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Pediatric Emergency Medicine


Pediatric Cervical  
Spine Injuries  
 

Daniel A. Hirsh, MD

Emory University School of Medicine

Children��s Healthcare of Atlanta 


2 

Objectives 

    • Epidemiology
    • Anatomy: Pediatric vs Adult
    • Types of injuries
    • Who can be cleared clinically
    • Imaging Choices
    • An approach to clearing a c-spine
    • Lateral Plain Film
    • Cases
    • Wrap Up

 


3 

    Epidemiology

4 

Epidemiology: Incidence 

    Pediatric Spinal Cord Injury (SCI) is rare

    Of Population:  ~1 in 1,000,0001 or 1,000  per year3

    Of Fractures:  1-2%, but highest mortality2

    Of Trauma:  1-2% 5,6

    Of All SCI:  Accounts for <10%, <15 years old 1 

    Likely under-reported3,4 

    Male : Female  2:1 

 


5 

Epidemiology: Incidence @ CHOA 

*Trauma Registry Patients: All patients that have a Trauma ICD9 code, admitted for greater than 24 hours, or transferred, or admitted to OR or ICU regardless of length of stay.

**Based on ICD-9 Codes


6 

Epidemiology: Age 

    • Most frequent in: 15-24 year age group4
    • In under 15 year olds, mean age is 8
    • @ CHOA, mean age 11

7 

Epidemiology: Age 

    Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery 39(3): 483-486.

    Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery 36(8): 1107-1114.

8 

Epidemiology: Age 

    Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery 39(3): 483-486.

    Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery 36(8): 1107-1114.

9 

Epidemiology: Age 

    • The younger the child the�� 
      • higher the lesion
      • higher mortality7

 


10 

Epidemiology: Age 

    Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

 


11 

Epidemiology: Age 

    Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

 


12 

Epidemiology: Age 

    Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.

 


13 

Epidemiology: Mechanisms 

  1. Garton  Et Al (2008). �� Detection of Cervical Spine  Injury�� Neurosurgery 62 (3) 700

14 

Epidemiology: Mechanisms


15


16


17


18 

Epidemiology: Mechanisms 

Vohra. Et al. (2006) ��Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic�� Pediatrics 119: e275-283


19 

Epidemiology: Mechanisms 

Vohra. Et al. (2006) ��Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic�� Pediatrics 119: e275-283


20 

Epidemiology: Mechanisms 

    Leonard, M., J. Sproule, et al. (2007). "Paediatric spinal trauma and associated injuries." Injury 38(2): 188-193.

21 

Epidemiology: Mechanisms 

  1. Garton  Et Al (2008). �� Detection of Cervical Spine  Injury�� Neurosurgery 62 (3) 700

22 

Epidemiology: Mechanisms 

  1. Garton  Et Al (2008). �� Detection of Cervical Spine  Injury�� Neurosurgery 62 (3) 700

23 

Epidemiology: Mechanisms 

  1. Garton  Et Al (2008). �� Detection of Cervical Spine  Injury�� Neurosurgery 62 (3) 700

24 

Epidemiology: Mechanisms 

    Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

25 

Epidemiology: Mechanisms 

    Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

26 

Epidemiology: Mechanisms 

    Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.

27 

Epidemiology: Associated Injuries 

    Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612. 
     

~40% of SCI have associated injuries


28 

Epidemiology: Associated Injuries 

    Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612. 
     

~40% of SCI have associated injuries


29 

    Anatomy:  
    Pediatric vs Adult

30 

    • \

31 

    37 yo driver lap/shoulder/airbag restrained and her 7 yo son backseat lap/shoulder restrained involved in head on accident. Both in a c-collar. Both have neck pain. 

    What are this boy��s anatomic disadvantages compared with his mom? 

Anatomy:  
Pediatric vs Adult


32 

    • Proportionally larger, heavier head= higher center of gravity:
      • ��..the human head reaches 50% of its adult circumference by age 18 months, whereas  thoracic circumference does not reach this milestone until 8 years of age.��
    • Weaker and underdeveloped neck musculature
    • Greater elasticity and laxity of ligaments
    • More horizontal orientation of facet joints
    • Fulcrum of Cervical Spine  Motion
      • Pediatric: C2-C3
      • Adult: C5-C6
 
 
 
 

Anatomy:  
Pediatric vs Adult


33 

    Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564. 
     

Anatomy:  
Pediatric vs Adult


34 

    Khanna G et Al (2007) ��Imaging of cervical spine injuries of childhood�� Skeletal Radiology. 36:477-494

35 

Anatomy:  
Pediatric vs Adult
 

    • Biomechanical and anatomic difference    Begins to disappear at 8 years old    Completes at 15-17 years old
    • Literature suggest 2 distinct groups <8 and >=8

36 

Anatomy:   
Pediatric vs Adult
 

    • Higher prevalence of lesions above C4
    • More cervical distraction injuries
    • Spinal Cord Injury Without Radiographic Abnormality (SCIWORA)

 


37 

Khanna G et Al (2007) ��Imaging of cervical spine injuries of childhood�� Skeletal Radiology. 36:477-494


38 

    Types of Injury

39 

Types of Injury 

    • Atlanto-occipital injuries
      • High energy
      • Typically fatal
      • More prevalent in young children than adults

40 

Lustrin et al (2003) ��Pediatric Cervical Spine: Normal  Anatomy,Variants, and Trauma1��Radiographics 23(3) 539


41 

Lustrin et al (2003) ��Pediatric Cervical Spine: Normal  Anatomy,Variants, and Trauma1��Radiographics 23(3) 539  

1 

2 

3 

4  anterior longitudinal ligament.


42 

Lustrin et al (2003) ��Pediatric Cervical Spine: Normal  Anatomy,Variants, and Trauma1��Radiographics 23(3) 539  

1 

2 

3 

4  anterior longitudinal ligament.


43 

Types of Injury 

    • Atlas Fracture
      • Axial load (like Jefferson burst fracture in adults)
      • Open synchondrosis

44 

Lustrin et al (2003) ��Pediatric Cervical Spine: Normal  Anatomy,Variants, and Trauma1��Radiographics 23(3) 539


45 

Types of Injury 

    • Traumatic Atlantoaxial Instability
      • Tear in transverse ligament
      • Rare

46 

Types of Injury 

    • Odontoid fracture
      • Most common fractures of cspine in children
      • Usually through the subdental synchondrosis in young children

47 

Types of Injury 

    • Odontoid fracture
      • Most common fractures of cspine in children
      • Usually through the subdental synchondrosis in young children

48 

Khanna G et Al (2007) ��Imaging of cervical spine injuries of childhood�� Skeletal Radiology. 36:477-494


49 

Types of Injury 

    • Pars interarticularis Fracture of  C2
      • Hangman��s (hyperextension)
      • Extremely rare
    • Distraction Injuries
 
 

Lustrin et al (2003) ��Pediatric Cervical Spine: Normal  Anatomy,Variants, and Trauma1��Radiographics 23(3) 539


50 

Pseudosubluxation 

    • Children have normal physiologic displacement @ C2-3 and C3-4 spaces
 

Lustrin et al (2003) ��Pediatric Cervical Spine: Normal  Anatomy,Variants, and Trauma1��Radiographics 23(3) 539


51 

Pseudosubluxation 

Lustrin et al (2003) ��Pediatric Cervical Spine: Normal  Anatomy,Variants, and Trauma1��Radiographics 23(3) 539


52 

Pseudosubluxation 

    • Children have normal physiologic displacement @ C2-3 and C3-4 spaces
 

Lustrin et al (2003) ��Pediatric Cervical Spine: Normal  Anatomy,Variants, and Trauma1��Radiographics 23(3) 539


53 

Types of Injury: SCIWORA 

    Spinal

    Cord

    Injury

    With

    Out

    Radiographic

    Abnomality

    • First described in 1980��s before advancements in MRI
    • Subsequent literature suggest up to 30% all pediatric cord injuries*

 


54 

Types of Injury: SCIWORA 

      Evolving Definition:

      Positive neurological findings

      weakness, paresthesias, lightening/burning sensation

      down the spine/extremity or related to neck movement 

      AND 

      Xray (-) , CT  (-),  MRI (+) 6% of SCI

      OR

      Xray (-) , CT  (-),  MRI (-) 1% of SCI3 
       

     


    55 

      Who can be cleared clinically?

    56 

    Which 7 yo can you clinically clear?  

      1. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck
      2. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Complains of arm pain with a deformity.
      3. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

     


    57 

    Which 7 yo can you clinically clear?  

      1. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck
      2. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Complains of arm pain with a deformity.
      3. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

     


    58 

    Which 7 yo can you clinically clear?  

      1. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Upset, but cooperates. Says he has midline tenderness on palpation of posterior midline neck
      2. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Complains of arm pain with a deformity.
      3. 7 yo male backseat lap/shoulder restrained passenger side involved in T-bone accident on driver��s side. In a c-collar. Oriented to self, not oriented to time or place. Becoming irritable

     


    59 

    Who can be cleared clinically? 

      • National Emergency Medicine XRay Utilization Study (NEXUS) 9
        • Prospective
        • Evaluation of c-spine injury in children
        • Identify patients at low risk

    60 

    NEXUS : Study Definitions 

      Low Risk Patient 

      Those with none of the following criteria:

        • Midline cervical tenderness
        • Focal neurologic deficits
        • Altered level of alertness
        • Evidence of intoxication
        • Distracting painful injury

     


    61 

    NEXUS : Study Definitions 

      High Risk Patient 

      Those with any of the following criteria:

        • Midline cervical tenderness
        • Focal neurologic deficits
        • Altered level of alertness
        • Evidence of intoxication
        • Distracting painful injury
        • Instability or inability to assess

     


    62 

    NEXUS: Study Definitions 

      Distracting Injury 

      Significant, painful injury

        • Skin   Large lacerations or heavy bleeding
        • Soft tissue   Crush injuries
        • Muscle
        • Bone    Any long bone fracture
        • Vascular structures
        • Viscera    Injury requiring surgical consultation
        • Any injury causing acute functional impairment 

    63 

    NEXUS : Study Results 

      • Of 3,065 children enrolled, 30 had c-spine injuries (0.98%)
      • All 30 were classified as: ��high-risk��
      • No child from the ��low-risk�� group had a c-spine injury

    64 

    NEXUS : Study Results 


      Value (95% CI)
    Sensitivity 100% (87.8 – 100%)
    Negative Predictive Value 100% (99.2 – 100%)

    65 

    Not so fast�� 

    1. Garton  Et Al (2008). �� Detection of Cervical Spine  Injury�� Neurosurgery 62 (3) 700

    66 

    Not so fast�� 

    1. Garton  Et Al (2008). �� Detection of Cervical Spine  Injury�� Neurosurgery 62 (3) 700

    67 

      Ehrlich et al Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients 2009

    68 

      Ehrlich et al Canadian C-spine Rule and the National Emergency X-Radiography Utilization Low-Risk Criteria for C-spine radiography in young trauma patients 2009

    69 

    Which 7 yo can you clinically clear?  

      • None of them!
      • Next step��

     


    70 

      • How to clinically clear patient with neck pain?

     


    71 

      Imaging choices

    72 

    Imaging choices  

      • Plain Film Xrays 
        • Pro: Less radiation than CT. Can be done in trauma bay. Can pick up most injuries if good technique. Less costly.
        • Con: Poor technique may lead to repeat shots. Can be difficult to get odontoid view in a young patient
      • CT Scan Neck
        • Pro: Highly sensitive for fracture.
        • Con: Higher radiation dose to neck. In current facility have to move patient to another area. More costly.
      • Issue of initial CT Head and CT Neck  versus Ct Head and Plain Film Neck: (Jimenez et al 2008) Plain film first, then CT if needed 

     


    73 

    Imaging choices  

      • Flexion and Extension Lateral Xrays 
        • Pro: Can help diagnose ligmentous injury not seen on Xray or CT
        • Con: Patient must Actively move their head. Muscle spasm often limits this test
        • Should not perform Passive Flex/Ex on unconscious patient
        • If patient has normal static cervical spine radiographs, addition flex-ext are of questionable use (Dwek, et al Chung 2000)
      • MRI 
        • Pro: ��Gold Standard�� (Munchow RD et al 2008) Highly sensitive for spinal cord injury. Helps with unconscious pts in whom there is high clinical suspicion of C-Spine injury . Visualizes the extradural space and integrity of the ligaments
        • Con: Higher cost, time

     


    74 

      An approach to clearing

      the c-spine following injury

    75 

      Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following

    76 

      Lateral Plain Film

    77 

    C-Spine Radiograph 

      Lateral Plain Film

        1. Film adequacy
        2. C-spine alignment and curves
        3. Inter-vertebral spaces: discs and joints
        4. Pre-vertebral space
        5. Pre-dental space aka atlantodens interval (ADI)

     


    78 

    C-Spine Radiograph 

      • Lateral film
      • Anteroposterior film
      • Open-mouth odontoid view

    79 

      Adequacy

        • Visualize entire cervical spine
        • Count 7 cervical bodies and 1 thoracic body
     
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    80 

      Adequacy

        • Visualize entire cervical spine
        • Count 7 cervical bodies, and 1 thoracic body
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    81 

      Adequacy

        • Visualize entire cervical spine
        • Count 7 cervical bodies, and 1 thoracic body
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    82 

      Adequacy

        • Visualize entire cervical spine
        • Count 7 cervical bodies, and 1 thoracic body
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    83 

      Alignment

      • C-Spine Curves
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 

      Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

    84 

      Alignment

      C-Spine Curves

        1. Anterior Vertebral Bodies
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 

      Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

    85 

      Alignment

      C-Spine Curves

        1. Anterior Vertebral Bodies
        2. Anterior Spinal Canal
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 

      Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

    86 

      Alignment

      C-Spine Curves

        1. Anterior Vertebral Bodies
        2. Anterior Spinal Canal
        3. Posterior Spinal Canal
     
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 

      Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

    87 

      Alignment

      C-Spine Curves

        1. Anterior Vertebral Bodies
        2. Anterior Spinal Canal
        3. Posterior Spinal Canal
        4. Spinous Process Tips
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 

      Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564

    88 

      Inter-vertebral spaces

        • Disc spaces
        • Cartiledge
        • Apophyseal joints
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    89 

      Pre-vertebral space 
       
       
       

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    90 

      Pre-vertebral space

        • Space between vertebral bodies and air column
     
     
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    91 

      Pre-vertebral space

        • Space between vertebral bodies and air column
     
     
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    92 

      Pre-vertebral space

        • Space between vertebral bodies and air column
        • Must measure space above the glottis
     
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    93 

      Pre-vertebral space

        • Space between vertebral bodies and air column
        • Must measure space above the glottis
        • Normal size
          • ~1/2 to 2/3 of adjacent vertebral body
        • Can be abnormal if
          • non-inspiratory film
          • Intubated
        • Often normal in C-Spine injuries
     
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    94 

      Pre-Dental Space: aka: atlantodens interval (ADI) 
       

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    95 

      Pre-Dental Space

        • Space between Dens of C2 and anterior side of C1 ring
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    96 

      Pre-Dental Space

        • Space between Dens of C2 and anterior side of C1 ring
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    97 

      Pre-Dental Space

        • Space between Dens of C2 and anterior side of C1 ring
        • Must be less than or equal to 5 mm
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    98 

    Cases


    99 

    Case 1 

      • 4 year old female, restrained, back seat
      • High speed, head on car crash – car versus tree
      • Eye witnesses noted the passengers�� heads violently snapped forward
      • The driver died at the scene
      • C-spine immobilized 
      • Minimally responsive
      • Intubated
      • Ng-tube placed
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    100 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    101 

    Fracture at pedicle of C2 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    102 

    Case 2 

      • 18 month old female, unrestrained, front seat
      • Car accident
      • Sitting in babysitter��s lap, babysitter died at scene
      • C-spine ��immobilized�� by gauze strapped with tape over child��s head  
      • Alert and awake
      • Severe respiratory distress, with decreased breath sounds on right chest
      • No movement of lower extremities
     
     
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    103 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    104 

    Distraction injury 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    105


    106 

    Case 3 

      • A 7 year old child
      • High speed MVC
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    107 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    108 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 

    Prevertebral Bleeding 

    Glottis


    109 

    Case 4 

      • 5 year old male, sitting in seatbelt, front seat
      • 25 mph head-on car crash
      • Airbag deployed
      • C-spine immobilized 
      • Alert and awake
      • Numerous abrasions to face, neck and left shoulder and arm
      • Left arm limp and without sensation
     

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    110 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    111 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental 

    Ruptured Transverse Ligament


    112 

    C2 - Axis 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    113 

    v 

    C1 - Atlas 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    114 

    ANTERIOR 

    POSTERIOR 

    ANTERIOR 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    115 

    ANTERIOR 

    POSTERIOR 

    ANTERIOR 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    116 

    ANTERIOR 

    ANTERIOR 

    POSTERIOR 

    Adequacy | Alignment | Spaces | Pre-vertebral | Pre-dental


    117 

    Wrap It Up 

    • Epidemiology
    • Anatomy: Pediatric vs Adult
    • Types of injuries
    • Who can be cleared clinically
    • Imaging Choices
    • An approach to the clearing the cspine
    • Lateral Plain Film
    • Cases
    • Wrap Up

     


    118 

      1. Reilly, C. (2007). "Pediatric Spine Trauma." J Bone Joint Surg Am 89(Suppl 1): 98-107.
      2. Leonard, M., J. Sproule, et al. (2007). "Paediatric spinal trauma and associated injuries." Injury 38(2): 188-193.
      3. Cirak, B., S. Ziegfeld, et al. (2004). "Spinal injuries in children." Journal of Pediatric Surgery 39(4): 607-612.
      4. Vitale MG, G. J., Matsumoto H, Roye DP Jr. (2006). "Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000." Journal of pediatric orthopedics 26(6): 745-749.
      5. Meyer, P.-G., F. Meyer, et al. (2005). "Combined high cervical spine and brain stem injuries: a complex and devastating injury in children." Journal of Pediatric Surgery 40(10): 1637-1642.
      6. Brown, R. L., M. A. Brunn, et al. (2001). "Cervical spine injuries in children: A review of 103 patients treated consecutively at a level 1 pediatric trauma center." Journal of Pediatric Surgery 36(8): 1107-1114.
      7. Patel, J. C., J. J. Tepas, et al. (2001). "Pediatric cervical spine injuries: Defining the disease." Journal of Pediatric Surgery 36(2): 373-376.
      8. Kadesky, K. M., C. Manarey, et al. (1998). "Cougar attacks on children: Injury patterns and treatment." Journal of Pediatric Surgery 33(6): 863-865.
      9. Viccellio, P., H. Simon, et al. (2001). A Prospective Multicenter Study of Cervical Spine Injury in Children. Pediatrics 108: e20-.
      10. Orenstein, J., B. Klein, et al. (1994). "Age and outcome in pediatric cervical spine injury: 11-year experience." Pediatric Emergency Care(3): 132-7.
      11. Zuckerbraun, B. S., K. Morrison, et al. (2004). "Effect of age on cervical spine injuries in children after motor vehicle collisions: effectiveness of restraint devices." Journal of Pediatric Surgery 39(3): 483-486.
      12. Eubanks, J. D., A. Gilmore, et al. (2006). Clearing the Pediatric Cervical Spine Following Injury. 14: 552-564
      13. Stiell, I. G., G. A. Wells, et al. (2001). The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. 286: 1841-1848.
      14. Mower, W. R. and J. Hoffman (2004). "Comparison of the Canadian C-Spine rule and NEXUS decision instrument in evaluating blunt trauma patients for cervical spine injury." Annals of Emergency Medicine 43(4): 515-51 7
      15. Platzer P et al. (2007) . ��Cervical Spine Injuries in Pediatric Patients�� The Journal of Trauma 62 (2) : 389
      16. Bilston LE et al (2007) ��Pediatric spinal Injury Type and Severity are Age and Mechanism Dependant. Spine. 32 (21) 2339-2347
      17. Khanna G et Al (2007) ��Imaging of cervical spine injuries of childhood�� Skeletal Radiology. 36:477-494
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