Spine Trauma

Abstract

The pediatric spine is more flexible than the adult spine, making it more resilient and therefore less susceptible to traumatic injury. The incidence of spinal column injury in children is low with rates varying from 1 to 5%. However, this increased flexibility contributes to the differing injury patterns seen in pediatric trauma when compared to the adult. In addition, due to physical and psychological immaturity, the clinical assessment and diagnosis can be extremely difficult. Significant head injury is a risk factor for cervical spine injury and any child with a suspected spinal injury should be immobilized in a hard cervical collar on a pediatric spine board. Since significant force is required to injure the spine, other regions may also be injured, with almost half of children having concomitant injuries.

Appendices

Summary Points

Immaturity of the pediatric spine makes it susceptible to ­different injury pattern than in adults.

Children are especially susceptible to spinal cord injury without radiographic abnormality (SCIWORA).

Children less than 8 years of age have a higher incidence of injury above the level of C4.

There is currently insufficient evidence to support the routine use of steroids in spinal cord injury in children.

Children who are cooperative, without altered level of consciousness, have no distracting injuries, no history of neurologic impairment, and who have no spine tenderness can be safely cleared clinically without extensive radiographic work-up.

The great majority of patients that cannot be cleared with physical exam alone can be cleared with a combination of plain radiographs or helical CT scanning with digital reconstruction. MRI should be reserved for those with negative imaging and a history of neurologic deficit or coma.

Shock should be treated empirically as hemorrhagic shock with appropriate fluid resuscitation. Only after hemorrhagic shock is ruled out should pressors be added to treat neurogenic shock.

CT angiography should be performed in upper cervical spine fractures to rule out vertebral artery injury or thrombosis.

The flexion-distraction fracture (Chance fracture) is often the result of inappropriate restraining of a child in a motor vehicle and is associated with intra-abdominal visceral and major vascular injuries.

Editor’s Comment

Spinal cord injuries are among the most devastating injuries that can occur in children. Because of anatomic, physiologic and emotional differences, all aspects of care in children, including especially identification of an injury and treatment of a known injury, are more challenging than the corresponding issue in adults. Ruling out a spine injury can be exceptionally difficult. Though CT and MRI are known to be more sensitive than clinical examination and plain radiographs, they are also associated with some risk and higher costs. Developing effective and efficient protocols that incorporate these modalities in everyday clinical practice is proving to be difficult. Trauma protocols that unambiguous guidelines in place help to avoid both over-use and under-use of these useful tools.

Though there is as yet no specific recommendation to administer intravenous corticosteroids in children with ­spinal injuries as there is in adults, I suspect most trauma centers that deal with children are doing it, based on a simple calculus that weighs the relatively small risks and the potential reward of the therapy. Nevertheless, until more data become available, it is not a recommended practice. It is much more important to avoid progression of the injury by proper immobilization (properly fitting hard collar, taking into consideration the relatively large size of the child’s occiput) and fastidiously addressing airway, breathing and circulation.

Differential Diagnosis

Shock

• Neurogenic

• Hemorrhagic

Neurologic Deficit

• Spinal “shock”

• Permanent disability

Diagnostic Studies

Plain radiographs

Helical CT with reconstruction

CT angiography

Flexion-extension radiographs

MRI

Parental Preparation

Permanent disability

Rehabilitation

Preventive strategies with front seat air-bags and age appropriate restraints

Preoperative Preparation

Rule out source of hemorrhagic shock

Clear cervical spine if possible

Informed consent

Technical Points

Get patient off of spine board as soon as possible to avoid pressure sores.

One must elevate the torso on pads to keep spine in neutral position.

When deciding between stabilization with internal fixation and external bracing, consider the effects on growth.