Combining the data presented in two studies allows some description of outcomes in children with CSI. (12,19) Eleven of 18 children younger than 5 years with CSI died. Fourteen of 19 children between the ages of 5 and 10 died. Of those older than 10 years, four of 42 children died. In one of the two studies, all children survived if they had an isolated Cervical spine fracture. One child out of nine with a fracture/Subluxation died. All 15 children with distraction injuries died (eight of which were occipito-cervical injuries).
Injury Etiology
CSI in young children tends to result from Motor vehicle collisions (MVCs), falls, pedestrian injuries, or child abuse. Older children are more active in sports and activities and may endure a CSI due to MVCs, sports, falls or bicycle accidents. (9-12,16-18,20-22)
To further clarify the force of impact necessary to cause CSIs in children, it is tempting to read injury reports regarding specific mechanisms of trauma. Many authors have published series of papers dealing with the injuries seen after specific types of trauma, including falls, (24-27) crashes, (28-31) and animal attacks. (32) These data series tend to reinforce to the clinician that a specific impact may be an injury-producing impact. Potentially more useful are series that emphasize mechanisms that did not result in a CSI from a specific type of trauma. CSI did not occur in any child in a series of 432 falls down stairs reported in two series. (33,34) One child died after a fall down stairs in a walker after suffering a CSI, skull fracture, and subdural hematoma. (35,36)
Similarly, a CSI did not occur in any child after falling from bed (207 children), (37) high chairs (103 children), (38) or shopping carts (62 children). (39) One author reported 151 falls from heights, none resulted in CSI. (40) Another group reported a series of 101 children admitted to the hospital with a skull fracture. None of these children had a concurrent CSI. (41)
One author published a series of eight children who sustained CSI after short falls. (42) All were symptomatic at the time of presentation (although the time from injury to symptom onset is not reported). In this series, a 4-year-old had a [C.sub.1]-[C.sub.2] subluxation after falling out of bed. A 9-month-old fell while pulling herself up and suffered a subluxation of [C.sub.1]-[C.sub.2] with an odontoid fracture. A 3 1/2-year-old fell while running and suffered a fracture of the neural arch of [C.sub.2] with subluxation of the inferior articulating facet. The other children had rotary subluxations after falling or somersaulting.
A general summary of the above data is necessary to give the clinician a sense of the type of impact that may cause a spine injury. Collisions in which a child impacts an object with a closing speed faster than a child can run or more than twice the child's height are greater-risk impacts. This is especially tree in situations where the child may initiate contact with the skull, as is common in sports injuries. While falls can result in CSI, the injury-producing falls tend to be higher, or there are extenuating circumstances. One such circumstance occurs when a child falls down stairs with the extra weight of a walker attached. Unfortunately, as demonstrated by one group, (42) these guidelines are not completely reliable, and CSI may result from minimal trauma.
