An epidemiology of paediatric cervical spine injuries at the Red Cross War Memorial Children's Hospital over a ten-year period

Abstract

Background: Paediatric cervical spine injury (CSI) is rare compared to adult CSI. Very little has been published regarding the epidemiology and outcome of CSI in children in South Africa. The objective of this retrospective study is to characterise the epidemiology and report on the outcome of CSI in children <13 years at a tertiary referral centre for paediatric trauma. Methods: We performed a retrospective study of CSI at our hospital over a ten-year period. The Picture Archiving and Communication System (PACS) of our institution was searched for patients with CSIs. Search terms included: cervical spine fracture, subluxation, dislocation, contusion, SCIWORA (spinal cord injury without radiographic abnormality) and retroclival haematoma. Demographic and clinical data were obtained from hospital records. Injury-related variables were compared for children ≤8 and >8 years due to anatomical and biomechanical differences observed. Outcome was assessed using the Frankel grading. Results: Sixty-six children were identified with a cumulative incidence of 0.1%. The median age was 7 years (inter-quartile range 4-8.8) and 65% were male. All injuries were caused by blunt trauma. Passenger motor vehicle injury (MVA) accounted for 52% of injuries. Injuries due to physical abuse, and recreational and sporting activities did not occur. Children ≤8 years of age incurred more injuries than those >8 years (74.2% vs 25.8%). Ninety-eight per cent of injuries occurred in the upper cervical spine (C1-C4) of children ≤8 years. Of the 13 (19.6%) children with neurologic injury, five (7.5%) had complete spinal cord injury, four (6%) had incomplete neurology, and three (4.5%) died. SCIWORA occurred in six (9%) children with variable outcome. Seven patients (10.6%) were operated for instability. An injury severity score (ISS) of 25 (13-34) was associated with poor outcome. The mortality rate was 4.5% and all children who died were ≤8 years with upper CSIs and closed head injuries (CHIs) related to MVA. Conclusion: CSI occurred in 0.1% of patients evaluated following trauma. MVAs, either pedestrian or passenger, were responsible for the majority of these injuries. Children ≤8 years were more frequently injured and sustained injuries to the upper cervical spine. The majority of paediatric CSIs are stable injuries that can be managed conservatively; however, urgent surgical stabilisation is indicated for unstable injuries. CSI with associated CHI caused by MVAs in young children is associated with death. Even though our patients are referred from high violence communities, no CSIs were attributed to physical abuse or penetrating injury.

Pediatric Upper Cervical Spine Trauma: A 10-Year Retrospective Review at a Pediatric Trauma Center

“…The mortality rate of cervical spine trauma in pediatric patients ranges from 16% to 18%, with a higher rate in pediatric patients sustaining upper cervical spine injuries [ 1 ]. Pediatric patients are more susceptible to cervical trauma than adults with up to 80% of pediatric vertebral injuries occurring within the cervical spine, while cervical spine trauma in adults only accounts for 30% to 40% of spine injuries [ 1 , 2 ].…”

“…In pediatric patients, the anatomy of the cervical spine changes continuously with their growth. Pediatric spines are characterized by increased elasticity of the interspinous ligaments, posterior joint capsule, and cartilaginous endplates [ 2 , 3 ]. Specifically, wedge-shaped vertebral bodies and the horizontal orientation of the facet joints may increase upper cervical spine trauma in children [ 2 ].…”

“…Pediatric spines are characterized by increased elasticity of the interspinous ligaments, posterior joint capsule, and cartilaginous endplates [ 2 , 3 ]. Specifically, wedge-shaped vertebral bodies and the horizontal orientation of the facet joints may increase upper cervical spine trauma in children [ 2 ]. In addition, pediatric patients have a relatively larger head mass, resulting in a higher center of gravity and a greater propensity for high cervical spine injury rates following dynamic movements or sport [ 3 ].…”