Cervical Spine Trauma in Children: A Review

Todd Mccall, MD; Dan Fassett, MD; Douglas Brockmeyer, MD

Disclosures

Neurosurg Focus. 2006;20(2):E5 

In This Article

Anatomy and Biomechanics

The unique anatomy and biomechanics of the pediatric cervical spine help explain the different radiographic features, injury patterns, and management options found in children compared with those in adults. The principal difference is that the pediatric cervical spine is intrinsically more elastic compared with that of adults, especially in the first 8 years of life.[43] In a study of neonatal cadavers, the vertebral column could stretch as much as 2 in without disruption, but the spinal cord could only stretch 0.25 in.[58] This elasticity is a result of several distinct features of the pediatric cervical spine. First, the facet joints are more shallow than in the adult spine and are oriented horizontally.[20,97] This has the effect of increasing translational mobility and movement during flexion and extension. Second, spinal ligaments and joint capsules can withstand significant stretching without tearing, which contributes to the occurrence of pseudosubluxation.[32,92,97] Third, several authors have argued that the anterior wedging of the VBs allows ventral slippage between motion segments,[32,92] although others have noted that the wedging that appears on radiographs is due to a ring apophysis that does not ossify before the age of 12 years, and that therefore this is merely a radiographic and not an anatomical finding.[33,57] Finally, absent uncinate processes and weak nuchal muscles also lend more flexibility to the spine.[7,97]

Another important feature in children younger than 8 years of age is the relatively large head compared with the body. The added weight shifts the fulcrum of movement to the upper cervical spine, with the greatest movement at C2-3 in infants and young children.[8,14,92,97,105] By 5 to 6 years of age, the fulcrum shifts to C3-4, and in adolescents and young adults the level of maximal flexion is C5-6, the same as in mature adults. This disparity in the fulcrum of movement explains why the majority of cervical spine injuries occur between the occiput and C-2 in children younger than 9 years of age, whereas the distribution of cervical injuries in children older than 9 years is similar to that in adults, with fractures and fracture-dislocations predominantly occurring in the lower cervical spine.[30,40,41]

A large head relative to the body has one other critical consequence, which is to force the cervical spine into kyphosis when a child is placed on a firm backboard. In the setting of trauma, this may exacerbate a traumatic kyphotic deformity and compromise neurological function.[46] In a study of 40 children, all patients required torso elevation (mean elevation 25 mm) to rest the neck in a neutral position.[66] Semirigid cervical collars are not adequate to prevent flexion, and therefore the torso needs to be raised or a recess for the occiput is required.[49,98]

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