Authors: Liz Herrieven / Editor: Charlotte Davies / Codes: PMP4, RP4, SLO4, SLO5, TP2 / Published: 26/10/2021
Spinal injuries are thankfully not common in children. Less than 2% of all children involved in major trauma will have a spinal injury. About 80% of these are high cervical injuries, compared to adults in whom thoracic or lumbar injuries are more common (70%) and in whom cervical injuries are more often the lower c-spine (refresh your paediatric trauma anatomy here).
The biggest cause of spinal injuries in children is road traffic collisions, particularly those with high speed, a rollover or an ejection from the vehicle, with second place going to falls in younger children and sporting injuries in older children.
So, why do children get a different pattern of injury compared to adults? Some of this will be mechanism of injury, but a lot is down to anatomy. I’m an ED physician, so I like to keep things simple. Think of a child’s head as a large lollipop, sitting on a weak and flimsy lollipop stick. That stick, the cervical spine, has weak and elastic ligaments and muscles and, until the age of 7, the vertebral bodies are wedged anteriorly, giving much more room for movement than in the adult spine with its square vertebral bodies. The largest amount of movement occurs just under the lollipop, right at the top of the cervical spine, so this is where most injuries occur.
Management starts in the ED with the Primary Survey. The best way to prevent secondary spinal injury is to ensure good oxygenation and a decent circulation. At the same time, we need to consider restriction of c-spine movement (ROCSM). We have moved away from hard collars in children, partly as they don’t do a great job of preventing movement and secondary injury and partly because there’s a relatively high rate of complications, ranging from pressure sores to worsening injury due to a child fidgeting to get comfortable. Instead, manual inline stabilisation (MILS) is a great option. A hand either side of the head can be reassuring, along with some eye contact and a friendly voice. For older children, it might be enough to ask them to stay still. How about children who are having a wriggle or refusing to lay still? A decision needs to be made: are they wriggling because their neck and back don’t hurt and they want to sit up, or are they distressed, with a spinal injury and in need of either convincing to stay still or even sedation??
Log-rolling may need to be performed, to restrict movement of the thoracic and lumbar spine. Make sure your team know what’s going on and make sure the child understands too. Take a look at our induction c-spine blog for further information about log rolling. This is also a good time to remind you how horrible it is to lay flat on your back, staring at the ceiling, whilst people you can’t see prod and poke you and talk about you (this is probably why the RCEM quality standards say you should have something on the ceiling. Do you?). Make sure someone keeps contact with the patient, letting them know what’s going on and letting them see a friendly face. If possible, a parent should be in sight too.
After the Primary Survey, when you have a bit more time to look for evidence of a spinal injury, the 6 Ps are a good starting point:
- Pain: not just tenderness, as anyone will be tender if you poke them hard enough, but are they in pain?
- Position: is there any torticollis? Are they laying comfortably and naturally?
- Paralysis or weakness
- Paraesthesia or altered sensation
- Ptosis or squint: can be a sign of high cervical injury, for example with compression of the 6th cranial nerve.
Those small children, in whom a full neurological examination might be more challenging, are often the ones who will clear their own neckby having a wriggle, moving about, showing you they are not in pain and have no neurological deficit.
When considering thoracolumbar injury, it’s worth re-visiting your abdominal examination. 50% of children with abdominal bruising from a seatbelt will have a spinal injury. It’s fairly difficult to bruise the soft abdomen of a child, so abdominal bruising in trauma is always significant, for example a handlebar bruise to the abdomen in a child who has come off their bike is a sign of an intra-abdominal injury until proven otherwise. In an RTC, if the lapbelt part of the seatbelt sits higher than it should, across the abdomen instead of across the thighs, which it might do if the seatbelt doesn’t fit properly, or if it’s not being worn correctly, then a sudden deceleration will cause hyperflexion across the lapbelt. This bruises the abdomen and potentially causes a spinal fracture such as a Chance fracture.
If the child is very unlucky, they might have Seatbelt Syndrome: abdominal bruising, spinal injury and intra-abdominal injury.
Imaging the C-spine
So, which children do we need to image? For the cervical spine, NICE advises that we follow the Canadian C-Spine rules. These have a high sensitivity, so pick up most injuries, but a low specificity, so will over-image many children. The NEXUS guidelines weren’t validated at all in children.
- First, look for a “high risk factor”. If there is either a dangerous mechanism of injury or paraesthesia, the child gets imaging. If there is ahigh index of suspicion, other body parts are being scanned, or a definitive decision is needed quickly, then a CT scan is the best option.For others, three cervical spine plain film views may be done (AP, lateral and open-mouth peg view), so as to reduce the radiation risk. MRIis gold-standard as far as the images go, although not always very practical, accessible or achievable in the acute phase of major traumamanagement. (Editor: Our local trauma centre suggests that before CT scanning a child (http://www.selkam.org.uk/), the neurosurgicalteam should be involved. They consider plain films first – but note the difficulties in obtaining PEG views in children <10. How do youmanage in your department?).
- If there are no high risk factors according to the Canadian C-Spine Rules, next we look for low risk factors.
- If there are no high risks, but at least one low risk factor, we can check for neck mobility. If the child can rotate 45 degrees to both theleft and the right, comfortably, we can clear the cervical spine. If not, we image.
Imaging the Rest of the Spine
There are no reliable rules for helping us to decide which children should have imaging of their thoracic or lumbar spine, so we need to relyon clinical suspicion. It’s worth remembering, though, that those children with thoracolumbar injuries are most often those children withmultiple injuries from major trauma. Don’t forget, force dissipates up and down the spine, so after one injury is found, the whole spineshould be imaged looking for others.
What about when you have abnormal neurology but a normal CT? Because the cervical spine is very flexible, particularly in small children,the spinal column, the bones, muscles and ligaments, can move up to 5cm from their starting point if enough force is applied. Theirelasticity allows them to move back to their starting point. The spinal cord, however, is not very mobile and can move only 5mm. So thecolumn might look pretty normal, with a very damaged cord. This is known as SCIWORA – spinal cord injury without radiologicalabnormality. 70% of cases occur in those under 8 years of age and SCIWORA makes up 20% of all spinal injuries in children.
Something else to consider with spinal injuries in neurogenic shock. This occurs with an injury above T6, which affects the sympatheticoutflow from the spinal cord. This causes peripheral and splanchnic venous dilatation which results in hypotension. This doesn’t respondto transfusion and might complicate things with a mixture of haemorrhagic and neurogenic shock. If the injury is above T2, then there mayalso be bradycardia, caused by interruption of the sympathetic supply to the heart. The child will be unable to mount a compensatorytachycardia in the face of hypovolaemia. Treatment is with vasopressors to squeeze blood in from the peripheral circulation, and positivechronotropic agents to counteract the bradycardia.
So, spinal injuries in children might not be very common, but they can be completely devastating. Remember the importance ofmechanism of injury, consider ROCSM, work your way through the Primary Survey and then the 6Ps and use the Canadian C-Spine rules.But most importantly, keep some human contact with your patient, explain what’s going on, reassure them and watch how they lay andmove, and you’ll get the answers you both need.
Interpreting the Paediatric C-Spine X-ray
Children can have pseudo-subluxation of the c-spine. If you’re not sure whether the injury is true or not, seek further advice. Read more about this
here on radiopedia.
A note on torticollis
Torticollis is an abnormal neck position, that may persist. Normally, this is atraumatic and we manage it easily in children. Occasionally itis linked with minor trauma which you wouldn’t expect to cause a problem, with no associated abnormal neurology eg. diving into aswimming pool but no head injury. Your gut often says that there is no significant injury, but your brain says “but what if”. My management here is normally to provide excellent analgesia, positive encouragement, and review. If pain persists, I normally obtain plain film imaging.
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- Ronán Murphy. Cervical Spine Injuries Module, Don’t Forget the Bubbles, 2020.
- Nikki Abela. Shedding light on Paediatric Trauma Imaging, RCEMLearning, 2016.
- Matt Burton, Charlotte Davies. C-spine skills – Induction. RCEMLearning, 2020.
- Jules Blackham, et al. Assessing and Clearing the Cervical Spine. RCEMLearning, 2021.