A Discussion on Swischuk’s Line. Literature Review
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Published:
Aug 20, 2024
Keywords:
Children, Swischuk line, C2-C3 cervical instability
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Abstract
Introduction: Traumatic injuries to the upper cervical spine are prevalent in young children. In 1977, Leonard Swischuk published an article on a cervical spinolaminar line to determine the physiological or pathological relationship between the second and third cervical vertebrae (C2-C3). The purpose of this study is to review the available literature on the indications and diagnostic limitations of this line, illustrating this with our own clinical examples.
Materials and Methods: We conducted bibliographic research on pediatric cervical spinal trauma including the following databases: PubMed (Medline, MedlinePlus and Cochrane), Elsevier, VHL Virtual Health Library of Bireme (which includes Lilacs) and the AAOT Database. In addition, a manual search was carried out, including citations from recently published references and specialty textbook chapters.
Results: Out of 72 articles, we selected 39 that addressed current epidemiological aspects, as well as others that focused on Swischuk’s line and upper cervical spine injuries, which were mostly case reports.
Conclusion: Swischuk’s line is an effective diagnostic tool for evaluating children’s spines after trauma or in some syndromic diseases. However, it may not be sensitive in some cases, such as C2-C3 subluxation or facetdislocation. Other complementary radiodiagnostic measures should be applied.
Materials and Methods: We conducted bibliographic research on pediatric cervical spinal trauma including the following databases: PubMed (Medline, MedlinePlus and Cochrane), Elsevier, VHL Virtual Health Library of Bireme (which includes Lilacs) and the AAOT Database. In addition, a manual search was carried out, including citations from recently published references and specialty textbook chapters.
Results: Out of 72 articles, we selected 39 that addressed current epidemiological aspects, as well as others that focused on Swischuk’s line and upper cervical spine injuries, which were mostly case reports.
Conclusion: Swischuk’s line is an effective diagnostic tool for evaluating children’s spines after trauma or in some syndromic diseases. However, it may not be sensitive in some cases, such as C2-C3 subluxation or facetdislocation. Other complementary radiodiagnostic measures should be applied.
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Fernández, C. A., Miranda, M. G., & Moreiro, M. E. (2024). A Discussion on Swischuk’s Line. Literature Review. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 89(4), 393-402. https://doi.org/10.15417/issn.1852-7434.2024.89.4.1897
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References
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2001;36(2):373-6. https://doi.org/10.1053/jpsu.2001.20720
2. Parada SA, Arrington ED, Kowalski KL, Molinari RW. Unilateral cervical facet dislocation in a 9-year-old boy.
Orthopedics 2010;33(12):929. https://doi.org/10.3928/01477447-20101021-31
3. Copley PC, Tilliridou V, Kirby A, Jones J, Kandasamy J. Management of cervical spine trauma in children. Eur J
Trauma Emerg Surg 2019;45(5):777-89. https://doi.org/10.1007/s00068-018-0992-x
4. Velasco Canziani JM, Saprizza S, Galli N, Otero N, García F. Luxofractura cervical en niños: revisión bibliográfica
y caso clínico. Rev Asoc Argent Ortop Traumatol 2020;85(3):270-82. https://doi.org/ 10.15417/issn.1852-7434.2020.85.3.1007
5. Gopinathan NR, Viswanathan VK, Crawford AH. Cervical spine evaluation in pediatric trauma: A review and an
update of current concepts. Indian J Orthop 2018;52(5):489-500. https://doi.org/10.4103/ortho.IJOrtho_607_17
6. Zeng J, Jiang H, Zhuo Y, Xu Y, Deng Z. A case report on a child with fracture and dislocation of the upper cervical spine accompanied by spinal cord injury. Medicine (Baltimore) 2022;101(30):e29717.
https://doi.org/10.1097/MD.0000000000029717
7. Carreon LY, Glassman SD, Campbell MJ. Pediatric spine fractures: a review of 137 hospital admissions. J Spinal
Disord Tech 2004;17(6):477-82. https://doi.org/10.1097/01.bsd.0000132290.50455.99
8. Corrado R, Tello C, Galaretto E, Balderrama S, Noel M, Francheri Wilson A, et al. Luxofractura de la columna
cervical en un recién nacido: Informe de un caso. Rev Asoc Argent Ortop Traumatol 2010;75(1):73-6. Disponible
en: https://www.aaot.org.ar/revista/2010/n1/art07.pdf?_gl=1*1mh1yt6*_ga*MTA1MDAwMTA1Ny4xNzE5ODc0N
zg3*_ga_BFFNBSGNHH*MTcxOTg3NDc4Ni4xLjAuMTcxOTg3NDc4Ni4wLjAuMA
9. Jones TM, Anderson PA, Noonan KJ. Pediatric cervical spine trauma. J Am Acad Orthop Surg 2011;19(10):600-11.
https://doi.org/10.5435/00124635-201110000-00004
10. Wang MY, Hoh DJ, Leary SP, Griffith P, McComb JG. High rates of neurological improvement following severe
traumatic pediatric spinal cord injury. Spine 2004;29(13):1493-7; E266. https://doi.org/10.1097/01.brs.0000129026.03194.0f
11. Ogden JA. Columna vertebral. En: Ogden JA. Traumatismos del esqueleto en el niño. Barcelona: Salvat Editores; 1986, p. 397-422.
12. Lebwohl NH, Eismont J. Cervical spine injuries in children. En: Weinstein SL (ed). The pediatric spine: Principles
and practice. New York: Raven Press, Ltd.; 1994, p. 725-42.
13. Swischuk LE. Anterior displacement of C2 in children: physiologic or pathologic. Radiology 1977;122(3):759-63. https://doi.org/10.1148/122.3.759
14. Tabernero AM, Suñén Sánchez E, Peña Jiménez D, Loste Ramos A, Tabuenca Sánchez A, Chárlez Marco A, et al.
Pseudoluxación C2-C3 en la infancia [Pseudoluxation C2-C3 in childhood]. Rev Fac Cien Med Univ Nac Córdoba
2017;74(3):288-92. https://doi.org/10.31053/1853. 0605.v74.n3.12863
15. O’Neill C, Wenzel A, Walterscheid Z, Carmouche J. Distinguishing pseudosubluxation from true injury: A case of C2-3 and C3-4 subluxation in a pediatric patient. J Am Acad Orthop Surg Glob Res Rev 2021;5(12). https://doi.org/10.5435/JAAOSGlobal-D-20-00238
16. Rathjen KE, Herring JA. Spinal injuries. En: Herring JA. Tachdjian’s pediatric orthopaedics, 5th ed. Philadelphia:
Elsevier Health Sciences; 2013, vol. 3, p. 1224-44.
17. Ahmet A, Caglar Y. Pediatric cervical spine. En: Cumhur Oner F, Vaccaro AR, Vialle LR. AOSpine masters series.
Volume 5: Cervical spine trauma. New York: Thieme Medical Publishers, Inc.; 2015, p. 156-68.
18. Grigoriou E, Dormans JP. Pediatric spine trauma. En: Akbarnia BA, Thompson GH, Yazici M, El-Hawary R (eds).
The growing spine: Management of spinal disorders in young children. 2nd ed. Berlín Heidelberg: Springer-Verlag; 2016, p. 359-82.
19. Loder RT. La columna cervical. En: Weinstein S. Lovell y Winter Ortopedia pediátrica. 7ma. ed. Venezuela: Amolca; 2017, p. 821-93.
20. Remondino R. Patología traumática del raquis pediátrico. En: Calcagni E, Ramírez J. Compendio de patología de la columna vertebral. SILACO, 2018, Módulo 7: 193-204.
21. Warner WC, Hedequist DJ. Cervical spine injuries in children. En: Waters PM, Skags DL, Flynn JM (eds.).
Rockwood & Wilkin’s fractures in children. 9th ed. Philadelphia: Wolters Kluwer; 2020, p. 1201-311.
22. Jones ET, Hensinger RN. C2-C3 dislocation in a child. J Pediatr Orthop 1981;1(4):419-22.
https://doi.org/10.1097/01241398-198112000-00011
23. Hamoud K, Abbas J. A new technique for stabilization of injuries at C2-C3 in young children. Injury
2014;45(11):1791-5. https://doi.org/10.1016/j.injury.2014.05.027
24. Fernández CA, Moreiro ME, Miranda MG. Instrucción Ortopédica de Posgrado - Imágenes. Presentación del caso. Rev Asoc Argent Ortop Traumatol 2023;88(6):592-3. https://doi.org/10.15417/issn.1852-7434.2023.88.6.1827
25. Fernández CA, Moreiro ME, Miranda MG. Instrucción Ortopédica de Posgrado - Imágenes. Resolución del caso. Rev Asoc Argent Ortop Traumatol 2023;88(6):692-3. https://doi.org/10.15417/issn.1852-7434.2023.88.6.1828
26. Pellicer-Garcia V, Baeza-Oliete L, Miranda-Casas L, Bas T, Bas P. Pseudosubluxación C2-C3: un hallazgo
radiológico frecuente en la infancia. Revista Española de Cirugía Osteoarticular 2009;44(239): 124-6. Disponible
en: http://www.cirugia-osteoarticular.org/adaptingsystem/intercambio/revistas/articulos/2240_5%20Pellicer.pdf
27. Shaw M, Burnett H, Wilson A, Chan O. Pseudosubluxation of C2 on C3 in polytraumatized children--prevalence and significance. Clin Radiol 1999;54(6):377-80. https://doi.org/10.1053/crad.1999.0192
28. Baumann F, Ernstberger T, Neumann C, Nerlich M, Schroeder GD, Vaccaro AR, et al. Pediatric cervical spine
injuries: A rare but challenging entity. J Spinal Disord Tech 2015;28(7):E377-84. https://doi.org/10.1097/BSD.0000000000000307
29. Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Surgery (Oxford) 2020;38(9):495-9. https://doi.org/10.1016/j.mpsur.2020.06.016
30. Al-Habib A, Al Aqeel A. C2/3 instability: unusual cause of cervical myelopathy in a child with Down syndrome.
Childs Nerv Syst 2013;29(1):163-5. https://doi.org/10.1007/s00381-012-1950-2
31. Citow JS, Munshi I, Chang-Stroman T, Sullivan C, Frim DM. C2/3 instability in a child with Down’s syndrome.
Case report and discussion. Pediatr Neurosurg 1998;28(3):143-6. https://doi.org/10.1159/000028638
32. Rusin JA, Ruess L, Daulton RS. New C2 synchondrosal fracture classification system. Pediatr Radiol
2015;45(6):872-81. https://doi.org/10.1007/s00247-014-3224-5
33. Martínez-Lage JF, Morales T, Fernandez Cornejo V. Inflammatory C2-3 subluxation: a Grisel’s síndrome variant. Arch Dis Child 2003;88(7):628-9. https://doi.org/10.1136/adc.88.7.628
34. Sellin JN, Shaikh K, Ryan SL, Brayton A, Fulkerson DH, Jea A. Clinical outcomes of the surgical treatment of
isolated unilateral facet fractures, subluxations, and dislocations in the pediatric cervical spine: report of eight cases and review of the literature. Childs Nerv Syst 2014;30(7):1233-42. https://doi.org/10.1007/s00381-014-2395-6
35. Chen Y, Wang X, Chen D, Liu X. Surgical treatment for unilateral cervical facet dislocation in a Young child aged 22 months old: a case report and review of the literature. Eur Spine J 2013;22(Suppl 3):S439-42.
https://doi.org/10.1007/s00586-012-2590-7
36. Herman MJ, Brown KO, Sponseller PD, Phillips H, Petrucelli PM, Parikh DJ, et al. Pediatric Cervical Spine
Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J
Bone Joint Surg Am 2019;101(1):e1. https://doi.org/10.2106/JBJS.18.00217
37. Eren B, Karagoz Guzey F. Is spinal computed tomography necessary in pediatric trauma patients? Pediatr Int
2020;62(1):29-35. https://doi.org/10.1111/ped.14064
38. Pannu GS, Shah MP, Herman MJ. Cervical spine clearance in Pediatric Trauma Centers: The need for
standardization and an evidence-based protocol. J Pediatr Orthop 2017;37(3):145-9.
https://doi.org/10.1097/BPO.0000000000000806
39. Karlin LI, Jordan EM, Miller PE, Shore BJ. Prevertebral soft tissue thickness of the cervical spine in children: An
insensitive but specific aid in the diagnosis of occult trauma. J Pediatr Orthop 2022;42(8):901-9.
https://doi.org/10.1097/BPO.0000000000002218
2001;36(2):373-6. https://doi.org/10.1053/jpsu.2001.20720
2. Parada SA, Arrington ED, Kowalski KL, Molinari RW. Unilateral cervical facet dislocation in a 9-year-old boy.
Orthopedics 2010;33(12):929. https://doi.org/10.3928/01477447-20101021-31
3. Copley PC, Tilliridou V, Kirby A, Jones J, Kandasamy J. Management of cervical spine trauma in children. Eur J
Trauma Emerg Surg 2019;45(5):777-89. https://doi.org/10.1007/s00068-018-0992-x
4. Velasco Canziani JM, Saprizza S, Galli N, Otero N, García F. Luxofractura cervical en niños: revisión bibliográfica
y caso clínico. Rev Asoc Argent Ortop Traumatol 2020;85(3):270-82. https://doi.org/ 10.15417/issn.1852-7434.2020.85.3.1007
5. Gopinathan NR, Viswanathan VK, Crawford AH. Cervical spine evaluation in pediatric trauma: A review and an
update of current concepts. Indian J Orthop 2018;52(5):489-500. https://doi.org/10.4103/ortho.IJOrtho_607_17
6. Zeng J, Jiang H, Zhuo Y, Xu Y, Deng Z. A case report on a child with fracture and dislocation of the upper cervical spine accompanied by spinal cord injury. Medicine (Baltimore) 2022;101(30):e29717.
https://doi.org/10.1097/MD.0000000000029717
7. Carreon LY, Glassman SD, Campbell MJ. Pediatric spine fractures: a review of 137 hospital admissions. J Spinal
Disord Tech 2004;17(6):477-82. https://doi.org/10.1097/01.bsd.0000132290.50455.99
8. Corrado R, Tello C, Galaretto E, Balderrama S, Noel M, Francheri Wilson A, et al. Luxofractura de la columna
cervical en un recién nacido: Informe de un caso. Rev Asoc Argent Ortop Traumatol 2010;75(1):73-6. Disponible
en: https://www.aaot.org.ar/revista/2010/n1/art07.pdf?_gl=1*1mh1yt6*_ga*MTA1MDAwMTA1Ny4xNzE5ODc0N
zg3*_ga_BFFNBSGNHH*MTcxOTg3NDc4Ni4xLjAuMTcxOTg3NDc4Ni4wLjAuMA
9. Jones TM, Anderson PA, Noonan KJ. Pediatric cervical spine trauma. J Am Acad Orthop Surg 2011;19(10):600-11.
https://doi.org/10.5435/00124635-201110000-00004
10. Wang MY, Hoh DJ, Leary SP, Griffith P, McComb JG. High rates of neurological improvement following severe
traumatic pediatric spinal cord injury. Spine 2004;29(13):1493-7; E266. https://doi.org/10.1097/01.brs.0000129026.03194.0f
11. Ogden JA. Columna vertebral. En: Ogden JA. Traumatismos del esqueleto en el niño. Barcelona: Salvat Editores; 1986, p. 397-422.
12. Lebwohl NH, Eismont J. Cervical spine injuries in children. En: Weinstein SL (ed). The pediatric spine: Principles
and practice. New York: Raven Press, Ltd.; 1994, p. 725-42.
13. Swischuk LE. Anterior displacement of C2 in children: physiologic or pathologic. Radiology 1977;122(3):759-63. https://doi.org/10.1148/122.3.759
14. Tabernero AM, Suñén Sánchez E, Peña Jiménez D, Loste Ramos A, Tabuenca Sánchez A, Chárlez Marco A, et al.
Pseudoluxación C2-C3 en la infancia [Pseudoluxation C2-C3 in childhood]. Rev Fac Cien Med Univ Nac Córdoba
2017;74(3):288-92. https://doi.org/10.31053/1853. 0605.v74.n3.12863
15. O’Neill C, Wenzel A, Walterscheid Z, Carmouche J. Distinguishing pseudosubluxation from true injury: A case of C2-3 and C3-4 subluxation in a pediatric patient. J Am Acad Orthop Surg Glob Res Rev 2021;5(12). https://doi.org/10.5435/JAAOSGlobal-D-20-00238
16. Rathjen KE, Herring JA. Spinal injuries. En: Herring JA. Tachdjian’s pediatric orthopaedics, 5th ed. Philadelphia:
Elsevier Health Sciences; 2013, vol. 3, p. 1224-44.
17. Ahmet A, Caglar Y. Pediatric cervical spine. En: Cumhur Oner F, Vaccaro AR, Vialle LR. AOSpine masters series.
Volume 5: Cervical spine trauma. New York: Thieme Medical Publishers, Inc.; 2015, p. 156-68.
18. Grigoriou E, Dormans JP. Pediatric spine trauma. En: Akbarnia BA, Thompson GH, Yazici M, El-Hawary R (eds).
The growing spine: Management of spinal disorders in young children. 2nd ed. Berlín Heidelberg: Springer-Verlag; 2016, p. 359-82.
19. Loder RT. La columna cervical. En: Weinstein S. Lovell y Winter Ortopedia pediátrica. 7ma. ed. Venezuela: Amolca; 2017, p. 821-93.
20. Remondino R. Patología traumática del raquis pediátrico. En: Calcagni E, Ramírez J. Compendio de patología de la columna vertebral. SILACO, 2018, Módulo 7: 193-204.
21. Warner WC, Hedequist DJ. Cervical spine injuries in children. En: Waters PM, Skags DL, Flynn JM (eds.).
Rockwood & Wilkin’s fractures in children. 9th ed. Philadelphia: Wolters Kluwer; 2020, p. 1201-311.
22. Jones ET, Hensinger RN. C2-C3 dislocation in a child. J Pediatr Orthop 1981;1(4):419-22.
https://doi.org/10.1097/01241398-198112000-00011
23. Hamoud K, Abbas J. A new technique for stabilization of injuries at C2-C3 in young children. Injury
2014;45(11):1791-5. https://doi.org/10.1016/j.injury.2014.05.027
24. Fernández CA, Moreiro ME, Miranda MG. Instrucción Ortopédica de Posgrado - Imágenes. Presentación del caso. Rev Asoc Argent Ortop Traumatol 2023;88(6):592-3. https://doi.org/10.15417/issn.1852-7434.2023.88.6.1827
25. Fernández CA, Moreiro ME, Miranda MG. Instrucción Ortopédica de Posgrado - Imágenes. Resolución del caso. Rev Asoc Argent Ortop Traumatol 2023;88(6):692-3. https://doi.org/10.15417/issn.1852-7434.2023.88.6.1828
26. Pellicer-Garcia V, Baeza-Oliete L, Miranda-Casas L, Bas T, Bas P. Pseudosubluxación C2-C3: un hallazgo
radiológico frecuente en la infancia. Revista Española de Cirugía Osteoarticular 2009;44(239): 124-6. Disponible
en: http://www.cirugia-osteoarticular.org/adaptingsystem/intercambio/revistas/articulos/2240_5%20Pellicer.pdf
27. Shaw M, Burnett H, Wilson A, Chan O. Pseudosubluxation of C2 on C3 in polytraumatized children--prevalence and significance. Clin Radiol 1999;54(6):377-80. https://doi.org/10.1053/crad.1999.0192
28. Baumann F, Ernstberger T, Neumann C, Nerlich M, Schroeder GD, Vaccaro AR, et al. Pediatric cervical spine
injuries: A rare but challenging entity. J Spinal Disord Tech 2015;28(7):E377-84. https://doi.org/10.1097/BSD.0000000000000307
29. Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Surgery (Oxford) 2020;38(9):495-9. https://doi.org/10.1016/j.mpsur.2020.06.016
30. Al-Habib A, Al Aqeel A. C2/3 instability: unusual cause of cervical myelopathy in a child with Down syndrome.
Childs Nerv Syst 2013;29(1):163-5. https://doi.org/10.1007/s00381-012-1950-2
31. Citow JS, Munshi I, Chang-Stroman T, Sullivan C, Frim DM. C2/3 instability in a child with Down’s syndrome.
Case report and discussion. Pediatr Neurosurg 1998;28(3):143-6. https://doi.org/10.1159/000028638
32. Rusin JA, Ruess L, Daulton RS. New C2 synchondrosal fracture classification system. Pediatr Radiol
2015;45(6):872-81. https://doi.org/10.1007/s00247-014-3224-5
33. Martínez-Lage JF, Morales T, Fernandez Cornejo V. Inflammatory C2-3 subluxation: a Grisel’s síndrome variant. Arch Dis Child 2003;88(7):628-9. https://doi.org/10.1136/adc.88.7.628
34. Sellin JN, Shaikh K, Ryan SL, Brayton A, Fulkerson DH, Jea A. Clinical outcomes of the surgical treatment of
isolated unilateral facet fractures, subluxations, and dislocations in the pediatric cervical spine: report of eight cases and review of the literature. Childs Nerv Syst 2014;30(7):1233-42. https://doi.org/10.1007/s00381-014-2395-6
35. Chen Y, Wang X, Chen D, Liu X. Surgical treatment for unilateral cervical facet dislocation in a Young child aged 22 months old: a case report and review of the literature. Eur Spine J 2013;22(Suppl 3):S439-42.
https://doi.org/10.1007/s00586-012-2590-7
36. Herman MJ, Brown KO, Sponseller PD, Phillips H, Petrucelli PM, Parikh DJ, et al. Pediatric Cervical Spine
Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J
Bone Joint Surg Am 2019;101(1):e1. https://doi.org/10.2106/JBJS.18.00217
37. Eren B, Karagoz Guzey F. Is spinal computed tomography necessary in pediatric trauma patients? Pediatr Int
2020;62(1):29-35. https://doi.org/10.1111/ped.14064
38. Pannu GS, Shah MP, Herman MJ. Cervical spine clearance in Pediatric Trauma Centers: The need for
standardization and an evidence-based protocol. J Pediatr Orthop 2017;37(3):145-9.
https://doi.org/10.1097/BPO.0000000000000806
39. Karlin LI, Jordan EM, Miller PE, Shore BJ. Prevertebral soft tissue thickness of the cervical spine in children: An
insensitive but specific aid in the diagnosis of occult trauma. J Pediatr Orthop 2022;42(8):901-9.
https://doi.org/10.1097/BPO.0000000000002218