Keywords

Spine Trauma Evaluation

  • Suspect spine trauma in high-energy injuries, head injuries, or multiple abdominal injuries.

  • Use a pediatric backboard – the high head/neck ratio in children may result in cervical hyperflexion when on a standard backboard.

  • Perform a thorough neurologic exam.

    • If deficits are present, check for spinal shock by checking the bulbocavernosus reflex.

Imaging

  • Begins with plain films of the affected area of the spine.

  • Any detected fracture mandates imaging of the entire spine and advanced imaging.

  • 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.

  • May perform flexion and extension plain films to check for occult ligamentous injury.

Upper Cervical Spine Trauma

Occipitocervical Dissociation or Atlanto-occipital Dissociation

  • Very high mortality.

  • Young children at highest risk due to a larger head/neck ratio, smaller occipital condyles, and ligamentous laxity.

  • Common measurements used to make the diagnosis, such as Power’s ratio or Harris’ rule of 12, may be ineffective.

  • Treated with surgical stabilization and immobilization in a halo.

Occipital Condyle Fractures

  • Rare in children, though CT should be performed in patients with basilar skull fractures or head injuries with neck pain

  • Three types:

    • Type 1 – comminuted impaction fracture

    • Type 2 – condyle fracture with associated basilar skull fracture

    • Type 3 – alar ligament avulsions

  • Most treated with cervical orthosis

    • Occipitocervical fusion or halo immobilization for unstable type 3 fractures

Atlas or C1 Ring Injuries

  • May fail through the bone or synchondrosis:

    • Posterior synchondrosis closes at 3 years of age, while neurocentral synchondrosis closes at 7 years.

    • Fractures through the synchondrosis are difficult to appreciate.

  • Type:

    • Anterior or posterior arch fracture

    • Burst or “Jefferson” fracture, bilateral anterior, and posterior arch fractures from axial load

    • Lateral mass fracture

  • Stability determined by the transverse atlantal ligament (TAL):

    • May evaluate TAL on open-mouth odontoid view or CT scan.

    • 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.

    • 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.

  • Treated with a cervical orthosis, Minerva cast, or halo vest if stable or halo traction if unstable:

    • Fusion required if instability persists

Atlantoaxial Rotatory Subluxation (AARS)

  • Fixed rotational deformity of C1 on C2 with loss of motion and pain:

    • Patients present with head tilted to one side and rotated toward the other.

  • May follow minor trauma, an upper respiratory infection (Grisel syndrome) or an ENT procedure.

  • Differentiate from congenital torticollis:

    • No pain in congenital torticollis.

    • Torticollis is passively correctable.

    • In torticollis, sternocleidomastoid tight on side contralateral to chin deviation, while in AARS, sternocleidomastoid tight on ipsilateral side as an attempt to correct deviation.

  • Types:

    • Unilateral rotation of C1 without displacement

    • Anterior displacement of one lateral mass by 3–5 mm and deficiency of TAL

    • Anterior displacement of both lateral masses by 5 mm and deficiency of the TAL and secondary ligaments

    • Posterior displacement due to an injury to the dens

  • May evaluate with lateral skull radiograph, open-mouth odontoid, or dynamic CT.

  • Treatment depends on duration of symptoms:

    • Less than 1 week – soft collar, anti-inflammatories, and physical therapy

    • Greater than 1 week – halter traction and muscle relaxants

    • Greater than 1 month – halo traction and bracing

    • Greater than 3 months or irreducible – posterior fusion

Odontoid or Dens Fractures

  • Most commonly through the synchondrosis at the base of the odontoid, Salter-Harris I fractures

    • Synchondrosis fuses at 6 years of age, so fractures usually before 6

  • Likely from sudden deceleration and forced head flexion

  • Spinal cord injury more common than in adults

  • Treated with closed reduction in extension followed by a halo or Minerva cast

Os Odontoideum

  • Hypoplastic dens separate from the C2 vertebral body with smooth cortical margins.

  • Unclear if developmental abnormality or nonunion after trauma.

  • May be asymptomatic, cause pain, cause myelopathic symptoms, or cause intracranial symptoms from vertebrobasilar ischemia.

  • Instability can be seen on flexion and extension radiographs.

  • Surgical fusion followed by halo immobilization required for neurologic symptoms or instability.

Traumatic Spondylolisthesis, also Called “Hangman’s Fracture”

  • Bilateral pars fracture caused by hyperextension and axial load

  • Neurologic injury rare, as this widens the canal

  • Often associated with child abuse

  • Anterolisthesis of C2 on C3 seen on radiographs, but must be differentiated from persistent synchondrosis or congenital arch defect

  • Treated with closed reduction with neck extension and placement of a halo or Minerva cast

Lower Cervical Spine Trauma

  • More common in adolescents as their spine approaches maturity

Ligamentous Injuries

  • Usually in children younger than 8

  • Caused by flexion and distraction

  • Diagnosed with radiography or MRI

  • Treated with immobilization in a hard collar or halo

  • Fusion required for persistent instability

Compression Fractures Are Failure of the Anterior Column or Anterior Vertebral Body

  • Caused by flexion and axial loading.

  • Must be differentiated from incomplete ossification of anterior vertebral body

  • Treated with hard collar if stable, surgical fusion required if unstable from injury to the posterior ligamentous complex.

  • Burst fractures include failure of the anterior and middle columns, often with retropulsion of fracture into the spinal canal.

  • Treated with a hard collar or halo in patients without neurologic symptoms or decompression and fusion if symptoms are present.

Facet Dislocations

  • Bilateral or unilateral

    • Unilateral facet dislocations missed frequently on plain radiographs.

  • May cause radiculopathy (more common with unilateral) or significant spinal cord injury (more common with bilateral).

  • Prereduction MRI performed if the patient is obtunded or unable to cooperate.

  • Reduction with Gardner-Wells tongs or a halo and hanging weights.

  • Surgical fixation should be considered following reduction.

Thoracolumbar Spine Trauma

Commonly Caused by Inappropriate Seat Belt Use

  • Tends to lie over the abdomen in small children, causing hyperflexion of the spine in deceleration.

  • Lap belts should always lie over the pelvis.

Denis Three-Column Classification

  • Anterior column consists of the anterior longitudinal ligament and anterior two thirds of the vertebral body.

  • Middle column consists of the posterior one third of the vertebral body, intervertebral disc, and posterior longitudinal ligament.

  • Posterior column consists of posterior elements of the osseous spine.

Compression Fractures

  • Most common thoracolumbar injury in pediatric spine trauma

  • Caused by flexion and axial compression

  • Failure of the anterior column only

  • Treated with 6–8 weeks of bracing in a thoracolumbosacral orthosis (TLSO)

Burst Fractures

  • Caused by axial load

  • Thoracic fractures more likely to cause neurologic injury due to tighter canal

  • Stability assessed by kyphotic deformity, lamina fracture, and posterior ligamentous injury

  • 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)

  • May be purely boney, purely ligamentous, or a mix

  • 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

  • Unique to children with open physes, typically under 10

  • Separation of the vertebral apophysis from the spongiosa of the vertebral body

  • Analogous to adult disc herniation, as the apophysis herniates into the canal

  • 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

  • Isolated fractures may be treated with pain control.

  • Lower lumbar transverse process fractures may be associated with unstable pelvic fractures.

Cauda Equina Syndrome

  • The spinal cord ends at L3 in newborns and then migrates to L1 in adults.

  • Injury to the neural elements caudal to the cord may cause cauda equina syndrome.

  • Bilateral lower extremity weakness, perianal and perigenital numbness, loss of bowel control, and urinary retention

  • Treated with emergent decompression

Spinal Cord Injury

  • Relatively rare in the pediatric population.

    • Most occur in the cervical spine

  • Neurologic prognosis is better than in adults, but development of scoliosis secondary to neurologic injury is common, especially in younger children.

  • Spinal cord injury without radiographic abnormality (SCIWORA):

    • Defined as traumatic myelopathy without evidence of vertebral column disruption on radiography or CT scans.

    • More common in children younger than 8 years.

    • Believed to be caused by ligamentous laxity allowing displacement of the cord without boney injury.

    • May present with complete or incomplete spinal cord injury.

    • MRI should be obtained to determine degree of soft tissue and neural injury.

    • Treated with bracing for 7–10 days if symptoms resolve within 24 h or 3 months for persistent symptoms.

      • May require surgical stabilization if ligamentous injury is present.