Low or subaxial cervical spine traumas (C3-C7) in children: what they are, how to treat them
Low or subaxial cervical spine traumas (C3-C7) are caused by traffic or sports accidents, especially in adolescents
They may require immobilisation or surgery, even complex surgery.
Any traumatic event (accidental fall, collision, sports accident, etc.) that involves the bony structures, ligaments, blood vessels or nerve structures of the neck and alters its normal function, more or less severely, is defined as cervical trauma.
Cervical trauma in childhood can be divided into 2 main groups:
- Traumas involving the high or axial cervical spine (C0-C1-C2 vertebrae);
- Traumas involving the low or subaxial cervical spine (C3 to C7 vertebrae).
Injuries to the low cervical spine, i.e. the vertebrae below C2, are rare in children under 8 years of age.
As the patient’s age increases and the cervical spine takes on the anatomical and biomechanical characteristics of an adult, the frequency of low cervical injuries, below the C2 vertebra, increases and so does the frequency of fractures in relation to ligament injuries.
Low cervical fractures account for less than 1% of all paediatric fractures.
These injuries are more frequent in adolescents and are caused by bicycle or motorbike accidents, sports injuries, and accidental falls.
The main and most frequent consequences of low cervical spine trauma can be distinguished in:
- Avulsion fractures of the spinous processes, in which the spinous processes (Figure) are detached from the body of the vertebra (C3-C7);
- Compression fractures of the vertebral bodies;
- Burst fractures of the vertebral bodies;
- Facet joint fractures;
- Dislocation/subluxation between 2 or more cervical vertebrae.
Fractures can cause various problems with increasing severity:
- Pain on neck and head movements with contracture of the neck muscles (torticollis), from microfractures (microscopic fractures) or bone bruising;
Pictures of even severe neurological impairment with:
- Deficits in the movements and sensitivity of the arms and legs;
- Respiratory problems;
- Heart rate alterations;
- Incontinence problems.
These situations are the consequence of trauma, generally severe, involving the spinal cord and requiring early diagnosis and appropriate treatment to resolve without leaving permanent outcomes.
Low or subaxial cervical spine trauma (C3-C7), the diagnosis
Diagnosis is based on an examination of the patient generally performed in the emergency room, with assessment of any vascular or neurological damage.
Fundamental to the diagnosis is the acquisition of X-ray images taken in precise projections according to the clinical suspicion.
Computed tomography (CT) and magnetic resonance imaging (MRI) complete the picture and allow, through precise computer measurements, the diagnosis of instability with subluxation or dislocation, or fracture.
Mild injuries show no abnormalities on X-ray or CT (computed tomography) examination.
More severe injuries are associated with widening of the space between the facet joints, widening or collapse of the spaces separating one vertebra from the other.
Dynamic X-rays (taken from the side, with the neck extended and then flexed) highlight any instability.
MRI (magnetic resonance imaging) may reveal injuries to soft tissue, joint capsules and epiphyseal cartilage.
Low or subaxial cervical trauma (C3-C7), treatment can be conservative or surgical
Ligament and soft tissue injuries in the absence of radiographic abnormalities can be treated with anti-inflammatory and pain-relieving therapy and immobilisation with a soft Schanz collar for a period of 8-10 days.
When ligament injuries with radiographic manifestations are present, immobilisation with a rigid collar for 2 weeks is useful, after which the patient must be re-evaluated with dynamic radiographs (see above) to document any instability.
Facet joint dislocation on one or both sides is a relatively common injury in cervical trauma in adolescents.
It is caused by a mechanism of flexion and distraction of the cervical spine with facet joint injury.
In a patient with dislocation of the facet joints on both sides, a neurological motor deficit usually appears and it is necessary to urgently restore the facet joints (reduction) followed by an MRI (magnetic resonance imaging) examination to assess the presence and extent of the neurological lesion.
Compound and stable fractures, without neurological symptoms, are generally treated conservatively, with rigid collars (e.g. Philadelphia collar), to be worn continuously for a minimum of 4-6 weeks.
More severe or decomposed fractures without neurological symptoms require the application of a rigid collar to be worn for a longer period of time and frequent clinical and radiographic checks.
Compound fractures or unstable dislocations with mild or severe neurological impairment often require surgery.
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Surgical treatments may mainly include
- Halo transcranial traction placement: a metal ring (halo) is applied around the head under general anaesthesia, attaching the ring to the child’s skull with multiple nails. The halo is not painful and is generally well tolerated. Weights are attached to the ring, which keep the unstable vertebrae spaced and locked together (in reduction) by pulling the head in relation to the spine. It may take several weeks before this device is safely removed;
- Placement of screws (or hooks) and rods to secure unstable or fractured vertebrae to adjacent ‘healthy’ vertebrae in the correct position. This intervention is called ‘stabilisation’ which can be temporary or definitive. If definitive, it is more properly called ‘arthrodesis’;
- Spinal cord decompression, through an opening of the spinal canal to allow expansion of the spinal cord compressed as a result of the trauma (e.g. by fracture bone fragments).
Two-stage surgical treatment, in some cases it is necessary to perform an initial acute spinal cord decompression operation, followed by an operation to correct the deformity of the vertebra resulting from the fracture itself.
These surgical treatments, in cases of persistent neurological damage, are followed by rehabilitation and physiotherapy treatments to recover impaired function and motility.
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