Cervical spine flexion-extension radiography versus magnetic resonance imaging in pediatric patients following blunt traumatic injury.

Background: In pediatric trauma patients, 60-80% of spinal cord injuries involve the cervical vertebrae. While the American College of Radiology offers guidelines for best imaging practices in the setting of acute pediatric trauma, there is a lack of uniformity in imaging-decision protocols across institutions. MRI has been shown to demonstrate high sensitivity for both bony and ligamentous injuries while also avoiding unnecessary radiation exposure in the pediatric patient population. However, the efficacy of flexion-extension (FE) radiography following initial MRI has not been evaluated in children. Our hypothesis is that FE radiography conducted following an initial MRI does not contribute significant diagnostic information or reduce time to cervical collar removal and thus can be removed from institutional protocols in order to avoid unnecessary testing and reduce pediatric radiation exposure. Methods: Trauma data were collected for pediatric patients presenting with suspected acute cervical spine injury from 2014 to 2021. A total of 108 patients were subdivided into 41 patients who received "MRI Only" and 67 patients who received both "MRI and FE" diagnostic cervical spine imaging. Chi-square testing and t-tests were performed to determine differences between MRI and FE radiographic detection rates of bony and ligamentous injuries in the subgroups. Results: In patients for whom FE did not find any injury, MRI detected bony and ligamentous injuries in 9/63 and 12/65 cases, respectively. In 3/21 (14.3%) cases in which MRI detected a bony and/or ligamentous injury and FE did not, patients eventually required surgical intervention for c-spine stabilization. No patients required surgical fixation when FE radiography showed an abnormality and MRI was normal. Addition of follow-up FE radiography after initial MRI did not have a significant effect on overall hospital length of stay (MRI Only vs MRI+FE: 9.2±12.0 days vs 8.6±13.5 days, p=0.816) or on rates of collar removal at discharge or greater than 48 hours after imaging (MRI Only vs MRI+FE: 41.5% vs 56.7%, p=0.124). Conclusions: FE radiography following initial MRI did not have a significant effect on reducing time to cervical collar removal or overall hospital length of stay. In addition, in 3 of 6 cases (50.0%) in which surgical fixation was required, MRI detected ligamentous and/or bony injury while FE radiography was normal. Level of Evidence: This study contributes Level 2b scientific evidence consistent with a well-designed cohort or case-control analytic study.

Retroperitoneal Sclerosing Lipogranuloma in an Adolescent With Congenital Atresia of the Inferior Vena Cava: Case Report and Literature Review.

Sclerosing lipogranuloma (SLG) in children is a rare, benign disease of unknown etiology suspected to be due to abnormal fatty tissue reaction. A 13-year-old girl presented with progressively worsening back pain. Cross-sectional imaging identified a retroperitoneal mass compressing the left ureter as well as infrarenal inferior vena cava atresia with extensive venous collaterals and chronic partially occlusive thromboses of the iliac veins. Surgical biopsy was consistent with SLG and it resolved spontaneously. SLG is typically a disease of adulthood but may be seen in children. The association between inferior vena cava atresia with venous thrombosis and development of SLG has not been reported previously.

Traumatic panhypopituitarism resulting in acute adrenal crisis.

Pituitary function plays an integral role in the physiologic response to traumatic injury. A significant proportion of trauma patients develop partial pituitary insufficiency. While isolated deficiencies of individual pituitary hormones are common, there are few reports in the literature of traumatic pan-pituitary failure with deficiency of all major pituitary hormones. We present a case of a patient involved in a motorcycle accident who sustained a sella turcica fracture, epidural hemorrhage, subdural hemorrhage, optic nerve palsy, and bilateral abducens nerve palsies. Three days after the accident, the patient became hypotensive and progressed to cardiopulmonary arrest. He was resuscitated and had spontaneous return of circulation. Despite adequate fluid resuscitation and vasopressor support, he remained profoundly hypotensive. Following administration of hydrocortisone, his blood pressures dramatically improved. He was found to have laboratory abnormalities, suggesting deficiencies of corticotropins, somatotropins, thyrotropins, gonadotropins, prolactin, and antidiuretic hormone. This is the first reported case of a patient with traumatic total panhypopituitarism complicated by acute adrenal crises during initial postinjury hospitalization. A review of the literature with comparison with other studies of trauma patients with deficiencies in five or more axes is presented. A high level of suspicion for central adrenal insufficiency and prompt administration of corticosteroids in the setting of symptomatic pituitary trauma can result in favorable outcomes. Screening for and treating posttraumatic hypopituitarism can result in improved rehabilitation and increased quality of life for trauma patients.