudosubluxation
Lustrin et al (2003) “Pediatric Cervical Spine: Normal Anatomy,Variants, and Trauma1”Radiographics 23(3) 539
52
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
58
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
67
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
81
Adequacy• Visualize entire cervical
spine• Count 7 cervical bodies,
and 1 thoracic body
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
82
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
90
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
97
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
98
Cases
99
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
102
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
114
ANTERIOR
POSTERIORANTERIOR
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
115
ANTERIOR
POSTERIORANTERIOR
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
116
ANTERIOR
ANTERIOR
POSTERIOR
Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental
117
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
118
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