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Cervical spine injuries in children
D Bohn1, D Armstrong, L Becker
1Department of Pediatrics and Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
High cervical spine injuries in children can cause cardiorespiratory arrest or hypotension, even without clear X-ray findings. This previously unrecognized cause of sudden death in pediatric trauma requires consideration in emergency evaluations.
Area of Science:
- Pediatric Traumatology
- Neurology
- Emergency Medicine
Background:
- Cardiorespiratory arrest post-trauma is typically attributed to cerebral injury, hemorrhage, or airway issues.
- A specific subgroup of pediatric trauma patients presents with unexplained absent vital signs or hypotension.
Purpose of the Study:
- To identify and characterize a distinct pattern of high cervical spine and cord injury in children presenting with cardiorespiratory arrest or severe hypotension.
- To highlight this previously unrecognized cause of pediatric cardiorespiratory arrest.
Main Methods:
- Retrospective review of 19 pediatric patients (mean age 6.3 years) with cardiorespiratory arrest/hypotension post-trauma.
- Analysis of radiologic (X-ray) and postmortem findings to identify cervical spine and cord injuries.
Main Results:
- 14 patients had injuries to the high cervical spine (C1-C3); 2 had lower cervical spine (C6-7) injuries, and 2 had normal cervical spine X-rays.
- 13 of 16 patients with postmortem examinations showed cord laceration or transection.
- 18 of 19 children were resuscitated but died from hypoxic/ischemic encephalopathy and cerebral injury.
Conclusions:
- A unique pattern of "juvenile" cervical spine injury involving the high spine and cord can lead to apnea, cardiorespiratory arrest, or severe hypotension.
- This diagnosis should be considered in pediatric trauma patients with absent vital signs, even with normal cervical spine imaging.
Abstract:
Cardiorespiratory arrest occurring immediately after multiple injuries is usually assumed to be due to severe cerebral injury, acute hemorrhage, or airway obstruction. We have identified a group of 19 children (mean age, 6.3 years) who presented with absent vital signs (VSA) or severe hypotension, unexplained by blood loss, where these findings were caused by injury to the high cervical spine and cord, demonstrated either by X-ray or postmortem examination. Fourteen had radiologic evidence of injury to the spine between C1 and C3. In two patients the bony injury was at the C6-7 level, while in two patients the cervical spine X-ray was normal. Eighteen of the 19 children were initially resuscitated but died from a combination of hypoxic/ischemic encephalopathy and cerebral injury. Sixteen patients underwent postmortem examination and in 13 there was evidence of cord laceration, up to and including cord transection. These findings demonstrate a distinct pattern of "juvenile" cervical spine injury involving the high spine and cord which results in either apnea and cardiorespiratory arrest, or severe hypotension. This previously unrecognized cause of cardiorespiratory arrest should be considered in all children presenting with VSA after multiple trauma, even when there is no apparent radiologic abnormality of the cervical spine.