About half of vertebral fractures and substantial ligamentous injuries of the spine in children occur in the cervical region. However, serious cervical spine injuries in children are rare. This relates in part to the resilient nature of ligaments and bones in children. In addition, young children are infrequently exposed to high-force injury mechanisms. In infants and young children, child abuse and birth trauma are the most common mechanisms of cervical spine trauma. Birth-related injuries of the spine and spinal cord most often are associated with a traumatic breech delivery. These injuries are usually in the lower cervical or upper thoracic region, and often result from traction forces. Spine injuries suffered during cephalic delivery tend to occur in the upper cervical region, and typically involve rotational forces. In older children and teenagers with spine injuries, common mechanisms include diving, sports injuries, and motor vehicle incidents. The prevalence of pediatric cervical spine injuries increases with age. In older patients, the mid and inferior aspects of the cervical spine are most commonly involved, whereas infants and young children tend to suffer injuries at the C3 level or higher. Because the pediatric spine has greater elasticity than the spinal cord (which is fixed by nerve roots), trauma-related neurological injuries can occur in the absence of fractures or malalignment.1–3
Cervical spine injuries range from mild ligamentous injuries to severe fracture-dislocations, with or without spinal cord involvement. The 5 major mechanisms consist of flexion, extension, lateral flexion, rotation, and axial compression. With excessive flexion, compressive force is applied to the anterior aspect of the vertebra, and distraction force posteriorly; this can lead to an anterior vertebral body fracture and posterior ligamentous disruption. Extension injuries subject the vertebrae to compressive forces dorsally and distracting forces anteriorly; fractures of the articular facets, pillars, and posterior elements may occur, as well as vertebral body avulsion injuries. Lateral flexion mechanisms can lead to vertebral compression injuries, fractures of the transverse or uncinate processes, and contralateral avulsion of the brachial plexus. Rotation injuries can cause locked facet, rotatory subluxation, or rotatory fixation; there are usually concomitant flexion or extension injuries. Burst-type fractures can result from axial compression forces.
The most common cervical spine fractures in children occur in the vertebral bodies; more than half involve the C6 or C7 vertebral bodies. Neural arch fractures of the cervical spine are uncommon in children. The most common site is the articular pillar, especially at the C6 level. These fractures are difficult to detect on standard radiographs; CT is diagnostic. Other neural arch fractures are less common. Laminar fractures tend to occur at the C5 and C6 levels. Most spinous process fractures involve C6 or C7. Fractures of the pedicles tend to occur at the C2 level. Transverse process fractures are rare in the cervical spine; the C7 level is the most frequent site of this injury.
Approximately 5% to 10% of pediatric cervical ...