Pediatrics

Acute neck injuries

OVERVIEW: What every practitioner needs to know Are you sure your patient has acute neck injury? What are the typical findings for this disease?

Minor neck injuries in children are common. Simple strains present with limited motion and pain, but resolve quickly. A child presenting with restricted range of motion and pain must be evaluated for a more serious injury, such as fracture or rotary subluxation (RS) of C1 on C2. Rarely, as in the case of fixed rotary subluxation of C1-2, a delay in diagnosis may result in the need for surgical treatment. Prompt recognition of significant cervical trauma can prevent long-term complications. Radiographs should be ordered to rule out significant bone or ligamentous injury, and appropriate folowup studies (CT, MRI) ordered if clinical concern exists for a radiographically occult injury.

Typically, patients will complain of neck pain. Very young children will often hold their head on each side with their hands, as if to prevent their head from "falling off." Other signs include decreased cervical motion and new-onset torticollis (head tilt) after minor trauma. In the rare case associated with significant spinal instability, numbness or weakness may be noted (and should be looked for).

Fracture

Children may sustain a fracture of the cervical vertebrae from seemingly minimal trauma. Their high head to body size ratio predisposes the cervical spine to a significant amount of force. In very young children (i.e., <4 years) the synchondrosis between the odontoid and body of C2 is a weak point. Persistent pain and restricted motion should be investigated.

Rotary Subluxation

A minor soft tissue injury to the neck may result in limited rotational motion to one side. The majority of neck rotation takes place between C1 and C2. C1 may become "overrotated," not permitting rotation in the opposite direction. Patients appear to have an acute onset of torticollis. The relationship between C1 and C2 may become fixed over time, precluding nonoperative reduction. Prompt recognition of RS is crucial for avoiding the need for surgical treatment.

What other disease/condition shares some of these symptoms?

Meningitis

Cervical adenopathy

Gastroesophgeal reflux (Sandifer syndrome)

Viral inflammation of C1-2 (Grisel syndrome)

Cervical strain

What caused this disease to develop at this time?

Fractures can be caused by relatively minor trauma resulting in extreme flexion, extension, rotation, or compression of the cervical spine. RS can be caused by trauma, but occassionally patients will "sleep funny" and wake up with a stiff neck. Because of connections bewteen the C1-2 facet joint and the lymphatic system of the neck, a viral infection may result in joint inflammation and acute RS. Gastroesophageal reflux disease (GERD) has been associated with acute spasmodic neck movements similar to RS (Sandifer syndrome), but the cause of this is unclear.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Laboratory studies are not helpful, although an increased erythrocyte sedimentation rate (ESR) may correlate with a recent viral infection.

Would imaging studies be helpful? If so, which ones?

Initial radiography should include anteroposterior (AP), lateral, and open-mouth views of the cervical spine. Clinical concern for injury should dictate further imaging. For fractures, computed tomography (CT) can be helpful for diagnosing occult fractures and should be ordered in the appropriate clinical setting. Magnetic resonance imaging (MRI) can be useful for identifying occult fractures, as well as ligamentous and/or disc injuries. MRI also is the treatment of choice for suspected vertebral infection.

RS is diagnosed by obtaining a computed tomographic scan in maximal degrees of rotation to both sides. In true RS, the relationship between C1 and C2 is fixed and will not change on the two scans.

Confirming the diagnosis

Clinical algorithms for clearing a cervical spine after trauma are well known and beyond the scope of this review In the child who presents with limited neck motion after trauma, routine cervical radiograms should be obtained. If they are normal and no neurologic symptoms exist, the child may be treated with nonsteroidal antiinflammatory drugs (NSAIDs) and a soft cervical collar. Failure of rapid resolution of symptoms (i.e., >1 week) should prompt referral to a specialist .

Neurologic symptoms (numbness, radicular pain, weakness) should prompt MRI evaluation.

Patients with acute torticollis should be treated aggressively. Failure to respond to conservative treatment (see below) in a few days should prompt referral to a specialist.

If you are able to confirm that the patient has an acute neck injury, what treatment should be initiated?

Patients with fractures should be referred for specialist evaluation. Patients with acute torticollis should be treated with antiinflammatory medication, antispasmodic agents (i.e., diazepam 0.1 mg/kg q 6-8 h), a soft cervical collar, and physical therapy for range of motion. Failure to improve should prompt dynamic CT and/or referral to a specialist, as patients who remain fixed for more than several weeks may require cervical traction. Fixed rotation longer than 3 months usually requires surgical treatment.

What are the possible outcomes of acute neck injuries?

Patients with fractures/soft tissue injuries have an excellent prognosis if the injury is recognized and treated promptly . Delay in diagnosis can lead to fracture displacement and the need for more aggressive treatment. Patients with long-standing RS may not respond to conservative treatment and therefore should have aggressive range of motion therapy once the diagnosis is made.

What causes this disease and how frequent is it?

As mentioned above, RS may be secondary to an upper respiratory infection, minor trauma, GERD, or muscle strain. True fixed rotary subluxation is uncommon, but early aggressive treatment is important to prevent long-term disability.

How do these exposures cause the disease?

The retropharyngeal lymphatic system has a close relationship to the C1-2 facet joints, leading to inflammation and rotary subluxation associated with upper respiratory infection.

What complications might you expect from the disease or treatment of the disease?

Failure to treat a fracture may result in angular deformity of the cervical spine and possibly late pain. As mentioned, failure to treat RS at the early stage may lead to fixed subluxation requiring more aggressive treatment. Patients who undergo surgical treatment usually have a permanent decrease in neck rotation.

What is the evidence?

The management and treatment options discussed here are based on standard practice for these conditions:

Cervical spine trauma:

Eubanks, JD, Gilmore, A, Bess, S. "Clearing the pediatric cervical spine following injury". J Am Acad Orthop Surg. vol. 14. 2006. pp. 552-64.

Harris, MB, Kronlage, SC, Carboni, PA. "Evaluation of the cervical spine in the polytrauma patient". Spine (Phila Pa 1976). vol. 25. 2000. pp. 2884-92.

Mirvis, SE, Shanmuganathan, K. "Trauma radiology: Part V. Imaging of acute cervical spine trauma". J Intensive Care Med. vol. 10. 1995. pp. 15-33.

Rotary subluxation:

Muñiz, AE, Belfer, RA. "Atlantoaxial rotary subluxation in children". Pediatr Emerg Care. vol. 15. 1999. pp. 25-9.

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