A 6-year-old previously healthy male presents with persistent left-sided headache and neck pain. Three days ago, he had been hanging upside down on a door-mounted pull-up bar approximately 4–5 feet in the air when he fell straight down onto his head, landing on a hardwood floor. He had no loss of consciousness, upper extremity weakness, or paresthesias. He continued to complain of headache and neck pain, and was evaluated by his pediatrician the following day. At that time, his exam was notable for a left-sided torticollis, as well as a mild amount of lateral neck pain that was diagnosed as a muscle spasm. He was discharged home with acetaminophen and ibuprofen. The patient continued to complain of neck pain with worsening torticollis and decreasing activity, which prompted his emergency department visit.
On arrival to the emergency department, he was awake and interactive with stable vital signs. His exam was notable for left-sided torticollis, tenderness along the upper cervical spine, and paraspinal muscles bilaterally. His neurologic exam was completely intact.
Given his history of axial-load mechanism trauma and his findings on physical exam, a CT of the neck is ordered and is shown next.
How common are these types of injuries in pediatric patients? How should this injury be managed at this time?
This CT demonstrates a mildly displaced, approximately 2–3 mm, fracture of the anterior C1 mass with associated left hinging/displacement.
Cervical spine injuries are rare in pediatric patients, with an incidence of 1%–1.5%. Some of the most common mechanisms of injury in pediatric patients are sports, motor vehicle collisions, falls from significant heights, and diving. In children under the age of 8, the upper cervical spine is more susceptible to injury, given certain anatomic features (a higher fulcrum) and more direct blunt mechanisms involving the head/upper cervical spine (Tilt et al., 2012). Upper cervical spine injuries carry a higher morbidity, including neurologic sequelae, and mortality, making prompt diagnosis imperative in a trauma evaluation.
This patient did not present with any neurologic symptoms. He was placed in cervical spine immobilization and followed closely as an outpatient. He did not require surgical intervention and recovered without sequelae.
Keywords: trauma, neurosurgery, neck injury,CT
Tilt L, Babineau J, Fenster D, Ahmad F, Roskind CG. Blunt cervical spine injury in children. Curr Opin Pediatr June 2012;24(3):301–6.