Cervical spine assessment in PICU
There is evidence to support guidelines only, not protocols. All patient should be stabilised prior to cervical spine clearance
General points
There is evidence to support guidelines only, not protocols
All patient should be stabilised prior to cervical spine clearance
Mechanism of injury is a poor predictor of spinal cord injury
One in six children with spinal injury have multiple levels of injury
Ligamentous instability may be more common than thought
The true incidence of C spine injury is not known, nor how many missed.
Common normal XR changes in paediatrics
Overriding of anterior atlas relative to odontoid on extension
Exaggerated atlanto-dens intervals
Radiolucent synchondrosis between odontoid and C2.
Pseudosubluxation of C2 on C3. (To differentiate between physiological and traumatic subluxation, draw a line through post arches of C1 and C3. In pseudosublux, line passes through, touches or lies up to 1 mm anterior to the anterior cortex of posterior arch of C2. If anterior cortex of C2 is 2mm or more behind line, then is true dislocation.
Technically adequate Xrays
Must see base of occiput and upper border of T1, odontoid which shows lateral masses of C1 and all of odontoid process.
Cervical Spine Guidelines
Immobilisation
Collars do not prevent forced flexion when supine on spinal boards
Collars alone do not prevent injury and may worsen respiratory function, lead to skin ulceration and thrombosis of neck veins
No collar provided acceptable immobilisation when used alone
Neutral position desirable:
<4 years old, need elevation of torso by more than 25 mm to eliminate positional neck flexion and achieve neutral alignment.
<8 years, need elevation of torso by 25 mm to achieve positional neck flexion and achieve neutral alignment
Recommendation
<8 years, should elevate thorax or recess the occiput. Achieve this by placing extra folded blanket to thickness of 25mm under the patient's body.
Combination of half spine board, rigid collar, sandbags and tape is best, but may affect respiratory function
Imaging
| Low risk | no cervical tenderness, alert, able to communicate, no neurological deficit, no intoxication, no unexplained hypotension or absent vital signs Recommendation: no imaging |
| Medium risk | with any of the above: Recommendation: • lateral and AP XR • If XR normal but pain, do flexion / extension views |
| High risk/ Comatose (majority of PICU patients) | Non verbal, due to age, head injury and pain. Recommendation for all ages: • AP and lateral Xray of spine. Odontoid view not required • CT scan of upper two C vertebrae with axial CT at 3mm intervals. If possible this can be done with the initial head CT. • For children transferred in to the PICU, CT of C1 and C2 should be requested with head CT at the referring hospital. If CT has already been taken at the time of referral call, then CT of C1 and C2 should be requested in Starship with the follow up CT head, or separately if no further cerebral imaging is planned. • Axial CT at 3mm intervals for suspicious areas or areas not well seen on lateral XR. • If view are adequate and no abnormality is seen, consider the spine to be stable and remove collar. False negative rate of <0.1% with Xrays and CT • MRI indicated only for - unstable spinal injuries who require surgical stabilisation, - exclusion cord or nerve root compression - evaluation of ligamentous integrity - information re neurological deficit Not recommended: • Flexion/extension views: <9 years if XR normal, few injuries below C3. No evidence for use, not more accurate than recommendations, high false negative rate and not cost effective • Routine MRI: sensitive but not specific, difficult to perform in unstable patient |
SCIWORA: Spinal Cord Injury without Radiological Abnormality
| Immobilisation | Recommended for: • Severe pain/ spasm:Immobilise until flexion/ extension views confirm stability • Transient or persisting neurological symptoms. Presenting examination relates strongly to outcome |
| Radiology | Recommendations: • Plain XRs: Whole spine to exclude fractures. Fracture, subluxation or pathological motion rules out SCIWORA • MRI: - if suspected neurological injury - To exclude compressive cord or nerve root lesions - To exclude ligamentous disruption - To determine time for immobilisation - To predict outcome: hematomyelia or disruption associated with severe permanent neurological injury, signal change may improve over time, normal do well. Not recommended: • spinal angiography or myelography • CT |