31 This situation may account for up to 70 percent of spinal cord injuries in children and is most common in children younger than eight years. As a result, the spinal cord also undergoes stretching, leading to neuronal injury or, in some cases, complete severing of the cord. SCIWORA syndrome occurs when the elastic ligaments of a child's neck stretch during trauma. This situation has been named “SCIWORA” ( spinal cord injury with out radiographic abnormality) syndrome. In children, it is not uncommon for a spinal cord injury to show no radiographic abnormalities. Unilateral facet dislocations ( Figure 5)Īnterior dislocation of 25 to 33% of one cervical vertebra on lateral views an abrupt transition in rotation so that lateral view of affected vertebra is rotated lateral displacement of spinous process on anteroposterior viewįlexion, such as when picking up and throwing heavy loads (such as snow or clay)Īvulsion of posterior aspect of spinous process frequently an incidental findingĪ special situation involving children deserves mention. Large wedge off the anterior aspect of affected vertebra ligamentous instability causes alignment abnormalitiesĪnterior displacement of 50% or more of one cervical vertebra on lateral views Occurs with sudden deceleration (hanging) and with hyperextension, as in motor vehicle accidentsīilateral pedicle fracture of C2 with or without anterior subluxation lateral view required May be difficult to see on plain films high clinical suspicion requires CT scanning Occurs in patients with Down syndrome, rheumatoid arthritis and other destructive processesĪsymmetric lateral bodies on odontoid view, increased predental space Once an injury to the spinal cord is diagnosed, methylprednisolone should be administered as soon as possible in an attempt to limit neurologic injury.īurst fracture occurs with axial load or vertebral compressionĭisplaced lateral aspects of C1 on odontoid view, predental space more than 3 mm The “SCIWORA” syndrome (spinal cord injury without radiographic abnormality) is common in children. The most common reason for a missed cervical spine injury is a cervical spine radiographic series that is technically inadequate. The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7 and T1. Views required to radiographically exclude a cervical spine fracture include a posteroanterior view, a lateral view and an odontoid view. Our goal was to optimize patient safety by choosing the most appropriate setting and perioperative personnel, and to mitigate those risk factors amenable to intervention.ĭown syndrome anesthesia perioperative preoperative surgery trisomy 21.Significant cervical spine injury is very unlikely in a case of trauma if the patient has normal mental status (including no drug or alcohol use) and no neck pain, no tenderness on neck palpation, no neurologic signs or symptoms referable to the neck (such as numbness or weakness in the extremities), no other distracting injury and no history of loss of consciousness. Using this evaluation in presurgical planning will allow physicians to better consider the individual circumstances for their patients with Down syndrome. The child's family should always be asked if he or she is on any nutritional supplements, as some products marketed to families may have secondary effects such as inhibition of platelet function. The potential for cervical spine instability should be considered, and the anesthesiologist may wish to have several options available both for the medications and equipment used. Pediatric cardiac anesthesiologists and intensivists should be involved as needed. Recommendations include obtaining a complete blood count to detect an increased risk for bleeding or stroke, and cardiology evaluation to identify patients with pulmonary hypertension, as well as undiagnosed or residual heart disease. We review a number of salient topics affecting these children in the perioperative period, including cervical spine instability, cardiovascular abnormalities, pulmonary hypertension, upper airway obstruction, hematologic disturbances, prematurity, low birth weight, and the use of supplements and alternative therapies. Little consensus exists, however, on the best way to evaluate children with Down syndrome in preparation for surgery. This creates unique physiologic concerns that can affect safety during anesthesia and surgery. Down syndrome is a common chromosome disorder affecting all body systems.
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