Updated: 6/23/2021

Pediatric Spinal Cord Injury

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  • 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
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Questions (1)

(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?

QID: 6131
1

10%

5%

(31/655)

2

20%

16%

(104/655)

3

50%

14%

(93/655)

4

70%

22%

(145/655)

5

100%

43%

(279/655)

L 5 E

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