Advanced Trauma Life Support ATLS Student Course Manual 2018

SPINAL CORD INJURY 205
oxygenation and ventilation can help avoid progressive
CNS damage. Attempts to orally intubate the trachea
in an uncooperative child with a brain injury may be
difficult and actually increase intracranial pressure. In
the hands of clinicians who have considered the risks
and benefits of intubating such children, pharmacologic
sedation and neuromuscular blockade may be used to
facilitate intubation.
Hypertonic saline and mannitol create hyperosmolality
and increased sodium levels in the brain,
decreasing edema and pressure within the injured
cranial vault. These substances have the added benefit
of being rheostatic agents that improve blood flow and
downregulate the inflammatory response.
As with all trauma patients, it is also essential to
continuously reassess all parameters. (Also see Chapter
6: Head Trauma and Appendix G: Disability Skills.)
Spinal cord injury
The information provided in Chapter 7: Spine and
Spinal Cord Trauma also applies to pediatric patients.
This section emphasizes information that is specific to
pediatric spinal injury.
Spinal cord injury in children is fortunately
uncommon—only 5% of spinal cord injuries occur in
the pediatric age group. For children younger than 10
years of age, motor vehicle crashes most commonly
produce these injuries. For children aged 10 to 14 years,
motor vehicles and sporting activities account for an
equal number of spinal injuries.
Anatomical Differences
Anatomical differences in children to be considered in
treating spinal injury include the following:
••
Interspinous ligaments and joint capsules are
more flexible.
••
Vertebral bodies are wedged anteriorly and
tend to slide forward with flexion.
••
The facet joints are flat.
••
Children have relatively large heads compared
with their necks. Therefore, the angular
momentum is greater, and the fulcrum exists
higher in the cervical spine, which accounts for
more injuries at the level of the occiput to C3.
••
Growth plates are not closed, and growth
centers are not completely formed.
••
Forces applied to the upper neck are relatively
greater than in the adult.
Radiological Considerations
Pseudosubluxation frequently complicates the
radiographic evaluation of a child’s cervical spine.
Approximately 40% of children younger than 7
years of age show anterior displacement of C2 on
C3, and 20% of children up to 16 years exhibit this
phenomenon. This radiographic finding is seen less
commonly at C3 on C4. Up to 3 mm of movement may
be seen when these joints are studied by flexion and
extension maneuvers.
When subluxation is seen on a lateral cervical spine
x-ray, ascertain whether it is a pseudosubluxation or
a true cervical spine injury. Pseudosubluxation of the
cervical vertebrae is made more pronounced by the
flexion of the cervical spine that occurs when a child lies
supine on a hard surface. To correct this radiographic
anomaly, ensure the child’s head is in a neutral position
by placing a 1-inch layer of padding beneath the entire
body from shoulders to hips, but not the head, and
repeat the x-ray (see Figure 10-2). True subluxation
will not disappear with this maneuver and mandates
further evaluation. Cervical spine injury usually can be
identified from neurological examination findings and
by detection of an area of soft-tissue swelling, muscle
spasm, or a step-off deformity on careful palpation of
the posterior cervical spine.
An increased distance between the dens and the
anterior arch of C1 occurs in approximately 20% of
young children. Gaps exceeding the upper limit of
normal for the adult population are seen frequently.
Skeletal growth centers can resemble fractures.
Basilar odontoid synchondrosis appears as a radiolucent
area at the base of the dens, especially in children
younger than 5 years. Apical odontoid epiphyses appear
as separations on the odontoid x-ray and are usually
seen between the ages of 5 and 11 years. The growth
center of the spinous process can resemble fractures
of the tip of the spinous process.
Children sustain spinal cord injury without radiographic
abnormalities (SCIWORA) more commonly
than adults. A normal cervical spine series may
be found in up to two-thirds of children who have
suffered spinal cord injury. Thus, if spinal cord
injury is suspected, based on history or the results
of neurological examination, normal spine x-ray
examination does not exclude significant spinal
cord injury. When in doubt about the integrity of
the cervical spine or spinal cord, assume that an
unstable injury exists, limit spinal motion and obtain
appropriate consultation.
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