Cervical spine injuries in infants and children are usually
associated with motor-vehicle accidents, falls, diving 129accidents,
sports injuries, gunshot injuries, and, occasionally, child abuse. They
range broadly from minor soft-tissue injuries to severe fracture-dislocations
with spinal cord injury or sudden death. Although rare, the injuries
are worthy of special attention because of particular aspects relating
to the pediatric cervical spine, including unique features of developmental
anatomy, injury patterns, treatment, and prognosis. Appropriate
algorithms for evaluation and management are essential for the care
of these injured children. Deformity, instability, posttraumatic
stenosis, and neurologic sequelae may be prevented with early recognition
and appropriate management of those at risk.
In order to adequately understand the differences in injury patterns
unique to the pediatric cervical spine, it is essential to understand
the anatomic and developmental features that are unique to infants
and children.
The notochord is formed by week two of fetal development and
is in close proximity to the paraxial mesoderm (mesenchymal tissue
running parallel to the notochord), which becomes segmented into
four cranial and eight cervical somites at weeks two and three1,2. The somites each differentiate
into cranial and caudal halves, which then reunite with the caudal
and cranial halves, respectively, of the adjacent somite, forming
each provertebra1,2. The notochord
eventually constitutes the apical and alar ligaments as well as the
nucleus pulposus of each intervertebral disc1,2.
During weeks five and six, chondrification takes place in each half
of the vertebral body and neural arch1,2.
Finally, ossification takes place in each body and lateral mass1-3.
The Atlas
The atlas develops from three ossification centers: the two primary
ossification centers of the lateral masses, which are ossified at
birth, and one secondary ossification center for the body, which ossifies
at approximately one year of age (Fig. 1)4,5.
The posterior arches fuse by the age of three or four years; the
neurocentral synchondroses between the lateral masses and the body
fuse at approximately seven years of age6.
The Axis
The axis is derived from five primary ossification centers, including
two lateral masses (or neural arches), an odontoid process (which
comprises two condensed longitudinally oriented halves at birth),
and a body or centrum (Fig. 1). There are two secondary centers:
the ossiculum terminale at the tip of the odontoid process and the
inferior ring apophysis6. The
two halves of the odontoid process are generally fused or condensed
at birth but may persist as two centers known as a dens bicornis6. The odontoid process is separated from
the body by a dentocentral, or basilar, synchondrosis, which lies
well caudad to the level of the superior articular facets, giving
the ossification centers the overall appearance of a "cork
in a bottle" on an open-mouth radiograph of the axis, with
the odontoid process being the "cork" and the
lateral masses and the body together forming the "bottle" (Fig. 1)4,6. The dentocentral synchondrosis
of the axis remains open in most children until the age of three
years, is present in 50% by the age of four to five years,
and is absent in most by the age of six years2,4,6.
The tip of the odontoid process is not ossified at birth but appears
around the age of three years and fuses to the odontoid process
by the age of twelve years6. Occasionally,
it remains as a separate ossiculum terminale persistens6.
The Lower Cervical Spine
The vertebrae of the lower cervical spine are each composed of
three primary ossification centers: one for the body and one each
for the two neural arches. The ring apophyses (the two secondary
ossification centers) eventually ossify during late childhood and fuse
in the early twenties. The neural arches fuse posteriorly by the
age of two or three years, and the neurocentral synchondroses fuse
between the ages of three and six years. The vertebral bodies are
wedge-shaped until the age of seven, when they begin to "square
off."
Unique Features of the Immature Cervical Spine
There are several physiological differences between the cervical
spine in children and that in adults. For instance, children who
are less than eight years old have increased neck motion, which is
due to the relative laxity of the ligaments, relative muscle weakness,
and incomplete ossification of the cartilaginous elements of the
pediatric cervical spine as well as to other factors such as the
horizontal orientation of the shallow facet joints4,7-10. As mentioned above, incomplete
ossification in the cervical spine in children accounts for differences
in measurements of certain relationships, including the basion-odontoid
interval and the atlanto-odontoid interval (4 mm is considered the
upper limit of the normal range for children). Furthermore, in children,
the vertebral bodies are more wedge-shaped than are those in adults. The
cervical spine approaches adult size and shape by the age of eight
years as the vertebral bodies gradually lose their oval or wedge
shape and become more rectangular11.
The facet orientation changes to become more vertical, the uncinate
processes increase in vertical height, and the ligaments and facet
capsules increase in tensile strength10.
These factors help to explain the occurrence of spinal cord injury
without radiographic abnormality, which is seen in infants and young
children and has been reported in a substantial percentage of young
children with spinal cord injury4,7,12,13.
Spinal cord injury without radiographic abnormality is due to stretching of
the vertebral column beyond the tolerance of the spinal cord or
to spontaneous reduction of a dislocation or apophyseal separation.
Biomechanical testing has shown that the immature cervical spine
stretches as much as 2 in (5 cm) prior to failure. The spinal cord can
tolerate stretching of only about 0.25 in (0.64 cm)14.
When a spinal cord injury occurs without radiographic abnormality,
careful neurologic evaluation is indicated to document the level
and type of injury, to determine whether the cord injury is complete
or incomplete, and to assess for the presence of spinal shock. Magnetic
resonance imaging may be useful to identify the nature of the injury.
In children with associated head trauma, monitoring of somatosensory
evoked potentials has also been useful13.
Multilevel spinal injuries also occur more frequently in children.
In one study of 105 patients (mostly children and young adults)
with cervical spine injuries, 24% of the injuries involved more
than one level15. The use of steroid
protocols soon after injury may be helpful in children with a spinal
cord injury16.
Spinal cord injuries occur at different levels in children than
in adults. In a study of 227 consecutively treated children with
a traumatic fracture of the cervical spine, 87% of those
who were less than eight years old had an injury of the third cervical
vertebra or higher and had an increased risk of dying from the injury17. Conversely, children who were more than
eight years old had an injury pattern similar to that of adults
(predominantly caudad to the fourth cervical vertebra), and none
died17.
Physiologic motion of the cervical vertebrae in children is greater
than that in adults, and a normal pediatric cervical spine may appear
to have a subluxation. When a subluxation is not present, the movement
is termed a pseudosubluxation and does not need treatment. Pseudosubluxation
of the second cervical vertebra on the third or of the third cervical
vertebra on the fourth is common in children4,8,9,18,19.
In one study, pseudosubluxation of the second cervical vertebra
on the third was seen in 19% of children who were one to
seven years old; pseudosubluxation of the third cervical vertebra
on the fourth was seen less frequently19.
Another study showed that pseudosubluxation occurs in 40% of
children under the age of eight years9.
Up to 4 mm of anteroposterior step-off of the second cervical vertebra
on the third in flexion may be seen in children with a normal cervical
spine9. The differentiation of
this phenomenon from true injury can be facilitated by the use of
Swischuk’s line4,19,
which is drawn along the posterior arch (the spinolaminar line)
from the first cervical vertebra to the third (Fig. 2). The line should
pass within 1.5 mm of the posterior arch of the second cervical
vertebra19. When a fracture is
present, the line is disrupted. Furthermore, pseudosubluxation reduces
with extension, whereas acute traumatic subluxation generally does
not reduce with extension, usually because of pain and muscle spasm.
Additionally, localized kyphosis in the midcervical spine (that
is, the absence of cervical lordosis) can be a normal finding on
lateral radiographs of children, occurring in up to 14% of
children who are less than sixteen years old8;
this finding in the adult cervical spine strongly indicates an abnormality.
In children, localized kyphosis in the midcervical spine that occurs
normally disappears with extension, whereas kyphosis resulting from
an injury does not.
Apparent overriding of the anterior arch of the atlas on the
odontoid process may also be seen, in extension, in very young children;
it occurs in 20% of those between the ages of one and seven
years8. Children who are less
than seven years old may have displacement of as much as two-thirds
of the arch above the odontoid process. (This finding is due to
the fact that the body of the atlas is not ossified at birth, and
the tip of the odontoid process is cartilaginous.) In addition,
anterior angulation of the odontoid process is seen in as many as 4% of
children9.
The presence or persistence of the basilar odontoid synchondrosis
of the axis may result in the false impression of fracture of the
base of the odontoid process at this level6.
The synchondrosis is normally seen in 50% of all children
up to the age of eleven and can mimic an odontoid fracture. The
synchondrosis appears sclerotic, unlike an acute fracture, and is located
well caudad to the base of the odontoid process, where most fractures occur
in adults7.
Traumatic injury of the spinal column is uncommon in children.
In most series of cervical spine injuries in adults and children,
only 2% to 3% of all spinal injuries involve children4. In a study performed at a large,
busy children’s hospital, the incidence of injuries of
the cervical spine averaged only 1.3 per year during a fifteen-year time-period20. In another large series of 631
cervical spine injuries, only twelve (1.9%) occurred in
children who were less than fifteen years old21.
The common causes of injury include motor-vehicle accidents, sports
injuries (including diving accidents), falls from a height, gunshot
wounds, and child abuse4,22. Most
spinal injuries in children who are less than eight years old involve
the third cervical vertebra or higher, and most deaths from cervical
spine injury occur in this age-group.
When a child has a suspected injury of the cervical spine, the
cervical spine should be immobilized in an adequate manner to prevent
motion that could cause spinal cord or other additional injury.
At my institution, the indications for immobilization after trauma
include loss of consciousness (a Glasgow Coma Scale score of <13
points), altered mental status, a mechanism of injury that could
be consistent with spinal injury (including, but not limited to,
a motor-vehicle-pedestrian or motor-vehicle-cyclist accident, a
fall from a considerable height, and a motor-vehicle accident in
which the patient was an unrestrained passenger), neck pain or guarding
of the neck, or associated head or facial trauma. A physical finding
such as a seat-belt sign may also be indicative of cervical spine
injury (Fig. 3).
Proper immobilization of the cervical spine on a spine board
must allow for the disproportionately large size of the infant’s
or child’s head with respect to the body. This may be accomplished either
by using a spine board with an occipital recess or, more commonly,
by placing a mattress or blankets beneath the shoulders and trunk
of the child (Fig. 4)23.
When an infant or child has a known or suspected cervical spine
injury, the cervical spine should initially be immobilized with
a rigid cervical orthosis, specifically designed and appropriate for
infants or children, and there should be sandbags on each side of
the head to prevent motion7. Movement
should be minimized, and the child should be moved only as necessary.
The back is inspected in a log-roll fashion with gentle in-line
cervical traction until all screening anteroposterior and lateral
radiographs of the spine as well as an open-mouth radiograph of the
odontoid process (if appropriate) have been reviewed. The cervical
spine remains immobilized until either initial radiographs are made
and evaluated and injury is ruled out or definitive treatment is
rendered.
Neurologic signs and symptoms, including the inability to move
the extremities or a history of numbness, tingling, or weakness,
are sought and may indicate a cervical spine injury. Examination
of the spine begins with inspection and palpation for abnormalities,
including sites of tenderness, deformity, ecchymosis, head tilt,
contusion, and abrasion. A high index of suspicion for occult cervical
spine injury should be maintained when patients have sustained multiple
trauma.
The range of motion should be evaluated only when the child is
conscious and cooperative and an unstable injury is not suspected.
If the child has no neck pain or cervical spine tenderness and has
a full, painless range of motion of the neck and spine, then the
cervical collar may be removed and the child can be taken off the
spine board. If the patient has tenderness or limitation of motion
despite normal findings on a high-quality radiographic trauma series of
the cervical spine, lateral radiographs with voluntary flexion and extension
of the spine can be made to rule out injury or instability that
was not detected on the initial radiographs. These studies should
be performed only if the child is alert, oriented, and of an appropriate
age to cooperate with the study. If the findings are negative and tenderness
persists, a soft collar can be used for comfort, and other studies, such
as magnetic resonance imaging, can be considered. Ideally, the patient should
not leave the emergency department unless the physician in charge
has either ruled out injury of the cervical spine or made a diagnosis
of a specific injury.
The Trauma Series
Initial radiographs include high-quality cross-table lateral
and anteroposterior radiographs and an open-mouth radiograph of
the odontoid process. It is mandatory that the cervicothoracic junction
(the disc space between the seventh cervical and first thoracic
vertebrae) be visualized radiographically in every patient with
adequate lateral plain radiographs (sometimes requiring careful
downward traction on the arms to lower the shoulders), a so-called
swimmer’s radiograph, or a computed tomography scan with
fine cuts through this portion of the spine.
Because of the variability in radiographic findings in children,
care must be taken in reviewing these studies and in correlating
this information with the history and physical findings in the child.
Serial physical examinations may be useful when attempting to determine if
a radiographic finding represents true abnormality or a normal variant
for that child. Rapid resolution of symptoms with restoration of
a voluntary range of motion suggests a normal variation, whereas
persistence of tenderness, limitation of motion, paraspinal muscle spasm,
or torticollis suggests the need for additional investigation.
Evaluation of the lateral radiograph begins with an assessment
of the four lines corresponding to the anterior vertebral bodies,
the posterior vertebral bodies, the inside of the lamina (the spinolaminar
line), and the tips of the spinous processes from the first to the seventh
cervical vertebra24 (Fig. 5). All four of
these lines should follow a smooth, even contour. There should be a
parallelism of the articular facets and a balance of the interspinous
distances and the posterior aspect of the disc spaces18. The retropharyngeal space should
be <7 mm, and the retrotracheal space should be <14
mm in children; however, these may be difficult to interpret in
a normal crying child25. Subtle
findings suggestive of an injury at these levels include a widened
disc space (apophyseal separation), avulsion fracture of the vertebral
end plates, fractures of the spinous processes, and an increased
distance between two spinous processes.
Another area of particular interest is the relationship of the
first cervical vertebra, the second cervical vertebra, and the spinal
cord as described by the atlanto-odontoid interval and the space available
for the cord (Fig. 6). The atlanto-odontoid interval
should be <4 mm in children who are less than eight years
old (some consider 5 mm to be acceptable4),
whereas
the value should be £3 mm in older children and adults26. In a child with atlantoaxial instability associated
with a traumatic rupture or avulsion of the transverse ligament,
the atlanto-odontoid interval may be substantially increased (Fig. 7).
The space available for the spinal cord is roughly defined by
the "rule of thirds" proposed by Steel26. At the level of the odontoid process, one-third
of the space is occupied by the spinal cord, one-third is occupied by
the odontoid process, and one-third is so-called free space.
At this level, the transverse ligament serves as the first line
of defense, maintaining the atlanto-odontoid interval at £4
mm. The alar, or check, ligaments form the second line of defense.
When the atlanto-odontoid interval exceeds 10 to 12 mm, then all
ligaments have failed and the space available for the spinal cord
is negligible, resulting in cord compression (Fig. 6)26,27. Magnetic resonance imaging or
computed tomography scans can also be used to evaluate for instability
and resultant compression in this area28.
These findings should be correlated with the history and the findings
of the physical examination to determine the clinical relevance
of the instability for each child.
As shown in Figure 6, several other lines (McGregor’s, McRae’s,
Chamberlain’s, and Wackenheim’s lines; the line
used in the ratio of Powers et al.; and the lines described by Wiesel
and Rothman8,29-31) have been
described to help to evaluate the upper cervical spine as seen on lateral
static radiographs. McGregor’s line is one of the best
for detecting basilar impression because the osseous landmarks are
usually clearly seen at all ages8.
The line is drawn from the superior surface of the posterior edge
of the hard palate to the most caudad point of the occiput. If the
tip of the odontoid process lies >4.5 mm above McGregor’s line,
the finding is consistent with basilar impression8.
McRae’s line defines the opening of the foramen magnum.
The odontoid process projects above this line in patients with basilar
invagination8. The lines of Wiesel
and Rothman are used to measure anteroposterior translation at the
atlanto-occipital joint, which should be no more than 1 mm30 (Fig. 6, B). The ratio
of Powers et al.31 is used to
evaluate atlanto-occipital dislocation (Fig. 6, C). Values of
1.0 are abnormal, and values of <1.0 are normal31. If there is suspicion of abnormalities,
a more detailed evaluation with magnetic resonance imaging or computed
tomography may be indicated7,28.
Wholey et al. noted that the middle half of the odontoid process
lies directly beneath the basion (the anterior lip of the foramen
magnum) at an average distance of 5 mm on the lateral radiograph4,25. This distance may be increased
up to 1 cm in children under the age of eight because of incomplete
ossification25. More recently,
the occipitovertebral relationship has been evaluated by measurement
of the basion axial interval32,
which is the distance between the basion and the posterior axial
line (the rostral extension of the posterior cortex of the body
of the axis). It has been observed that this interval should not exceed
12 mm in children who are less than thirteen years old32. The basion-odontoid interval has
been found to be less reliable in young children.
At the base of the odontoid process, an optical phenomenon that
can be mistaken for a fracture can occasionally be produced on plain
radiographs. Mach bands are dark and light lines that appear at
the borders of structures with different radiodensities and commonly occur
at the base of the odontoid process where it joins the body of the
axis and where the lateral masses join the odontoid33. Computed tomography may be useful to
demonstrate definitively the presence or absence of a fracture in
patients with persistent tenderness following trauma.
Special Studies
Special studies may supplement plain radiographs of the cervical
spine in children. Oblique radiographs are useful in showing detail
of the facet joints and pedicles. Lateral radiographs made, under
careful supervision, with the cervical spine in flexion and extension,
as mentioned above, are used to evaluate for instability but may
be inappropriate for very young or obtunded infants and children
with head injury. False-negative findings may also occur when the child
has pain, is guarding the neck, or is frightened. Flexion and extension radiographs
of the cervical spine should never be made when the patient is unconscious.
Tomography is very helpful for the evaluation of trauma of the
upper cervical spine. However, these studies are associated with
an increased amount of radiation compared with computed tomography
scans and magnetic resonance imaging. At many hospitals, computed
tomography scanning with three-dimensional reconstruction has replaced
tomography.
Computed tomography scans allow better definition of bone injury,
but fractures in the same plane as the plane of the imaging (such
as fractures of the odontoid process with transverse images) may
be missed without three-dimensional reconstructions or reformatted
sagittal or coronal images. A computed tomography scan with three-dimensional
reconstruction should be used when plain radiographs are not definitive28. Computed tomography scans do not visualize
ligaments and soft tissue well. Dynamic computed tomography scans with
neutral cuts and rotation cuts to the left and right are used to
evaluate atlantoaxial rotatory displacement34.
Computed tomography scans with three-dimensional reconstructions
and reformatted sagittal and coronal images are also helpful at
times to examine children with congenital anomalies of the cervical
spine.
Myelography and computed tomography myelography are used less
commonly but may be indicated occasionally to demonstrate the presence
of dural bands or compression in cases of stenosis or basilar impression.
Magnetic resonance imaging (either static, or dynamic in flexion
and extension) is an excellent technique for examination of the
brain stem and spinal cord, soft tissues (discs, ligaments, and
so on), and bone of the cervical spine and for detection of hemorrhage associated
with injury. Magnetic resonance imaging is very helpful in evaluating
a comatose or unconscious child who cannot safely undergo dynamic radiography.
When appropriate, a magnetic resonance imaging study of the cervical
spine can be easily added to a magnetic resonance imaging study
of the head. Sedation usually is required. Magnetic resonance imaging
is also useful for evaluating a child with spinal cord injury without
radiographic abnormality12.
Once a cervical collar or other immobilization device is in place
(that is, applied either before or after the child arrives at the
hospital), formal clearance (that is, a determination that the cervical
spine is free of injury) to remove the collar is required. Clinical examination
can be used if the patient is awake and alert, has no signs or symptoms
of neck injury, and does not have a mechanism of injury consistent
with a spine injury (as described above).
If, after adequate plain radiographs have been made, an unconscious
child with a suspected cervical spine injury is to undergo magnetic
resonance imaging or computed tomography scanning for evaluation
of a head or abdominal injury, one can consider performing those
studies to evaluate the cervical spine as well.
For unconscious, uncooperative, or very young patients, magnetic
resonance imaging may be used to reveal soft tissue and osseous
injury of the cervical spine and its supporting structures that
are not visible on plain radiographs. These studies may be the best way
to rule out cervical spine injury and allow the removal of the cervical collar
from unconscious individuals, thereby preventing the skin breakdown that
can occur from prolonged use of such a collar.
The value of clearance protocols to rule out pediatric cervical
spine injuries is still debated. Suspected cervical spine injuries
are more difficult to rule out in young children not only for the
reasons mentioned above, but also because the children are often
unable to describe pain and are often uncooperative. Plain radiographs
alone may not demonstrate occult injuries (for example, synchondrosis
injury) and do not visualize the soft tissues (that is, the ligaments
and discs) well. The cephalad and caudad ends of the cervical spine
are also often difficult to evaluate, especially in children.
The role of magnetic resonance imaging in identifying spinal
injuries is well established; however, its role in evaluating children
with suspected spinal injuries is less clear. Magnetic resonance
imaging is the study of choice for the evaluation of the spinal
cord and is the most sensitive for the evaluation of soft tissue,
ligaments, discs, and growth cartilage.
A retrospective study35 performed
at my institution between 1993 and 1997 identified 237 children with
an ICD-9 (International Classification of Diseases, Ninth Revision)
coding for neck injury. Ninety-three of these children had a cervical
spine injury, and seventy-nine had magnetic resonance imaging studies
that revealed injuries not seen on plain radiographs. Fifteen (19%)
of the seventy-nine patients had negative findings on radiographs
and positive findings on magnetic resonance images. Seven of them had
ligamentous injuries, mostly at the first and second cervical levels.
Seven others had other soft-tissue (muscle) injury only. One had
a fracture (of the first cervical lateral mass) not seen on plain
radiographs. Magnetic resonance imaging also made it possible to
rule out injuries suspected on plain radiographs. Seven children
had radiographs with suspicious findings (two had questionable subluxation
of the second on the third cervical vertebra, one had an anomaly
of the first cervical vertebra, three had a suspected fracture of
the odontoid process, and one had a suspected fracture of the fourth
cervical vertebra) that were later discounted with magnetic resonance
imaging as indications of injury. Magnetic resonance imaging also
made it possible to rule out injuries suspected on computed tomography.
Three children who had a suspected odontoid fracture on computed
tomography scans had negative findings on magnetic resonance imaging.
Of those with evidence of ligamentous injuries on magnetic resonance imaging,
six were successfully treated with immobilization only and one died of
associated injuries. Magnetic resonance imaging was also helpful
in definitively ruling out cervical spine injury in intubated, obtunded,
or uncooperative children. Twenty-five intubated or uncooperative
children had magnetic resonance imaging of the cervical spine. Three
of them were found to have serious injuries. The remaining twenty-two
children had negative findings, their collars were removed, and they
had no problems later.
Magnetic resonance imaging is a very sensitive method for evaluating
children with suspected cervical spine injuries. It is useful when
plain radiographs or computed tomography scans are equivocal. Magnetic
resonance imaging is my choice for ruling out injury of the cervical
spine in obtunded, intubated, or uncooperative children. Our sequence
protocol for magnetic resonance imaging currently includes sagittal
T1-weighted images, conventional sagittal T2-weighted images, axial
T1-weighted and T2-weighted images, and coronal T2-weighted images
(if there is suspicion of unilateral injury). Determining which
of the more subtle findings on magnetic resonance imaging constitute
instability requires further study.
Trauma is a common cause of atlantoaxial rotatory subluxation.
Other causes include infection, postoperative inflammation, and
other inflammatory conditions, such as rheumatological conditions.
Children with atlantoaxial rotatory subluxation present with pain and
torticollis and are best evaluated with plain radiographs and a
dynamic rotation computed tomography scan. Atlantoaxial rotatory
subluxation represents a spectrum of abnormalities ranging from
mild displacement to severe fixed displacement (atlantoaxial rotatory
fixation). The Fielding and Hawkins classification is used to describe
the abnormal relationship between the first and second cervical
vertebrae in this disorder and to guide management (Fig. 8)34.
There are several commercially available rigid cervical orthoses
specifically designed for infants or children with a known or suspected
cervical spine injury. Sandbags can also be used on each side of
the head in combination with the spine board to prevent motion. Once
the child arrives in the hospital and a diagnosis is made, traction
can be used if appropriate. Traction can be applied with Gardner-Wells
tongs or a halo ring. The advantage of a Minerva brace or cast is
that no skeletal pins are needed, but the disadvantage is that contact
dermatitis can develop under the brace or cast, especially the chin portion,
and can contribute to temporomandibular joint pain and difficulties with
eating.
A halo ring and vest has been used for immobilization of the
cervical spine in children for some time. The advantages include
ease of application, better immobilization and positioning, earlier mobilization
of the patient than is possible when traction is used, fewer skin complications
than occur with other orthoses, ease of access to wounds of the
neck or scalp, and freedom of mandibular motion for eating and talking.
The technique for applying the halo ring and vest in children
differs from that in adults as children have thinner skulls. A computed
tomography scan made prior to halo application may be helpful in
the placement of pin sites so that cranial sutures in infants and
other thin areas of the skull in young children can be avoided.
Eight to twelve pins are used with low insertional torques (1
to 5 in-lb) in children, whereas the standard construct in adults
consists of four pins with an insertional torque of 6 to 8 in-lb.
Complication rates for children treated with pediatric halo constructs
(including multiple-pin constructs) are similar to those reported
in adult series, with infection at anterior pin sites being the most
common complication seen in children36.
The evaluation of a child with a suspected cervical spine injury
differs substantially from that of an adult. Knowledge of the developmental
anatomy and injury patterns is necessary to evaluate and manage
these children effectively. Improved imaging techniques are facilitating
the radiographic evaluation of such patients, and the understanding
of trauma patterns and how these patterns influence the stability
of the cervical spine is increasing. With the growing awareness
of the pathoanatomy and natural history of these injuries, it will
be possible to manage the issues related to the cervical spine in
children more effectively.
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