Volume 1, Case 5

Cervical Spine Malalignment -True or Pseudo Subluxation ?
Radiology Cases in Pediatric Emergency Medicine
Volume 1, Case 5
Loren G. Yamamoto, MD, MPH

A 6 year old female was taken to a rural emergency department with a complaint of neck pain. Her behavior was described as slightly different. She didn't want to walk around and she was not moving her head much. The only history of trauma that was obtained was being thrown into a swimming pool about 32 hours ago. She was difficult to examine but she was noted to have some tenderness over her posterior neck. A cervical spine series was obtained.

Neck

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During transport, she fell asleep and the transport took place without incident. Upon arrival, she awoke and became very agitated despite the presence of her mother. She complained that she couldn't breathe and the back of her head hurt. She was moving her head around excessively despite the immobilization measures. The physician on duty examined the radiographs and felt that the C2-C3 malalignment represented a normal finding, pseudosubluxation. An opinion with a radiologist was sought via teleradiology, who agreed that this was a pseudosubluxation. Because of her agitation, she was taken out of cervical spine immobilization. The risk of cervical spine injury was felt to be low because of the normal radiographs, the relatively benign mechanism of injury, and her delayed ambulatory presentation.

After the cervical spine immobilization was removed, the examination of her neck revealed mild tenderness on palpation of the spinous processes in the mid portion of her neck. Range of motion was limited in all directions and associated with some pain. It was difficult to assess the degree of muscle spasm in her neck. There were no complaints of paresthesia. Motor and sensory functions were fully intact.

What is your Diagnosis?

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 Loren Yamamoto, 
      MD, MPH Associate Professor of Pediatrics University of Hawaii John A. Burns 
      School of Medicine loreny@hawaii.edu