Paediatric Emergency Medicine Database



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An approach to Paediatric Cervical spine injury

Browne GJ, Cheng, NG, McCaskill ME, Phin S and Cree A

Department of Emergency Medicine, Orthopaedics and Spinal Surgery

The Children's Hospital at Westmead

An approach to cervical spine injury in children

The difficulties in predicting a paediatric cervical spine injury (CSI) are considerable. Unrecognised CSI can produce catastrophic neurological disability[i]. Alternatively, fear of failing to diagnose such injuries may lead to unnecessary imaging and a reluctance to pass the spine as normal[ii],[iii]. The unfortunate consequence of this can be prolonged immobilisation of the child in the emergency department (ED) while waiting for a final decision to clear the spine, often resulting in complications such as pressure areas[iv]. The challenge to the emergency physician therefore is the timely assessment and appropriate management of the child with a possible CSI.

Paediatric CSI is uncommon. On best available evidence, the prevalence of paediatric CSI is 1-2% of major trauma. Prevalence data are highly variable and depend upon patient census within the reporting ED. Even in tertiary paediatric trauma centres, CSI reports vary depending on geoanthropological factors[v],[vi],[vii],[viii],[ix].

Adult studies have reported the effectiveness of various algorithms and have suggested ways of risk stratification of adult patients with possible CSI[x], [xi], [xii], [xiii]. Few studies have addressed these issues in children[xiv],[xv],[xvi]. Large prospective studies have been performed but they mostly evaluate adult CSI with small numbers of children included5. In particular they have reported few children with CSI under nine years of age, making clinical recommendations in this age group difficult. The study findings were extrapolated into clinical practice for younger children. Despite this short fall in best practice evidence, reports have suggested that in the case of younger children with a potential CSI, significant modifications in approach may be prudent14,[xvii].

Children of all ages present to EDs every day for assessment of possible CSI following trauma. We present our approach, based on current evidence and joint consensus between the ED, our trauma committee and the spinal unit.

Unique factors in children with potential cervical spine injury

The majority of paediatric CSIs are due to blunt trauma related to high-speed motor vehicle or pedestrian accidents7, 8, 16. Gunshot wounds and non-accidental injuries are less common causes7, 8, [xviii]. Of those children with potential CSI, most have multi-trauma8; associated head injury may occur in up to 67% of these cases[xix], [xx], [xxi].

Despite the low prevalence, a number of biomechanical factors may predispose children to CSI17, [xxii], [xxiii]. Children have a relatively large, heavy head and underdeveloped cervical musculature, allowing the head to move around in an uncontrolled fashion during trauma. The ligaments and joint capsules in children are relatively hyper-mobile with considerable laxity, thus allowing for considerable movement of one cervical vertebra on the other. The natural fulcrum for flexion of the neck in children is at a higher level, C2/3 and C3/4, rather than at C5/6 as occurs in adults. The articular surfaces of the vertebral bodies, facet joints and uncinate processes lie more horizontally than in adults and this allows for greater movement in the cervical region, even during a minor fall or accident.

CSIs fall into four distinct patterns: fracture only, fracture with subluxation, subluxation only and spinal cord injury without radiological abnormality (SCIWORA) 1, 5, [xxiv]. It should be noted that in the years since it was first described SCIWORA has become a misnomer. A combination of plain films, CT scans and MRI scans will eventually display spinal lesions in almost all patients (see “Other imaging modalities” below).

In most cases reported in retrospective studies CSI involves the upper cervical spine (C4 or above) of younger children (below nine years of age), with the lower cervical spine more vulnerable to injury in older children4, 6, 7, 8, [xxv]. A recent prospective study, though lacking in numbers, has also shown this, with all patients nine years old or less having lesions above C4, whilst 13/17 subjects between 10 and 16 years of age had injuries below C45. Mortality in all studies remains high with lesions above C3, increasing exponentially with higher lesions, with C1 lesions having a reported 30% mortality[xxvi], [xxvii], [xxviii].

There are reports of delayed diagnosis of CSI in children1, 2. Several factors contribute to this delay. Cervical spine clearance in paediatric patients can be problematic particularly in young children of variable developmental age. The young child’s verbal skills and their poor ability to localise pain limit clinical assessment. Developmental issues also impair the child’s ability to cooperate with spinal immobilisation. SCIWORA may not become evident until several days have elapsed[xxix].

The process of cervical spine assessment

The most time-consuming process in trauma for the emergency physician may well be the assessment of a child with a potential CSI. However, no published data exists that quantifies the proportion of time devoted to this task. In our trauma centre, assessment alone accounts for the majority of the activity in the ED devoted to these patients. The treatment of defined injuries is a minor component of our paediatric ED and spinal surgical work. Of those patients with potential CSI treated in our centre, further management is required in approximately 10% of cases. Our management therefore mainly consists of close observation and expectant recovery.

Most CSI patients are multi-trauma cases 8, 18, 19, 20, 21, [xxx], [xxxi] and are often admitted to high dependency wards or the PICU. Very few patients who present to our institution (less than 1%) with a potential CSI will have a serious injury needing specific surgical intervention. Of these cases around two to three present annually with an unstable injury that will require urgent operative intervention or fixation. Even in a large institution such as ours the rate of presentations of SCIWORA remains unclear, being estimated at around three to four per annum 1, 9, 31.

Interpretation of paediatric cervical spine x-rays present a number of difficulties that may make assessment in the ED challenging17, 22, 23, [xxxii]. These include:

• Incomplete ossification of vertebrae; unfused synchondroses have the appearance of a fracture

• Increased pre-odontoid space is common due to laxity of the transverse ligament

• When the head is held in mild flexion in infants and young children there may be an anterior pseudo-subluxation between adjacent vertebrae at C2/3

• Widening of pre-vertebral space with dynamic soft tissues

Hence, considerable expertise and experience is required in correct interpretation of even basic x-rays. A further confounding factor is the presence of congenital anomalies, which adds further anxiety and difficulty in assessment of paediatric CSI23. These congenital issues are beyond the scope of this paper and the reader should consult the comprehensive reviews available.

The remainder of this paper will focus on an approach to the child with a potential CSI in the ED and will refer to the algorithm presented in figure 1 (see figure 1).

History and examination of the potential paediatric CSI patient

History

The history is the key to the evaluation of CSIs. In patients who have had recent trauma, subsequent symptoms of pain or neurological change at any stage should arouse suspicion of CSI.

If pain is the presenting symptom, the physician must ask about the location, radiation and duration of the pain. It is also important to inquire about factors that exacerbate or relieve pain and other symptoms. Radicular pain may direct the evaluation to a specific nerve root level.

Elicit any history of paraesthesia, numbness or weakness. Evaluate muscle weakness urgently, especially if it is progressive. Specific inquiry for neurological symptoms with sacral sparing is important, as it is a characteristic feature of some CSIs.

Several elements in the patient's history, if elicited, are “red flags” (see Table 1)2, [xxxiii] . In situations in which it may be extremely difficult to interpret non-classic signs and symptoms, the examining doctor exercises best judgment to determine an indication for diagnostic testing or referral to a spine specialist16.

|Table 1 : Historical indicators of C-spine injury |

|Mechanism of injury |

|Pedestrian / cyclist hit > 30km/hr |

|Motor vehicle passenger – collision > 60km/hr |

|Fall – more than 3 meters (in smaller children a fall from a proportionally lower height is an indication) |

|Kicked by or fall from a horse |

|Backed over by a car |

|Thrown from vehicle |

|Thrown over handlebars of bike |

|Severe electric shock |

|Serious injury of other occupants in a vehicle accident |

|Multiple trauma |

|Neck trauma |

|Neck pain or neurological deficit at any time since injury (even if resolved) |

|Significant injury above the clavicles, eg, the head, face or mandible |

Physical Examination of the injured child

The physical examination of children is challenging, particularly in a high acuity setting such as trauma. Developmental immaturity is a major factor, as exemplified in a preverbal frightened child. Keen observational skills are required in these situations, where subtle signs of pain, such as limitation of neck movement, may be a vital clue.

Examination

Any child presenting with the symptoms or signs in Table 2 after an injury is at risk of cervical spinal injury2, 33. Irritability in an infant in the context of trauma is also a suspicious finding and necessitates careful examination for cervical pain.

|Table 2 : Indicators on examination of C-spine injury |

|Neck tenderness, particularly midline tenderness |

|Limitations of neck movement due to pain |

|Any signs of spinal cord injury below the cervical spine |

|Acute peripheral neurological deficit |

|Infant with acute torticollis |

|Significant injury above clavicles |

|Trauma with unexplained hypotension or bradycardia |

|Other major injuries (eg, fractured limbs, abdominal injury) |

|Chest injury with another body system injured |

The examining doctor should perform a systematic, thorough motor and sensory examination of the patient's extremities. Progressive neurological signs demand urgent attention. An important aspect of the physical examination is a rectal examination to assess sphincter tone, especially if the patient mentions bowel or bladder dysfunction.

The Babinski sign and hyperreflexia are widely understood to be cardinal signs of the upper motor neuron syndrome that typically occurs in spinal cord compression. The examining doctor should be aware that a positive (abnormal/upwards) Babinski sign is helpful, but a negative or absent sign does not exclude severe disease, especially since the Babinski sign is typically absent in the acute phase of trauma. One ED study found that patients who presented with severe myelopathy had a low incidence of extensor plantar responses and hyperreflexia. This study had small numbers (nine patients) Additionally, the Babinski sign is highly unreliable in young infants, with either an upward or downward response being normal at this age[xxxiv], [xxxv].

If positive findings are noted on neurological assessment consideration should be given as to whether they may represent a complete spinal cord lesion[xxxvi] or incomplete lesion such as central cord, anterior cord, posterior Cord or Brown-Sequard syndrome.

Examination of the cervical spine for pain on voluntary movement

This examination is the final step in clearing a cervical spine if history, initial examination and imaging appear normal. Remove the hard collar (with cervical spine control) and palpate the cervical spine for midline tenderness again. If this is absent, active flexion, extension, lateral flexion and rotation is encouraged so long as it does not cause the patient pain or neurological symptoms. Cease this examination and reapply the hard collar if any neurological symptoms or pain occurs.

Case 1

LC was a three-year, six-month old girl who was the front seat passenger of a stationary car that was hit by a bus at high speed. Her seven-year old brother, the back seat passenger, was rendered unconscious possibly sustaining a serious head injury. Her father, the driver, received abrasions only.

As LC was considered stable she was transferred to a district level ED for assessment. LC was a difficult child to assess. No major injuries were apparent and she was haemodynamically stable. Abrasions were noted over her neck and pelvis. Neck pain was documented but her GCS was 15 and she was neurologically normal. A single lateral X-ray of the cervical spine showed no abnormality and she was discharged home.

LC represented three days later to our institution complaining of neck pain. On examination her GCS was 15 and she was neurologically normal. Traumatic torticollis was diagnosed. A hard collar was applied. A three film cervical spine series showed an abnormality of C2. Focused CT scan confirmed this abnormality.

Immobilisation of the Cervical Spine in children

Paediatric patients with suspected or possible CSI must have their cervical spine and the rest of the spinal column properly immobilised if possible. Suspicion of a CSI is raised by the mechanism of injury, the energy involved or by historical or examination findings (see history and examination of the potential paediatric CSI patient)12, 33. Immobilisation takes place as soon as trained carers are on hand either at the scene or in hospital. Current techniques do not stop all movement of the cervical region but do reduce it when used appropriately[xxxvii], [xxxviii]. In children the age, size and cooperation of the child and the child’s level of consciousness all impact on the decision to immobilise and the techniques used16.

The need for continued immobilisation is reviewed after the history and examination are completed and again after imaging. In the absence of midline neck tenderness, peripheral neurological signs and distracting injuries the cooperative child can proceed to an examination for pain voluntary movement (see above)14. Immobilisation may cease if this is clear.

How to immobilise the cervical spine 37, 38, [xxxix]:

1. Explain to child and parents that they need to remain still.

2. Place a hard collar of the appropriate size for the child (a one-piece hard collar is used in the initial stages). For the Stiffneck( collar measure the distance from the top of the patient’s shoulder to the angle of the jaw with your hand. This should correspond to the distance from the bottom of the rigid plastic rim of the collar to the "measuring post".

3. Lie child flat on their back on a bed with a thin mattress that will maintain the alignment of the whole spine.

4. If needed, use manual immobilisation to reduce movement of head and torso of the child to immobilise the whole spine. One person places their hands on either side of the child’s head to reduce movement at the neck. Another person holds the shoulders and a third person holds the pelvis to reduce thoracic and lumbar spinal movement respectively.

5. Use a head immobiliser or sandbags to limit lateral movement.

6. If continued restraint is needed place child on an age-appropriate spinal board. If the child is less than eight years old use a board allowing for the occipital prominence, if possible. If no such board is available, a towel folded several times and placed under the shoulders will help maintain spinal alignment in young children [xl], [xli], [xlii].

7. If a spinal board is used then strap the child’s head to the head immobilisers or sandbags and the spine board. Strap the torso at the level of the shoulders and the pelvis as well. Significant deformity can occur in the cervical spine of an agitated child if the rest of the body is moving freely.

8. If the child’s head is strapped, be particularly aware of vomiting and risk of aspiration. Someone must be with the patient at all times. Avoid fixing the patient to the trolley or bed, otherwise turning the patient to the side is impossible if vomiting occurs.

9. Spinal immobilisation in children less than three years old is especially challenging. Rigid cervical collars do not usually fit these patients. They should be immobilised with staff holding the head and body, or with sandbags or towels. Strap the head and torso to a spinal board.

10. Children with pain or anxiety need to be evaluated on a case-by-case basis. Where required adequate intravenous analgesia and/or conscious sedation must be carefully titrated. If sedation/analgesia is given, the patient should undergo full imaging and consideration given to a CT scan. Sedation to the extent of needing intubation to aid cervical spine immobilisation is rarely needed.

11. If a hard collar has been in place for more than four hours, change to a fitted collar such as Philadelphia or Aspen collar4, [xliii]. This may improve tolerance of immobilisation.

Patients with an altered level of consciousness

Any paediatric trauma patients with an altered level of consciousness should be appropriately immobilised as if a CSI is present. These children need imaging of their spine and cannot comply with active examination. Prolonged immobilisation may be necessary so hard collars should be changed to a fitted collar and the patient taken off hard spinal boards as soon as practical to reduce pressure areas .

The uncooperative child

This is problematic as immobilisation techniques may agitate and distress the patient, thus increasing movement of the cervical spine. It is important to be gentle but firm and institute manual restraint first. Some children settle when held firmly. The presence of parents and close relatives is vital as it can reassure and calm the child[xliv]. If immobilisation attempts appear to cause more movement of the cervical spine than if they are not applied, they should be abandoned. Further history, examination and in particular active examination will be necessary once the child has calmed.

The cooperative child

In a cooperative child with a suspected CSI, institute immobilisation until a full history and examination is obtained. If on history and examination there is no evidence of neck pain or tenderness, acute peripheral neurological deficit at any time after the injury or the presence of another major injury then examine the neck actively. However, if any of these features are present continue immobilisation and obtain imaging. If imaging is normal and the neck pain or tenderness settles examine the cervical spine actively. If prolonged immobilisation is likely, change to a fitted collar43.

Case 2

LJ is a 2-year-old boy who was kicked in the face while chasing a horse.

He did not lose consciousness. Ambulance personnel reported his GCS was 15. His only obvious injuries were a fractured left zygoma and fractured left clavicle. His cervical spine was adequately immobilised using a hard collar.

LJ was transported to hospital. During transport, he became “unstable”. The hard collar caused pain at the fracture sites with restlessness and desaturation on oximetry, He developed an irritable cry and had considerable torso and neck movement. The ambulance personnel’s concerns of a serious head injury were communicated to the hospital.

Upon arrival, the trauma team assessed him as clinically normal. X-ray films were reviewed and reported as normal. The hard collar was removed and the child’s condition rapidly improved.

Imaging

Selection of patients to x-ray

Not all trauma patients must have cervical spine radiographs, even if they arrive in the ED wearing a cervical collar and immobilised on a spinal board[xlv], [xlvi], [xlvii]. Clinical clearance without radiographs may be possible depending on the level of expertise of the clinician.

Low-risk criteria do exist for adults to exclude CSI, based on the patient's history and physical examination. Patients who meet these criteria do not require x-rays to rule out CSI. However, there is limited applicability of these studies to children, even those able to verbalise their injuries. Preverbal children, who cannot communicate symptoms, respond to the examination, nor cooperate as well as older patients are a separate, even more difficult group to manage.

In spite of the limited evidence to guide evaluation of paediatric CSI, a set of criteria that identify patients with a low risk of CSI can be established (see Table 3). Patients who fulfil these criteria do not need to have a cervical spine x-ray12, 16.

|Table 3: Features that obviate the need for cervical spine x-rays. The presence of any of these factors should prompt consideration of|

|cervical spine imaging |

| |

|No mechanism of injury suggesting increased risk of CSI (see table 1) |

|No history of loss of consciousness |

|No neck pain |

|No neck tenderness on palpation |

|No neurological signs or symptoms referable to the neck eg, paraesthesia or weakness in extremities (includes transient symptoms now |

|resolved) |

|No mental status changes resulting from trauma, alcohol, drugs etc |

|No distracting painful injuries eg fractured ankle, fractured ribs etc |

Selection of x-rays to order

Once deciding to proceed with a x-ray evaluation, proper views are required. A single lateral cervical spine x-ray is insufficient to exclude a cervical spine fracture, having only 70% sensitivity16. Immobilise the patient's neck until a full cervical spine series is performed in the radiology department. In children two years or older, this is a three view series including lateral, anteroposterior (AP) and open mouth odontoid views, which will pick up the injury in the majority of cases. The lateral view must include all seven cervical vertebrae as well as the C7-T1 junction. If no arm injury is present, traction on the arms may facilitate visualisation of all seven cervical vertebrae. If all seven vertebrae and the C7-T1 junction are still not visible, a swimmer's view, taken with one arm extended over the head, may allow full visualisation. The importance of obtaining adequate x-rays cannot be overemphasised[xlviii]. While some missed cervical fractures, subluxations and dislocations are the result of misinterpretation; the most frequent cause of overlooked injury is an inadequate film series2.

There has been recent discussion about whether it is necessary to obtain the open-mouth odontoid view in infants and young children. Dens fractures in infants and young are usually visible on the lateral x-ray, as most fractures in this age group are through the dens synchondrosis and/or due to a flexion injury causing anterior displacement of the dens. In addition it is often extremely difficult to obtain good quality open mouth odontoid views in this age group. A retrospective study by Swischuk et al showed that there was an extremely low miss rate of dens fractures on a single lateral cervical spine view. They therefore suggest not performing routine open mouth odontoid views for children under the age of five years[xlix]. As our radiologists feel capable of reading open mouth odontoid views of children over two years of age, we do perform all three views from the age of two years onwards.

Some authors recommend flexion/extension views to help identify ligamentous injuries. However, in the acute setting, ligamentous injury often causes muscle spasm, limiting the usefulness of these views. Moreover, children are often too young to understand what is happening or too scared or anxious to be able to rely on them to cooperate fully with this potentially dangerous task. Therefore, we do not include flexion/extension views in the acute setting of our pathway[l], [li], [lii].

Cervical spine x-rays do have limitations. There is a small but substantial miss rate in cervical bony injury2. Further, x-rays do not reveal cases of SCIWORA (by definition). Other forms of imaging of the cervical spine may therefore be required under certain circumstances.

Other imaging modalities

The role of spiral CT scan in the intubated, unconscious child in order to clear their cervical spine is controversial. The CT scan has excellent sensitivity for detecting fractures, but not for ligamentous injuries48, [liii], [liv], [lv].

|Table 4: Indications for focused CT scan |

| |

|Any question of an abnormality on plain radiographs |

|Patient has neck pain that seems disproportionate to the findings on plain radiographs |

|Detailed assessment of a recognised abnormality on plain radiographs |

Some studies have used magnetic resonance imaging (MRI) as an adjunct to plain films and CT scanning. It is superior to CT scanning in the detection of ligamentous injuries and soft tissue injuries such as epidural haematomas and traumatic disc protrusions[lvi], [lvii], [lviii]. However, the lack of wide availability and the relatively prolonged time required for MRI scanning limits its usefulness in the acute setting.

Clearing the cervical spine of injury

Who can clear the c-spine?

In our institution, if the patient is to be discharged from the ED, a consultant from the following units may clear the cervical spine (the clearing doctor):

Emergency (paediatric or emergency training streams)

Intensive Care

Orthopaedic

Neurosurgery

General Surgery

Registrars from the same units may also clear the cervical spine after discussion with the ED consultant on duty. EMST/APLS (or equivalent) certification is a prerequisite. Cervical spine clearance for an inpatient or potential an inpatient may only occur after consultation with the neurosurgical consultant, orthopaedic consultant or the emergency consultant (if the patient is still in the ED).

How to clear the c-spine

It is imperative that the clearing doctor has both examined the patient and viewed the x-rays.

1. Examination: Perform a comprehensive focused neurological and cervical examination.

2. View the films: Seek a second opinion if there is any doubt about the ‘normality’ of the films.

3. Re-examine the patient: While a trained staff member maintains the head alignment the collar is removed and the clearing doctor checks for the following:

17. Inadequacy of the examination for pain and tenderness

18. The presence of other (distracting) pain/injuries

19. Neck pain, especially tenderness over the cervical spine

20. Motor or sensory abnormalities

21. Limitation of active neck movement

22. Limitation of head control

If any of the above are present, the cervical collar should remain in situ. Consultation by the orthopaedic and neurosurgical service should be requested.

Documenting clearance of the cervical spine:

The clearing doctor must document explicitly in the patient’s records whether or not the cervical spine is clear and hence the feasibility of removing the collar. If the cervical spine is not cleared a plan for further cervical spine assessment must also be documented. The hard collar should be changed to a fitted collar. A timely decision is mandatory.

Pitfalls in the Emergency Department

SCIWORA, Spinal Cord Injury Without Radiological Abnormality

SCIWORA occurs when the elastic ligaments of a child's neck stretch during trauma. Therefore, the spinal cord also undergoes stretching, leading to neuronal injury or, in extreme cases, complete severing of the cord24, 29, [lix], [lx]. The incidence of this condition is uncertain; reports vary widely from 1.3 to 75 percent, with most retrospective series reporting 20 to 30 percent of paediatric CSI29, 59. Initial reports suggest that SCIWORA is most common in children younger than eight years24, 29, but firmer evidence is not available. A recent prospective study did not have sufficient numbers to clarify either the incidence or demographics of SCIWORA in children5. Symptoms and/or signs may be present on the patient's arrival in the ED. However, up to 30 percent of patients have a delayed onset of neurological signs, which may not occur until up to four days after the injury29, 59. Many of these patients have transient neurological symptoms at the time of injury that resolve24. It is important to inform the parents of young patients with neck trauma about this possibility so that they will be alert for any developing symptoms or signs.

MRI can evaluate SCIWORA-type injuries and thus aid prognostication58. Fortunately, most children with partial or delayed onset SCIWORA have a complete recovery. In those children with a major defect and a definite MRI finding the prognosis, as with other major spinal cord injuries, is poor.

No adequate studies of the treatment of SCIWORA exist48, 59. In a child who has sustained significant trauma but recovered completely, restriction from physical activities for several weeks is prudent. In definite lesions, steroids are of possible benefit but currently controversy surrounds their use (see below).

Case 3

An 8-year-old boy was performing handstands at the Sydney Olympic Superdome during a school conference. He lost balance and fell onto his head. He complained of decreased strength in right arm and neck pain. Cervical spine x-rays were normal. Subsequent MRI showed an incomplete cervical cord lesion.

Steroids in Paediatric Cervical Spine injury

There is controversy surrounding the use of steroids in CSI. The most recent National Acute Spinal Cord Injury Study (NASCIS) of steroid therapy in acute CSI has, as with its predecessors, been widely criticised[lxi], [lxii], [lxiii], [lxiv] both in terms of outcome and adverse effects. A recent Cochrane review indicates suggested possible benefit from steroids administered within eight hours of injury and weak evidence of possible further benefit from later doses in certain situations[lxv]. However, adverse effects from using high dose steroids in CSI are significant. In the NASCIS studies high dose methylprednisolone increased the incidence of pneumonia62 and other sepsis64. It also increased the duration of ventilation and intensive care admission64. They should be only used if indicated by orthopaedic and/or neurosurgical opinion. Therefore, the discovery of a CSI mandates urgent orthopaedic or neurosurgical consultation.

Juvenile cervical spine injury and atlanto-occipital dissociation

In 1990, Bohn et al described a syndrome they called “juvenile cervical spine injury”[lxvi]. The syndrome occurs in the context of high speed motor vehicle accidents. The patients they described presented with multiple injuries and either absent vital signs or profound hypotension not secondary to exsanguination. X-ray or autopsy findings showed CSI. None of the 19 patients studied survived. The authors postulated a distinct paediatric pattern of high CSI representing a previously unrecognised cause of cardiorespiratory arrest/profound hypotension.

Atlanto-occipital dissociation is a closely related catastrophic injury where the upper cervical spine undergoes a severe hyperextension injury48, [lxvii]. The condition is usually fatal due to disruption of the brainstem respiratory centres. Some children, particularly those with partial dissociation, may survive the initial injury48, [lxviii]. Difficulty in diagnosing this condition may occur especially if reduction occurs after the subluxating injury in an incomplete lesion27, [lxix]. A high index of suspicion is required and in all cases there must be immobilisation of the cervical spine without traction.

Case 4

A nine year old female pedestrian was hit by a car at high speed and thrown a considerable distance along the road. Bystanders provided cardiopulmonary resuscitation. Paramedics transferred her to hospital. Pulses were present but she had a profoundly depressed GCS of five.

On arrival in ED, severe head injury, right haemothorax, fractured right

femur, fractured iliac crest, fractured right clavicle, multiple bruises and abrasions were documented. The lateral cervical spine x-ray was normal. MRI showed complete craniocervical disjunction with complete transection of the cord. Initial cardiopulmonary resuscitation was successful and she went to PICU but subsequently died. Post-mortem confirmed the MRI findings.

Summary

The evidence for assessment and clearance of potential and actual paediatric CSI is far from complete. Considerable variations in protocols exist between tertiary paediatric centres. Our protocol utilises the best available evidence for spinal clearance with modifications to allow for local factors. If any of part of or the entire protocol is considered for use in another institution, these modifications should be noted and any adjustments necessary should be made.

Paediatric CSI is primarily a preventable condition. The permanent sequelae that can occur as an outcome to CSI causes very significant morbidity. Therefore, further efforts at improving prevention eg, enhanced motor vehicle safety, would have significant effects in terms of reducing the burden of illness for this modern disease.

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References

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