What is the management of a cervical ligament injury in a 4-year-old boy?

Cervical Ligament Injury Presentation in a 4-Year-Old Boy

Cervical ligament injuries in a 4-year-old boy typically present with upper cervical spine involvement due to the child's unique anatomy, and may manifest as SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) with neurological symptoms despite normal radiographs or CT scans. 1

Anatomical Considerations

• In children under 8 years of age, cervical spine injuries most commonly affect the upper cervical spine due to incomplete ossification, unfused synchondroses, ligamentous laxity, and a large head-to-body ratio 1
• Young children have greater ligamentous laxity compared to adults, making them more susceptible to ligamentous injuries without associated fractures 1
• The large head-to-body ratio in young children creates a fulcrum of motion higher in the cervical spine (C2-C3) compared to adults (C5-C6) 1

Clinical Presentation

• Neck pain, limitation of movement, and refusal to move the neck are common presenting symptoms 2
• Altered mental status or inability to communicate due to developmental stage may limit clinical assessment in a 4-year-old 1
• Neurological deficits may range from subtle to severe, including:
  • Weakness or paralysis in extremities 3
  • Numbness, tingling, or loss of sensation 3
  • Impaired balance or coordination 3
  • Altered level of consciousness 3

SCIWORA Presentation

• Children have a higher risk of SCIWORA (Spinal Cord Injury Without Radiological Abnormality) than adults 1
• SCIWORA is defined as "clinical symptoms of traumatic myelopathy with no radiographic or CT features of spinal fracture or instability" 1, 3
• Certain sports and recreational activities in children are associated with higher odds of SCIWORA 1
• Neurological symptoms may be immediate or delayed, ranging from transient paresthesia to complete spinal cord injury 4

Diagnostic Challenges

• Clinical assessment may be limited in a 4-year-old due to developmental stage and limited communication abilities 1
• Neck pain and muscle spasm may limit spinal motion during examination 1
• Cervical flexion and extension views in children with acute blunt cervical trauma are unlikely to yield additional results and are rarely needed 1
• Standard radiographs may appear normal despite significant ligamentous injury 1, 3

Red Flags Requiring Immediate Attention

• Any neurological deficit, including weakness, sensory changes, or abnormal reflexes 3, 5
• Midline cervical tenderness 5
• Painful distracting injury or unexplained hypotension 5
• Altered mental status 3, 5
• History of high-energy trauma mechanism (motor vehicle accidents, falls from height) 3, 2

Management Considerations

• MRI is the modality of choice for suspected ligamentous injury or SCIWORA 1
• MRI of the cervical spine should be strongly considered as it can detect ligamentous injuries that are not visible on radiographs or CT 1
• Conservative treatment using rigid immobilization (cervical collar) is typically the preferred option in stable injuries 2
• Frequent clinical and radiological monitoring is required to ensure the patient's condition does not deteriorate 2

Common Pitfalls

• Relying solely on radiographs or CT scans may miss ligamentous injuries in young children 1
• Failing to recognize that normal radiographs do not exclude significant spinal cord injury in children 1, 3
• Inadequate immobilization during evaluation and treatment can worsen injuries 5
• Underestimating the significance of subtle neurological findings in a young child 3, 4