Offered by the PTS Education Committee
Prepared by: Leslie Dingeldein, MD and Rachael Pridgeon, RN, Rainbow Babies and Children's Hospital, Cleveland, OH
A previously healthy 10 year old female presented to a Level I pediatric trauma center after being a rear passenger in a MVC, and restrained with a lap belt. The car was traveling 30-40mph at the time of the collision and further details of the collision were unavailable at the time of presentation. She had self-extricated, was ambulatory at the scene, and arrived to the trauma bay sitting up on the gurney. C-spine precautions were initiated upon arrival and a c-collar was placed shortly after arrival to the trauma bay. Initial vitals signs were: T 36.5 HR 113 RR 24 BP 122/71 O2 100% on RA. These remained stable throughout her ED course. She initially complained of abdominal pain and had abdominal tenderness and a seatbelt sign. In addition, her initial GCS was 13 (E3 V5 M6). Secondary survey was otherwise normal, including no cervical spine tenderness. Repeat GCS 10 min after arrival was 10 (E2 V4 M4) and her mental status continued to wax and wane, but did not continue to worsen. X-rays of the chest, pelvis, and c-spine were unremarkable. Due to abdominal tenderness and altered mental status, a CT abdomen/pelvis and head CT were obtained. CT abd/pelvis was significant for mild enlargement of the pancreas with some peri-pancreatic fluid without other identified injury. Laboratory evaluation also showed mild transaminitis with lipase of 300. CT head showed subarachnoid hemorrhage within the pre-pontine and pre-medullary cisterns and upper cervical spine thecal sac. These findings prompted a CTA head and CT c-spine to be performed and the neurosurgery team was consulted. Repeat C-spine exam on tertiary survey revealed mild high midline c-spine tenderness as well. Strength and sensation and reflexes on neurologic exam remained normal. C-spine imaging showed a tectorial membrane tear and partial disruption of the dorsal clivus venous plexus. MRI was ordered and PICU admission was planned.
MRI further revealed disruption of the apical ligament and likely high-grade sprain involving the fibers of the superior cruciate ligament and a 4mm posterior displacement of the tip of the odontoid. No spinal cord injury or narrowing of the spinal canal was noted. She was transferred to the PICU and started on a precedex drip to limit movement and was taken to the OR a few hours later for atlanto-axial stabilization with halo placement. Orotracheal fiberoptic intubation was performed for OR by ENT to limit C-spine disruption.
Follow up: Pt was discharged on hospital day #5 after evaluation by OT and PT, after adequate pain control and post-op goals were achieved. No outpatient rehabilitation was indicated. Activity at home was slowly increased as tolerated by the patient. She had an uneventful post-injury course and the halo was removed 3 months after initial injury.
1) This patient had no neurologic deficits, but had risk factors for c-spine injury including abdominal injury and altered mental status, and later, neck pain. Other risk factors for c-spine injury include axial load mechanisms of injury, diving injury, loss of consciousness, inability to move the neck, thoracic injury, hypoxemia, focal neurologic deficits, pre-existing conditions predisposing for c-spine injury, high-risk MVC, and intubation.
2) C-spine motion restriction or immobilization in the pre-hospital setting is important in the setting of blunt trauma until full evaluation in the hospital can be accomplished especially in the setting of distracting injuries, as in this patient's abdominal injury. The relatively large occiput of small children should be taken into consideration during immobilization to avoid neck flexion that could occur on a flat, hard surface.
3) Motor vehicle collisions are the leading cause of spinal cord injury in kids, followed by falls and sports injuries.
4) MRI can be utilized to better define ligamentous injury not seen well on other imaging modalities.
5) C-spine clearance protocols should be utilized to maximize injury identification, reduce unnecessary radiation exposure, and effectively utilize human and health care resources. There are evidence-based recommendations to guide the development of c-spine clearance protocols.
1) Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G, Reardon M, Holroyd B, Lesiuk H, and Wells GA. Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. N Engl J Med 2003;349:2510-8.
2) Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, Lerner B, Kuppermann N. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics 2019;144(1):e20183221
3) Kreykes NS, Letton RW. Current Issues in the Diagnosis of Pediatric Cervical Spine Injury. Seminars in Pediatric Surgery 2010;19:257-64.
4) Herman MJ, Brown KO, et al. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am. 2019;101:e1(1-9)
5) Konovalov N, Peev N, Zileli M, Sharif S, Kaprovoy S, Timonin S. Pediatric Cervical Spine Injuries and SCIWORA: World Federation of Neurosurgical Societies Spine Committee Recommendations. Neurospine 2020;17(4):797-808.