Updated: 10/30/2016

Pediatric Spinal Cord Injury

Topic
Review Topic
0
0
Questions
1
0
0
Evidence
2
0
0
https://upload.orthobullets.com/topic/2068/images/92-124-f.jpg
https://upload.orthobullets.com/topic/2068/images/f1.large-2.jpg
https://upload.orthobullets.com/topic/2068/images/mrisag-mmtear-pcm_moved.jpg
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
 

Please rate topic.

Average 2.6 of 14 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (1)

You have 100% on this question.
Just skip this one for now.

(SAE07PE.71) A 9-year-old child sustained a fracture-dislocation of C-5 and C-6 with a complete spinal cord injury. What is the likelihood that scoliosis will develop during the remaining years of his growth? Review Topic

QID: 6131
1

10%

4%

(7/178)

2

20%

20%

(35/178)

3

50%

17%

(31/178)

4

70%

27%

(48/178)

5

100%

31%

(56/178)

L 5

Select Answer to see Preferred Response

SUBMIT RESPONSE 5
ARTICLES (6)
Topic COMMENTS (5)
Private Note