Treatment of spinal fractures in children and adolescents: long-term results in 44 patients

[Conservative treatment of trauma-associated fractures of the cervical spine with orthoses-A review]

BACKGROUND

Traumatic injuries of the cervical spine are common and can significantly differ in the prognosis and treatment depending on the structure affected. We present the current evidence for conservative treatment of these fractures with orthoses in this review.

METHODOLOGY

The literature search followed the PRISMA protocol. The risk of bias was assessed using ROBINS‑I and evidence levels were determined according to AHCPR.

RESULTS

A total of 22 studies were identified. The level of evidence according to AHCPR is limited (IIb, III and IV) and every study had a serious risk of bias in at least one subdivision. Of the authors 11 presented conservative treatment concepts for C2 dens fractures, 7 studies focussed on vertebral arch fractures and 9 on vertebral body fractures. Radiological parameters (kyphosis angle, bone consolidation) and the neurological status were frequently reported as endpoints.

CONCLUSION

Stable C2 dens fractures without relevant clinical restrictions allow conservative treatment in a rigid cervical orthosis under radiological monitoring every 1-4 weeks. Type II fractures require special attention due to the risk of instability. Hangman's fractures can be safely treated in rigid cervical orthoses. The current state of knowledge does not allow any recommendation for conservative treatment of Hangman's fractures with orthoses. Stable vertebral body fractures without involvement of the spinal canal can also be treated conservatively with orthotic devices. Randomized controlled studies are required to develop a secure state of evidence and are currently not available.

Diagnostic Yield of Axial Computed Tomography Scans for Pediatric Axial Skeletal Injuries

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the diagnostic yield of computed tomography (CT) imaging of the axial skeleton in pediatric patients evaluated a level I trauma center.

SUMMARY OF BACKGROUND DATA

CT imaging has become ubiquitous in the assessment of axial skeletal injuries in trauma patients.

METHODS

This is a retrospective study from one Level I trauma center of patients undergoing CT imaging during pediatric trauma assessment. Medical records of pediatric trauma patients 18-year old and younger who underwent axial skeletal CT imaging from 2013 to 2015 were evaluated. The following were assessed: mechanism of injury, age, sex, race/ethnicity, presence of fracture, management of fracture.

RESULTS

A total of 831 patients were assessed, there were 355 (42.7%) females and 476 males (57.3%) with an average age of 15.4 (2 mo-18 yrs). 588 (70.8%) were White, 164 (19.7%) were African-American, 12 (1.4%) were Asians, 67 (8.1%) other, and 46 (5.5%) identified as Hispanic. There were 45 patients (5.4%) who sustained 52 fractures. Common mechanisms were motor vehicle accidents (MVA) 28%, sports injuries (18%), and fall from height (15%). 35.9% of fractures were identified on plain radiographs. Nine injuries were treated surgically (one cervical, two thoracic, two lumbar, and four pelvic); three of these were identified on radiographs. From the 14 patients with cervical spine fractures none were detected on radiographs.

CONCLUSION

In this large series of 831 pediatric patients undergoing axial CT imaging, the rate of axial fractures was 5.4%. The majority of these fractures were managed non-surgically. Only 35.9% of fractures were identified on radiographs.Level of Evidence: 3.

Surgical management of burst fractures in children and adolescents: A Multicentre Retrospective Study

BACKGROUND

Spinal fractures are rare in children, in whom they contribute only 2% to 5% of all traumatic spinal injuries. The management of burst fractures is well standardised in adults but remains controversial in paediatric patients, due to specific growth-related considerations. The objective of this study was to assess the clinical and radiographic outcomes of surgical management in a multicentre cohort of paediatric patients with burst fractures, in order to devise an optimal therapeutic strategy.

HYPOTHESIS

A therapeutic strategy for burst fractures in children and adolescents can be devised based on data from a patient cohort and on previously published information.

MATERIAL AND METHODS

Patients younger than 18 years who were managed surgically for one or more burst fractures (Magerl A3) were included in this retrospective multicentre study. Clinical, radiographic, and surgical data were collected before surgery, within 3 months after surgery, and 2 years after surgery. The primary surgical approach was posterior in all patients. Computed tomography (CT) was performed post-operatively to assess the extent of anterior bone loss in order to determine whether anterior fusion was required. The 26 included patients had a mean age of 15±1 years. The thoraco-lumbar spine was involved in 15 (57%) patients. Surgery consisted in correction by instrumentation and posterior fusion only in 14 patients and in posterior correction with anterior fusion in 12 patients. In 10 (38%) patients, the instrumentation extended one vertebra above and one vertebra below the fractured vertebra.

RESULTS

Significant correction of the vertebral kyphosis was achieved (17°±11° before vs. 4°±2° after surgery, p=0.001). Anterior and posterior vertebral heights were significantly increased (15±3mm vs. 20±3mm, p=0.01 and 23±4mm vs. 26±4mm, p=0.04, respectively).

DISCUSSION

The decision to perform surgery rests on the degree of kyphosis and presence of instability. Anterior bone grafting can be added if the instrumentation is short or a bone defect persists after posterior correction. Correction of the local kyphosis is important to prevent sagittal malalignment with its adverse functional consequences in adulthood. Neural decompression must be performed in patients with neurological deficits.

LEVEL OF EVIDENCE

IV.

A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries

CONTEXT

Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system.

EVIDENCE ACQUISITION

The data on pediatric traumatic spinal cord injuries has been narratively reviewed.

RESULTS

Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges.

CONCLUSION

Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.

Chance Fractures in the Pediatric Population Are Often Misdiagnosed

BACKGROUND

Flexion injuries of the spine range from mild compression fractures to severe flexion-distraction injuries, that is, Chance fractures. Chance fractures are often unstable and Arkader and colleagues demonstrated improved outcomes when Chance fractures are treated operatively compared with those managed nonoperatively.

METHODS

A retrospective review was conducted of all patients treated over a 5-year period (2008 to 2013) for a flexion injury, either a Chance or a compression fracture, of the thoracolumbar spine at our tertiary pediatric level I trauma center. Patients were excluded if they had prior spine surgery or had a pathologic fracture.

RESULTS

Of the 26 patients who met the inclusion criteria, 27% (7/26 patients) had a Chance fracture and 73% (19/26) had compression fracture(s). The mean age of the 7 patients with Chance fractures was 14.6 years (range, 13 to 16 y). In total, 71% (5/7) of the patients with Chance fractures were initially misdiagnosed: (3 as compression fractures, 1 as a burst fracture, 1 as muscular pain) and 80% (4/5) of these misdiagnoses were made by a neurosurgeon or orthopaedic surgeon. Average delay to correct diagnosis was 95 days (range, 2 to 311 d), with 57% (4/7) of the patients having ≥1 month delay. These 4 patients with a Chance fracture and ≥1 month delay in correct diagnosis presented to our clinic electively with chronic back pain. None of the patients with Chance fractures had a neurological injury. Six patients with posterior ligamentous disruption were treated with surgical instrumentation and fusion. All Chance fractures occurred between the levels of T12 and L3.

CONCLUSIONS

The majority of pediatric Chance fractures in this series were initially misdiagnosed (71%; 5/7) or mistreated (14%; 1/7) by neurosurgeons or orthopaedic surgeons. Mean time to the correct diagnosis was 3 months for the Chance fractures in this series.

LEVEL OF EVIDENCE

Level IV.

Treatment of pediatric multilevel cervical spine fractures in resource-limited settings: a case report

AIM OF THE STUDY

The main purpose of this study was to highlight the therapeutic approach of pediatric multilevel noncontiguous cervical spine fractures in resource-limited settings.

CASE PRESENTATION

We report the case of a 15-year-old teenager with C1, C2, C4, C6, and C7 fractures following fall from height treated with a modified external fixator. At final follow-up, he fully recovered neurologic functions with bone healing.

CONCLUSION

The modified external fixator is a therapeutic modality for pediatric multilevel noncontiguous cervical spine fractures.

Management of Pediatric Posttraumatic Thoracolumbar Vertebral Body Burst Fractures by Use of Single-Stage Posterior Transpedicular Approach

PURPOSE

The posterior transpedicular approach (PTA) is a posterior approach that has the advantage of achieving circumferential arthrodesis by a single posterior-only approach. The purpose of this study was to analyze our experience with PTA in the management of pediatric traumatic thoracolumbar burst fractures (TTLBFs).

METHODS

Consecutive pediatric patients (age ≤18 years) with TTLBFs treated with PTA for 6 years were included in this retrospective study. Correction of kyphotic deformity and change in neurologic status were analyzed to assess outcome. The Cobb angle and American Spinal Injury Association (ASIA) grade were used for this purpose.

RESULTS

There were 6 male and 8 female patients. Five patients had complete injury (ASIA-A), and 9 had incomplete injury. The mean Thoracolumbar Injury Classification and Severity score was 6.71. The mean preoperative Cobb angle was 14.71° and improved to -3.35° postoperatively (mean kyphosis correction -18.05°). Two of the patients experienced iatrogenic nerve root injury. There was 1 postoperative mortality due to complications unrelated to the surgery. The mean Cobb angle was -0.07° at the 32.2-month follow-up visit. Six patients experienced cage subsidence, but none required revision surgery. Postoperatively, 11 (78.5%) patients showed neurologic improvement, and none experienced deterioration. The average ASIA score improved from 2.5 to 3.78. A fusion rate of 100% (n = 12) was observed at the last follow-up visit.

CONCLUSIONS

The present study demonstrates that PTA is a feasible approach in selected pediatric patients with unstable traumatic thoracolumbar burst fractures, with results comparable with those in the adult population. This study demonstrates in detail the procedure, along with the neurologic and radiologic outcomes of this approach in the pediatric population.

[Injuries of the thoracolumbar spine in children]

BACKGROUND

Injuries of the thoracolumbar spine in children are rare and challenging for the treating physician. Besides knowledge of fracture treatment, the anatomical particularities of the spine in children are of great importance.

METHODS

The article gives an overview of the diagnosis and therapy with the most common classification of injuries of the thoracolumbar spine.

RESULTS

Taking into account the children's age and the fracture morphology most cases can be treated conservatively, especially because the young spine has great potential for remodelling. The older the child becomes, the more smoothly the transition to adult treatment occurs; thus, unstable fractures should be treated with surgery.

CONCLUSION

The difficult indication and the specific characteristics of surgery necessitate treatment in a spine centre with experience with surgery on children.

Pediatric cervical spine injuries with neurological deficits, treatment options, and potential for recovery

Purpose: The purpose of the present study was to highlight the challenges in managing cervical spine injuries in children with neurological deficits.

Introduction: Cervical spine injuries in children are relatively rare. Pattern, severity, and level of these injuries are age dependent. Neurological deficits in young children are uncommon and usually have a good potential for recovery.

Patients and methods: This report includes four cases with pediatric cervical spine injuries with variable degrees of spinal cord injuries and neurological deficits. All the four patients were five years old or younger at the time of injury. Those patients were presented with different patterns of injuries and the treatment was customized for every patient. Marked neurological improvement occurred in all patients at the last follow-up.

Conclusion: The treatment of pediatric cervical spine injuries should be individualized. Children with stable injuries should do well with non-operative treatment while operative treatment is recommended when the indication is appropriate and the expertise is available. Neurological deficits due to spinal cord injuries in pediatric patients have a high potential for recovery, provided that adequate management is considered.

Conservative treatment of pediatric thoracic and lumbar spinal fractures: outcomes in the sagittal plane

To assess sagittal plane spinopelvic balance and functional outcomes in a pediatric cohort of patients with a thoracic and/or a lumbar fracture treated conservatively. A multicentric study retrospectively reviewed radiological and functional outcomes (mean follow-up 49 months) of 48 patients (mean age 12 years) with thoracic and/or lumbar spinal fractures that occurred between 1996 and 2014. Demographic data and radiological spinopelvic parameters were analyzed. Functional outcome was evaluated by a telephone interview. First, a comparison between the initial and the last follow-up full-spine radiographs was performed for the assessment of bone remodeling and sagittal plane balance. Then, patients were classified into two groups (group 1: Risser≤2 and group 2, Risser>2) to assess the influence of skeletal maturity on the restoration of a correct sagittal balance. A total of 62% of the patients were at skeletal maturity at the final follow-up (Risser 4 and 5). Patients with a Risser grade of 2 or less had a higher remodeling potential. The mean residual local kyphosis in thoracic and lumbar fractures was, respectively, 8.2° and 8.7°. The mean thoracic global kyphosis remains stable at the last follow-up, in contrast to lumbar lordosis, which increased significantly. Sagittal plane global measurements on the basis of the C7-plumbline remained unchanged at the last follow-up. There was no change in the pelvic parameters, except for the sacral slope in the group 1 for patients with a lumbar fracture. The current study confirms a greater correction in younger patients (Risser≤2) in spinal fractures and reported that thoracic fractures have a higher remodeling potential than lumbar fracture. A local kyphosis of almost 10° remained at the last follow-up. However, no deterioration in the sagittal plane balance was found. This suggests compensatory mechanisms in adjacent structures for children and adolescents and excludes the only hypothesis of bone remodeling.

Traumatic pediatric spinal cord injury: long-term outcomes of lower urinary tract function

Long-term urodynamic and urological outcomes were evaluated in pediatric patients following traumatic spinal cord injury (SCI). The medical charts of three pediatric patients following traumatic SCI were retrospectively reviewed. The level of the injury was cervical in two patients and thoracic in one. Two patients, whose initial urodynamics demonstrated voluntary or reflex detrusor contraction with synergic sphincter relaxation, managed to void; however, urinary management was switched in one of these patients from voiding to clean intermittent catheterization (CIC) with anti-cholinergic agents because of a treatment for urinary incontinence. There were also no episodes of hydronephrosis, vesicoureteral reflux (VUR) or renal dysfunction in these two patients. Although one patient with hyperreflexic bladder was initially managed with CIC and anti-cholinergic agents, detrusor myectomy was ultimately performed because of severe VUR associated with the progressive worsening of lower urinary tract (LUT) function. Careful follow-ups including urodynamics are mandatory for children with progressively deteriorated LUT function or problematic urinary incontinence.

The influence of brace immobilization on the remodeling potential of thoracolumbar impaction fractures in children and adolescents

PURPOSE

Different treatment methods including immediate mobilization with or without brace, bed rest or immobilization using thoracolumbosacral orthosis have been applied for stable compression fractures of the pediatric spine. The aim of this study was to evaluate the influence of bracing on the remodeling capacity of pediatric thoracolumbar type A 1.2 impaction fractures. Additionally, the prevalence of pain and functional disabilities were assessed.

METHODS

All children treated conservatively between 2000 and 2011 with impaction fractures of the thoracolumbar spine (A 1.2) were included and re-invited for a clinical [including VAS 0-100, Oswestry disability index (ODI)] and radiological follow-up examination. Changes of the sagittal index (SI) at the time of the accident, the latest control visit and at the follow-up examination were analyzed.

RESULTS

Seventy-two patients with a mean age of 12 years (1.8-18 years) and a total number of 133 fractured vertebrae were included. The mean SI at the time of injury was 0.76 (range 0.45-0.94, SD 0.08); 34 patients with 67 fractured vertebrae were included in the follow-up examination after a mean of 7.9 years (2.4-13.1 years). The mean SI of the 67 affected vertebrae at follow-up significantly increased to 0.92 (range 0.74-1, SD 0.06). The initial treatment regimen (brace vs no brace) did not influence the remodeling capacity. More than half of the patients (n = 18, 53 %) complained about occasional back-related pain which was not associated with the remodeling process. The mean ODI was 5.8 (range 0-26, SD 6.6) and the mean VAS of the re-evaluated patients was 87 (range 53-100, SD 14).

CONCLUSIONS

A significant remodeling capacity of thoracolumbar vertebral impaction fractures sustained in childhood is demonstrated. Bracing does not seem to influence the long-term outcome of these injuries. More studies have to be performed to define the role of bracing in these fractures.

TREATMENT OF UNSTABLE THORACOLUMBAR FRACTURES IN PEDIATRIC PATIENTS

Objective:To analyze the characteristics of unstable thoracolumbar fractures in the pediatric population.Methods:A retrospective cross-sectional study was conducted with pediatric patients (0 to 15 years) who presented with unstable thoracolumbar fracture with or without neurological damage. Twenty-four operated patients were analyzed: 13 male and 11 female.Results:Falls from height are the most common cause, being the thoracolumbar junction the anatomical site most frequently injured.Conclusion:The thoracolumbar fractures are rare in the pediatric population, as well as post-surgical instrumentation structural deformities.

Post-trauma scoliosis after conservative treatment of thoracolumbar spinal fracture in children and adolescents: results in 48 patients

PURPOSE

Authors examined a case series of patients younger than 18 years old who had sustained a traumatic thoracolumbar spine fracture to evaluate radiological and clinical findings of coronal spinal balance, after conservative treatment.

METHODS

From 1996 to 2014, a tricentric cohort of 48 patients with an average age of 12 years was radiographically reviewed at 50 months. Cobb angle of fractured vertebra and regional Cobb angle were measured both at baseline and follow-up. Analyses were done according to initial Risser grade, number of fractures and level of injury.

RESULTS

There was a total of 11 scoliosis. In group with Risser grade 3 or above, with a single vertebral fracture and lumbar fracture, final regional Cobb angle was statistically higher than initial regional Cobb angle.

CONCLUSIONS

The prevalence of scoliosis in our population is higher than those of idiopathic scoliosis; Risser grade 3 or above, lumbar fracture and a single fracture seem to account for more severe coronal deformation.

A new technique for stabilization of injuries at C2-C3 in young children

BACKGROUND

Reported surgical treatment for injuries and instabilities of the paediatric cervical spine most commonly involves posterior fusion with internal fixation, usually posterior wiring.

PURPOSE

To present a new simple technique of stabilization without fusion of the upper cervical spine of young children.

STUDY DESIGN

A technical report.

METHODS

Detailed description of the surgical procedure carried out for stabilizing an unstable flexion-distraction injury in a 23 month-old toddler, with severe head injury and pneumothorax is presented.

RESULTS

A rare unstable flexion-distraction injury in the upper cervical spine of a toddler was successfully treated with a posterior Number 2 Vicryl (polyglactin 910) suture fixation, with good healing of the ligaments and endplates, without fusion. Preservation of motion was achieved without obvious instability at 63 months post-surgery.

CONCLUSIONS

In selected cases of cervical spine injuries in the young paediatric population, a limited approach to the injured spinal segments and simple stabilization using suitable degradable sutures, can provide sufficient stability until healing occurs.

ADVANTAGES

fusion is avoided, growth disturbances are prevented and spinal motion maintained.

Results of fusion and instrumentation of thoracic and lumbar vertebral fractures in children: a prospective ten-year study

BACKGROUND

Researches on the results of surgical treatment of thoracolumbar spine fractures are infrequent. The aim of this study was to determine midterm outcomes of surgical treatment of these fractures in a prospective survey.

METHODS

A case series study on pediatric patients with the diagnosis of thoracic and/or lumbar vertebral fractures was conducted over a ten-year period. Surgically treated patients were evaluated in the follow-up period, based on back pain, independent function, neurological status, and radiographic indices.

RESULTS

There were 102 pediatric individuals, 61 boys and 41 girls, aged 3-17 years (mean 12 years of age) with thoracic and/or lumbar spinal fractures. Motor vehicle accident was the most common mechanism of injury (45.0 %). L1 was the most frequent level of fractured vertebra (24.4 %), and pelvic fracture was the most common associated orthopedic injury (21.5 %). Totally, 20 patients underwent surgery, but only fifteen (14 boys and one girl) participated in follow-up (mean 49 months; range 12-81 months). Posterior spinal fusion and instrumentation was accomplished in 12 cases. Three patients were operated by anterior approach and fusion followed by posterior fusion and instrumentation because of delay in diagnosis. There were no major perioperative complications. Two cauda equina syndromes and two incomplete spinal cord injuries improved back to normal. Five cases (33.3 %) reported occasional back pain, and all patients were functionally independent. Radiographic indices improved significantly.

CONCLUSIONS

Spinal fusion and instrumentation in pediatric patients with unstable thoracolumbar vertebral fractures with or without spinal cord injuries have favorable radiographic and functional outcomes.

A review of pediatric lumbar spine trauma

Pediatric spine fractures constitute 1%–3% of all pediatric fractures. Anywhere from 20% to 60% of these fractures occur in the thoracic or lumbar spine, with the lumbar region being more affected in older children. Younger children tend to have a higher proportion of cervical injuries. The pediatric spine differs in many ways from the adult spine, which can lead to increased ligamentous injuries without bone fractures. The authors discuss and review pediatric lumbar trauma, specifically focusing on epidemiology, radiographic findings, types and mechanisms of lumbar spine injury, treatment, and outcomes.

Cervical spine injury patterns in children

BACKGROUND AND OBJECTIVE

Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children.

METHODS

We conducted a 5-year retrospective review of children <16 years old with CSIs at 17 Pediatric Emergency Care Applied Research Network hospitals. Investigators reviewed imaging reports and consultations to assign CSI type. We described cohort characteristics using means and frequencies and used Fisher's exact test to compare differences between 3 age groups: <2 years, 2 to 7 years, and 8 to 15 years. We used logistic regression to explore the relationship between injury level and age and mechanism of injury and between neurologic outcome and cord involvement, injury level, age, and comorbid injuries.

RESULTS

A total of 540 children with CSIs were included in the study. CSI level was associated with both age and mechanism of injury. For children <2 and 2 to 7 years old, motor vehicle crash (MVC) was the most common injury mechanism (56%, 37%). Children in these age groups more commonly injured the axial (occiput-C2) region (74%, 78%). In children 8 to 15 years old, sports accounted for as many injuries as MVCs (23%, 23%), and 53% of injuries were subaxial (C3-7). CSIs often necessitated surgical intervention (axial, 39%; subaxial, 30%) and often resulted in neurologic deficits (21%) and death (7%). Neurologic outcome was associated with cord involvement, injury level, age, and comorbid injuries.

CONCLUSIONS

We demonstrated a high degree of variability of CSI patterns, treatments and outcomes in children. The rarity, variation, and morbidity of pediatric CSIs make prompt recognition and treatment critical.

Loss of correction in spinal cord injury-related scoliosis after pedicle screw fixation

PURPOSE

Spinal cord injury (SCI) in the pediatric population is an infrequent but clinically important disease to scoliosis surgeons. Spinal deformity after SCI is extremely common and almost uniformly develops in patients being injured before the growth spurt. Most treatment paradigms extrapolate management from both the adult literature as well as adolescent idiopathic scoliosis data. Since these patient populations are different in many respects, we sought out to investigate the rates of loss of correction over time as well as the factors associated with loss of correction in pediatric patients undergoing pedicle screw fixation for treatment of SCI-related scoliosis.

METHODS

All consecutive pediatric patients with spinal cord injury and paralytic scoliosis managed with pedicle screw constructs were identified at a single institution. Clinical and radiographic parameters were reviewed and analyzed with specific focus on parameters associated with loss of correction at an average follow-up of 2 years.

RESULTS

Approximately 15 % of patients had a loss of correction of greater than 10° of Cobb angle. Postoperative sagittal imbalance was found to be significantly greater in patients who lost greater than 10° of correction compared to patients who did not lose correction (53.6 ± 39.9 vs 4.3 ± 41.3 mm, p = 0.02).

CONCLUSIONS

Correction of patients with paralytic associated scoliosis should aim for a neutral sagittal balance in order to prevent postoperative loss of correction. Further study is needed on this subgroup of patients with scoliosis given the differences in strategies needed to correct and maintain their deformity correction.

[Fractures of the thoracolumbar spine in childhood and adolescence]

BACKGROUND

The aim of our study was to evaluate the clinical and radiological outcome after operative treatment of fractures of the thoracolumbar spine in children.

PATIENTS AND METHODS

Over a period of 10 years, 14 patients (10 girls and 4 boys) with a mean age of 12.6 years were treated operatively. The mean follow-up was 47.4 months. At follow-up range of motion, residual pain, and activities of daily living were considered. Radiological X-rays were performed in anterior and lateral views, and kyphosis deformity as well as reduction of the height were determined.

RESULTS

Most fractures were comprehension fractures (71.4%). In 13 patients dorsal decompression and internal fixation was performed. Off the six patients who had neurologic injuries, two had complete return of neurologic function. Five patients had no pain. Radiologically, five patients showed a mean kyphosis deformity of 12.7° as well as a mean height reduction of 2.7mm. Ten patients reported no problems in activities of daily living. Overall our patients showed good results in clinical outcome.

CONCLUSION

Those patients who need operative therapy require prompt diagnosis and therapy to minimize permanent damage.

Back pain in the pediatric and adolescent athlete

Clinicians taking care of athletes are likely to see many young patients complaining of back pain. The young athlete places significant repetitive stresses across the growing thoracolumbar spine, which can cause acute and overuse injuries that are unique to this age and patient population. Fortunately, by using a careful and systematic approach, with a sport-specific history, careful physical exam, and proper imaging, most problems can be properly identified. Although it is important to always remember that rare and more serious problems such as a neoplasm or infection maybe a source of pain in the athletic patient, most problems are benign and can be treated conservatively. Accurate diagnosis and management of back pain not only can prevent long-term deformity and disability, but it can also allow young athletes to return to doing what they love to do most: play sports.

Internal stabilization of a flexion-distraction injury of the upper cervical spine of a toddler: a new technique and literature review

STUDY DESIGN

A case report and literature review.

OBJECTIVE

To present a new and simple technique of fixation without fusion of a rare unstable Salter-Harris type I injury in the upper cervical spine of a 23-month-old toddler.

SUMMARY OF BACKGROUND DATA

Surgical treatment of unstable pediatric cervical spine injuries most commonly involves posterior fusion with internal fixation, usually posterior wiring.

METHODS

Detailed description of the surgical procedure carried out for fixating an unstable flexion-distraction injury in a 23-month-old toddler, with severe head injury and pneumothorax, is presented.

RESULTS

A rare unstable flexion-distraction injury in the upper cervical spine of a toddler was successfully treated with a posterior Number 2 Vicryl (polyglactin 910; ETHICON Division of Johnson & Johnson) suture fixation, with good healing of the ligaments and end plates, without fusion. Preservation of motion was achieved without obvious instability at 28 months postsurgery.

CONCLUSION

In selected cases of cervical spine injuries in the young pediatric population, simple stabilization of the spine using degradable Number 2 Vicryl (polyglactin 910) sutures with minimal exposure can provide sufficient stability until healing occurs. Advantages are that fusion is avoided and motion preserved.

Pediatric multilevel spine injuries: an institutional experience

OBJECT

Spinal column trauma is relatively uncommon in the pediatric population, representing 1-2% of all pediatric fractures. However, pediatric spinal injury at more than one level is not uncommon. The purpose of this study was to evaluate the mechanisms and patterns of the injury and factors affecting management and outcomes of pediatric multilevel spine injuries.

PATIENTS AND METHODS

Patients with pediatric spine injury (183) were retrospectively reviewed. Patients (28 boys, 20 girls; mean age 12.8 years; range 3 to 16 years) identified with multilevel spinal injuries were 48 (26.2%): 7 patients (14.5%) were between 3 and 9 years of age, and 41 patients (85.5%) were between 9 and 16 years of age. Of the 48 patients, 30 (62.5%) were at contiguous levels and 18 (37.5%) were at noncontiguous. A total of 126 injured vertebrae were diagnosed. The cervical region alone was most frequently (31.2%) involved, and the thoracic region alone was the least frequently involved (12.5%). Overall, 73% of patients were neurologically intact, 4.1% had incomplete spinal cord injury (SCI), and 8.3% had complete SCI. Treatment was conservative in 36 (75%) patients. Surgical treatments were done in 12 patients (25%). Postoperatively, one patient (16.6%) with initial neurologic deficit improved. The overall mortality rate was 6.2%.

CONCLUSIONS

Multilevel spine injuries are most common in children between 9 and 16 years of age and are mainly located in the cervical region. The rostral injury was most often responsible for the neurologic deficit. The treatment of multilevel spine injuries should follow the same principles as single level injury, stability and neurologic symptoms indicate the appropriate treatment.

Unique features of pediatric spinal cord injury

STUDY DESIGN

Systematic review.

OBJECTIVE

The objective of this systematic review was to identify the unique features associated with pediatric spinal cord injury (SCI) with the intention of determining the most effective spinal stabilization methods and identifying the optimum treatment for post-traumatic spinal deformity in pediatric patients with a SCI.

SUMMARY OF BACKGROUND DATA

Spinal injuries occur in 1.99/100,000 children, 10% are under 15 years, 60% to 80% occur in the cervical spine, and 5.4% to 34% in the thoracolumbar spine. The most frequent incident of spinal injury (50%-56%) occurs during motor vehicle accidents.

METHODS

A systematic review of the English language literature explored articles published between 1950 and 2009. Electronic databases (Medline and Embase) and reference lists of key articles were searched to identify unique features of pediatric SCI based on 2 questions: (1) "What is the most effective means to achieve spinal stabilization in pediatric patients with a SCI?" and (2) "What is the most effective treatment of post-traumatic spinal deformities in pediatric patients with a SCI?" Three Spinal Trauma Study Group faculty members assessed the level of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria and disagreements were resolved by a modified Delphi consensus.

RESULTS

No Level 1 or 2 evidence articles were discovered. Question 1 was addressed by 417 abstracts; from those 15 were selected for inclusion. This literature proved to be controversial, mostly focused on the adult population, pediatric series were retrospective, and most treatments were based on adult experience. The evidence supporting stabilization of the spine in the pediatric SCI population is very low for both the cervical and thoracic spinal regions. Question 2 was discussed in 517 abstracts; 8 relevant articles were selected. The principal key points, regarding the most effective treatment of post-traumatic spinal deformity in the pediatric SCI patients, suggest that the deformity should be prevented before the age of 10 to 12 years, younger SCI patients are unfavorable, nearly 100% of patients with SCI will develop a deformity, and brace treatment is generally recommended. Current evidence in support of brace use is very low.

CONCLUSION

Despite the lack of well-designed prospective studies to establish the efficacy of instrumentation in these cases, there remains very low evidence that supports the use of instrumentation in unstable pediatric spines to prevent neurologic injury and maintain spinal alignment. The very low evidence of benefits from early bracing clearly outweighs the risks and complications associated with its use. Close monitoring should be initiated early so as to delay surgical correction as late as possible. There is very low evidence to support the use of surgery for the treatment of deformity triggered by a SCI. There may be evidence suggesting that the correction techniques used for neuromuscular deformities are useful for SCI patients. In conclusion, there is a strong recommendation for the use of instrumentation in the unstable pediatric spinal injured population, and there is a strong recommendation for traditional neuromuscular spinal deformity treatment techniques to be adopted as a treatment of progressive spinal deformities after a neurologic injury.

Burst fractures of the thoracic and lumbar spine in children and adolescents

BACKGROUND

Burst fractures are rare in the pediatric population. There is limited information available on the best treatment for these injuries. The aims of our study were to evaluate the risk of spinal cord injury (SCI) and the potential for neurologic recovery associated with pediatric burst fractures; to compare sagittal alignment between nonoperative and operative treatment; and to determine whether functional outcomes are improved after surgery.

METHODS

All pediatric patients who sustained thoracic or lumbar burst fractures at 2 institutions between 1991 and 2005 were identified. The medical records were reviewed for patient demographics, injury, treatment, and outcomes. Health Survey data were collected from a subset of patients in both the operative and nonoperative groups.

RESULTS

Thirty-seven patients met the inclusion criteria. There were 17 male patients and 20 female patients, with an average age of 14.6 years (range, 6 to 18 y). Nine patients were treated nonoperatively and 28 patients were treated operatively. The nonoperative group was treated with hyperextension casting or bracing and showed progression of kyphotic deformity from 16.1 degrees at injury to 23.1 degrees at final follow-up. In patients treated operatively, the kyphotic deformity improved from 17.1 degrees at presentation to 7.2 degrees at final follow-up. Twenty-four patients were neurologically intact at presentation, whereas 13 presented with neurologic deficit. Six of 13 patients with SCI had some improvement. The risk of SCI was highest in patients with thoracic-level fractures. The risk of SCI did not correlate with canal compromise. There were no significant differences in functional outcome between the 2 groups.

CONCLUSIONS

The risk of neurologic injury in pediatric burst fractures of the spine may be more closely related to the level of injury (thoracic) than the degree of spinal canal compromise. Prognosis for recovery of neurologic injury is related to the severity of the initial neurologic injury.

LEVEL OF EVIDENCE

Prognostic level 2.

Unstable Cervical Spinal Injury in Children - Case Report and Review of the Literature

Large studies about the management of pediatric patients with unstable flexion-distraction injuries of the midcervical spine are rare. We present the case of a 12-year-old girl who sustained a cervical spinal injury with unilateral facet dislocation and discuss details and problems of diagnostic procedures and treatment in the light of the recent literature. The management and pitfalls of a unilateral facet dislocation in a child are summarized. After initial reposition, a multisegmental instability with neurology developed. Although distraction-flexion cervical spine injuries are common in adults and often occur with concomitant neurological sequelae, they also can occur in the pediatric population. In conclusion, an MRI seems advisable. A treatment of postoperative malalignment with reposition via a halo-fixator cannot be recommended. Repositioning is possible but was lost when the fixator was removed. Comparing the historic and recent literature there is only weak evidence overall, nevertheless a ventral fusion seems to be the treatment option of choice.

Thoracolumbar and sacral spinal injuries in children and adolescents: a review of 89 cases

OBJECT

The authors evaluated the mechanisms and patterns of thoracic, lumbar, and sacral spinal injuries in a pediatric population as well as factors affecting the management and outcome of these injuries.

METHODS

The records of 89 patients (46 boys and 43 girls; mean age 13.2 years, range 3-16 years) with thoracic, lumbar, or sacral injuries were reviewed. Motor vehicle accidents were the most common cause of injury. Eighty-two patients (92.1%) were between 10 and 16 years old, and seven (7.9%) were between 3 and 9 years old. Patient injuries included fracture (91%), fracture and dislocation (6.7%), dislocation (1.1%), and ligamentous injury (1.1%). The L2-5 region was the most common injury site (29.8%) and the sacrum the least common injury site (5%). At the time of presentation 85.4% of the patients were neurologically intact, 4.5% had incomplete injuries, and 10.1% had complete injuries. Twenty-six percent of patients underwent surgery for their injuries whereas 76% received nonsurgical treatment. In patients treated surgically, an anterior approach was used in six patients (6.7%), a posterior approach in 16 (18%), and a combined approach in one (1.1%). Postoperatively, six patients (26.1%) with neurological deficits improved, one of whom recovered fully from an initially complete injury.

CONCLUSIONS

Thoracic and lumbar spine injuries were most common in children older than 9 years. Multilevel injuries were common and warranted imaging evaluation of the entire spinal column. Most patients were treated conservatively. The prognosis for neurological recovery is related to the initial severity of the neurological injuries. Some pediatric patients with devastating spinal cord injuries can recover substantial neurological function.

Pediatric injuries: prevention to resolution

Despite improved education and prevention initiatives, trauma remains the leading cause of death in children. A variety of preventative measures have been developed to decrease the morbidity and mortality, and the financial burden on the health care system. This article discusses injury prevention strategies, issues in prehospital care, and key points of initial resuscitation. In addition, the major injury patterns are described with attention paid to the diagnosis and management of patients with multiple traumatic injuries.

[Pediatric acute spinal cord injury]

INTRODUCTION

Pediatric acute spinal cord injury is rare but is often associated with significant disability and prolonged stay in the intensive care unit (ICU).

OBJECTIVES

The main objective of this study was to determine the epidemiology, initial clinical abnormalities, diagnostic studies, treatment and outcome of acute spinal cord injuries in a tertiary level pediatric hospital. A second objective was to analyze whether early tracheostomy allows earlier discharge of these patients.

PATIENTS AND METHODS

A retrospective analysis of patients with acute spinal cord injuries admitted to our pediatric ICU since 1992 was performed.

RESULTS

We included 16 patients in the study, 12 of whom were boys (75 %). The patients were aged from birth to 19 years on admission to the ICU. The length of stay in the ICU was between 12 hours and 6 years. The cause of the lesion was birth trauma in four patients; one died and the remaining three live at home under mechanical ventilation. Traumatic injuries occurred in seven patients, two of whom died; a further two live in a long-term care facility and the remaining three live at home. Vascular spinal malformation occurred in two patients, and the three remaining injuries occurred during the acute postoperative period following spinal surgery. Of the 16 children, 56.2 % were tracheostomized and 83 % of the survivors live at home.

CONCLUSIONS

Early tracheostomy, the availability of invasive ventilation for home use and parent education permit earlier discharge of these patients and allow more of them to live at home.

Vertebral fractures in late adolescence: a 27 to 47-year follow-up

The long-term outcome of thoracic and lumbar fractures in late adolescence is sparsely described and it is unclear whether a fractured vertebral body in these years, as in young children, can be resituated in height. The purpose of this study was to in late adolescence determine the incidence, the long-term outcome and the modelling capacity in fractures of the thoracic and lumbar region. The incidence of vertebral fractures 1950-1971 in individuals aged 16-18 years was through the radiological archives evaluated in a city cohort of 228,878 citizens, of whom 13,893 were aged 16-18. A follow-up, 27-47 years after the injury, including subjective, objective and radiological evaluation was conducted in 18 boys and 5 girls. Twenty-nine boys and 11 girls were registered with a thoracic or lumbar vertebral fracture during the study period conferring an annual incidence of 0.14 per thousand. Of the 23 individuals that attended the follow-up, 14 had one-column compression fractures, one a Denis type A, six a Denis type B, one a Denis type D and one a Chance fracture. At injury, one had a partial paresis in one leg and one developed a transient paraparesis during the first week. All were treated non-operatively. At follow-up, 18 individuals had no complaints while 5 had occasional back pain, 20 were classified as Frankel E and 3 as Frankel D. The radiographic ratio of anterior height to posterior height of the fractured vertebral body was unchanged during the study period. Thoracic and lumbar vertebral fractures in late adolescence with no or minor neurological deficits have a predominantly favourable long-term outcome, even if no modelling capacity of the fractured vertebral body remains in late adolescence.

Internal fixation without fusion of a flexion-distraction injury in the lower cervical spine of a three-year-old

BACKGROUND

Reported surgical treatment of unstable pediatric cervical spine injuries typically involves posterior fusion with internal fixation, usually with posterior wiring.

PURPOSE

To discuss management issues in the treatment of an unstable Salter-Harris type I pediatric cervical spine injury and surgical intervention without fusion.

STUDY DESIGN

A case report.

METHODS

Summary of the management of an unstable flexion-distraction injury in a 3-year-old child is presented with literature review.

RESULTS

A rare unstable flexion distraction injury of the pediatric cervical spine was successfully treated with posterior wiring without fusion. The wires underwent fatigue failure and maintenance of motion achieved without instability at 2-year follow-up.

CONCLUSIONS

In select physeal injuries of the pediatric cervical spine, internal fixation can provide stability while healing occurs, with avoidance of fusion and maintenance of motion.

A child who recovered completely after spinal cord injury complicated by C2-3 fracture dislocation: case report

STUDY DESIGN

This was a case of a child who recovered completely after spinal cord surgery complicated by C2-C3 fracture dislocation.

OBJECTIVES

To clarify the important issue with regard to the diagnosis and treatment of possible spinal cord injury complicated by C2-C3 fracture dislocation in children.

SUMMARY OF BACKGROUND DATA

Reports on spinal cord injury complicated by C2-C3 fracture dislocation in children who recovered completely after surgery are very rare. Moreover, there are no reports of cases in which described MRI and magnetic resonance angiography obtained 5 years after surgery.

METHODS

A 4-year-old girl with complete fracture dislocation of C2-C3 and spinal cord injury of Frankel B because of a traffic injury. A middle incision was made in a prone position under general anesthesia, and C2-C3 was fixed with interlaminal wiring according to the McGraw modified method.

RESULTS

The postoperative course was excellent, and the patient recovered completely. An MRI performed 5 years after surgery revealed no definitive abnormality in spinal cord and patency of vertebral arteries.

CONCLUSION

This was a very rare case of spinal cord injury complicated C2-C3 fracture dislocation in children. The present case is of interest in that it demonstrated the possibility of recovery in a child from spinal cord injuries of Frankel B immediately after injury, if complex injuries in multiple organs are controlled by systemic management.