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associated with a hypoplastic dens. This leads to a risk of increased mobility and
cord injury at the C1–C2 level and may require surgical stabilization. This
condition can be confused with a fracture at the base of the odontoid. The
ossiculum terminale is a small ossicle at the tip of the dens ( Fig. 112.36 ). It is
seen in most children, fusing with the rest of the dens by adolescence. This ossicle
can be large and associated with a hypoplastic dens, as previously described.

FIGURE 112.35 Example of os odontoideum. Note the hypoplastic dens and overgrown
ossiculum terminale or ossiculum odontoideum (O ). The arrow indicates posterior
displacement, attesting to instability of the lesions. (Reprinted with permission from Swischuk
L. Emergency Radiology of the Acutely Ill or Injured Child . 2nd ed. Baltimore, MD: Williams
& Wilkins; 1986:717.)

Spinal epidural hematomas are also seen in the pediatric population. These
hematomas are venous bleeds that compress the adjacent spinal cord and present
hours or days after a sometimes minor traumatic event, with ascending neurologic
symptoms as the bleed progresses. An MRI scan can be helpful in evaluating
these patients ( Fig. 112.37 ). Rapid evaluation and surgical decompression are
mandatory.
Treatment of children with suspected cervical spine injuries may involve basic
and advanced life-support measures, initiation and/or maintenance of
immobilization, and neurosurgical or orthopedic consultation. Airway support for
patients with traumatic quadriplegia should be anticipated because they will
develop respiratory failure as their respiratory muscles fatigue. Children may
present in spinal shock (hypotension, bradycardia, peripheral flush) from the loss