From the Guidelines
The management for this 11-year-old patient with suspected cervical spine injury involves conservative treatment since both the odontoid view X-ray and follow-up CT scan ruled out acute fracture or significant malalignment. The initial X-ray showed slight lateral offset of the right C1 lateral mass relative to C2, but this was likely positional due to rotation rather than traumatic injury, as confirmed by the normal CT findings 1. Treatment should include:
- Rest
- Over-the-counter pain medications like acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (10 mg/kg every 6-8 hours) for pain relief
- Application of ice for the first 48-72 hours to reduce inflammation The patient should avoid strenuous activities and contact sports for 1-2 weeks. A soft cervical collar may provide comfort and support if the patient has neck pain or muscle spasm, but should be used for only a short period (3-5 days) to prevent muscle weakness 1. Physical therapy focusing on gentle range of motion exercises and strengthening can be initiated after acute symptoms resolve. Parents should monitor for any worsening symptoms such as increased pain, numbness, tingling, or weakness in the extremities, which would warrant immediate medical attention. This conservative approach is appropriate because pediatric cervical spine injuries without fractures or instability typically heal well with supportive care, as suggested by the American College of Radiology Appropriateness Criteria for suspected spine trauma in children 1.
From the Research
Cervical Spine Injury Assessment
- The patient's odontoid view shows a slight lateral offset of the right lateral mass of C1 with respect to C2 lateral mass, which could be positional due to rotation, as the contralateral left C1 lateral mass has compensatory medialization in position 2.
- The CT scan reads no acute fracture or significant malalignment, but this does not rule out the possibility of ligamentous injury or spinal cord injury, as seen in cases where CT scans were "negative" for cervical spine fracture or dislocation 3, 4.
Management of Cervical Spine Injury
- In cases of suspected cervical spine injury, CT scans can be highly sensitive in detecting unstable injuries, especially in obtunded patients without high-impact trauma 5.
- However, MRI may be necessary to diagnose intrinsic spinal cord injuries, which may not be unstable in the presence of a negative CT scan 5, 4.
- Surgical intervention may be necessary in cases of cervical fracture dislocation, even with mild neurological deficits, to prevent further injury and promote recovery 6.
Importance of Further Evaluation
- The presence of degenerative changes of the cervical spine and developmental narrowing of the spinal canal can increase the risk of spinal cord injury without associated bone injuries 4.
- Further evaluation, including MRI, may be necessary to understand the level and mechanisms of spinal cord injury and to guide treatment decisions 3, 5, 4.