Diagnostic imaging of cervical spine injuries in children

Normal Variants and False Fractures

X-ray examination of the cervical spine in young children is associated with a number of objective difficulties. The pediatric skeleton is in a stage of active growth and formation, so specific anatomical features are regularly identified on radiographs that an inexperienced specialist could mistakenly interpret as a serious injury.

• Ossification of the C1 lateral masses: The ossification process of the atlas lateral mass occurs unevenly. Often, this structure may visually significantly exceed the underlying second cervical vertebra (axis, C2) in size. As a result, a characteristic radiological picture is created where C1 appears to "overhang" the axis. The magnitude of this overhang can reach up to 6 mm, which is an absolutely physiological normal variant and requires no treatment.
• Pseudo anterior wedging (Pseudo anterior wedging): The anterior parts of the vertebral bodies in children may have a slightly slanted, wedge-like shape. The acceptable height of such a deformation is up to 3 mm. This phenomenon is particularly common at the level of the third cervical vertebra (C3) and is a classic normal variant that must be distinguished from compression fractures.
• Multiple ossification centers: The presence of unfused apophyses and isolated ossification centers causes the greatest difficulties when analyzing radiographs. The radiologist is required to conduct a thorough and meticulous analysis of each segment to differentiate these normal age-related states from true traumatic bone injuries.

Trauma Breakdown: Hangman's Fracture

In addition to differentiating from normal variants, the most important task is the accurate diagnosis of actual injuries. A classic clinical example of severe neck trauma is the Hangman's fracture, or Hangman fracture. This specific injury is a bilateral fracture of the posterior arch of the axis (C2).

To most accurately assess the severity of the patient's condition and plan further treatment, a multimodal approach is used, including three main imaging methods:

1. Radiography: This is the baseline examination method performed when a patient is admitted to the hospital. It allows for initial suspicion of pathology and visualization of the bilateral fracture of the neural arch of the axis.
2. Computed Tomography (CT): This is the gold standard for detailed evaluation of bone structures. CT scans clearly visualize the fracture line itself, assess the degree of bone fragment diastasis and displacement, which is critically important for surgeons.
3. Magnetic Resonance Imaging (MRI): Unlike CT, this method is indispensable for visualizing soft tissues and central nervous system structures. In a Hangman's fracture, MRI allows assessment of the spinal cord condition. In typical cases, the scans clearly demonstrate pronounced spinal cord edema (cord oedema), extending caudally (below) the level of the bone injury.

Non-Accidental Trauma (Battered Child Syndrome)

A special and extremely complex category in pediatric traumatology and radiology is non-accidental trauma (nonaccidental injury). This term refers to any physical injuries that an infant or older child receives at the hands of their caregivers (caregiver).

Extensive terminology and many synonyms are used in world medical literature to describe this phenomenon: inflicted injuries (inflicted injuries), battered child syndrome (battered child syndrome), and the infamous shaken baby syndrome (shaken baby syndrome — SBS).

The concept of SBS has its own history. This term was first described in medical literature in 1946. Initially, its classical definition included a clear triad of signs: subdural hemorrhages, massive retinal hemorrhages (in the fundus) obligatorily combined with bone fractures. However, over the past decade, this term has evolved and is now more often associated exclusively with intentional and severe head injuries caused by aggressive shaking of an infant (abusive head injuries sustained by shaking).

Epidemiology and Statistics of the Problem:

• Even based on data from developed industrial countries, it can be concluded that the true frequency of such crimes is underreported (underreported), and the level of physical abuse remains steadily and frighteningly high.
• There is a clearly defined high-risk group — infants and young children. Statistics are relentless: up to 80% of all identified cases of non-accidental trauma occur in children under the age of 5. At the same time, half of them (up to 50%) are defenseless infants under the age of one year.
• According to US statistics, the overall child mortality rate from various forms of abuse is about 2.3 per 100,000 children. In 2015 alone, about 1,670 child deaths were recorded. Notably, 44% of the deceased children suffered severe physical abuse, applied either alone or in combination with other forms of abuse.
• A deeply tragic fact is that in nearly 80% of all diagnosed cases, the main perpetrators (perpetrators) of the injuries are the child's own parents, who commit abuse acting alone or even in concert.

Clinical Presentation and the Radiologist's Role: The clinical manifestations of physical abuse are extremely diverse. However, as a rule, the child is admitted to the emergency department with quite obvious external injuries. Doctors record pronounced soft-tissue swelling (soft-tissue swelling), multiple hematomas and bruises at different stages of healing (haematomas, bruises), as well as burn marks (burns).

The key role of the radiologist is to search for specific skeletal injuries. Fractures are detected in a significant proportion of abused children. Fractures are particularly common and multiple in infants (infants), which should serve as a red flag for the diagnostic radiologist and a reason to initiate a proper investigation.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Evaluation of ununited apophyses and vertebral ossification centers
• Differential diagnosis of compression fracture and pseudowedging
• Clinical and radiological presentation of classic battered child syndrome
• Spinal cord injuries: interpretation of MRI findings of edema

Other Topics in "Pediatric Diagnostic Radiology"

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