ORIGINAL ARTICLE Five cases of paediatric cervical spine distraction • •Injury Abstract Cervical spi ne distraction injury was considered rare in children, but current literature claims that atlanto-occipital distraction is a major contri butor to paediatric trauma mortal ity. Lower cervical spine distraction is considered rare and usually results in quadriplegia. Three cases of atlanto- occipital distraction are presented here, supporting these claims. The two cases of lower cervical spine distraction are presented as good examples of a rare injury that is sustained in the same S Andronikou Red Cross Children's Hospital University of Cape Town Department of PaediatriC Radiology S Dix-Peek Red Cross Children's Hospital University of Gape Town D Meerkotter Johannesburg Hospital University of the Witwatersrand Department of Radi%gy a SA JOURNAL OF RADIOLOGY. October 2000 manner as atlanto- occipital distraction, but may result in survival of the patient with quadriplegia. Case report Case 1 A three-year-old female was in- volved in a motor vehicle accident as a passenger. She was removed from the vehicle without prior stabilisation of the cervical spine. She presented to the emergency unit with quadriparesis, but stable vital signs. Examination revealed absent motor and sensory activity in all four limbs. The lateral cervical spine film and chest X-ray demonstrated a widened interspace at the C6/7 level with pos- terior listhesis of C6 on C7. MRI showed complete transection of the cord at the C4 and C6/7 levels asso- ciated with disruption of the poste- rior longitudinal and interspinous liga- ments. The child's condition deterio- rated and mechanical ventilation was instituted. At the time of this report the patient remains quadriplegic. Figure 1: (Case 1) AP plain radiograph showing a widened interspace at C6/7 (arrow) topageg Five cases of paediatric cervical spine distraction injury (rompage8 Figure 2: (Case 1) Lateral plain radiograph showing a wide interspace at C6/7 and subluxation of C6 on C7 (arrow) Figure 3: (Case 1) Saggital T2 weighted MRI showing complete cord transecton (closed arrow) and disruption of the posterior longitudinal (arrowhead) and interspinous ligament (open arrow) Case 2 A three-year-old male was caught under a reversing vehicle. On exami- nation the vital signs were stable but there was flaccid quadriparesis. Lat- eral cervical radiograph revealed dis- traction of the lower cervical spine at the C617 interspace. The patient died as a result of cardiorespiratory arrest 48 hours later. and the coma scale was calculated at its minimum (2T). A CT scan was performed to assess the intracranial compartment and a scanogram and CT of the cervical spine was obtained Figure 4: (Case 2) Plain radiograph demonstrates wide interspace at C6/7 (arrow) Case 3 A five-year-and-ten-month-old female patient was involved in a mo- tor vehicle accident as an unrestrained passenger. Bystanders attempted re- suscitation and paramedics intubated the child and transferred her to the emergency department. On arrival the patient's pupils were fixed and dilated Figure 5: (Case 3) Digital CT scanogram demonstrating cranio-cervlcal distraction (arrow) 9 SAJOURNAL OF RADIOLOGY. October 2000 Figure 6: (Case 3) Multi-planar reconstruction showing a wide atlanto-occipital Interspace (open arrow) and good visualisation of the basion (B), opisthion (0) and dens (D) at the same examination. The scanogram demonstrated distraction at the eranic-cervical junction. Brady- cardia ensued, but no further resusci- tation was undertaken and the patient was declared dead at cardiac arrest. Case 4 A nine-year-old female was in- volved in a motor vehicle accident as a pedestrian. She was intubated at the scene and was brought to the emer- gency department. Her blood pressure was low and temperature was de- creased. Her coma scale was calcu- lated at the minimum and her pupils were fixed and dilated. Her respira- tion was spontaneous. There were also numerous injuries to the appendicu- lar skeleton. Neurosurgical assessment revealed no brainstem or spinal re- flexes.The lateral cervical spine radio- graph revealed massive prevertebral soft tissue swelling, and an increased interspace at the eranic-cervical ar- ticulation in keeping with a distrac- tion injury. The patient then required assisted ventilation. The blood pres- sure dropped further the following-----to page 10 Five casos of pdediZllric cervical spi n(-~cj ist r 1 is consid- ered diagnostic of AOD.2,3,4Kaufman et al measure the distance from the to page 12 • CONVENIENCE Schering understands that timing, accuracy and efficacy are of essence inMRI • SIMPLICITY Pre-filled syringes offer fast and easy application • EASE OF USE Injected volume instantly visible through reverse scaling Magnevist • Another innovative product in the Schering Diagnosties range.Enhancing MRI Schering (Ply) Ltd (Reg. No. : 64/09072/07) 106 Sixteenth Road, Randjespark, Midrand 1685. P.O. Box 5278, Halfway House 1685. UlO 3198 Tel: (011) 313-9700. Fax: (011) 313·9793. e-mail: schering@icon.co.za lSI] Magnevist- 20 ml. 1 ml solution contains Gadopentetic acid, Dimeglumine salt 469,01 mg DTPA, Meglumine sail max. 1,02 mg. Reg. No.: W/281199. 32851 mailto:schering@icon.co.za Five cases of paediatric cervical spine distraction injury frampage 10 superior facets of the atlas to the oc- cipital condyles, and consider any value >5 mm as abnormal.' The BD distance is that between the basion (B) and the dens (D) and is recorded by Georgopoulos et al to be 5 mm in a normal adult." Bulas et al compared the different methods and concluded that the BD distance is the most reli- able, with a mean measurement of 8.3 mm in children.ê The post mortem work by Bucholz and Burkhead is misrepre- sented by both Bulas et al and Shamoun et al. Only three of the 20 children in the Bucholz and Burkhead study hadAOD (15%), and not nine as reported by Bulas et ap,6 Shamoun et al quote that 33% of the cervical spine injuries in the same se- ries were AO Ds, but fail to add that this figure included adult patients.V However, a five-year review by Shamoun et al reports lOcases of AOD, representing 18% of all trauma deaths in their institution. There is also a comment in the same paper that one quarter of patients dying from cervical spine injuries have AOD.3 Conclusion We present five cases of paediat- ric cervical spine distraction injury accumulated randomly over a two- year period. Three of the children had AOD and died within 12 hours of admission to hospital. One of these was a nine-year-old, who should have attained adult characteristics to the cervical spine. The other two cases presented are rare, as they involve dis- traction occurring at lower cervical spine in children less than four years of age. One of these children died, while the other survives as a quadri- plegic. Reports oflower cervical spine distraction in children are scarce, but this case report supports the modern literature, which claims thatAOD is not rare and that it is a significant contributor to paediatric mortality in cervical spine trauma. The cases of lower cervical spine distraction in chil- dren younger than eight years are pre- sented as examples of a rarer form of the same process. References I. Sherek HH, Schut L, Lane JM. Fractures and dislocations of the cervical spine in children. Orthop Clin NorthAm 1976; 9 (3): 593-604. 2. Bulas DI, Fitz CR, Johnson DL. Traumatic atlanto-occipital dislocation in children. Radiology 1993; 188 (1): 155-157. 3. Shamoun JM, Riddick L, Powell RW. Atlante-occipital subluxation/dislocation: A "survivable" injury in children. Am Surg 1999; 65: 317-320. 4. Georgopoulos G, Pizzutillo PO, Lee MS. Occipito-atlantal instability in children. J Bone and Joint Surg 1987; 69A (3): 429-436. 5. Grabb BC, Frye TA, Hedlund GL, Vaid YN, Grabb PA, Royal SA. MRI diagnosis of suspected atlanto-occipital dissociation in childhood. Pediair Radial 1999; 29: 275- 281. 6. Bucholz RW, Burkhead WZ. The pathological anatomy of fatal atlante- occipital dislocations. J Bone and Joint Surg 1979; 61A (2): 248-250.