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Introduction
  • Spinal cord injuries in children are rare
  • 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
    • location
      • upper cervical spine injuries (C1-4) are more common than lower cervical spine injuries (C5-7)
  • 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
  • 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
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
 

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