Epidemiology Incidence 2-5% of all spinal cord injuries 83% involve the cervical spine Demographics male:female ratio of approx.1.5:1 cervical spine injuries more common in children aged <8 years due to large head-to-body ratio thoracolumbar spine injuries more common in children aged >8 years Anatomic location upper cervical spine injuries (C1-4) are more common than lower cervical spine injuries (C5-7) Etiology Pathophysiology mechanism of injury includes: motor vehicle accidents (most common) falls from height sport-related injuries child abuse sledding and ATV (high risk for thoracolumbar spine injury) Orthopedic considerations pattern of injury cervical spine occipitoatlantal, atlantoaxial dislocation atlantoaxial rotatory fixation odontoid fracture subaxial ligamentous injuries spinal cord injury without radiographic abnormality (SCIWORA) thoracolumbar spine compression fracture (most common) burst fracture flexion-distraction injury combined fracture-dislocation Associated conditions head injuries (>30%) intra-thoracic injuries intra-abdominal injuries Anatomy Spinal Cord spinal cord ends at L3 in the newborn migrates cephalad during childhood to end at L1 - L2 reaches adult size by the age of 10 Osteology vertebral bodies undergo chondrification around the 5th or 6th week gestation ossification occurs throughout adolescents deforming forces are commonly translated through the relatively weak physeal cartilage of maturing vertebral bodies Biomechanics greater flexibility of the pediatric spinal column compared to adults is due to: increased ligamentous laxity of the spine immature supporting structures thoracolumbar facets are more shallow and horizontal the nucleus pulposes has greater water content and less collagen crosslinking, which allows for a greater ability to dissipate force Classification Pediatric Glasgow Coma Scale Best Motor Response 6 - Normal sponateous movement 5 - Withdrawals to touch 4 - Withdrawals to pain 3 - Flexion is abnormal 2 - Extension, either spontaneous or to painful stimulus 1 - None (flaccid) Best Verbal Response 5 - Smiles, oriented to sound, follows objects, interacts 4 - Cries but is consolable, innappropriate interations 3 - Inconsistently consolable, moaning 2 - Inconsolable, agitated 1 - No vocal response Best Eye Opening 4 - Spontaneously 3 - To verbal stimulation or to touch 2 - To pain 1 - No response Evaluation Primary survey formation of a multi-disciplinary pediatric trauma team assessment as per Advanced Trauma and Life Support(ATLS) protocol for children Airway Breathing Cardiovascular support use of the Broselow pediatric emergency tape may be used for estimating children's weight in the pediatric patient during trauma resusitation Disability spinal precautions with cervical spine immobilization and log-roll procedures should be performed pediatric spine board or an adult spine board with a torso pad/head cut out should be used to prevent flexion of the cervical spine evaluate neurologic response using the Pediatric Glasgow Coma Scale Exposure Secondary survey trauma specific history mechanism of injury, last meal, PMHx, Allergies, medications full neurological examination motor and sensory examination by myotome and dermatome, respectively rectal and genital examination bulbocavernosus reflex, when appropriate physical examination inspection and palpation of the entire spine and paraspinous region note step-offs, crepitus, bruising, pain, or open injuries head-to-toe assessment for associated injuries Imaging Radiographs recommended views AP and cross table lateral views of the C-T-L spine additional views swimmer's view open-mouth view AP view of chest and pelvis flexion-extension views findings malalignment fracture relatively high chance of multilevel spinal involvement dislocation CT indications poly-trauma high energy injuries high clinical suspicion of spine injury altered mental status head and facial injuries findings risk of radiation overexposure in young children not to be used as a spine screening examination MRI indications neurological deficits without radiographic abnormalities limits ionizing radiation exposure findings spinal cord injury soft-tissue edema inferior to CT for evaluating osseous anatomy Treatment Nonoperative pain control and activity as tolerated indications stable fracture patterns apophyseal fractures spinous process fractures transverse process fractures activity modification and spinal immobilization indications cervical collar immobilization (8 to 12 weeks) fracture patterns stable odontoid fractures atlantoaxial instability acute atlantoaxial rotatory displacement (AARD) stable subaxial cervical spine trauma thoracolumbosacral braces (8 to 12 weeks) fracture patterns compression fractures (<50% anterior height loss) burst fracture (<50% retropulsion, no neurological deficit) purely osseous flexion-distraction fracture modalities cervical collar rigid collar vs. soft collar (depends on injury, often controversial) halo collar considered for unstable cervical spine fractures thin calvaria increases risk of skull penetration Operative surgical stabilization of cervical spine indications occipitocervical instability atlantoaxial instability subaxial instability techniques occipitocervical fusion transarticular screws pedicle screws with rigid loops and plate or rod constructs surgical stabilization of thoracolumbar spine indications unstable burst fracture spinal cord compression irreducible fracture-dislocation ligamentous flexion-distraction injury techniques pedicle instrumentation one to two levels above and below injury Complications Complete neurological deficits Progressive spinal deformity Poor wound healing with operative treatment Cauda equina syndrome Prognosis Natural history of disease most spinal cord injuries in children are incomplete all injuries need to be followed to maturity due to risk of spinal column deformities Neurologic injury spinal cord injury is more common/lethal in patients younger than 8 years old prognosis for recovery is better than patients older than 8 years old