Epidemiology Incidence 2-5% of all spinal cord injuries 83% involve the cervical spine Demographics male:female ratio of approximately 1.5:1 cervical spine injuries more common in children <8 y/o due to large head-to-body ratio thoracolumbar spine injuries more common in children >8 y/o 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 login to view 5 more bullets thoracolumbar spine login to view 4 more bullets 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 10 y/o Osteology vertebral bodies undergo chondrification around the 5th or 6th week of gestation ossification occurs throughout adolescence 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 pulposus 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 spontaneous movement 5 - withdraws to touch 4 - withdraws 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, confused 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 login to view 1 more bullet Disability login to view 3 more bullets Exposure Secondary survey trauma specific history mechanism of injury, last meal, past medical history, allergies, medications full neurologic 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 cervical, thoracic, and lumbar spine additional views swimmer's view open-mouth view AP view of chest and pelvis flexion-extension views findings malalignment fracture login to view 1 more bullet dislocation CT indications polytrauma 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 login to view 4 more bullets activity modification and spinal immobilization indications login to view 11 more bullets modalities login to view 5 more bullets Operative surgical stabilization of cervical spine indications login to view 3 more bullets techniques login to view 3 more bullets surgical stabilization of thoracolumbar spine indications login to view 4 more bullets techniques login to view 1 more bullet 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 <8 y/o prognosis for recovery is better in patients >8 y/o