Extract
The vast majority of spinal column and cord injuries that are sustained in
North America occur in patients who are between the ages of fifteen and forty
years. Children rarely have spinal injuries and even less frequently have
spinal cord injuries. Patients who are younger than fifteen years of age
account for fewer than 10% of patients who sustain spinal cord
injuries1,2.
The Canadian National Trauma Registry data reflect a similar conclusion: in
1998, there were twenty-eight spinal cord injuries nationally in children who
were younger than fifteen years of age in comparison with 511 injuries
reported for young adults from fifteen to forty years of
age3. The base
population-adjusted incidence suggests an annual pediatric spinal cord injury
rate of 1 in 1,000,000, and an annual rate of young adult injury of 17 in
1,000,000.
The vast majority of spinal column and cord injuries that are sustained in
North America occur in patients who are between the ages of fifteen and forty
years. Children rarely have spinal injuries and even less frequently have
spinal cord injuries. Patients who are younger than fifteen years of age
account for fewer than 10% of patients who sustain spinal cord
injuries1,2.
The Canadian National Trauma Registry data reflect a similar conclusion: in
1998, there were twenty-eight spinal cord injuries nationally in children who
were younger than fifteen years of age in comparison with 511 injuries
reported for young adults from fifteen to forty years of
age3. The base
population-adjusted incidence suggests an annual pediatric spinal cord injury
rate of 1 in 1,000,000, and an annual rate of young adult injury of 17 in
1,000,000.
However, despite a lower frequency of injury, a number of features unique
to pediatric patients demand specific attention. Children have different
activity profiles, putting them at risk for different injury patterns
(Fig. 1). Spinal column
injuries are associated with a variety of injury mechanisms to which children
are exposed, such as birth injuries, nonaccidental injuries, snowboarding, and
tobogganing4-8.
The most common causes of spinal injury in children are motor-vehicle
collisions, falls, and sporting
injuries9-11.
Penetrating injuries are unusual in children.
In addition, the growing spinal column has certain biomechanical features
that result in specific injury patterns. Spinal cord injury without
radiographic abnormality accounts for approximately one-third of all cord
injuries in young
children11,12.
The great elasticity of the pediatric spinal column, the high head-to-body
ratio in children, and the design of automobile restraint systems all play a
role in the etiology of these
injuries13,14.
The pediatric spinal column may also fail through a growth plate or disc,
leading to neural element compression by cartilage fragments not visualized on
radiographs. Children also have specific underlying factors that put them at
risk for injury, such as ligamentous instability, spinal dysplasia, or
congenital deformity. Different surgical management techniques may be required
in children, allowing the surgeon to deal with small anatomy, future growth,
and different activity profiles. The rehabilitation and follow-up of young
patients also present unique challenges, such as the development of spinal
deformity with ongoing growth.
The spinal column undergoes progressive dramatic anatomic and biomechanical
changes during the first fifteen years of life. Ossification centers enlarge
and spinal synchondroses fuse, slowly increasing the stiffness of the child's
spine. The paraspinal structures, especially the paraspinal musculature and
ligamentous structures, are underdeveloped. As the child grows, this envelope
around the spine also strengthens. In young children, these properties allow
the spine to lengthen to a much greater degree than the spinal cord, allowing
cord injuries to occur without vertebral column
injury14,15.
The upper cervical facets in young children are more horizontal, which also
allows for greater upper cervical motion; this may be evident on radiographs
as pseudosubluxation. The biomechanical features of the immature spine result
in a much higher prevalence of injury above C4 in children who are younger
than eight years of
age16. These
features also allow for a relatively high incidence of spinal cord injury
without vertebral column injury in children. In adults, the SCIWORA (spinal
cord injury without radiographic abnormality) pattern is often associated with
underlying spinal stenosis. Interestingly, the pediatric spinal column is
relatively capacious. Synchondrosis growth allows the canal to expand until
approximately eight years of age, after which little further enlargement
occurs17,18.
However, premature synchondrosis closure or deficient synchondrosis growth, as
seen in vertebral dysplasias, can lead to stenosis in children and increase
their risk of spinal cord injury.
Radiographic studies of the immature spinal column greatly assist in the
evaluation of injuries, but they must be interpreted with a full understanding
of pediatric anatomy and biomechanics. Careful positioning of traumatized
pediatric patients for radiographic studies is critical. The relatively large
head size of pediatric patients can lead to excessive anterior cervical
translation in the injured spine if children are placed on standard adult
immobilization boards.
Interpretation of radiographs in young patients with cervical trauma is
challenging. Pseudosubluxation is seen commonly in children who are younger
than eight years of
age19,20.
The amount of vertebral translation should not exceed 4 mm and should reduce
on extension, and the alignment of the posterior spinolaminar line of Swischuk
should be
preserved21,22.
The atlantodens interval can be larger in children, and it is possible for
flexible children to have values of 4 mm without having an anatomic
abnormality23. It
is also common for young children to have a relative kyphosis across the
midcervical portion of the spine, a finding which would be considered abnormal
in an adult study. Anatomic features can also complicate interpretation;
persistence of cervical synchondroses can simulate traumatic injury as can
congenital cervical fusions or deformities. Variations in odontoid development
or synchondrosis closure are commonly misinterpreted on cervical
radiographs17,20,24.
Interpretation of soft-tissue anatomy can also be more difficult in children.
The posterior soft tissues may appear increased in a crying child who is
uncooperative during the examination. The size variability in children also
requires that the soft tissues be judged in reference to vertebral body size,
with the prevertebral soft tissues being two-thirds or less of the sagittal
length of the adjacent vertebral body. Despite the increasing use of magnetic
resonance imaging, flexion-extension radiographs remain important tools in the
assessment of pediatric cervical injuries. Children are at increased risk for
traumatic cervical instability with no osseous injury. They may be relatively
uncooperative initially with an examination in the emergency department, and
cervical range of motion may therefore be limited by paraspinal spasm or
guarding. If the results of clinical examination and plain radiographs provide
a relatively low index of suspicion, the completion of dynamic radiography in
a delayed fashion can serve to rule out subtle instability patterns, thus
allowing the child to return to his or her accustomed activities and
sports.
Computed tomography scans provide excellent delineation of osseous injury
patterns. Routine three-dimensional studies and sagittal and coronal
reconstructions provide the physician with a detailed understanding of the
osseous injury. These studies have important implications in understanding the
mechanism of injury, judging potential instability, evaluating deformity, and
planning surgical procedures. Magnetic resonance imaging plays an increasingly
important role in the evaluation of pediatric spinal trauma and has supplanted
computed tomographic myelography in this
regard25. Magnetic
resonance imaging studies allow for superior soft-tissue and neural element
visualization, providing specific advantages in the pediatric population. The
inherent greater instability of the pediatric spine, a higher prevalence of
SCIWORA, and a substantial prevalence of late instability makes clearance of
the cervical spine in uncooperative, multiply injured, or head-injured
children problematic. The ability to quickly rule out problems in the cervical
spine greatly facilitates the care of patients in the intensive care unit
environment. Delays in obtaining this knowledge may interfere with bedside
care, patient positioning, initiation of therapy, airway management,
extubation, and operative procedures. Magnetic resonance imaging protocols
have been clearly demonstrated to be useful in detecting injuries that were
not appreciated on plain radiography, to rule out the presence of injuries as
suspected on the basis of plain radiographs, to predict cervical stability and
allow for collar removal, and to play a role in evaluating the potential for
recovery in patients with spinal cord
injuries26-30.
Spinal cord injury without radiographic abnormality (SCIWORA) was defined
by Pang and Wilberger in
198212. Over a
period of twenty years at their center, these authors identified twenty-four
patients with spinal cord injuries, none of whom exhibited evidence of
radiographic abnormalities. Their study did not include the use of magnetic
resonance imaging. Since that time, many authors have recognized and defined
series of patients with
SCIWORA13,31-33.
The exact prevalence of this entity is difficult to define. In young children,
SCIWORA may account for up to a third of cord injuries. It is most common in
the cervical spine, and the neurologic injury is usually severe. The entity is
less common in older children and is more likely to present as an incomplete
lesion13. SCIWORA
in the thoracic spine may be associated with severe injuries and prolonged
hypotension. The prognosis of SCIWORA, like that of spinal cord injuries in
general, is related to the severity of the presenting neurologic injury more
than to the injury classification. Magnetic resonance imaging findings can
provide prognostic information. In some patients, a normal signal in the
spinal cord may predict an opportunity for complete
recovery31.
In comparison with other types of imaging studies, magnetic resonance
imaging is more sensitive in detecting soft-tissue injuries, including
end-plate avulsion injuries, disc injuries, and posterior soft-tissue injuries
(Figs. 2-A and 2-B). Despite
its sensitivity, magnetic resonance imaging in some young pediatric patients
results in a finding of normal extradural tissues even though the patients
have complete cord injuries, including cord
transections31.
Extradural magnetic resonance imaging findings are often predictive of the
intradural changes seen on the studies and suggest hypermobility as a
mechanism of injury. The addition of magnetic resonance imaging studies has
confused the definition of SCIWORA to some degree. Subtle extradural changes
may be difficult to differentiate from normal variants. It is clear, however,
that severe spinal cord injury can occur in the absence of any magnetic
resonance imaging evidence of injury in the extradural tissues.
The management of patients with SCIWORA should follow the general
principles that have been applied to the management of patients with spine
injuries. Spinal precautions should be maintained until instability is ruled
out. The results of conventional imaging studies are insufficient in
establishing the presence of spinal stability in this patient group, and a
conservative approach should be taken. In the original description of SCIWORA
by Pang and Wilberger, half of the patients had a delayed presentation of
neurologic
injury12.
A normal magnetic resonance imaging scan can rule out major instability,
but restriction of extremes of range of motion seems prudent if there is any
question of the possibility of a partial neurologic injury or the potential
for recovery. The use of Minerva-type orthoses are frequently recommended for
two to three months. In a cooperative patient, flexion-extension radiographic
studies can be completed as an adjunct to the magnetic resonance imaging
study. Surgical management should be directed toward managing instability or
ongoing neural element compression as neurologic function deteriorates. There
is no indication for routine laminectomy in this diagnostic entity in the
absence of a specific surgical
indication32.
Children with injuries to the cervical spine present a great challenge to
medical facilities. The uncommon nature of these injuries means that even
tertiary centers will likely manage only a few cases each year. In addition,
the small child presents challenges (in assessment, imaging, and both
operative and nonoperative management) that are not present in adults. Simple
management algorithms that are used for adult injuries often do not apply to
injuries in children. Accurate epidemiologic data are difficult to obtain
regarding injury rates. In a study of patients seen at the Mayo Clinic, over a
forty-year time-period, the age-adjusted incidence of cervical injury was 7.41
per a population of 100,000 per year. Young children were injured in falls and
had a high rate of neurologic
injury34. Although
it is true that these injuries occur relatively infrequently, their complex
diagnosis and management and the long-term potential patient morbidity demand
that specific attention be paid to this group of patients. In addition, two
unique mechanisms of cervical spine and spinal cord injury should be
investigated in pediatric patients: first, the possibility that the injury has
been caused by physical
abuse4,5,
and second, the possibility that the injury is the result of birth
trauma7. When a
nonaccidental injury is suspected, the spine should be closely examined for
evidence of old or acute injury. There may be a high risk of severe injury in
the future. The second group of unique injury mechanisms is comprised of
injuries to the cervical spine and spinal cord during birth. Although these
injuries occur very rarely, they are accompanied by enormous implications.
Initial management of children with cervical spine injuries should follow
the basic principles of trauma care. Standard backboard immobilization
techniques have been shown to cause displacement of unstable pediatric
cervical injuries. When a child is strapped to a backboard, the relatively
large size of the head causes flexion of the
neck34. A specific
technique should be used to prevent cervical malalignment. A pediatric spine
board with an occipital hollow can be used or an additional pad can be placed
under the trunk, which allows for a more posteriorly positioned occiput.
Physical assessment of severely injured, uncooperative young patients can
be challenging. A high index of suspicion and an appreciation of the mechanism
of injury should be maintained. Indirect signs of cervical injury, such as
anterior chinstrap lacerations, facial contusions, and palpable posterior
ligamentous defects, are signs of potential severe cervical injury. Neurologic
examination may require extensive observation and patience.
Atlanto-occipital injuries are associated with high energy and are
frequently fatal35.
Children appear to be at increased risk for an injury at this site. The injury
is frequently associated with severe cord and brainstem injury, causing
respiratory arrest. Increasingly, however, series of patients surviving this
injury14,36-40
and patients with atlanto-occipital dislocations with intact neurologic
function have been
reported41.
The early diagnosis of this problem can be challenging. The initial
displacement may reduce with cervical immobilization. In children, the
relationship between the basion and the tip of the odontoid can be unreliable
due to variable ossification of and difficulty visualizing the odontoid
process. The Powers ratio
42 was described to
help in identification of the injury. This ratio was calculated by dividing
the distance from the basion to the posterior arch of the atlas by the
distance from the opisthion of the occipital bone to the anterior arch of the
atlas, with a ratio of >1.0 identifying abnormal anterior displacement of
the occiput on the atlas. The Powers ratio has limited clinical application;
posterior displacement is not accounted for in the ratio. In addition,
anatomic variation, adjacent level trauma, and poor visualization can make the
ratio difficult to interpret. Frequently, the instability can be appreciated
if traction is applied for a radiographic study or, in the case of small
children, when a large rigid cervical collar imparts a distractive force
across the atlanto-occipital junction (Fig.
3).
Treatment of atlanto-occipital injuries is challenging. The patients are
usually intubated, multiply injured, and often have a major head injury.
Defining the extent of brain and spinal cord injury can be very difficult.
Severe cranial nerve injuries can further confuse the issue, with the patient
conscious but "locked in" and unable to communicate
(Fig. 4). Communicating with
family members is an extremely important task in the early management and
decision-making stage of treatment for these patients.
If atlanto-occipital instability is detected, stabilization should be
provided initially with a halo-thoracic vest. Traction cannot be used.
Definitive stabilization of true atlanto-occipital dislocation requires
posterior occipito-cervical
fusion36,41.
Fusion to C2 is recommended to avoid C1-C2 instability and to promote a high
fusion rate. A wide variety of posterior fusion techniques have been utilized,
including onlay grafting, wiring, wire-rod combinations, and posterior
screw-rod constructs (Fig. 5).
Posterior occipital plate fixation with cervical screws and rods provides
excellent stability and a high fusion rate if the local anatomy will allow for
the technique. In cases of preserved neurologic function, the fusion can be
limited to C1 to preserve C1-C2 motion. A wire fusion technique has been
described for use in this rare
occurrence41.
Isolated atlas fractures are an uncommon injury in
children34,43.
The injury mechanism, an axial load injury, is believed to be similar to that
seen in Jefferson fractures in
adults44,45.
Pediatric C1 ring injuries are unique because of the presence of an open
synchondrosis which can remain open until late in the first decade of
life46. The
synchondrosis fails in tension, allowing the ring to widen. It may occur in
association with an osseous injury. It may also fail when a posteriorly
directed force is applied to the
head46
(Fig. 6).
Diagnosis of the injury is challenging because plain radiographs may
demonstrate only very subtle abnormalities. If the mechanism of injury and the
clinical examination suggest high cervical injury, the plain radiographs must
be inspected very closely. A good-quality open-mouth radiographic view will
allow the ondontoid and the lateral masses to be visualized. In the absence of
a history of torticollis or congenital anomaly, the lateral masses of C1
should be symmetric, as should the distance between the lateral masses and the
odontoid. There should also be symmetry between the outer edge of the lateral
masses of C1 and C2. If a C1 fracture is suspected, computed tomographic
images of the injury should be acquired.
The neurologic status of patients with an isolated C1 injury tends to be
intact because the space available for the spinal cord is preserved.
Immobilization is the usual management technique, either with a cervical
orthosis or a halothoracic vest.
Isolated C1-C2 acute ligamentous instability, secondary to a tear in the
tranverse ligament, is an uncommon
injury43. As is the
case with other ligamentous injuries, it tends to occur in younger children,
where greater relative head size and flexibility focus the load on the upper
cervical spine34.
Surgeons are more familiar with managing C1-C2 instability in association with
other nontraumatic conditions, such as Down syndrome or os
odontoideum47. An
understanding of the immature cervical spine is critical for safe radiographic
evaluation of the C1-odontoid relationship in a child who has undergone
cervical trauma. The greater flexibility of the cervical spine in a young
patient can create a 4-mm change in the atlantodens interval between flexion
and extension
films26. A greater
degree of segmental motion is also present, allowing a larger angular change
between C1 and C2, tipping C1 and increasing the atlantodens interval at the
superior margin of C1. In both traumatic and chronic C1-C2 instability, the
surgeon should also carefully evaluate the space available for the cord and
the anatomy of the posterior arch of C1. Hypoplasia of the arch exacerbates
the risk of spinal cord injury associated with C1-C2 instability and must be
considered in treatment
decisions47.
Management of this type of ligamentous injury is less well defined in
adults than in children. The concern of chronic instability and the
biomechanics of transverse ligament rupture have led to a general
recommendation for surgical stabilization in
adults48. In
children, surgical stabilization seems warranted when anterior translation
suggests a marked ligamentous injury, the atlantodens interval is increased to
8 mm, or when a neurologic deficit is
present49. In some
instances, a conservative approach may be warranted. Computed tomography
investigation may indicate an osseous avulsion of the transverse ligament,
with a small flake of bone torn from C1. A greater degree of stability may be
expected to be achieved with nonoperative management of such an injury in a
child.
In older children, fractures of the odontoid process are similar to those
seen in adults. In younger children, prior to the adolescent growth spurt,
this injury typically represents a failure through the synchondrosis at the
base of the
odontoid50. In the
very young, radiographic interpretation can be challenging due to the presence
of an unossified transverse line of mesenchymal tissue, commonly seen in a
variety of
dysplasias51.
Although relatively uncommon, the injury can be associated with neurologic
injury. It is frequently due to a motor-vehicle collision involving a
restrained child52.
These injuries heal well with adequate immobilization. If displacement of the
odontoid is evident on initial presentation, closed reduction and halo
immobilization should be undertaken. The closed reduction procedure can be
performed safely under sedation to allow for continuous neurologic assessment
of the child. Undisplaced injuries may be managed with Minerva-style jacket
immobilization in cooperative patients.
Odontoid abnormalities have a reputation for being missed, leading to a
situation of future instability and the potential risk of neurologic
injury51. Careful
clinical and radiographic assessment should lead to computed tomography
examination and sagittal reconstruction in questionable cases. The sagittal
studies demonstrate the injury pattern well. It does appear that os
odontoideum can represent an odontoid
nonunion53.
Clearly, odontoid injuries can occur from relatively minor injuries in young
children and may not be detected at the time of the initial
evaluation52.
Traumatic disruption at the C2 pedicle (a hangman's fracture) has been well
described in adult
patients54. It is
not usually associated with neurologic injury and, in almost all cases, if
reduced, will heal well with conservative immobilization techniques. The
injury is extremely rare in
children34. Small
series and case reports exist in the
literature55,56.
It appears that a variety of mechanisms of injury can lead to this fracture,
with hyperextension being the most common.
In young children, the synchondrosis between the body and the pedicle
ossification centers may be mistaken for a traumatic
disruption57.
Computed tomographic and magnetic resonance imaging scans may be required to
differentiate normal ossification patterns from traumatic changes in patients
in whom an injury is suspected. The synchondrosis should not automatically be
associated with instability; rather, the patient should be followed until the
synchondrosis has ossified, which usually occurs sometime between three and
six years of age. Persistence of a lucency at the C2 pedicle may be seen in
certain skeletal dysplasias and is also associated with Klippel-Feil
anomalies.
C2 pedicle fractures in children are managed conservatively. Undisplaced
fractures can be treated with removable external immobilization. Unstable or
reduced injuries should be managed with halo-vest immobilization.
Subaxial injuries are uncommon in children, especially in children who are
younger than nine years of
age58. In the
adolescent patient population, the injury patterns are similar to those in
adults. Injury types include fracture-dislocations, burst fractures, simple
compression fractures, facet dislocation, or fracture dislocations and
posterior ligamentous injuries. These injuries usually involve major trauma
and are most frequently related to motor-vehicle
collisions59.
Anterior instrumentation and fusion is less commonly performed in immature
children than in adults because of concerns regarding anterior growth.
Pediatric fracture-dislocations and burst injuries should be managed by
realigning the canal and immobilizing the spine, usually with use of halo-vest
immobilization. In rare cases, neural element decompression is required.
Simple stable compression fractures may only require collar immobilization for
four to six weeks.
Unilateral and bilateral facet dislocations require reduction, similar to
the method of management in adults. Anesthesia-guided sedation techniques work
well in children, allowing for a controlled reduction in a cooperative
patient. Multiple-pin halo rings can provide enough traction for reduction in
children and can be immediately converted to halo immobilization. Three months
of halo immobilization followed by evaluation with dynamic flexion-extension
radiography should be sufficient for most of these injuries. Facet fracture
dislocation is a more unstable injury for which conservative management
techniques are more likely to fail. Primary posterior instrumentation and
fusion may be required to provide long-term stability in these patients.
Growing vertebral bodies have superior and inferior physeal plates which
are at risk for failure in injuries that distract the spine. Injury to the
inferior end plate is most
common60. Young
children may present with a type-1 physeal separation. These injuries are
frequently associated with neurologic injury and should be considered to be
very unstable. They may be difficult to visualize radiographically in a young
child and are frequently only appreciated on magnetic resonance images. If
well reduced and stabilized in a halo, these injuries should heal rapidly,
with appropriate immobilization. Older patients more frequently sustain a
partial physeal, or type-3, injury to the anterior-inferior aspect of the end
plate. These injuries are more stable and heal quickly with
immobilization.
Injuries to the thoracic and lumbar spine are rare in the pediatric
population. The literature suggests that spinal injuries in children are
relatively balanced between the cervical and thoracodorsal
spine61. Young
children sustain thoracodorsal spine injuries as a result of child abuse or in
motor-vehicle collisions
62, whereas older
children may sustain them during sports activities such as snowboarding and
mountain-biking. Most such injuries are centered around the thoracolumbar
junction and are often related to a seat-belt
injury63,64.
Patients who present with fractures in this region often have multisystem
injuries65-71.
It is critical for the pediatric orthopaedic surgeon to play an active role in
the management of these patients. The physical examination in the emergency
room can demonstrate features that are indicative of major spinal trauma,
including abdominal bruising and evidence of a posterior distraction injury.
Detection of a fascial tear by palpation can provide the clinician with
evidence of a serious injury pattern despite minimal findings with radiography
or computed
tomography72.
Neurologic injury is not uncommon in these patients and can be partial or
complete63.
The diagnostic work-up of fractures in children is similar to that in
adults. Severe spinal injuries should be evaluated with computed tomography,
and neurologic deficits should be evaluated with magnetic resonance imaging
scanning. Magnetic resonance imaging plays an important role in evaluating
patients with SCIWORA. Management principles are also similar. Spinal injuries
in children may have a greater potential for remodeling, especially if the
injury is reduced and the end-plate growth has been
preserved73.
Pediatric spinal instrumentation systems have increased in sophistication,
allowing stable instrumentation constructs to be established across fewer
spinal segments, thus minimizing long-term effects on spinal health. Pedicle
screw constructs are commonly applied.
The mechanism of injury in the thoracic and lumbar spine determines the
fracture pattern that is seen and is reflected in fracture classification and
spinal stability. Moderate flexion moments can lead to compression fractures.
Greater axial load can lead to a burst pattern with failure of the posterior
column. The classic Chance fracture, described in 1948, is created with a
posterior distractive force and a flexion moment and is commonly referred to
as a flexion-distraction
injury74. The
anterior column may fail as a result of compression in these injuries, or it
may be intact75.
Fracture dislocations are rare injuries in children and are characterized by
severe multiplane instability, translational displacement, and a high
prevalence of neurologic injury.
Compression injuries are most common at the thoracolumbar junction. They
are characterized by failure of the anterior column in compression in the
absence of either clinical or radiographic evidence of posterior element
injury. The superior end plate fails more commonly than the inferior end plate
does. These injuries can occur over multiple levels and may occur with a
relatively low-energy injury in a growing patient.
Most compression injuries can be managed conservatively, either with
activity restriction or orthotic treatment. Long-term kyphosis is rare in
these injuries. Anterior growth is preserved and often may lead to correction
of the initial kyphosis. Injuries with more than 50% compression of the
anterior column should be closely evaluated for evidence of posterior injury
and closely followed over time. Instrumentation may be required to control the
kyphosis.
Burst injuries are rare in pediatric patients and are managed similarly to
burst injuries in adult patients. Computed tomography evaluation is critical
in understanding the morphology of the fracture and the potential pitfalls,
such as laminar injuries. If the injury is unstable, the use of posterior
instrumentation is preferred in patients with an immature spine to preserve
any possible remaining anterior growth. Sagittal plane correction can be
observed with ongoing growth. The use of smaller-diameter pedicle screws also
allows the surgeon to preserve more lumbar levels than can be preserved with
the use of hook constructs. Single-level stabilization may be augmented with a
brace or cast.
Seat-belt injuries in children have been well recognized by clinicians
since the original description by Chance in
194874. We reviewed
the cases of twenty-seven patients with flexion-distraction injuries that
occurred within a seventeen-year
period73. The
characteristics and injury patterns of the patients were similar to those
described in smaller series in
children63,64,67,76-81.
All injuries were the result of a motor-vehicle collision. Three-point
harnesses were worn by nine of the children, indicating the limited ability of
three-point restraint systems in preventing this type of spinal injury in
children. The youngest patient was thirty-two months of age. In older
children, the injuries cluster around the thoracolumbar junction. In younger
children, the level of the injury is likely to be more caudal and tends to
occur at L3. Three patients in our series had major vascular injuries,
including one patient who presented with a traumatic aortic dissection
(Fig. 7). Major abdominal
injuries occurred in almost half of the patients. Jejunal transection is a
common finding in these patients and occurred in four of our twenty-seven
patients. Small-bowel perforation occurred in five others. A delay in
diagnosis of these injuries puts the patient at great risk.
Management of these spinal injuries has not been well defined in children.
Flexion-distraction injuries involving a major osseous component that remains
well aligned should heal well with immobilization alone and should achieve
long-term stability. Indications for operative management may include
multisystem injuries, progressive kyphosis, or appreciable initial kyphosis.
When the initial segmental kyphosis is >15°, we recommend spinal
stabilization. In our series, reconstitution of the anterior vertebral body
with a decrease in the amount of kyphosis was observed in the patients who
underwent instrumentation but not in the patients who received conservative
treatment. These major injuries are associated with long-term morbidity and
poor disease-specific outcome scores. Our patient group scored poorly on the
American Academy of Orthopaedic Surgeons Lumbar Spine-Baseline Questionnaire
(version 2000) at the time of final follow-up.
Spinal cord injury in a growing patient is associated with a high risk of
future spinal deformity. As with most spinal deformities, the adolescent
growth spurt has a major effect on evolution of the deformity. The prevalence
of spinal deformity approaches 100% in children who sustain a spinal cord
injury prior to the age of ten
years82,83.
Scoliosis is the most common deformity, followed by kyphosis and lordosis.
Bracing plays an important role in aiding seating, but skin care must be
meticulous. Early bracing may reduce the need for spinal stabilization in this
group; however, most of these children will have continued progression, an
increasing deterioration of seating ability, and the eventual need for spinal
stabilization. A long spinopelvic fusion should be performed to minimize the
chance of future deformity. Fusions ending below T3 may be associated with a
segmental kyphosis at the end of the construct in this patient group.
Correcting pelvic obliquity to produce balanced seating is critical, and an
anterior release may be required in larger structural curves to achieve pelvic
balance.
Progressive spinal deformity, increasing pain, and neurologic deterioration
may be associated with the development of a posttraumatic
syrinx84. Routine
preoperative magnetic resonance imaging studies are indicated in patients with
posttraumatic paraplegia and quadriplegia who are undergoing spinal
arthrodesis to identify a syrinx. Patients who present with neurologic
deterioration or increasing pain should also be closely evaluated with
magnetic resonance imaging whenever possible. ?
Kewalramani LS, Tori JA. Spinal cord
trauma in children. Neurologic patterns, radiologic features, and
pathomechanics of injury. Spine.
1980;5:
11-8.511
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