J. E. Baerg1, A. Thirumoorthi1, R. Vannix1, R. Hazboun1, P. Krafft1, A. Zouros1 1Loma Linda University School Of Medicine,Pediatric Surgery,Loma LInda, CA, USA
Introduction:
To compare the pattern of cervical spine (c-spine) injuries and outcomes in children younger than 36 months with a closed head injury from confirmed inflicted vs. accidental trauma.
Methods: After IRB approval, a prospective cohort study was performed. Data were collected between July 2011 and January 2016. Inclusion criteria were: age below 36 months, loss of consciousness after confirmed inflicted or accidental trauma, and one of the following on initial computed head tomography (CT): subdural, intra-parenchymal, intraventricular, subarachnoid hemorrhage or cerebral edema. An imaging protocol of brain and neck magnetic resonance (MR) imaging and MR angiography was obtained within 48 hours of admission. Variables collected were: age, gender, initial head CT findings, extremitiy fractures, retinal hemorrhages, brain MRI findings at 48 hours, Injury Severity Score (ISS), Glasgow Coma Score (GCS), and any c-spine injury identifed on imaging protocol. Outcomes were recorded. Variables were compared by t-test for continuous and chi-square test for categorical variables. A p<0.05 achieved significance.
Results: During the study period, 73 were identified, 67% males. The median age was 11 months (range: 1-35 months). There were 52 with inflicted (71%) and 21 with accidental trauma (29%). Ten cervical spine injuries were identified (14%) by imaging protocol, 7 from inflicted (13%) and 3 with accidental trauma (14%). There were significantly more subdural hematomas (p= 0.03), brain infarction at 48 hours (p=0.01), retinal hemorrhages (p=0.02) and extremity fractures (p=0.02) in the inflicted group. The inflicted group had a significantly higher ISS (p= 0.02) and lower GCS (p=0.01) on admission. No other significant differences were identifed. C-spine injuries identified in the inflicted group were: ligamentous injury (2), atlanto-occipital dissociation (AOD) (1), vertebral artery shear injury (1), cord injury with cord epidural hematoma (2) and isolated cord epidural hematoma (1). C-spine injuries identifed in the accidental group were; ligamentous injury (1), AOD (1), and cord epidural hematoma (1). Seven died, all in the inflicted group (9.5%). One mortality had an AOD, and 6/7 mortalities had no c-spine injury. Six children with inflicted trauma and a c-spine injury survived with neurologic devastaion. Three with accidental trauma and a c-spine injury survived without disability, including one that underwent successful operation for AOD.
Conclusion: When compared to young children with accidental trauma and a closed head injury, children with inflicted trauma have a similar incidence of c-spine injury, a higher mortality, more extensive initial injuries, more long-term disability and a pattern consistent with shaking.