FIGURE 112.29 Examples of cervical compression injuries A: Teardrop fracture This patient sustained a whiplash injury with resultant flexion injury A typical flexion teardrop fracture is demonstrated at An increased interspinous distance and an associated avulsion fracture of the posterior elements of C5 are demonstrated at B: Anterior C6 vertebral wedge fracture (arrow ) C: Burst fracture of C4 vertebral body (arrow ) (A : Reprinted with permission from Swischuk L Emergency Radiology of the Acutely Ill or Injured Child 2nd ed Baltimore, MD: Williams & Wilkins; 1986:674.) Vertebral Compression Injuries Vertebral compression injuries are most frequently caused by axial loading and hyperflexion They are suggested by isolated anterior wedging, teardrop fractures, or burst vertebral bodies ( Fig 112.29 ) The vertebral bodies should be regular, cuboid, and consistent between adjacent cervical levels ( Fig 112.29 ) A flexion/rotation stress can lead to anterior subluxation of one vertebral body on another with facet dislocation (“locked” or “jumped” facet) ( Fig 112.30 ) If the anterior displacement is less than 50% of the vertebral body width, it is consistent with a unilateral facet dislocation ( Fig 112.30 ) More than a 50% anterior subluxation suggests a bilateral facet dislocation ( Fig 112.30 ) These injuries are often accompanied by widened interspinous and interlaminar spaces, anterior soft tissue swelling, and a narrowed disc space Spinal Cord Injury Without Radiographic Abnormality SCIWORA was initially described as occurring in up to 67% of all children with cervical cord injuries ( Fig 112.31 ), and up to 25% of cervical cord injuries in children younger than years SCIWORA has been described as mainly occurring in children younger than years who present with, or develop symptoms consistent with, cervical cord injuries without any radiographic or tomographic evidence of bony abnormality Some authors have recently suggested that the diagnosis of SCIWORA be applied only to those patients who also not have abnormal MRI findings The original characterization of this syndrome occurred during a period when MRI was less available and it is important to note there are distinct differences between patients with and without MRI findings in the setting of persistent neurologic abnormalities Regardless, this type of injury is not often seen in children older than years because the forces necessary to injure the spinal cord also cause persistent spinal column abnormalities In older children, sports-related injuries have been found to have a higher association with SCIWORA (OR 3.5) as compared to those injured by other mechanisms The young child’s elastic spinal column, ligamentous laxity, horizontal facets, and underdeveloped spinous processes allow the spine to deform beyond physiologic extremes, injuring the cord, and then reducing spontaneously without any persistent (radiographic) evidence of bone injury The causes of the neurologic compromise can include segmental spinal instability, vascular injury (occlusion, spasm, and infarction), ligamentous injury, disc impingement, or incomplete neuronal destruction A subset of patients has initial transient neurologic symptoms as previously described, temporarily recover, and then return, on average, day later with neurologic abnormalities Therefore, hospitalization, immobilization, and further radiographic evaluation (MRI) for this group of patients may be optimal Neurosurgical consultation is recommended if the history suggests a SCIWORA-type injury in a child younger than years FIGURE 112.30 Unilateral facet dislocation C4 is offset anteriorly on C5 less than 50% of the width of the vertebral body Arrows denote the offset of vertebral body and apophyseal joints The disc space between C4 and C5 is narrowed Note that the distance between the posterior cortex of the apophyseal joint facet and the anterior cortex of the spinous process tip is wider below the level of dislocation than above the level (stars ) Anterior vertebral offset of more than 50% would denote a bilateral facet dislocation (Reprinted with permission from Swischuk L Emergency Radiology of the Acutely Ill or Injured Child 2nd ed Baltimore, MD: Williams & Wilkins; 1986:697.) FIGURE 112.31 Magnetic resonance imaging (MRI) of a SCIWORA patient Accompanying cervical spine radiographs were normal The MRI demonstrates an area of cord contusion in the midcervical area (arrows ) This patient had physical evidence of a central cord syndrome (Reprinted with permission from Swischuk L Emergency Radiology of the Acutely Ill or Injured Child 2nd ed Baltimore, MD: Williams & Wilkins; 1986:710.) Torticollis (Wry Neck) Torticollis is a common complaint in the pediatric ED The clinician should always inquire about traumatic events because an underlying bone injury may be present Often, however, torticollis is caused by spasm of the sternocleidomastoid (SCM) muscle In the patient with muscular torticollis, their chin points toward the unaffected side, while SCM spasm occurs on the affected side This condition is different from rotary subluxation Rotary subluxation is a cervical spine injury that is often misdiagnosed or undiagnosed because of difficulty in interpreting a ... Swischuk L Emergency Radiology of the Acutely Ill or Injured Child 2nd ed Baltimore, MD: Williams & Wilkins; 1986:710.) Torticollis (Wry Neck) Torticollis is a common complaint in the pediatric. .. than 50% would denote a bilateral facet dislocation (Reprinted with permission from Swischuk L Emergency Radiology of the Acutely Ill or Injured Child 2nd ed Baltimore, MD: Williams & Wilkins;