quiz patient with a possible neck injury

[Admin]

A four-year old child is an unrestrained passenger in a rollover motor vehicle crash. He has a cephalohematoma and has intermittent periods of crying and quiet sleep. On physical exam of the neck there is torticollis with a seat belt impression. He has no obvious focal neurologic deficits.

The next best step in ther management of this patient with a possible neck injury is

A cervical spine computerized tomography (CT) or magnetic resonance imaging.

B CT angiogram of the neck because of the seat belt impression.

C anterior posterior, lateral and odontoid cervical spine films.

D transport to the CT scanner on a backboard.

E emergent flexion and extension films.

[Admin]

correct answer
A cervical spine computerized tomography (CT) or magnetic resonance imaging.

Cervical spine injuries (CSI) are rare in children (one to two percent of injuries), but are associated with a high mortality (15 to 18%). In children less than ten years of age, the injury is often in the C1 through 4 area because in this age group, children have relatively larger heads than bodies. In adults, NEXUS (National Emergency X-ray Utilization Study) and the Canadian Cervical Spine Rule (CCSR) defined clinical criteria to guide radiologic studies. Unfortunately, when the same criteria were applied to pediatric trauma patients the sensitivities were unacceptably low at 43% and 86%. The American College of Radiology Appropriateness Criteria (last reviewed in 2012) recommended that children age 14 years or older be treated as adults since their spines have fully developed.

Clinical clearance of the cervical spine is acceptable by a trained clinician if there is no spine tenderness, torticollis or bony abnormality. If there is distracting injury, altered mental status, head injury or inability to communicate (language barrier or young age) clinical clearance may not be appropriate. Cervical spine radiographs are good initial screening tools, with lateral and anterior posterior views correctly identifying CSI’s in 89% of patients under the age of nine years. Open mouth odontoid views are difficult to obtain in young children wearing cervical collars and oblique views contribute little to the evaluation of the cervical spine. Flexion and extension films are not indicated in the acutely injured child because of muscle spasm; they are best used in follow-up for possible ligamentous injuries.

Computerized tomography (CT) is superior to plain radiographs in detecting cervical spine fractures. Coronal and sagittal reconstructions should be done routinely. Dose reduction of radiation should be considered.

Magnetic resonance imaging (MRI) has proven to be valuable in diagnosing cervical spine injuries in intubated and/or obtunded children, facilitating removal of cervical collar and decreasing length of intensive care unit stay. Magnetic resonance imaging can alter the diagnosis in up to 34% of these patients with new findings refuting those suggested by cervical spine radiographs and/or CT. MRI is the best modality to evaluate the soft tissue, ligaments and spinal cord.

There are no standard screening guidelines to evaluate blunt cerebrovascular injury in children. Fracture of the petrous temporal bone or through the carotid canal, focal neurological deficit, stroke, and a Glasgow coma score of less than eight are independent risk factors for blunt carotid vascular injury. Blunt carotid injury accompanies C1 through 3 injury and fracture subluxation of the cervical spine in 30% of patients. Advanced Trauma and Life Support guidelines recommend that patients with these injuries have a CT angiogram to evaluate for carotid and vertebral artery injury. CT angiograms have largely replaced MR angiograms to screen for possible carotid or vertebral arterial injuries in children. A seat belt sign across the neck has been shown NOT to be associated with cerebrovascular trauma.

Because of this child’s neurologic status and apparent torticollis clinical clearance of the cervical spine is inadequate. Cervical spine films alone are insufficient in the evaluation of this child. CT or MRI should be performed.

Patients who are on backboards can develop pressure sores if not moved off the board after evaluation of the back. This is especially true in patients who have neurologic deficits.

[Abusnaina mohammed]

A cervical spine computerized tomography (CT) or magnetic resonance imaging.

[Aey]

A

[Admin]

correct answer
A cervical spine computerized tomography (CT) or magnetic resonance imaging.

Cervical spine injuries (CSI) are rare in children (one to two percent of injuries), but are associated with a high mortality (15 to 18%). In children less than ten years of age, the injury is often in the C1 through 4 area because in this age group, children have relatively larger heads than bodies. In adults, NEXUS (National Emergency X-ray Utilization Study) and the Canadian Cervical Spine Rule (CCSR) defined clinical criteria to guide radiologic studies. Unfortunately, when the same criteria were applied to pediatric trauma patients the sensitivities were unacceptably low at 43% and 86%. The American College of Radiology Appropriateness Criteria (last reviewed in 2012) recommended that children age 14 years or older be treated as adults since their spines have fully developed.

Clinical clearance of the cervical spine is acceptable by a trained clinician if there is no spine tenderness, torticollis or bony abnormality. If there is distracting injury, altered mental status, head injury or inability to communicate (language barrier or young age) clinical clearance may not be appropriate. Cervical spine radiographs are good initial screening tools, with lateral and anterior posterior views correctly identifying CSI’s in 89% of patients under the age of nine years. Open mouth odontoid views are difficult to obtain in young children wearing cervical collars and oblique views contribute little to the evaluation of the cervical spine. Flexion and extension films are not indicated in the acutely injured child because of muscle spasm; they are best used in follow-up for possible ligamentous injuries.

Computerized tomography (CT) is superior to plain radiographs in detecting cervical spine fractures. Coronal and sagittal reconstructions should be done routinely. Dose reduction of radiation should be considered.

Magnetic resonance imaging (MRI) has proven to be valuable in diagnosing cervical spine injuries in intubated and/or obtunded children, facilitating removal of cervical collar and decreasing length of intensive care unit stay. Magnetic resonance imaging can alter the diagnosis in up to 34% of these patients with new findings refuting those suggested by cervical spine radiographs and/or CT. MRI is the best modality to evaluate the soft tissue, ligaments and spinal cord.

There are no standard screening guidelines to evaluate blunt cerebrovascular injury in children. Fracture of the petrous temporal bone or through the carotid canal, focal neurological deficit, stroke, and a Glasgow coma score of less than eight are independent risk factors for blunt carotid vascular injury. Blunt carotid injury accompanies C1 through 3 injury and fracture subluxation of the cervical spine in 30% of patients. Advanced Trauma and Life Support guidelines recommend that patients with these injuries have a CT angiogram to evaluate for carotid and vertebral artery injury. CT angiograms have largely replaced MR angiograms to screen for possible carotid or vertebral arterial injuries in children. A seat belt sign across the neck has been shown NOT to be associated with cerebrovascular trauma.

Because of this child’s neurologic status and apparent torticollis clinical clearance of the cervical spine is inadequate. Cervical spine films alone are insufficient in the evaluation of this child. CT or MRI should be performed.

Patients who are on backboards can develop pressure sores if not moved off the board after evaluation of the back. This is especially true in patients who have neurologic deficits.