Chapter 112: Cervical Spine Injury in Infants and Children

INTRODUCTION AND EPIDEMIOLOGY

Cervical spine injuries occur in approximately 1.8% of pediatric blunt trauma patients.^1,2 Although the incidence of cervical spine injuries in children is lower than adults (2.4%), children have higher rates of mortality (7.4%) compared to adults (1.2%).^3-6 In children <8 years old, nearly three fourths of all spinal injuries occur in the cervical spine,⁷ and three fourths of the cervical spine injuries involve the axial cervical spine (occiput through C2).³ Cervical spine injuries in these younger children are more likely associated with neurologic deficits and head or other major organ injury.^3,8 In addition, spinal cord injury without radiographic abnormality (SCIWORA) may occur in children and typically involves the cervical spine. The incidence of SCIWORA among pediatric trauma patients ranges from 0.15% to 0.2%, comprising 4.5% to 35% of pediatric spine injuries.^3,9-11 Motor vehicle crashes are the most common mechanism of cervical spine injuries, followed by falls, and in teenagers, diving and sports injuries.³ Boys are affected more often than girls. Child abuse can result in cervical spine injuries in younger patients via a shaking mechanism, although this is a rare manifestation of inflicted injury.¹² Note that injuries to the spine and spinal cord outside of the cervical spine are discussed in Chapter 110, “Pediatric Trauma.”

PATHOPHYSIOLOGY

A number of anatomic differences between the pediatric and adult cervical spine predispose children to different patterns of injury (Table 112-1). In particular, the larger head-to-body ratio in young children creates a fulcrum at C2–C3 (compared to C5–C6 in adults) that accounts for higher rates of cervical spine injury above C3 in children. Weaker muscles and ligaments combined with anterior wedging and shallow facets connecting cervical vertebrae and immature growth centers together allow for easier anterior-posterior slipping of the vertebrae than in adults.

Patients younger than 8 years of age incur high ligamentous injuries more often than older children and adults. Fractures tend to occur at the weak points in the bones—synchondroses and ossification centers. Dens fractures occur most commonly along the synchondrosis, especially in children younger than age 7 years. The mechanism of injury is usually a forward-facing child in a high-speed motor vehicle crash with rapid forward flexion. Atlanto-occipital and atlantoaxial dislocation injuries are devastating vertical distraction injuries that occur in the very young child, most commonly from a motor vehicle crash, and usually result in rapid death (Figure 112-1).