fractures of the spine in children steven frick, md created march 2004; revised august 2006
TRANSCRIPT
Fractures of the Spine in Children
Steven Frick, MD
Created March 2004; Revised August 2006
Important Pediatric Differences
• Anatomical differences
• Radiologic differences
• Increased elasticity
• Periosteal tube fractures – apparent dislocations
• Immobilization well tolerated
Cervical Spine Injuries
• Rare in children - < 1% of children’s fractures
• Quoted rates of neurologic injury in children’s C spine injuries vary from “rare” to 44% in large series
• < age 7 – majority of C spine injuries are upper cervical, esp. craniocervical junction
• > age 7 – lower C spine injuries predominate
Multiple Small Diameter Pin Child’s Halo for Displaced C2 Fracture
Note bolster behind neck to maintain lordosis and reduce angulation
Traumatic Spinal Cord Injury
• Rare in children
• Better prognosis for recovery than adults
• Late sequelae = paralytic scoliosis (almost all quadriplegic children if injured at less than 10 years of age)
Anatomy – C1
• 3 ossification centers at birth – body and 2 neurocentral arches
• Neurocentral synchondroses (F) fuse at about 7 years of age
Anatomy – C2
• 4 ossification centers at birth – body, 2 neural arches, dens
• Neurocentral synchondroses (F) fuse at age 3-6 years
• Synchondrosis between body and dens (L) fuses age 3 – 6 years
• Thus no physis / synchondrosis should be visible on open mouth odontoid view in child older than 6 years
Anatomy – C2
• Summit ossification center (H) appears at age 3 – 6 and fuses around age 12
• Do not confuse with os odontoideum
Os Odontoideum
• Thought to be sequelae of prior trauma
• May result in C1-C2 instability
Os Odontoideum
Anatomy – Lower Cervical Vertebrae C3 – C7
• Neurocentral synchondroses (F) fuse at age 3-6 years
• Ossified vertebral bodies wedge shaped until square at about age 7
• Superior and inferior cartilage endplates firmly attached to disc
Mechanism of Injury
• Child’s neck very mobile – ligamentous laxity and shallow angle of facet joints
• Relatively larger head
• In younger patients this combination leads to upper cervical injuries
• Falls and motor vehicle accidents most common cause in younger children
Cervical Spine Injuries from Birth Trauma
• Can occur• May have associated
spinal cord or brachial plexus injury
• Upper cervical injuries may be a cause of perinatal death
Newborn with C5/6 fracture dislocation
Typical Fracture Pattern
• Fractures tend to occur within the endplate between the cartilaginous endplate and the vertebral body
• Clinically and experimentally fractures occur by splitting the endplate between the columnar growth cartilage and the calcified cartilage
• Does not typically occur by fracture through the endplate – disc junction
C Spine Immobilization for Transport in Children
• Large head will cause increased flexion of C spine on standard backboard
• Bump beneath upper T spine or cutout in board for head to transport child with spine in neutral alignment
C Spine Radiographic Evaluation in Children
• Be aware of normal ossification centers and physes
• C2/3 pseudosubluxation common in children younger than 8, check spinolaminar line of Swischuk
• Evaluation of soft tissues anterior to spine may be unreliable in the crying child
C Spine Evaluation in Children
• Similar protocol as adults
• Consider mechanism of injury
• Physical exam – tenderness (age, distracting injuries), neurological exam
• C Spine series
ED C Spine Evaluation
Spinal Cord Injury without Radiographic Abnormality (SCIWORA)
• Cervical spine is more flexible than the spinal cord in children
• Can have traction injury to spinal cord in a child with normal radiographs
• Usually occurs in upper C spine, in children younger than 8
• MRI can diagnose injury to spinal cord and typically posterior soft tissues
Occiput –C1 SCIWORA
SCIWORA
• Spinal cord injury without radiographic abnormality (plain x-rays, not MRI)
• distraction mechanism of injury
• spinal cord least elastic structure
• young children <8 yo
• be aware GCS 3 and normal CT head may be upper cervical spinal cord injury
O – C1 Spinal Cord Injury
Not “Cleared” by Plain Films
• CT scan – much of peds c-spine cartilaginous
• Advantage – fast (no sedation -anesthesia)
• Assess alignment
Not “Cleared”• MRI scan – currently favored
• Rapid sequence/image acquisition algorithms – gradient echo
• Evaluate non osseous tissues and spinal cord
• MRI scan should be considered in critically injured child for whom adequate plain films cannot be obtained to rule out spinal injury
Imaging
• 3 view plain film series
• Obliques if requested by radiologist
• CT scan upper C-spine (O-C2) if intubated, or consider MRI
If not “Cleared” within 12 Hours
• Switch to pediatric Aspen or Miami J collar
• Consider CT or MRI
Baker et al AJEM 1999
• 5 year review peds CSI
• 40/72 evident on plain XR
• 32 SCIWORA
• 80% abnormal PE
• 16% neuro abnormal
• 3 view XR 94% sensitive
Finch and Barnes JPO 1998 CSI
• <10 years old- MVC, upper C-spine
• >10 years old- recreational sports, lower C-spine.
Givens et. al J Trauma 1991
• 3 year review, 34 children CSI
• 53% also TBI• 41% mortality• 50% of pts <8 injury
below C4
Fatal O-C1 dislocation
Keiper Neuroradiology 1998
• 31 % of peds trauma patients (+) MRI C-spine
• Persistent neck symptoms or radiographs inconclusive- check MRI
Scarrow et al Peds Neurosurgery 1999
• 3 view XR, CT (-)
• Persistent altered mental status
• Flex/ext with SSEP monitoring
• If (+) --- MRI
• Risks--- just do MRI
Flynn, Dormans et al. CHOP Protocol
• Obtunded patient• Unable to clear within 36 hrs• MRI C spine• If normal discontinue C collar• No significant missed injuries• Continue C collar if posterior soft tissues
appear injured on MRI, obtain later dynamic studies
If You See a Spine Fracturein a Child
• Look hard for another one
• “The most commonly missed spinal fracture is the second one”. -J. Dormans
• High incidence of noncontiguous spine fractures in children
Thoracic Spine Fractures
• Less common spinal fracture in children than in more mobile regions
• Rib cage offers some support / protection
• Motor vehicle crashes, falls from heights
• Child abuse in very young
• Compression fractures in severely osteopenic conditions (OI, chemotherapy)
Multiple Compression Fractures in 4 year old Leukemia Patient
Thoracic Spine Fracture Dislocations
• High energy mechanisms
• Often spinal cord injury, can be transected
• Prognosis for recovery most dependent on initial exam – complete deficits unlikely to have recovery
• Infarction of cord (artery of Adamkiewicz) may play some role –especially in delayed paraplegia
Thoracolumbar Junction InjuriesT11-L2
• Classically lap-belt flexion-distraction injuries
• Chance fractures and variants
• High association with intraabdominal injury (50-90%)
• Neurologic injury infrequent but can occur
Lap Belt Sign
• High association with intraabdominal injury and lumbar spine fracture
• Lumbar spine films mandatory
4 yo Lap Belt Restrained PassengerIntraabdominal Injuries, Paraplegic
2 Year Old with Old L2-3 Fracture Dislocation from NAT
Lumbar Spine Fractures L3-L5
• Infrequent until late adolescence• Usually compression fractures that are stable
injuries• Can be associated with lap belt injuries• Burst fractures – may progress to kyphosis• Lumbar apophyseal injuries – posterior
displacement can cause stenosis, may need surgical excision
Chance Fractures and Variants
• Flexion over fulcrum• Posterior elements fail in tension, anterior elements
in compression• Can occur through bone, soft tissue or combination• Pure bony injuries can be treated with
immobilization in extension• Injuries with posterior ligamentous component may
be best treated with surgical stabilization
Rumball and Jarvis JBJS 74BSeatbelt Injury Classification
Flexion-Distraction Injury L2-L3 6 Months after Compression
Fixation, Posterolateral Fusion
Lumbar Apophyseal InjuriesSlipped Apophysis
• Compression-shear injuries• Same age group as SCFE• Typically adolescent males, inferior
endplates of L4 or L5• Traumatic displacement of vert. ring
apophysis and disc into spinal canal• If causes significant compression of cauda
equina, treatment is surgical excision
3 Types of Slipping of Vertebral Apophysis
Tarr et al. J Comput Assist Tomogr
Burst Fractures
• Usually in older adolescents
• Treatment similar to adults
• May not need surgery in neurologically intact patient
• Injuries at thoracolumbar junction higher risk for progressive kyphosis
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