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Pediatric spine injuries

Introduction

Pediatric spinal trauma is relatively uncommon, representing only 1-2% of all pediatric fractures,1 with children comprising less than 10% of spinal injuries seen in emergency departments in the United States.2 The cervical spine is the most commonly injured,1-3 with motor vehicle crash being the most frequent mechanism of injury. Diagnosis of pediatric spinal column injuries presents challenges unique to the patient population, and the protocols in place to evaluate for adult spinal injury may not be the most reliable for children.4  Certain injuries are unique to children, including spinal cord injury without radiographic abnormality (SCIWORA), posterior limbus injury, and trauma secondary to child abuse.5

Relevant Anatomy

Knowledge of the developmental anatomy in the pediatric spine is essential to understanding the different injury patterns in pediatric patients.  The epidemiologic differences between adult and pediatric spinal column injury may be explained by incomplete ossification, unfused synchondroses, increased relative proportion of head to body size, and overall increased ligamentous laxity.6-7  Immature intervertebral discs transmit energy more efficiently to adjacent levels, and the associated inability of immature bone to resist traumatic deformation may account for the higher incidence of multilevel injury in children,6 as well as for the occurrence of SCIWORA in this population.

Ossification of the epiphysis begins between seven and eight years of age.8  By 12 to 15 years, these foci form the apophyseal ring, which closes by age 21 to 25.  Fractures crossing the disk in the immature spine traverse almost exclusively through the growth zone of the physis.9  Longitudinal growth of the vertebral bodies occurs by endochondral ossification at the end plate.  Notably, the spinal cord terminates at L3 at birth and gradually moves to the adult level of L1-2 at about 2 months after birth.10

Pathogenesis

Motor vehicle crashes (MVCs) are the most common injury mechanism for cervical spine injury (66%), followed by falls (15%). High-energy sports injuries have also been reported in older children.11 Complete spinal cord injury was observed in 3.2% of all MVCs in the National Trauma Registry.3 Child abuse is also an important consideration in the absence of obvious trauma, or if there are inconsistencies in the history; the true incidence is not known, but likely ranges from 0% to 3%.12-14

Epidemiology and Natural History

The cervical spine is the most commonly injured, with an incidence of 1.3% of all pediatric patients admitted nationally for blunt trauma and approximately 30% of all pediatric spine injuries;1,3 the thoracic spine is the least commonly injured.1 The reported incidence of multilevel spine injury in children has ranged from 6% to 50%, higher than the 6-23.8% reported for a similar adult population. The injury pattern involves contiguous levels in approximately 60% of patients.1  The level of cervical spine injury has been shown to vary by age group as well, with infants and young children sustaining primarily upper cervical (C1-C4) injury after blunt trauma, while children older than eight and adolescents tend to sustain lower cervical injury (C5-C7).3,6

The natural history of the process varies based on the level and grade of the injury. Recovery of neurologic function following severe traumatic spinal cord injury occurs with a significantly greater incidence in children than adults, and these improvements can occur over a prolonged post-injury period.15

Clinical Presentation

Pediatric spinal trauma presents similarly to spine trauma in adults. The mechanism of injury can usually be elucidated via a careful history. Tenderness of the posterior spinal elements suggests ligamentous injury. Neurologic examination must be performed initially and at frequent intervals: While most patients with significant spinal cord trauma have neurologic findings at presentation, a small subset may have a delayed manifestation, ranging from 30 minutes to 4 days post-injury.16 It is also not uncommon for patients sustaining severe spine trauma to have associated injuries; therefore, a thorough trauma workup should be initiated immediately. In the absence of a clear trauma history, or if there are inconsistencies in the history, child abuse must be consideration on the differential diagnosis.

Imaging and Diagnostic Studies

While the utility of plain radiographs in diagnosing pediatric spinal trauma is apparent, more subtle injuries and, by definition, SCIWORA, are often missed. For children younger than eight years, combination plain-film/occiput-C3 computed tomographic scan had a sensitivity of 94%. In patients older than eight, the sensitivity of combined plain film-CT scan was 97%6.

Fractures through the vertebral apophysis, or limbus fractures, are difficult to visualize on standard radiographs or magnetic resonance imaging scans, and computed tomography (CT) or myelography-CT studies may have more utility in diagnosing these injuries.5

Magnetic resonance imaging may be useful if soft tissue injury, such as herniated disk, neuroforaminal encroachment, hematoma, spinal cord edema, or post-traumatic spinal cord cyst, is suspected.5 Flynn et al17 evaluated the utility of MRI in pediatric patients with suspected cervical spine injury; inclusion criteria consisted of an obtunded or nonverbal child suspected of having CSI, equivocal plain films, neurologic symptoms without radiographic findings, or an inability to clear the cervical spine within 3 days. MRI confirmed the plain film diagnosis in 66% of cases, and modified the diagnosis in 34%. 

Classification

There are several clinical entities unique to spine trauma in a pediatric population: SCIWORA, posterior limbus or apophyseal ring injuries, and trauma secondary to child abuse.5  These entities exist in conjunction with injury patterns that are similar to adults, such as compression fractures, burst fractures, and fracture-dislocations (Chance fractures). The pediatric entities will be discussed.

Spinal Cord Injury without Radiographic Abnormality

A complete spinal cord lesion without an associated fracture occurs in 19-34% of all pediatric spine trauma patients.18 One study evaluating the elastic properties of the pediatric spinal canal found that the canal itself can be stretched up to 2 inches, but the cord could only be stretched 0.25 inches before rupture.19 Nearly half (44%) of patients with SCIWORA have complete lesions, while only 31% of pediatric patients with fractures or dislocations had complete lesions of the cord.20

Posterior Limbus Injury

Fractures through vertebral apophysis are mostly traumatic lesions and are typically found in adolescents and young adults; the level most commonly affected is L4-L5.21 These fractures have been described as a potential cause of SCIWORA, although this assertion remains unproven.5 These fractures have been classified by Takata,22 with a modification suggested subsequently by Epstein et al23

  • Type I lesions: Pure cartilage avulsions of the posterior cortical vertebral margin without attendant osseous defects
  • Type II lesions: Larger central fractures that include portions of the cortical and cancellous bony rim
  • Type III lesions: More localized and lateralized as teardrop fractures (Figure 1)
  • Type IV lesions: Span the entire length and breadth of the posterior vertebral body
Fractures Secondary to Child Abuse

Vertebral body subluxation with or without fracture has high specificity for child abuse if a history of trauma is absent or inconsistent with the injuries.24 One recent systematic literature review25 found that all patients with spine injury caused by abuse had focal findings on physical exam, namely lumbar kyphosis or thoraco-lumbar swelling.

Treatment, Complications, and Controversy

The most important element in the treatment of pediatric spine fractures is prevention of the initial injury. Motor vehicle collisions are by far the most common cause of pediatric spine trauma, and the changing center of gravity in growing children presents a challenge for appropriate restraint within a vehicle. Child safety seats, booster seats, and over-the-shoulder seat belts in older children are the primary means of prevention in the pediatric population.

The remodeling potential of the pediatric spine is greater than that of adults; a pediatric spine fracture that is stable and shows no indication of neurologic compromise may be treated conservatively. Even burst fractures have high remodeling potential, and the fragments in the canal may be left alone if there is no suggestion of neurologic compromise.

The recommended treatment for SCIWORA is usually conservative, with immobilization for 1 to 3 weeks. Decompression is indicated if a distinct lesion can be demonstrated or progressive neurologic deficit occurs. Laminectomy often leads to spinal instability and post-laminectomy kyphosis.5 Compression fractures with less than 50% loss of height are good candidates for non-surgical management.5 However, kyphotic deformities that remain after crushing of the epiphyseal plate may also spontaneously progress.

Assessment of stability, need for reduction and the degree of canal compromise guide surgical decision-making. Patients with neurologic deficits in the presence of traumatic canal compromise or with progressive deformity are candidates for surgical intervention.

However, there is a paucity of evidence supporting stabilization of the spine in the pediatric spinal cord injury population. Parent et al26 performed a systematic literature review to determine the most effective means of stabilization and the most appropriate treatment of post-traumatic deformity. Most of the literature included in the study focused on the adult population, with only small, retrospective studies examining an exclusively pediatric population; no level 1 or 2 studies were included in the analysis. The available literature does suggest that (1) nearly 100% of pediatric patients with spinal cord injury will develop a deformity, (2) the deformity should be prevented before the age of 10 to 12 years, (3) younger patients tend to have worse outcomes, and (4) brace treatment is generally recommended. However, there is no consensus on the use of bracing in the post-traumatic population.

In a retrospective analysis27 of 35 pediatric patients sustaining traumatic fracture-dislocations of the spine (Chance fractures), 62% of the patients included had a good final clinical outcome, defined as no chronic pain or neurologic deficit. The rate of a good outcome was 45% in the nonoperative group, as compared to 84% in the operative group. The most common complication in the operative group was painful prominence of the surgical implants.

Controversy also exists regarding the optimal treatment of limbus fractures. While generally agreed that after failure of conservative treatment, or in the presence of neurologic compromise, surgery is indicated, the choice of operation is unclear. Surgical treatment via the posterior approach consists of performing laminectomy with discectomy and removal of the bone fragment,28 but the role of fusion has not been clarified,21 and post-laminectomy kyphosis remains a concern.

Overall, appropriate candidates for surgery appear to be patients with unstable fractures or dislocations, with apparent or worsening neurologic compromise, or with progressive deformity. However, the most appropriate surgical treatment for these pediatric patients has not been adequately studied, and requires further research.

Outcomes

Recovery of neurologic function following severe traumatic spinal cord injury occurs with a significantly greater incidence in children than adults,15 although the potential for high morbidity remains despite the remodeling potential of the pediatric spine. The overall mortality rate ranges from 6.8% to 28%in some studies,1,11 and when compared with similar trauma patients without cervical spine injury, those with cervical injury are more likely to die in the emergency department or to be admitted to the intensive care unit.5

Pearls and Pitfalls

Many trauma protocols in place throughout the nation are less effective at identifying pediatric spinal injuries than adult spine injury:4

  • Children sustain a different range of spinal injuries than adults.
  • Children cannot verbalized the same understanding of their injuries as adults.

There is an inconsistency among trauma centers in obtaining skeletal surveys, and while an anterior-posterior view of the spine is usually included in the survey, oftentimes a lateral radiograph of the cervical spine is not included. It is likely that the incidence of cervical spine trauma in child abuse is underreported and may be easily missed.5 Therefore, despite its low incidence in the pediatric trauma population, a high index of suspicion for spinal trauma must be maintained in these patients.

References

  1. Martin M. Mortazavi et al. Pediatric multilevel spine injuries: an institutional experience Child's Nervous System Volume 27, Number 7, 1095-1100
  2. C. Brian Jankowitz, David O. Okonkwo, Christopher Shaffrey. Pediatric Spine Injury. Book: Chapter 23 Acute Brain and Spinal Cord Injury: Evolving Paradigms and Management, First Edition. March 2008.
  3. Shahin Mohseni et al. Effect of age on cervical spineinjury in pediatric population: a National Trauma Data Bank review. J Ped Surg. Volume 46, Issue 9, September 2011, Pages 1771--1776
  4. Nathaniel S. Kreykes, MD, Robert W. Letton Jr, MD. Current issues in the diagnosis of pediatric cervical spine injury. Seminars in Pediatric Surgery. Volume 19, Issue 4, November 2010, Pages 257--264
  5. Behrooz A. Akbarnia MD. PEDIATRIC SPINE FRACTURES. Orthopedic Clinics of North America - Volume 30, Issue 3 (July 1999)  
  6. Garton, Hugh J.L. M.D., M.H.Sc.; Hammer, Matthew R. B.S. Detection of Pediatric Cervical Spine Injury. Neurosurgery. March 2008 - Volume 62 - Issue 3 - p 700-708
  7. Fesmire FM, Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med. 1989 Mar-Apr;7(2):133-42
  8. Taylor J: Growth of human intervertebral discs and vertebral bodies. J Anat 120:49-68, 1975  
  9. Aufdermaur M: Spinal injuries in juveniles: Necropsy findings in 12 cases. J Bone Joint Surg Br 56:513-519, 1974  
  10. O'Rahilly R, Benson D: The development of the vertebral column. In Bradford DS, Hensigner RM (eds): The Pediatric Spine. New York, Thieme, 1985
  11. Platzer P et al. Cervical spine injuries in pediatric patients. J Trauma. 2007 Feb;62(2):389-96; discussion 394-6
  12. Akbarnia B: The role of the orthopaedic surgeon in child abuse. In Morrissy RT, Weinstein SL (eds): Pediatric Orthopaedics, ed 4. Philadelphia, Lippincott-Raven, 1996
  13. Akbarnia B, Torg J, Kirkpatrick R, et al: Manifestations of the battered-child syndrome. J Bone Joint Surg Am 56:1159, 1974
  14. Akbarnia B, Torg J, Kirkpatrick R, et al: Manifestations of the battered-child syndrome. J Bone Joint Surg Am 56:1159, 1974
  15. Wang MY, Hoh DJ, Leary SP, Griffith P, McComb JG. High rates of neurological improvement following severe traumatic pediatric spinal cord injury. Spine (Phila Pa 1976). 2004 Jul 1;29(13):1493-7; discussion E266
  16. Pang D, Wilberger J: Spinal cord injury without radiographic abnormalities in children. J Neurosurg 57:114-129, 1982 
  17. Flynn, John M. M.D.; Closkey, Robert F. M.D*.*; Mahboubi, Soroosh M.D.†; Dormans, John P. M.D. Role of Magnetic Resonance Imaging in the Assessment of Pediatric Cervical Spine Injuries Journal of Pediatric Orthopaedics: September/October 2002 - Volume 22 - Issue 5 - pp 573-57
  18. Launay, Franck MD*; Leet, Arabella I MD†; Sponseller, Paul D MD. Pediatric Spinal Cord Injury without Radiographic Abnormality: A Meta-analysis. Clinical Orthopaedics & Related Research: April 2005 - Volume 433 - Issue - pp 166-170
  19. Leventhall H: Birth injuries of the spinal cord. J Pediatr 56:447-453, 1960  
  20. Yngve D, Harris W, Herndon W, et al: Spinal cord injury without osseous spine fracture. J Pediatr Orthop 8:153-159, 1988
  21. Xue-yuan Wu MD, Wei Ma MD Posterior lumbar ring apophysis fracture. Orthopaedic Surgery Volume 3, Issue 1, pages 72--77, February 2011
  22. Takata K, Inoue S, Takahashi K, et al: Fracture of the posterior margin of a lumbar vertebral body. J Bone Joint Surg Am 70:589-594, 1988  
  23. Epstein N, Epstein J: Limbus lumbar vertebral fractures in 27 adolescents and adults. Spine 16:962-966, 1991
  24. Kleinman P (ed): Diagnostic Imaging of Child Abuse. Baltimore, Williams & Wilkins, 1987
  25. Kemp AM, Joshi AH, Mann M, Tempest V, Liu A, Holden S, Maguire S. What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review. Arch Dis Child. 2010 May;95(5):355-60. Epub 2009 Nov 27
  26. Parent, Stefan MD, PhD*†; Dimar, John MD‡; Dekutoski, Mark MD§; Roy-Beaudry, Marjolaine MSc. Unique Features of Pediatric Spinal Cord Injury. Spine: 1 October 2010 - Volume 35 - Issue 21S - pp S202-S208
  27. Arkader, Alexandre; Warner, William C. Jr; Tolo, Vernon T. MD; Sponseller, Paul D. MD; Skaggs, David L. MD.^ ^Pediatric Chance Fractures: A Multicenter Perspective. Journal of Pediatric Orthopaedics:  October/November 2011 - Volume 31 - Issue 7 - p 741--744
  28. Ehni G, Schneider SJ. Posterior lumbar vertebral rim fracture and associated disc protrusion in adolescence. J Neurosurg. 1988 Jun;68(6):912-6

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