title: Combined high cervical spine and brain stem injuries: a complex and devastating injury in children.
abstract: BACKGROUND
  In young children, high cervical spine injuries (HCSI) can result in inaugural reversible, cardiac arrest or apnea. We noted in children sustaining such injuries an unusual incidence of associated brain stem injuries and defined a special pattern of combined lesions.
  
  
  METHODS
  Children with HSCI surviving inaugural cardiac arrest/apnea were selected for a retrospective analysis of a trauma data bank. Epidemiologic, clinical, and radiological characteristics, and outcome were reviewed and compared with those of the rest of the trauma population with severe neurologic injuries (defined by a Glasgow Coma Scale < 8).
  
  
  RESULTS
  Thirteen children with HCSI above the C3 spinal level and inaugural cardiac arrest/apnea were identified and compared with 819 severely head injured children without HSCI. Mean age was 4.7 +/- 2.9 years, and median Glasgow Coma Scale was 3 (3-6) after resuscitation. Initial standard x-ray views missed spine injuries in 6 patients. Spiral computed tomographic (CT) scan showed cervical fracture-dislocations associated with diffuse brain lesions and brain stem injury in all patients. Children with combined lesions had more frequent severe facial and skull base fractures compared with the rest of the population. They also were younger and sustained more frequent severe distracting injury to the neck than the rest of the population. Mortality rate (69%) was 2.6-fold higher than that observed in children without HCSI. In survivors, none demonstrated spinal cord injury resulting in persistent peripheral neurologic deficits, but only one achieved a good recovery.
  
  
  CONCLUSIONS
  Combined HCSI and brain stem injuries must be suspected in young children sustaining a severe distracting injury to the craniocervical junction. Early recognition of these catastrophic injuries by systematic spiral cervical spine and brain stem computed tomographic scan evaluation is mandatory.
authors.affiliation: Department of Pediatric Anesthesiology, Hôpital Necker Enfants Malades, Université René Descartes-Paris 5, 75743 Paris, France. philippe.meyer@nck.ap-hop-paris
authors.forename: Philippe-Gabriel
authors.initials: PG
authors.lastname: Meyer
authors.forename: Fabien
authors.initials: F
authors.lastname: Meyer
authors.forename: Gilles
authors.initials: G
authors.lastname: Orliaguet
authors.forename: Stéphane
authors.initials: S
authors.lastname: Blanot
authors.forename: Dominique
authors.initials: D
authors.lastname: Renier
authors.forename: Pierre
authors.initials: P
authors.lastname: Carli
mesh_terms: D000465:Algorithms; D001933:Brain Stem / Q000293:injuries*; D002574:Cervical Vertebrae / Q000293:injuries*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009104:Multiple Trauma / Q000150:complications / Q000175:diagnosis*; D012189:Retrospective Studies