Case Study: A New Approach to Stabilization of the Cervical Spine in Infantsby Jeffrey A. Nemeth, CPO, FAAOP ABSTRACTA case study to introduce a unique approach to immobilization of the newborn unstable cervical spine. BACKGROUND: Immobilization of the cervical spine in an infant is a challenge for the trauma team, and existing methods of stabilizing the spine through a combination of cervical collars and spine boards do not provide adequate immobilization. They are also inappropriate for extended periods, and may compromise the infant's airway alignment. CASE STUDY AND METHODS: A newborn infant suffered an occiput C1 dislocation secondary to an aggressive tong delivery, and was placed in a custom-fabricated copolymer Infant CTLSO. DISCUSSION: The type of orthosis described in this case study is appropriate for infants aged 0–3 months. It appropriately immobilizes the cervical spine, while addressing the issues of airway alignment. It takes into account the unique anatomical differences between an infant and an adult, and maintains the infant's airway alignment. The rigid structure of the Infant CTLSO also (1) prevents positional and deformational plagiocephaly; (2) addresses parental concerns, allowing the primary caregiver to maintain a nurturing role; and (3) allows for proper hygiene of the infant. BACKGROUND
Immobilization of an unstable cervical spine in a newborn poses many challenges for the trauma team. Often a combination of existing devices (i.e., a cervical collar strapped to a spine board) is used in an attempt to stabilize the spine in these patients who are too small for alternate external immobilization. However, these combinations do not appropriately allow for the large head-to-torso ratio found in children, and may compromise the ability of the spine to be maintained in a neutral position (1). Other articles document that such combinations are not adequate in achieving necessary or acceptable levels of immobilization, nor are they appropriate for the extended period of treatment such infants are likely to require (2). A review of current literature makes clear that there is a need for a more appropriate method of immobilization to account for the unique physical constraints of the youngest patient population (1–4). CASE STUDY
This case study involves an infant who suffered a dislocation (occiput C1) secondary to an aggressive tong delivery. (Figure 1). The goal of the trauma team was to stabilize the severe spinal injury in this newborn so that further diagnostic studies could be employed, to determine an appropriate course of treatment. METHODSThe infant in this case study was placed in a newly designed immobilization device, the Infant CTLSO. A copolymer or polyethylene shell was first fabricated from a plaster cast. The material was then laid out in a pattern and the infant, with the stockinette already donned, was placed in the material (Figure 2). An alternate technique would be to make a positive mold fabricated using a CAD/CAM system. The infant remained in the Infant CTLSO for approximately three weeks, after which time he died due to the severity of his injuries. DISCUSSIONThis type of orthosis, an Infant CTLSO, would be appropriate for treatment of injuries arising from trauma, congenital instability/stenosis, postsurgical instability, or rigid internal fixation. Although the population for such an orthosis is small, when the need arises, it poses significant obstacles to the physician and orthotist in treating and stabilizing the injury. The Infant CTLSO appropriately immobilizes the unstable cervical spine arising from such injuries, while addressing the unique issues surrounding treatment of these young patients.
It is critical in achieving proper immobilization to understand the anatomical constraints a child in this age group presents. Because of relative head shape, an offset between the occiput and thorax exists, which must be maintained to ensure proper airway alignment (5-6). Areas of difference to note between adult and pediatric anatomy are the offset space between the back of the head and the shoulders, which diminishes over time until it is a negative space in the adult, and the occipital angle, which increases over time (Figure 3). Treatment options that do not account for airway alignment and proper positioning compromise the infant’s airway and ability to breathe. (Figures 4 and 5) show MRIs of the compromised airway in an improperly positioned 11-year old child; this effect would only be exacerbated in an improperly positioned infant. The Infant CTLSO used in this case study has a rigid structure that allows the infant to maintain a position of proper airway alignment.
In addition to accommodating the unique anatomical considerations of an infant, the design of the Infant CTLSO also offers several practical benefits. First, the rigid copolymer shape around the infant’s occiput functions to prevent deformational and positional plagiocephaly, an issue when an injured infant is likely to spend a high proportion of time in a supine position. Second, the Infant CTLSO addresses parental concerns, allowing the infant to be handled by the primary caregiver so that a nurturing relationship may exist. Finally, it allows for proper hygiene of the infant (i.e., accommodates for diaper changes). This type of immobilization is primarily effective in the 0–3 months population, although similar concepts may be effective in older children, and while the child is preambulatory. Other authors have indicated that once an infant is past the neonatal period, halo fixation may be appropriate (3). A commercially available prefabricated Infant CTLSO is available through Jerome Medical (Moorestown, New Jersey). REFERENCES
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