Pediatric Spinal Care
Kirk Eriksen
Julie Mayer Hunt
Learning Objectives
After studying this chapter, the reader should be able to better understand and manage the following aspects of the pediatric patient:
Learn about etiological factors that can contribute to the vertebral Subluxation of the pediatric patient, which include birth and motor vehicle accident trauma.
Understand various risk factors for sudden infant death syndrome and possible causes.
Appreciate the unique developmental anatomy of the pediatric patient.
Modify patient placement for infants and toddlers when taking cervical X-rays.
Learn how to conduct an accurate pediatric Supine leg check.
Set up the pediatric patient on the adjusting table and deliver the Adjustment.
Determine an upper cervical Listing if X-rays are not possible.
This chapter will help the doctor manage the pediatric patient for the purpose of administering Orthospinology care. Some aspects related to the uniqueness of the pediatric patient are covered in this chapter to help the doctor have a better appreciation of this type of patient. Modifications to X-ray setups and the actual Adjustment procedure are provided to help the doctor achieve the best patient outcome. Appropriate chiropractic care is vitally important for the optimum development of a child’s spine and its impact on the nervous system. However, to best help these young patients, it is essential for the doctor and staff to be well prepared before the child’s arrival at the office.
The upper cervical spine is a critical area to be free from stress on the nervous system, and given extensive growth rate, this is an extremely important concern in pediatric Health care. A 1999 study1 identified 58 articles regarding chiropractic care of the pediatric patient, and all of the cases involved upper cervical Adjustments. These cases document the success of chiropractic care in providing significant improvements and/or total resolution of a myriad of conditions commonly affecting children. Moreover, these children typically responded favorably to care in one to three Adjustments. The conditions cited included attention deficit Hyperactivity disorder, allergies, asthma, glaucoma, headaches, hemiparesis, infantile colic, nocturnal enuresis, otitis media, seizures, sinusitis, tonsillitis, and torticollis. Although chiropractic is not used to treat a specific disease or condition, it seems to produce whole-body effects that have been observed empirically in clinical practice and reported in the literature. This paper summarizes the results of more than 1,000 children under chiropractic care, and the findings show the focal area of care in virtually all cases involves the upper cervical spine.1
Vertebral Subluxation Etiology
Birth Trauma
Towbin2 reported the results of a study of spinal cord/brainstem injuries in newborns he conducted at Harvard University’s Department of Neuropathology. He performed autopsies on more than 2,000 newborns that died shortly after birth. In his report he states, “Spinal cord and brainstem injuries often occur during the process of birth, but frequently escape diagnosis.” He
also states, “Life for the newborn depends on the preservation and Healthy functioning of the brainstem and upper cervical cord.”2 Gottlieb3 reviewed reports of birth trauma that described dislocations and fractures of vertebrae, stroke, hemorrhage with tearing of meninges, and even “direct observation on decapitations of mature stillborn infants by linear tension.” Facial palsies, extraocular muscle imbalance, and other cranial nerve deficits can result from birth-induced brainstem trauma as well. However, facial palsies and paralysis can also be associated with direct injury to the face by forceps. It is interesting to note how the majority of affected children are labeled as having cerebral palsy or epilepsy at birth rather than being diagnosed that way from birth.
also states, “Life for the newborn depends on the preservation and Healthy functioning of the brainstem and upper cervical cord.”2 Gottlieb3 reviewed reports of birth trauma that described dislocations and fractures of vertebrae, stroke, hemorrhage with tearing of meninges, and even “direct observation on decapitations of mature stillborn infants by linear tension.” Facial palsies, extraocular muscle imbalance, and other cranial nerve deficits can result from birth-induced brainstem trauma as well. However, facial palsies and paralysis can also be associated with direct injury to the face by forceps. It is interesting to note how the majority of affected children are labeled as having cerebral palsy or epilepsy at birth rather than being diagnosed that way from birth.
Dunn4 reviewed 6,000 cases of babies delivered after breech presentation. It was found that 20% to 25% of these babies had deformities, such as mandibular asymmetry, talipes equinovarus (clubfoot), and torticollis. Forty-two percent of the children developed postural Scoliosis, and about 50% of breech children had hip dislocations.4 The breech position pushes the head posterior and can either Hyperextend or Hyperflex the cervical spine, depending on the position of the chin. Torticollis can also result from overstretching the sternocleidomastoid muscle in the neck from the delivery process, and this can lead to craniofacial asymmetry if the neck distortion becomes chronic. However, medical physicians have even noted that not only can atlantoaxial Subluxations be related to torticollis, but they are likely caused by birth trauma.5,6 Indeed, birth trauma by use of vacuums and forceps, as well as “normal” birth deliveries, can induce cervical Subluxation(s) (Fig. 18-1).
Gutmann7 and Biedermann8 have each studied about 1,000 newborns and observed an incidence of upper cervical dysfunction/Subluxation ranging from 80% to 12%, respectively. These medical physicians attributed various Health symptoms to the “suboccipital strains” and provided Adjustments to either the atlanto-occipital or the atlantoaxial joints with successful outcomes. Medically oriented obstetric care is associated with some risk of birth injuries, although it is acknowledged that these occurrences are somewhat rare. A more frequent concomitant of the birth process is the development of vertebral Subluxation(s). The United States has been ranked last (out of 13 industrialized countries) in low-birth-weight percentages, neonatal mortality, and infant mortality.9 The first month of life is the period of greatest mortality in the childhood years. According to the Centers for Disease Control and Prevention, more than 28,000 deaths occurred in children younger than the age of 1 year in 2002. Sudden infant death syndrome (SIDS) accounted for about 2,300 deaths that same year.10
 FIGURE 18-1 Delivery of the newborn. Upward traction on the head is used to deliver a posterior shoulder over the perineum. (From Plaugher G. Textbook of Clinical Chiropractic: A Specific Biomechanical Approach. Baltimore: Williams & Wilkins 1993:385, modified from Willson JR, Beecham, CT, Forman I, Carrington ER, eds. Obstetrics and Gynecology. St. Louis: CV Mosby, 1958:336.) |
Sudden Infant Death Syndrome
The etiology of SIDS has been attributed to many conditions. Pamphlett and colleagues11,12 have found that the vertebral arteries of some infants could be compressed by neck extension or rotation. Their studies have concluded that this action could induce lethal brainstem ischemia in infants with inadequate collateral blood flow or with poor compensatory arterial dilation and may be the underlying cause of some cases of SIDS. This may be a result of anatomic differences in infants at the base of the brain and skull. The atlas lateral masses normally provide a buttress against vertebral artery compression; however, these osseous structures are small in infants. Pamphlett et al.12 found that vertebral artery compression was more likely to occur when the posterior atlanto-occipital membrane was particularly thick, and it was observed that (unlike adults) the artery did not lie in the vertebral artery sulcus on the surface of C1, leaving the vessel more vulnerable to compression. It was also noted that an unstable atlanto-occipital joint (resulting from Subluxation or birth trauma) and a large Foramen magnum could allow the atlas to invert into the Foramen magnum on neck extension, resulting in compression of the vertebral arteries.
Gilles13 found that in 10 of 17 cadaveric infants, the atlas posterior arch inverted through the Foramen magnum during extension of the head. Dissection of the base of the skull revealed that the Foramen magnum was larger than the atlas posterior arch. It was also found
that all of the infants had some degree of side-to-side, anterior-to-posterior, and superior-to-inferior motion of the head on the atlas before fixation. Schmorl and Junghanns14 have discussed how SIDS is possibly related to birth trauma, cervical Subluxation, and subsequent brainstem involvement. Dwyer et al.15,16 and Scragg17 have previously reported that infants sleeping prone had an increased risk of SIDS. It is possible that stomach sleeping and the resultant rotation and/or extension of the cervical spine exacerbates the upper cervical Subluxation and/or instability. Specific upper cervical chiropractic care may help to stabilize a child’s unstable and misaligned spine, which emphasizes the importance of assessing children for possible Subluxations during infancy.
that all of the infants had some degree of side-to-side, anterior-to-posterior, and superior-to-inferior motion of the head on the atlas before fixation. Schmorl and Junghanns14 have discussed how SIDS is possibly related to birth trauma, cervical Subluxation, and subsequent brainstem involvement. Dwyer et al.15,16 and Scragg17 have previously reported that infants sleeping prone had an increased risk of SIDS. It is possible that stomach sleeping and the resultant rotation and/or extension of the cervical spine exacerbates the upper cervical Subluxation and/or instability. Specific upper cervical chiropractic care may help to stabilize a child’s unstable and misaligned spine, which emphasizes the importance of assessing children for possible Subluxations during infancy.
Koch et al.18,19 have observed vegetative reactions (i.e., flush, apnea, Hyperextension, sweating) and a significant decrease in heart rate in about half the infants studied after the application of a unilateral mechanical impulse to the upper cervical region. Almost a quarter of all the infants given the upper cervical impulse reacted with apnea. The authors Hypothesized that the same reaction could be triggered under different circumstances, (e.g., when an infant is in the prone position). However, the study was not carried out on SIDS infants, but on a group of babies with abnormalities such as wryneck, Scoliosis, and asymmetry in the configuration of skull and face, as well as infants with specific functional weaknesses.18 Klougart et al.20 conducted a study involving 316 babies suffering with infantile colic. The results demonstrated a 94% successful outcome, and 94% of the babies received an upper cervical Adjustment. Data from a Randomized controlled clinical trial showed that spinal Adjustment/Manipulation was effective in relieving signs and symptoms related to infantile colic. In this study, the spinal Adjustment group performed significantly better than the group that only received the drug dimethicone.21
Motor Vehicle Accident Trauma and Safety
According to the National Highway Traffic Safety Administration (NHTSA), a subsidiary of the U.S. Department of Transportation, 7,410 children and youth from birth to age 20 were killed and approximately 730,000 were injured in passenger vehicle crashes in 2002.22 In 2004, an average of six children (≤14 years old) were killed and 673 were injured in motor vehicle accidents (MVAs) on a daily basis.23 Accidental injury is by far the leading cause of mortality and morbidity among children age 1 to 14 years,24,25 with MVAs being the leading cause of death for children from 3 to 14 years old.23 MVAs account for 37% to 50% of injury-related deaths among children and result in significant morbidity among those who survive the trauma.26,27 Indeed, more children die from MVAs than from any disease in the United States.28 Statistics have shown that 1 in every 48 children born in the United States will die in an MVA before the age of 25, and 1 in 20 will be seriously injured.28 Sadly, 21% of the fatalities among children age 14 and younger in 2004 occurred in crashes involving alcohol.23 These sobering statistics make it imperative to protect children while traveling in motorized vehicles.
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