Abstract
Spine trauma is fairly uncommon in pediatric patients but can cause significant morbidity and mortality. Due to ligamentous laxity, underdeveloped paraspinal musculature, and incomplete ossification, the pediatric spine is more mobile than the adult spine. The anatomy of the cervical spine is especially unlike the mature spine. Additionally, pediatric bone has expanded ability to heal and remodel, so bracing with orthoses or use of halo-vest immobilization is often effective in children when surgical fusion may have been preferred in adults. However, appropriate suspicion and accurate diagnosis remain essential to effective treatment and avoidance of complications.
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Keywords
Spine Trauma Evaluation
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Suspect spine trauma in high-energy injuries, head injuries, or multiple abdominal injuries.
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Use a pediatric backboard – the high head/neck ratio in children may result in cervical hyperflexion when on a standard backboard.
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Perform a thorough neurologic exam.
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If deficits are present, check for spinal shock by checking the bulbocavernosus reflex.
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Imaging
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Begins with plain films of the affected area of the spine.
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Any detected fracture mandates imaging of the entire spine and advanced imaging.
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Low-dose CT or MRI should also be performed in the setting of high clinical suspicion, head injuries, altered mental status, or inability to cooperate with exam.
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May perform flexion and extension plain films to check for occult ligamentous injury.
Upper Cervical Spine Trauma
Occipitocervical Dissociation or Atlanto-occipital Dissociation
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Very high mortality.
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Young children at highest risk due to a larger head/neck ratio, smaller occipital condyles, and ligamentous laxity.
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Common measurements used to make the diagnosis, such as Power’s ratio or Harris’ rule of 12, may be ineffective.
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Treated with surgical stabilization and immobilization in a halo.
Occipital Condyle Fractures
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Rare in children, though CT should be performed in patients with basilar skull fractures or head injuries with neck pain
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Three types:
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Type 1 – comminuted impaction fracture
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Type 2 – condyle fracture with associated basilar skull fracture
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Type 3 – alar ligament avulsions
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Most treated with cervical orthosis
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Occipitocervical fusion or halo immobilization for unstable type 3 fractures
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Atlas or C1 Ring Injuries
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May fail through the bone or synchondrosis:
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Posterior synchondrosis closes at 3 years of age, while neurocentral synchondrosis closes at 7 years.
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Fractures through the synchondrosis are difficult to appreciate.
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Type:
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Anterior or posterior arch fracture
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Burst or “Jefferson” fracture, bilateral anterior, and posterior arch fractures from axial load
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Lateral mass fracture
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Stability determined by the transverse atlantal ligament (TAL):
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May evaluate TAL on open-mouth odontoid view or CT scan.
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Rule of Spence – if lateral masses displaced more than 6.9 mm (8 mm with radiographic magnification), then TAL is disrupted, and fractures are unstable.
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Displacement of the lateral masses >2 mm relatively to the superior articular facet of the axis is concerning in adults, but in children younger than 4, a “pseudo-spread” is commonly seen.
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Treated with a cervical orthosis, Minerva cast, or halo vest if stable or halo traction if unstable:
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Fusion required if instability persists
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Atlantoaxial Rotatory Subluxation (AARS)
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Fixed rotational deformity of C1 on C2 with loss of motion and pain:
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Patients present with head tilted to one side and rotated toward the other.
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May follow minor trauma, an upper respiratory infection (Grisel syndrome) or an ENT procedure.
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Differentiate from congenital torticollis:
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No pain in congenital torticollis.
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Torticollis is passively correctable.
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In torticollis, sternocleidomastoid tight on side contralateral to chin deviation, while in AARS, sternocleidomastoid tight on ipsilateral side as an attempt to correct deviation.
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Types:
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Unilateral rotation of C1 without displacement
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Anterior displacement of one lateral mass by 3–5 mm and deficiency of TAL
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Anterior displacement of both lateral masses by 5 mm and deficiency of the TAL and secondary ligaments
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Posterior displacement due to an injury to the dens
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May evaluate with lateral skull radiograph, open-mouth odontoid, or dynamic CT.
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Treatment depends on duration of symptoms:
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Less than 1 week – soft collar, anti-inflammatories, and physical therapy
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Greater than 1 week – halter traction and muscle relaxants
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Greater than 1 month – halo traction and bracing
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Greater than 3 months or irreducible – posterior fusion
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Odontoid or Dens Fractures
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Most commonly through the synchondrosis at the base of the odontoid, Salter-Harris I fractures
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Synchondrosis fuses at 6 years of age, so fractures usually before 6
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Likely from sudden deceleration and forced head flexion
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Spinal cord injury more common than in adults
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Treated with closed reduction in extension followed by a halo or Minerva cast
Os Odontoideum
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Hypoplastic dens separate from the C2 vertebral body with smooth cortical margins.
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Unclear if developmental abnormality or nonunion after trauma.
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May be asymptomatic, cause pain, cause myelopathic symptoms, or cause intracranial symptoms from vertebrobasilar ischemia.
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Instability can be seen on flexion and extension radiographs.
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Surgical fusion followed by halo immobilization required for neurologic symptoms or instability.
Traumatic Spondylolisthesis, also Called “Hangman’s Fracture”
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Bilateral pars fracture caused by hyperextension and axial load
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Neurologic injury rare, as this widens the canal
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Often associated with child abuse
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Anterolisthesis of C2 on C3 seen on radiographs, but must be differentiated from persistent synchondrosis or congenital arch defect
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Treated with closed reduction with neck extension and placement of a halo or Minerva cast
Lower Cervical Spine Trauma
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More common in adolescents as their spine approaches maturity
Ligamentous Injuries
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Usually in children younger than 8
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Caused by flexion and distraction
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Diagnosed with radiography or MRI
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Treated with immobilization in a hard collar or halo
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Fusion required for persistent instability
Compression Fractures Are Failure of the Anterior Column or Anterior Vertebral Body
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Caused by flexion and axial loading.
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Must be differentiated from incomplete ossification of anterior vertebral body
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Treated with hard collar if stable, surgical fusion required if unstable from injury to the posterior ligamentous complex.
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Burst fractures include failure of the anterior and middle columns, often with retropulsion of fracture into the spinal canal.
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Treated with a hard collar or halo in patients without neurologic symptoms or decompression and fusion if symptoms are present.
Facet Dislocations
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Bilateral or unilateral
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Unilateral facet dislocations missed frequently on plain radiographs.
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May cause radiculopathy (more common with unilateral) or significant spinal cord injury (more common with bilateral).
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Prereduction MRI performed if the patient is obtunded or unable to cooperate.
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Reduction with Gardner-Wells tongs or a halo and hanging weights.
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Surgical fixation should be considered following reduction.
Thoracolumbar Spine Trauma
Commonly Caused by Inappropriate Seat Belt Use
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Tends to lie over the abdomen in small children, causing hyperflexion of the spine in deceleration.
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Lap belts should always lie over the pelvis.
Denis Three-Column Classification
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Anterior column consists of the anterior longitudinal ligament and anterior two thirds of the vertebral body.
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Middle column consists of the posterior one third of the vertebral body, intervertebral disc, and posterior longitudinal ligament.
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Posterior column consists of posterior elements of the osseous spine.
Compression Fractures
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Most common thoracolumbar injury in pediatric spine trauma
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Caused by flexion and axial compression
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Failure of the anterior column only
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Treated with 6–8 weeks of bracing in a thoracolumbosacral orthosis (TLSO)
Burst Fractures
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Caused by axial load
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Thoracic fractures more likely to cause neurologic injury due to tighter canal
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Stability assessed by kyphotic deformity, lamina fracture, and posterior ligamentous injury
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Treated with 6–8 weeks of bracing in a TLSO or hyperextension cast if stable and instrumentation with or without decompression and fusion if unstable
Flexion-Distraction Injuries (Chance Injuries)
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May be purely boney, purely ligamentous, or a mix
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Treated with 8 weeks of TLSO immobilization if the injury is boney and the fracture is reduced or surgical stabilization with instrumentation if purely ligamentous
Apophyseal Fractures
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Unique to children with open physes, typically under 10
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Separation of the vertebral apophysis from the spongiosa of the vertebral body
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Analogous to adult disc herniation, as the apophysis herniates into the canal
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Treated with 8 weeks of TLSO immobilization and anti-inflammatories if no neurologic symptoms but may require decompression if symptoms are present
Spinous and Transverse Process Fractures
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Isolated fractures may be treated with pain control.
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Lower lumbar transverse process fractures may be associated with unstable pelvic fractures.
Cauda Equina Syndrome
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The spinal cord ends at L3 in newborns and then migrates to L1 in adults.
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Injury to the neural elements caudal to the cord may cause cauda equina syndrome.
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Bilateral lower extremity weakness, perianal and perigenital numbness, loss of bowel control, and urinary retention
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Treated with emergent decompression
Spinal Cord Injury
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Relatively rare in the pediatric population.
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Most occur in the cervical spine
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Neurologic prognosis is better than in adults, but development of scoliosis secondary to neurologic injury is common, especially in younger children.
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Spinal cord injury without radiographic abnormality (SCIWORA):
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Defined as traumatic myelopathy without evidence of vertebral column disruption on radiography or CT scans.
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More common in children younger than 8 years.
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Believed to be caused by ligamentous laxity allowing displacement of the cord without boney injury.
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May present with complete or incomplete spinal cord injury.
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MRI should be obtained to determine degree of soft tissue and neural injury.
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Treated with bracing for 7–10 days if symptoms resolve within 24 h or 3 months for persistent symptoms.
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May require surgical stabilization if ligamentous injury is present.
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© 2017 Springer International Publishing AG
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DePasse, J.M., Eberson, C.P., Daniels, A.H. (2017). Pediatric Spine Trauma. In: Eltorai, A., Eberson, C., Daniels, A. (eds) Orthopedic Surgery Clerkship. Springer, Cham. https://doi.org/10.1007/978-3-319-52567-9_143
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DOI: https://doi.org/10.1007/978-3-319-52567-9_143
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