Pediatric Spinal Cord Injuries

Placing a pediatric patient on an adult longboard provides inadequate immobilization and is likely to cause neck flexion unless significant padding is provided. If this is the only option on a scene, then place 2–4 cm of padding beneath the shoulders and back level with the occipital region of the head. Without padding the child’s neck will flex forward. The padding beneath the shoulders needs to extend continuously from the shoulders through the thoracic and lumbar spine to the pelvis (Figure 3). Simply padding beneath the shoulders flexes the thoracic and lumbar spine. Additionally pad between the patient and the edges of the board. Imagine a small child in the center of a longboard and bringing the board’s straps across from the edge and over the patient. A large triangular void forms between the strap, the board and the patient and allows the patient to slide laterally. Adequate padding on both sides fills these voids and prevents lateral shifting.

For younger children the Kendrick Extrication Device (KED) has been demonstrated as a safe and effective immobilization tool.¹¹ This technique places the child supine on the KED with their head in the same location an adult’s would occupy and the rest of the body lying in the torso section. For proper immobilization, however, it is essential to pad the KED with a blanket or towels to maintain the child’s head in a neutral position. The KED’s torso folds can be rolled up alongside the child’s chest and pelvis and secured to stabilize the lower spine. Then the head flaps can be folded up and, with supplemental padding, be used to secure the head.

Several specialized pediatric immobilization devices are available. These take into mind the child’s smaller body and larger head. They are designed with a recess for the head (some with multiple removable pads) to maintain the cervical spine in a neutral position. Remember, though, that these recesses are not designed for all age groups, and additional padding beneath the shoulders or behind the head may be necessary for your specific patient. Additionally, they are designed to eliminate excessive voids between the patient and straps. Most specialized devices will accept children up to about 85 lbs (38 kg).

Infants and other young children up to about age 5 are small enough to require transport in car seats and are unlikely to be candidates for spine assessment. They will require immobilization if there is a high suspicion of injury, such as with a car seat being ejected from a car. Children of this age most likely will be unable to understand the questions necessary to complete a spine exam. When injury occurs in an MVC, there is some debate whether to maintain the child inside the car seat or remove them onto another device. Always remove the child from their car seat and into another immobilization device if the car seat is cracked or broken in some way, or when you cannot provide adequate care with the child in the seat. Remember, the infant car seat is not designed for spinal immobilization and will not maintain the child in a neutral position. The advantage to leaving the child in the car seat until arrival at the hospital is that it limits the number of movements the patient must experience. Thus, when you can adequately assess and provide necessary care (think airway management and bleeding control), it may be reasonable to stabilize the patient in their seat with careful padding and tape.

Immobilizing younger children, particularly those younger than 5, may be a particular challenge because of both communication barriers and the fact that EMS providers are strangers. Constant calming and reassurance is necessary. When possible consider having a parent in view of the child. If a child is too scared and resists immobilization significantly, it may be less risky to forego immobilization and simply provide a comfortable ride to the hospital. Fighting a child onto an immobilization device may cause more harm to the child.

Summary

Roughly 2,000 U.S. children experience spinal column injuries annually. However, thousands more present to emergency departments with mechanisms of injury that could injure their spine. When children can follow commands and understand questions, performing a careful and accurate spine assessment may eliminate the need for unnecessary spine immobilization. When a spine injury is suspected, proper pediatric immobilization requires careful control of the spine’s weight centers and proper padding to ensure the spine remains in a neutral position.

References

1. Centers for Disease Control and Prevention. Spinal Cord Injury (SCI): Fact Sheet, http://www.cdc.gov/TraumaticBrainInjury/scifacts.html.

2. Dogan S, Safavi-Abbasi S, et al. Pediatric subaxial cervical spine injuries: origins, management, and outcome in 51 patients. Neurosurg Focus 2006 Feb 15; 20(2): E1.

3. Brooks M. Clinical tool helps predict pediatric cervical spine injury after blunt trauma. Reuters Health, 2010.