Pathology of Cervical Spine Trauma in Children

Pathophysiology

Age-dependent mechanism and type of fracture

• Neonatal injury usually at birth: Most of the injuries in neonates are birth injuries, with a breech presentation being more common, but these injuries can also occur with a caesarian section after a vaginal delivery has been attempted.
  Neonatal injury mostly upper cervical spine: A complete atlanto-occipital dislocation is common (8,43),but any level can be involved. The injury is due to the intrinsic laxity of the newborn’s spinal column, which permits up to 2 inches of distraction, whereas the spinal cord distracts only a few millimeters before damage ensues (8,43).  As a consequence, the cord is at risk for a distraction injury, and, in fact, such injuries account for 10% of neonatal deaths (8).
• Spinal Cord Injury Without Radiological Abnormality (SCIWORA): 15–20% of spine injuries in infants and children will be due to SCIWORA (36,40).. The ligaments are lax in this age group, allowing for greater movement and the potential for injury without fracturing the spine. Neck pain is common; neurological symptoms such as numbness and tingling are also frequent complaints. Overt radiculopathy and myelopathy have been reported but are less common.
• High cervical spine injuries most commonly in infants and younger children:The most common location for injury in infants and children is the upper cervical spine and these can be due to seemingly minor events such as falls in addition to more serious events such as MVAs. The facet joints in the spine are more horizontal than those of an adult, resulting in less resistance to shear loading in comparison with an adult. With aging, the joints become more vertical in orientation.
• Cervical spine injuries below C2 are more common in older children and adolescents: In this age group, injury is commonly due to a MVA or sports innjuy, and typically involves the cervical spine below the axis. Overall, cervical spine injuries are more common in this age group compared with younger children and tend to resemble those seen in adults because the biomechanics of the spine are approaching those of adults.

Fracture types in children

• Dependent on the developmental stage of spine: As the child ages, the spine undergoes changes that affect the type of fracture that occurs, the radiographic appearance of the spine, and how the fracture is managed. Consequently, it is necessary to understand the normal developmental patterns of the child’s spine .
• Named fractures and dislocations for atlas, axis, and subaxial cervical spine: Several named injuries exist for the cervical spine. They include the atlanto-occipital dislocation, the atlanto-axial dislocation, the atlanto-axial rotary subluxation, the Jefferson fracture, the odontoid fractures, the hangman’s fracture, the teardrop fracture, the cervical compression fractures, and the ligamentous injury. These will be discussed in the Evaluation section of this chapter.