Cervical spine fracture-dislocation birth injury: prevention, recognition, and implications for the orthopaedic surgeon

Stillbirth Investigations: An Iconographic and Concise Diagnostic Workup in Perinatal Pathology

Introduction  Stillbirth is a dramatic event for the parents, health care team, and anyone close to the expectant parents. Multidisciplinary team (MDT) meetings are essential to improve communication in health care. We review the most frequent findings discussed at MDT meetings. Methods  A PubMed search was conducted through December 2021 since the inception (1965) using clinical queries with the key terms "stillbirth" AND "investigation" AND "pathology" AND "human." The search strategy included reviews, meta-analyses, randomized controlled trials, clinical trials, and observational studies. This systematic review is based on, but not limited to, the search results. It is the experience of more than 30 years of pediatrics, obstetrics, and pathology staff. Results  Two hundred and six articles were screened and complemented through the perusal of congressional activities and personal communications. Pathological findings following perinatal death can be divided into macroscopic, histologic, and placental findings. The placenta is crucial in fetal medicine and is key in determining the cause of stillbirth in a substantial number of events. Perinatal lung disease is essential to evaluate the response of newborns to extrauterine life and address newborns' outcomes appropriately. Conclusions  Stillbirth remains one of the less explored areas of medicine, and we can determine the cause in a limited number of cases. Nevertheless, placental pathology is critical in the etiology discovery pathway. Accurate investigations and discussion of photography-supported findings are vital in promoting communication at MDT meetings.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

Successful surgical repair and recovery in a 2-week-old infant after birth-related cervical fracture dislocation

Cervical spine injuries are the most common spine injuries in the pediatric population. The authors present the youngest known patient who underwent cervical spine fusion to repair birth trauma-induced cervical fracture dislocation, resulting in spondyloptosis and spinal cord injury. A 2-week-old boy was found to have spondyloptosis and spinal cord injury after concerns arose from reduced movement of the extremities. The patient's birth was complicated by undiagnosed abdominal dystocia, which led to cervical distraction injury. At 15 days of age, the boy underwent successful C-5 corpectomy, with anterior C4-6 and posterior C2-7 arthrodesis, using an autologous rib graft for a C-5 fracture dislocation. MRI performed 2 weeks postoperatively revealed significant improvement in the alignment of the spinal canal. The patient was discharged from the hospital in a custom Minerva brace and underwent close follow-up in addition to occupational therapy and physical therapy. At the latest follow-up 4.5 years later, the patient was able to walk and ride a tricycle by himself. The authors describe the patient's surgery and the challenges faced in achieving successful repair and cervical spine stabilization in such a young patient. The authors suggest that significant neurological recovery after spinal cord injury in infants is possible with appropriate, timely, and interdisciplinary management.

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.

Birth-related mid-posterior rib fractures in neonates: a report of three cases (and a possible fourth case) and a review of the literature

BACKGROUND

Posterior rib fractures in young children have a high positive predictive value for non-accidental injury (NAI). Combined data of five studies on birth trauma (115,756 live births) showed no cases of rib fractures resulting from birth trauma. There have, however, been sporadic cases reported in the literature.

OBJECTIVE

We present three neonates with both posterior rib fractures and ipsilateral clavicular fractures resulting from birth trauma. A review of the literature is also presented. The common denominator and a possible mechanical aetiology are discussed.

MATERIALS AND METHODS

In total, 13 cases of definitive birth-related posterior rib fractures were identified.

RESULTS

Nearly all (9/10) posterior rib fractures were (as far as reported in the original publications) in the midline. In 12 of the 13 children, birth weight was high and in 7 children birth was complicated by shoulder dystocia. An interesting finding was that in cases where a clavicular fracture was present, this was on the ipsilateral side.

CONCLUSION

Radiologists, when presented with a neonate with posterior rib fractures, should be aware of this rare differential diagnosis.

Spinal cord injury at birth: a hidden causative factor

A case of perinatally acquired spinal cord injury (SCI) is presented. The foetus was vigorous until birth, the breech presented and delivery was performed by a non-traumatic Caesarean section. The infant displayed symptoms of severe SCI but diagnosis was delayed due to severe co-morbidity. Diagnostic considerations are briefly reviewed. Ventilatory support was withdrawn at the age of 20 days when the infant had still not exhibited any respiratory effort or spontaneous movements. Autopsy revealed a serious congenital malalignment of the upper cervical vertebrae and at the histological examination extensive reactive changes were observed in the same area. To our knowledge such findings have not been published previously.

CONCLUSION

In cases of serious perinatally acquired SCI, claim of malpractice is often apparent. In this case a hidden congenital malformation of the cervical vertebrae was revealed, highlighting the need of careful postmortem examinations in such cases.

Pediatric cervical spine instability

Cervical spine instability in children is rare but not exceptional and may be due to many factors. Although it mostly occurs at the upper cervical spine, all vertebrae from the occiput to T1 may be involved. It may be acute or chronic, occurring secondary to trauma or due to congenital anomaly, skeletal or metabolic dystrophy or rheumatoid arthritis. It can be isolated or associated with other musculoskeletal or visceral anomalies. A thorough knowledge of embryology, anatomy, physiology and physiopathology of the cervical spine in children is essential to avoid pitfalls, recognize normal variants and identify children at risk of developing cervical spine instability and undertake the appropriate treatment.

Part 1: recognizing neonatal spinal cord injury

Neonatal spinal cord injury can occur in utero, as well as after either a difficult delivery or a nontraumatic delivery. Spinal cord injury can also be related to invasive nursery procedures or underlying neonatal pathology. Early clinical signs of spinal cord injury that has occurred in utero or at delivery includes severe respiratory compromise and profound hypotonia. Knowledge of risk factors and awareness of symptoms is required for early recognition and appropriate treatment. This article reviews the embryological development of the spinal column highlighting mechanisms of injury and identifying underlying factors that increase the risk of spinal cord injury in newborns. Signs and symptoms of injury, cervical spine immobilization, and the differential diagnosis are discussed. Nursing implications, general prognosis, and research in spinal cord injury are provided.