Spinal Injury

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Spinal injury is relatively rare in children and adolescents, affecting 1 to 2 percent of pediatric blunt trauma patients. Spinal injury is most often caused by trauma as a result of motor vehicle collisions, falls, force applied to the head, clotheslining force, head trauma, and certain sports and recreational activities.

The estimated incidence rate of cervical spinal cord injury is 30 to 46 cases per million populations each year in the United States and Canada. Over half of these injuries occur in those aged between 16 and 30, with males making up the majority of cases.

The common mechanisms of spinal injury differ depending on age, and in some cases, injury can occur at birth due to problematic delivery. The exact location of the spinal injury also varies for different age groups.

This article primarily looks at cervical spine injuries in children and adolescents. These types of spinal injuries often require surgery and cause neurologic deficits in 21 percent of patients. Cervical spine injuries lead to death in around 7 percent of cases.

Cervical spine anatomy

The cervical spine is a delicate portion of the spinal cord located in the neck region, roughly between the shoulders and the nape of the neck. The cervical spine supports the weight of the skull and facilitates movement of the head and neck.

Children under 8 years of age are more susceptible to cervical spine injury due to their unique anatomy. Their heads are quite large in relation to their bodies and develop at a much faster rate. For example, by age 2 a child’s head is already 50% the size of an adult’s head.

Children in this age group also have weaker neck muscles and ligaments, as well as immature vertebral joints.

In children over the age of 8, the most common injuries are vertebral body and arch fractures which usually occur in the lower cervical spine.

Causes

Cervical spine injuries are often caused by trauma. Such trauma can be caused by:

• Motor vehicle accidents
• A fall from a height that is over 10 feet or that is 2 to 3 times the child’s height
• Axial compression (force applied to the top of the head and through the spine; e.g. diving accidents)
• Acceleration-deceleration of the head (e.g. hitting the head off the dashboard in a motor vehicle collision)
• Clotheslining force (e.g. running into a cable or outstretched arm at neck level)
• Multiple system trauma (when multiple body systems are seriously injured at once)
• Vaginal delivery in the breech position

Evaluation and management

Any child who suffers an accident similar to those listed above or is otherwise suspected of having a spinal injury should be evaluated by a medical professional. This includes any kind of multisystem blunt trauma, or head, neck, and torso trauma resulting in an altered level of consciousness.

Initial management of cervical spine injuries in children involves the following:

• Spinal immobilization: The clinician must restrict the motion of the spine during the evaluation and management of the injured child. They must ensure that a neutral cervical position is maintained to keep the airway open and to prevent further movement and injury. Precautions for restricting spinal motion involve using what is called the “sniffing position” and placing padding under the back and shoulders.
• Airway management: Cervical spine injuries often cause airway problems in children, such as airway obstruction or respiratory paralysis. For children who cannot maintain their airway, the attending clinician should use a chin lift or intubation to open the airway.
• Spinal shock: Spinal injury can cause transient loss of spinal cord function, which in turn can result in hypotension (abnormally low blood pressure) or bradycardia (abnormally slow heartbeat). This can require medication or pacing (regulating cardiac contractions to stabilize heart rate).

Neck symptoms

Common symptoms of cervical spine injury that arise in the neck area include:

• Localized cervical pain
• Muscle spasms
• Deceased range of motion

General indications

• Torticollis (head leaning to one side due to muscle contractions)
• Altered mental status
• Substantial co-existing injuries, especially injuries to the torso
• Neurologic signs (e.g. involuntary movements, loss of muscle control, or weakness)

Predisposing condition

Certain conditions can make a child more prone to cervical spine injuries than others. These include [7]:

• History of cervical spine surgery
• History of cervical spine arthritis 
  • Rheumatoid arthritis
  • Ankylosing spondylitis (an inflammatory disease that can cause vertebrae to fuse together)
• Congenital syndromes that affect spinal development
  • Down syndrome
  • Klippel-Feil syndrome
  • Morquio syndrome
  • Larsen syndrome
• Conditions that affect the integrity of bones and soft tissue
  • Osteogenesis imperfecta
  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • Rickets

Diagnosis

Diagnosis of cervical spine injuries involves 3 key factors:
Checking vital signs — Examining the child for issues such as respiratory distress, hypotension, bradycardia, and temperature instability.

1. Neck examination — Checking for muscle spasms, local tenderness, or obvious deformity.
2. Neurologic assessment — Assigning a Glasgow Coma Scale score, evaluating tone, strength, and reflexes, and identifying sensory deficits.