Rosen & Barkin's 5-Minute Emergency Medicine Consult (665 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

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ETIOLOGY

Birth – breech vaginal delivery
<8 yr – MVC and falls
>8 yr – MVC and sports injuries

DIAGNOSIS
SIGNS AND SYMPTOMS

Local cervical spine pain
Limited range of motion
Neurologic deficit (may be transient)
May be masked by altered mental status or distracting injury
Abnormal vital signs:
- Hypotension
- Bradycardia
- Hypoventilation or apnea
Neck signs:
- Tender to palpation over cervical spine
- Limited range of motion
- Muscle spasm
Neurologic signs:
- Paresthesias or sensory deficit
- Flaccid tone
- Loss of rectal tone
- Paralysis
Paralysis:
- Anterior cord syndrome:
  - Hyperflexion injury
  - Paralysis
  - Loss of pain sensation, preservation of light touch, and proprioception
- Central cord syndrome:
  - Hyperextension injury
  - Weakness upper greater than lower extremities
  - Burning sensation in hands and fingers
- Brown-Séquard syndrome:
  - Cord hemisection
  - Ispilateral paralysis
  - Contralateral loss of pain
- Horner's syndrome:
  - Disruption of sympathetic chain
  - Ipsilateral ptosis, miosis, anhidrosis
  - Also consider carotid dissection
- Quadriplegia
- Absent reflexes
Preverbal child may be unable to express symptoms and may not cooperate during exam.

ESSENTIAL WORKUP

Obtain cervical spine radiographs for:
- Cervical spine tenderness
- Altered mental status
- Neurologic deficit (even if transient)
- Distracting injury
- Mechanism of injury
Additional imaging studies (CT, MRI) may be indicated if plain radiographs are inconclusive OR clinical exam suggests injury
Nexus criteria can be applied safely to children >8 yr of age, but not younger

DIAGNOSIS TESTS & NTERPRETATION
Imaging

Cervical spine radiographs:
- Standard initial views: Anteroposterior, cross-table lateral, and open-mouth odontoid
- Cross-table lateral identifies ∼80% of fractures, dislocations, and subluxations
- Addition of AP and odontoid increases sensitivity
- Need to visualize all 7 cervical vertebrae and C7–T1 junction
- Space between anterior arch of C1 and anterior aspect of odontoid process:
  - 5 mm or smaller in children and 3 mm in adults
- Thickening of prevertebral soft tissue:
  - Suggests underlying fracture or ligamentous injury
  - Also occurs with neck flexion, expiration, swallowing
  - Too much variability exists for measurements to be highly sensitive.
  - Soft tissue below the glottis should be approximately twice as thick as above the glottis.
- Pseudosubluxation of C2:
  - Normal variant
  - A result of ligamentous laxity and often resolves by the age of 8 yr
  - C2 anteriorly displaced on C3
  - Posterior cervical line retains normal relationships.
  - Line drawn between anterior aspect of spinous processes of C1 and C3 should pass within 2 mm of anterior aspect of spinous process of C2.
  - Larger than 2-mm space suggests underlying hangman fracture.
  - Can be applied only at C1–C3
- Anterior vertebral wedging of C3 and C4:
  - May be mistaken for compression fracture
- Epiphyseal growth plates may resemble fractures:
  - Posterior arch of C1 fuses by 4 yr of age.
  - Anterior arch of C1 fuses by age 6 yr of age.
  - Base of odontoid fuses with body of C2 by 7 yr of age.
- Flexion and extension views:
  - Limited use
  - May be useful if suspected occult ligamentous injury
  - Negative cervical spine films
  - No neurologic abnormalities
CT scan:
- If fracture suspected despite negative plain radiographs
- For further definition of fracture identified on plain radiographs
- Suspicion of a fracture seen on plain radiographs
- Inadequate radiographs
MRI:
- Suspected spinal cord injury with or without abnormalities found on plain radiographs or CT

DIFFERENTIAL DIAGNOSIS

Cervical muscle strain
Torticollis
Cervical adenitis
Retropharyngeal abscess
Meningitis

TREATMENT
PRE HOSPITAL

Immobilize all infants and children with potential cervical spine injuries
Appropriate size cervical collar
Tape, towels, padding in combination with car seat or spine board if formal collar not available
Place padding under neck, shoulders, and back, as relatively larger cranium can cause flexion
In setting of sports injuries, helmets should be left on

INITIAL STABILIZATION/THERAPY

Maintain cervical spine immobilization.
Logroll patient.
Maintenance of inline cervical spine immobilization if intubation is required.

ED TREATMENT/PROCEDURES

Any trauma patient with neurologic deficit consistent with spinal cord injury should have methylprednisolone considered.
Neurosurgical consultation:
- True subluxation
- Fracture
- Transient or persistent neurologic deficit

MEDICATION
CONTROVERSIAL

Methylprednisolone: Loading dose 30 mg/kg IV over 1 hr; maintenance infusion 5.4 mg/kg/hr over next 23 hr; initiate within 8 hr of injury
Can cause immunosuppression and increase risk of infection
Recommend discussion with neurosurgery prior to initiation

FOLLOW-UP
DISPOSITION
Admission Criteria

Altered mental status
Signs/symptoms of spinal cord injury
Fracture
Obtain appropriate consultation:
- Neurosurgery
- Orthopedic spine

Discharge Criteria

Completely normal mental status
No radiographic abnormalities
No transient or persistent neurologic deficit
Educate parents:
- SCIWORA can present with delayed onset of symptoms.
- Patient should return to hospital if paresthesias, weakness, or paralysis is present.

FOLLOW-UP RECOMMENDATIONS

Follow up with orthopedic surgeon or neurosurgeon as directed
If concussion suspected, follow-up suggested
Children with significant trauma should have psychological follow-up.

PEARLS AND PITFALLS

Maintain appropriate immobilization during evaluation.
In most cases, plain radiographs can be used as initial screening tool.
Be aware of unique features of pediatric cervical spine.
Symptoms of SCIWORA can be transient or delayed.

ADDITIONAL READING

Bracken MB. Steroids for acute spinal cord injury.
Cochrane Database Syst Rev.
2012;1:CD001046. doi:10.1002/14651858.CD001046.pub2.
Caviness AC. Evaluation of cervical spine injuries in children and adolescents. UpToDate. Available at
http://www.uptodate.com/contents/evaluation-of-cervical-spine-injuries-in-children-and-adolescents
.
Mohseni S, Talving P, Branco BC, et al. Effect of age on cervical spine injury in pediatric population: A National Trauma Data Bank review.
J Pediatr Surg
. 2011;46(9):1771–1776.
Swischuk LE.
Imaging of the Cervical Spine in Children
. New York, NY: Springer-Verlag; 2004.