Pediatric Spine Fractures

The Thoracolumbar Injury Classification and Severity Score Appropriately Predicts Treatment in Children Aged 10 and Under

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

This study aims to assess the validity of the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients ≤10 years old.

SUMMARY OF BACKGROUND DATA

TLICS is a validated measure developed to help facilitate clinical decision-making regarding thoracolumbar spinal trauma in adults. Studies examining the utility of TLICS in children skew toward older pediatric patients, where the spine's biomechanical properties are more similar to adults. Due to differences in a preadolescent spine compared with a more mature, adolescent spine, it is unclear if TLICS can be applied to younger patients.

METHODS

A single-center spine trauma registry was queried for patients ≤10 with an acute, traumatic thoracolumbar fracture treated at a level-1 pediatric trauma center between 2006 and 2020. Test characteristics and receiver-operator curve were used to evaluate TLICS based on TLICS <4 recommedning nonsurgical treatment and TLICS >4 recommending surgery.

RESULTS

We identified 94 patients with traumatic thoracolumbar fractures (surgical=20; nonsurgical=74). Despite TLICS-suggested operative management in 28 patients with TLICS >4, nine (32.1%) were initially treated nonoperatively. All patients who deviated from TLICS-suggested treatment had flexion-distraction injuries (FDI). Sensitivity, specificity, positive predictive value, and negative predictive value were 100%, 89.2%, 70.4%, and 100%, respectively. The receiver operating characteristic curve demonstrated a strong diagnostic ability of TLICS in predicting the need for surgery (area under the curve: 0.97, F1-score: 0.86).

CONCLUSION

TLICS score <4 showed strong validity and is highly specific in predicting non-operative management for patients ≤10 years old with thoracolumbar fractures. However, TLICS >4 has more limited specificity in indicating the necessity for surgical intervention, as many FDIs were successfully treated without surgery. Additional factors other than TLICS score may need to be considered for these more severe injuries to optimize management in this age group.

[Pediatric Upper Cervical Spine Injuries: a Systematic Review]

PURPOSE OF THE STUDY

The study aimed to systematically review the available literature focusing on upper cervical spine injuries in children, namely the age and sex of patients, epidemiology of injuries, classifications used, diagnosis and treatment methods, neurologic deficit, concomitant injuries, and potential complications.

MATERIAL AND METHODS

The systematic review was elaborated in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The studies assessing pediatric upper cervical spine injuries were searched for in the MEDLINE database in September 2023. The studies included were published between 1991 and 2022.

RESULTS

A total of 1354 studies were found through the database search. Subsequently, 53 articles were excluded as duplicates and 1217 due to irrelevant title or abstract. The full text of 84 studies was reviewed. Sixty-nine manuscripts failed to meet the predefined criteria. In the end, the systematic review was based on 15 studies. In the cohort of paediatric patients with upper cervical spine injuries, the girls accounted for 51.1% and boys for 48.9%. X-ray (64.9%) and CT (56.2%) were the most commonly used imaging for diagnosis, with MRI (51.5%) being the least used diagnostic method. Surgical procedure was opted for in treating more than a quarter of cases (27.6%). Most of the surviving patients were neurologically intact (69.2%), a fairly large number of patients (14.4%) died. The most common concomitant injury was craniocerebral trauma (39%) and the most common treatment complication was the instrumentation failure (11.3%).

DISCUSSION

Upper cervical spine injuries are rare in children and represent a relatively heterogeneous group. The literature on this topic is mostly inconsistent. Currently, there is just a few studies dealing with pediatric upper cervical spine injuries as a whole; more often the papers focus on a single type of injury. Inconsistencies also occur in defining the age limit for the pediatric spine and in defining the upper cervical spine. For these reasons, comparing the results of individual studies can be difficult.

CONCLUSIONS

The mean age of pediatric patients with upper cervical spine injuries was 6.7 years, with a slight predominance of girls. The most common cause of injury was traffic accidents. X-ray and CT were the most commonly used diagnostic methods and surgical therapy was opted for in treating more than a quarter of cases. More than two-thirds of the surviving patients were neurologically intact. Instrumentation failure was the most common treatment complication and craniocerebral trauma was the most common concomitant injury.

Increasing Trends of Pediatric Thoracic and Lumbar Spine Fractures in the United States from 2004 to 2023: A 20-year National Injury Review Depicting Shifts in Mechanisms of Injury

BACKGROUND

Fractures of the thoracic and lumbar spine are uncommon injuries in children and adolescents, but they carry substantial morbidity and a real risk of death. Compared with the adult spine, the pediatric spine has unique anatomic and biomechanical properties that yield different fracture patterns than the adult population. The mechanisms of injury and degree of skeletal maturity constitute important predictors of the outcomes of pediatric thoracic and lumbar fractures; however, there remains a paucity of meaningful epidemiologic data with specific attention to the pediatric spine.

QUESTIONS/PURPOSES

(1) What are the overall incidence and trends of all-cause pediatric thoracic and lumbar fractures in the past 20 years, and how do these differ by age and sex? (2) What are the primary mechanisms of injury responsible for all-cause pediatric thoracic and lumbar fractures, and how do these differ by age and sex? (3) What are the sex-specific incidence risks of all-cause pediatric thoracic and lumbar fractures in the past 20 years? (4) What are the age-specific incidence risks of all-cause pediatric thoracic and lumbar fractures in the past 20 years?

METHODS

The National Electronic Injury Surveillance System (NEISS) is a publicly available database from a nationally representative sample of emergency departments that offers key details on mechanisms of injury and a statistically valid calculation method of national injury estimates. The NEISS was retrospectively queried for patients ages 0 to 18 years who presented with all-cause thoracic and lumbar fractures between 2004 and 2023. Thoracic and lumbar fractures were identified from upper trunk and lower trunk fracture NEISS diagnosis codes, filtering out nonpertinent diagnoses such as rib, hip, or pelvis fractures (72% [5853 of 8131]). From relevant thoracic and lumbar fractures, only acute fractures were included after narrative review; chronic or incidental fractures or spondylolysis (0.2% [5 of 2278]) and acute fractures that did not specify an affected thoracic or lumbar region (6% [136 of 2278]) were subsequently excluded. Collected variables included age, sex, hospitalization, primary mechanism of injury, fracture level(s), and fracture type. Each NEISS case record is assigned a statistical weight, representing an estimate of such injury occurring nationally. The aggregate of these weights in patients presenting with a thoracic or lumbar fracture provides a total national estimate of these injuries. Age was subsequently classified into children (younger than 14 years) and adolescents (ages 14 to 18 years). There were 1064 case records of thoracic fractures, 988 case records of lumbar fractures, and 85 case records of thoracic and lumbar fractures between 2004 and 2023, corresponding to a national estimate of 26,732 thoracic fractures, 29,274 lumbar fractures, and 2083 thoracic and lumbar fractures after computing the aggregate statistical weights of the associated case records. Fractures affecting both the thoracic and lumbar spine were included in the separate cohorts of thoracic and lumbar fractures, totaling a final national estimate of 28,814 thoracic fractures and 31,357 lumbar fractures. Of patients with thoracic fractures, 43% (12,264 of 28,814) and 57% (16,550 of 28,814) were children and adolescents, respectively, and 64% (18,328 of 28,814) and 36% (10,486 of 28,814) were male and female, respectively. Of patients with lumbar fractures, 29% (9109 of 31,357) and 71% (22,248 of 31,357) were children and adolescents, respectively, and 61% (19,084 of 31,357) and 39% (12,273 of 31,357) were male and female, respectively. Incidence rates were calculated using provided national estimates and as incidence per population at-risk using US census data. Simple linear regression analysis characterized overall and demographic-specific trends over the 20-year period, with the beta coefficient (β) representing change in fracture national estimates per year. Incidence rate ratios were calculated to compare demographic groups with regard to overall fracture incidence, recreation-related mechanism of injury, multilevel injury, and hospitalizations.

RESULTS

The mean ± SD annual incidence rate over the 20-year study span was 19 ± 6 pediatric thoracic fractures and 20 ± 5 pediatric lumbar fractures per 1 million person-years. There were overall increasing trends in pediatric thoracic fractures by 58 fractures per year (β = 58 [95% confidence interval (CI) 30 to 86]; p < 0.001). Increases in thoracic fractures were noted among males, females, children, and adolescents, with the largest increases in males by 41 fractures per year (β = 41 [95% CI 19 to 63]; p < 0.001) and adolescents by 41 fractures per year (β = 41 [95% CI 19 to 64]; p = 0.001). There were overall increasing trends in pediatric lumbar fractures by 38 fractures per year (β = 38 [95% CI 9 to 67]; p = 0.01), most prominently in males by 30 fractures per year (β = 30 [95% CI 9 to 51]; p = 0.007). These slight yearly increases resulted in substantial total increases in thoracic and lumbar fractures over the 20-year period. Falls from height and motorsports were the most common mechanisms of injury for overall pediatric thoracic and lumbar fractures. Males primarily sustained thoracic and lumbar fractures from motorsports, football, and falls from height, whereas females primarily sustained thoracic and lumbar fractures from falls from height, horseback riding, winter sports, and playground accidents. Children primarily sustained thoracic and lumbar fractures from falls from height and playground accidents, whereas adolescents primarily sustained thoracic and lumbar fractures from motorsports, falls from height, and winter sports. Age- and sex-based differences in motorsports were especially large, with motorsports accounting for nearly fourfold as many fractures in males than in females and more than twofold as many fractures in adolescents than in children. The overall rate of thoracic and lumbar fractures was 1.82 (95% CI 1.77 to 1.86; p < 0.001) and 1.63 (95% CI 1.60 to 1.67; p < 0.001) times higher in males compared with females. The overall rate of thoracic and lumbar fractures was 3.67 (95% CI 3.58 to 3.75; p < 0.001) and 6.69 (95% CI 6.52 to 6.85; p < 0.001) times higher in adolescents compared with children.

CONCLUSION

Our findings suggest that increased public policy attention be directed toward recreational activities such as motorsports and football, which disproportionately affect adolescent males. Formal safety training, strict age requirements, and regulations on the speed and horsepower of all-terrain vehicles and dirt bikes should be considered for motorsports. Similar age limits and introduction of modified tackling and football skills development should be considered prior to full-contact football. It is the responsibility of orthopaedic surgeons to increase public attention on the fracture risk of horseback riding, which has been traditionally perceived to be low risk. Increased barrier protection on bunk beds, windows, staircases, and playground equipment may lower the rate of accidental falls for all demographics.

LEVEL OF EVIDENCE

Level III, prognostic study.

Epidemiology of pediatric thoracolumbar spinal fractures and associated injuries: a single-center experience

OBJECTIVE

This retrospective study aimed to investigate the epidemiology of pediatric patients with thoracolumbar spinal fractures and the characteristics of associated injuries.

METHODS

Sixty-one patients under 18 years old with thoracolumbar spinal fractures were included in the study. Patients were divided into two groups: ≤ 8 years (Group 1) (n = 13) and > 8 years (Group 2) (n = 43). Patients were analyzed for age, gender, fracture type, fracture level, etiology, and associated injuries.

RESULTS

The mean age was 158.7 (± 53.1) months, and the male/female ratio was 1.26. The most common fracture etiology was motor vehicle accidents (39.4%) and falls from height (18%). There was no correlation between the fracture type, the number of fractured vertebrae, and age. The most common associated injury was orthopedic injuries (34.3%). In Group 2, associated injuries developed more frequently in the presence of a major fracture, whereas in Group 1, associated injuries could occur even in isolated minor fractures. In Group 1, intrathoracic injuries associated with fractures (36.4%) were significantly higher than in Group 2 (4.2%). Surgical intervention was required in 9.8% of patients.

CONCLUSION

Although thoracolumbar spinal fractures are rare in children, they are essential because preventable accidents essentially cause them and can have devastating consequences. There are significant differences in epidemiologic and clinical features between age groups. In this study, we have shown that even minor thoracolumbar vertebral fractures may be accompanied by associated injuries in children under 8 years of age. In contrast, major fractures are more frequently related to other organ injuries in older children. This may be because more severe trauma is required for a fracture of the thoracolumbar spine, which is more flexible and elastic in young children compared to adolescents. Our study has provided current and essential results regarding the etiology of pediatric thoracolumbar spine fractures. More multicenter studies are needed to understand the characteristics of thoracolumbar fractures in pediatric patients.

A Focal Traumatic Injury to the Neonatal Rodent Spinal Cord Causes an Immediate and Massive Spreading Depolarization Sustained by Chloride Ions, with Transient Network Dysfunction

In clinics, physical injuries to the spinal cord cause a temporary motor areflexia below lesion, known as spinal shock. This topic is still underexplored due to the lack of preclinical spinal cord injury (SCI) models that do not use anesthesia, which would affect spinal excitability. Our innovative design considered a custom-made micro impactor that provides localized and calibrated strikes to the ventral surface of the thoracic spinal cord of the entire CNS isolated from neonatal rats. Before and after injury, multiple ventral root (VR) recordings continuously traced respiratory rhythm, baseline spontaneous activities, and electrically induced reflex responses. As early as 200 ms after the lowering of the impactor, an immediate transient depolarization spread from the injury site to the whole spinal cord with distinct segmental velocities. Stronger strikes induced higher potentials causing, close by the site of injury, a transient drop in spinal cord oxygenation (SCO2) and a massive cell death with a complete functional disconnection of input along the cord. Below the impact site, expiratory rhythm and spontaneous lumbar activity were suppressed. On lumbar VRs, reflex responses transiently halted but later recovered to control values, while electrically induced fictive locomotion remained perturbed. Moreover, low-ion modified Krebs solutions differently influenced impact-induced depolarizations, the magnitude of which amplified in low Cl-. Overall, our novel ex vivo platform traces the immediate functional consequences of impacts to the spinal cord during development. This basic study provides insights on the SCI pathophysiology, unveiling an immediate chloride dysregulation.

Epidemiology of pediatric spinal trauma with neurological deficits in Catalonia: a 36-year experience

PURPOSE

Existing literature on pediatric traumatic spinal cord injury (PTSCI) demonstrates large variations in characteristics, incidence, time-periods and etiology, worldwide. Epidemiological studies addressing injuries to the total spine, conducted in Southern European regions are remarkably scarce; therefore we aimed to investigate long-term trends analyzing etiology, fracture location and type, single or multiple fractures, associated lesions and neurological status in Catalonia, Spain.

METHODS

We conducted a retrospective observational study. We analyzed post-acute patients after PTSCI, aged 0-17, admitted with neurological deficits between 1986 and 2022 to a specialized hospital in Catalonia. Neurological deficits were assessed using the American Spinal Injury Association Impairment Scale (AIS).

RESULTS

Two hundred and forty nine children were included, 174 (69.9%) boys and 75 (30.1%) girls; mean age was 13.9 years (range, 2 months to 17 years). Two hundred and four children (82%) had ≥ 1 spinal fractures, 66 (26.5%) dislocations and 8 (3.2%) SCIWORA. Fractures were multilevel contiguous in 108 (43.4%) cases. Fracture types comprised 81 vertebral compactions (32.5%), 22 burst fractures (8.8%), 7 odontoid (2.8%) and 4 tear-drops (1.6%). There were ≥ 1 associated lesions in 112 cases (45%): in limbs in 23 cases (9.2%), thorax or abdomen in 59 (23.7%) and skull or face in 81 (32.5%). In 44 cases (39% of the 112) there were multiple lesions. Locations comprised cervical spine in 105 cases (42%), thoracic spine in 124 (49%), lumbar spine in 18 (7%), and sacrum in 2 (0.8%). Road traffic accidents (RTAs) were the main etiology (62.2%) over the whole period. However, from 2016 onwards, RTAs dropped below the rate of falls and sports injuries. The most common sites for injury in those aged 9 years or older were in the cervical (41.1%) and thoracic (50.7%) regions. Those aged 8 or under were far more likely to sustain a complete SCI (80.0%) or an accompanying traumatic brain injury (45.0%) likely due to higher numbers of pedestrian versus car RTAs. A significant peak in the occurrence of cases during 2006-2010 (20.1%) was identified with an absolute drop immediately after, during 2011-2015 (8.8%). A marked shift in trend is observed between 2016-2022 regarding age of injuries (an increase in 9 years or older), etiology (increase in falls and sports versus RTA), AIS grade (increase in incomplete lesions AIS B-D versus AIS A), severity (increase in tetraplegia versus paraplegia) and location (increase in cervical versus lumbar and thoracic injuries).

CONCLUSIONS

A shift in trend is observed in the past 7 years regarding age of injuries (increase in those older than 9), etiology (increase in falls and sports versus RTA), AIS grade (increase in incomplete lesions AIS B-D versus AIS A), severity (increase in tetraplegia versus paraplegia) and location (increase in cervical).

LEVEL OF EVIDENCE

IV.

Advances in the clinical diagnosis and treatment of multiple-level noncontiguous spinal fractures

Multiple-level noncontiguous spinal fractures (MNSF) are spinal fractures that involve at least 2 sites and are characterized by the presence of one intact vertebra or intact functional spinal unit between the fractured vertebrae. MNSF account for 2.5-19% of all spinal fractures. MNSF are easily missed or have a delayed diagnosis in clinical practice and their treatment is more complex than that for single-segment spine fractures. In this article, the authors briefly summarize the advances in the etiology and mechanisms of MNSF, the identification of their involved sites and their classification, diagnosis, treatment, and prognosis.

Unstable C2-3 Posterior Ligamentous Injury in a Pediatric Patient with Successful Nonoperative Treatment: A Case Report

CASE

The authors present a case of a 6-year-old boy who was treated nonoperatively for an unstable C2-3 hyperflexion injury with posterior cervical ligamentous disruption 8 years ago. The patient was managed with cervical collar immobilization for 2.5 years with long-term follow-up demonstrating complete healing of posterior element disruption, normal sagittal vertebral alignment on dynamic imaging, and full return to activities of daily living and sports.

CONCLUSION

Pediatric spine injuries up to the C2-3 level with posterior ligamentous disruption alone without neurological deficit may be successfully treated nonoperatively with careful long-term immobilization and close follow-up.

Pediatric cervical spine clearance after blunt trauma and negative CT: What is the role of MRI?

BACKGROUND AND PURPOSE

The cervical spine in children has marked anatomical and biomechanical differences compared to adults, leading to significantly different patterns and incidence of spinal injury, and consequently to different X-ray and computed tomography (CT) imaging recommendations. Magnetic resonance imaging (MRI) has been validated to clear cervical spine trauma in adults, but not in pediatric patients. We hypothesized that MRI findings have a low probability to change management in children with spine trauma and negative CT findings.

MATERIALS AND METHODS

We reviewed records for admitted pediatric patients due to blunt trauma from January 2011 to May 2021, and identified 212 patients who underwent MRI within 3 days of a negative CT. Two neuroradiologists independently reviewed all CT and MRI images for the following categories: fracture, subluxation, spinal canal compromise, ligamentous injury, spinal canal hemorrhage, cord contusion and soft tissue hemorrhage. We identified follow-up MRI examinations as negative or positive for the above categories, and calculated the prevalence of each category as a percentage of cases with negative CT. We also evaluated whether negative and positive MRI groups differed significantly with respect to age and sex of the patients.

RESULTS AND CONCLUSIONS

In our study of 212 children with cervical spine trauma and a negative CT, most follow-up MRI scans were found to be negative (79.9 %). Positive MRI findings consisted mainly of ligamentous sprain without disruption (15.1 %). Ligamentous disruption and epidural or soft tissue hemorrhage were found in 4.5 %, and focal cord contusion in 0.5 %. There was no statically significant difference between negative and positive MRI groups with respect to age (P = 0.45) and sex (P = 0.52).

CONCLUSION

In our patient group with a negative CT, MRI did not significantly impact management nor contribute to cervical spine clearance in children.

Evaluation and Management of Thoracolumbar Spine Trauma in Pediatric Patients: A Critical Analysis Review

» Pediatric thoracolumbar trauma, though rare, is an important cause of morbidity and mortality and necessitates early, accurate diagnosis and management.» Obtaining a detailed history and physical examination in the pediatric population can be difficult. Therefore, the threshold for advanced imaging, such as magnetic resonance imaging, is low and should be performed in patients with head injuries, altered mental status, inability to cooperate with examination, and fractures involving more than 1 column of the spine.» The classification of pediatric thoracolumbar trauma is based primarily on adult studies and there is little high-level evidence examining validity and accuracy in pediatric populations.» Injury pattern and neurologic status of the patient are the most important factors when determining whether to proceed with operative management.

Paediatric spine injuries in the thoracic and lumbar spine-results of the German multicentre CHILDSPINE study

BACKGROUND

Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking.

OBJECTIVES

The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients.

MATERIALS AND METHODS

A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years).

RESULTS

A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%).

CONCLUSIONS

The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed.

Activity-restriction only as treatment yields positive outcomes in pediatric spinal compression fractures: a prospective study of 47 patients at medium-term follow-up

BACKGROUND AND PURPOSE

We aimed to evaluate the clinical outcomes, radiographic results, and health-related quality of life in pediatric AO type A1 spinal compression fractures treated with activity-restriction only.

PATIENTS AND METHODS

All children between 2014 and 2020 with an AO type A1 spinal compression fracture treated with activity-restriction only identified from an institutional fracture registry were invited to a prospective outcomes study. Clinical findings and spinal radiographs were assessed at median 3 years, interquartile range (IQR) 1-4 follow-up from injury. Oswestry Disability Index, Pediatric Quality of Life Inventory Generic Core Scale (PedsQL), and PedsQL Pediatric Pain Questionnaire were compared with reference values. 63 children were identified, of whom 47 agreed to participate. 8 were polytrauma patients.

RESULTS

Age at injury was median 11 (IQR 9-14) years. The number of injured vertebrae was median 2 (IQR 1-3). 82% (94 of 115) were thoracic vertebrae fractures and 70% (33 of 47) of the patients had thoracic vertebrae fractures only. At follow-up all but 2 fractures showed radiographic remodeling. There was no difference from the published reference values in the patient-reported outcome measures. A lower PedsQL physical functioning score was associated with higher patient-reported pain (P = 0.03). At follow-up 12 patients had hyperkyphosis (median difference from the reference values 4°, IQR 3-6, 95% confidence interval [CI] 3-6) and 5 hypolordosis (median difference from reference 8°, IQR 4-11, CI 4-14). None of the patients had surgery for deformity during follow-up.

CONCLUSION

Clinical, radiographic, and health-related quality of life outcomes were good after activity-restriction treatment in pediatric A1 spinal compression fractures.

Surgical and Medical Management of Pediatric Spine Trauma

Pediatric spine trauma is rare but presents unique challenges to clinical management. Special considerations include but are not limited to the need to minimize ionizing radiation in this patient population, anatomic immaturity, physiologic variants, and injuries seen only in the pediatric population. Here we review the epidemiology of pediatric spine trauma, presentation, diagnosis, and treatment of the most common injuries and discuss specific medical and surgical strategies for treatment.

Pediatric Spinal Trauma at a Single Level 1 Trauma Center: Review of 62 Cases

Background

Traumatic spinal injuries in children are uncommon and result in different patterns of injuries due to the anatomical characteristics of children's spines. However, there are only a few epidemiological studies of traumatic spinal injury in children. The purpose of this study was to investigate the characteristics of traumatic spinal injury in children.

Methods

We retrospectively reviewed the cases of pediatric patients (age < 18 years) with traumatic spinal injury who were treated at a level 1 trauma center between January 2017 and December 2021. We divided them into three groups according to age and analyzed demographics, injury mechanism, level of injury, and injury pattern.

Results

A total of 62 patients (255 fractures) were included, and the mean age was 13.8 ± 3.2 years. There were 5 patients (22 fractures) in group I (0-9 years), 24 patients (82 fractures) in group II (10-14 years), and 33 patients (151 fractures) in group III (15-17 years). Both the Injury Severity Score and the Revised Trauma Score were highest in group I, but there was no statistical difference between the age groups. Fall from height was the most common injury mechanism, of which 63% were suicide attempts. The level of spinal injury was different in each age group, T10-L2 injury being the most common. In all age groups, the number of multilevel continuous injury was larger than that of single-level injury or multilevel noncontinuous injury. Surgical intervention was required in 33.9%, and mortality was 3.2%.

Conclusions

In our study, fall from height was the most common mechanism of injury, and there were many suicide attempts associated with mental health issues. Thoracolumbar junction injuries were predominant, and the rate of multilevel contiguous injuries was high. The support and interest of the society and families for adolescent children seem crucial in preventing spinal trauma, and image testing of the entire spine is essential when evaluating pediatric spinal injuries.

A systematic review and meta-analysis of the global epidemiology of pediatric traumatic spinal cord injuries

Despite being relatively rare, pediatric traumatic spinal cord injury (TSCI) is a debilitating event with high morbidity and long-term damage and dependency. This study aims to provide insight on the epidemiological characteristics of pediatric TSCI worldwide. The studies were included if they provided data for the pediatric population with the diagnosis of TSCI. Information sources included PubMed, Embase, Web of Science, and Scopus. All databases were searched from 1990 to April 2023. The quality of included studies was evaluated by Joanna Briggs Institute Critical Appraisal Tools. The results of the meta-analysis were presented as forest plots. PROSPERO Registration code: CRD42020189757. We identified 87 studies from 18 developed and 11 developing countries. Of the 87 studies evaluated, 52 studies were considered medium quality, 27 studies were considered high quality, and 8 studies were considered low quality. In developed countries, the proportion of TSCIs occurring in patients aged 0-15 years was 3% (95% CI: 2.2%; 3.9%), while in developing countries, it was 4.5% (95% CI: 2.8%; 6.4%). In developed countries, the pooled incidence of pediatric TSCI was 4.3/millions of children aged 0-15/year (95% CI: 3.1; 6.0/millions children aged 0-15/year) and boys comprised 67% (95% CI: 63%; 70%) of cases. The most prevalent level of injury was cervical (50% [95% CI: 41%; 58%]). The frequency of SCI Without Obvious Radiological Abnormality (SCIWORA) was 35% (95% CI: 18%; 54%) among children 0-17 years. The most common etiology in developed countries was transport injuries (50% [95% CI: 42%; 57%]), while in developing countries falls were the leading cause (31% [95% CI: 20%; 42%]). The most important limitation of our study was the heterogeneity of studies in reporting age subgroups that hindered us from age-specific analyses.   Conclusion: Our study provided accurate estimates for the epidemiology of pediatric TSCI. We observed a higher proportion of pediatric TSCI cases in developing countries compared to developed countries. Furthermore, we identified distinct epidemiological characteristics of pediatric TSCI when compared to adult cases and variations between developing and developed countries. Recognizing these unique features allows for the implementation of cost-effective preventive strategies aimed at reducing the incidence and burden of TSCI in children. What is Known: • Pediatric Traumatic Spinal Cord Injury (TSCI) can have profound physical and social consequences for affected children, their families, and society as a whole. • Epidemiological insights are vital for they provide the data and understanding needed to the identification of vulnerable populations, aiding in the development of targeted prevention strategies and effective resource allocation. What is New: • The estimated incidence of pediatric TSCI in developed countries is 4.3 cases per million children aged 0-15. The proportion of pediatric TSCI cases in relation to all-age TSCI cases is 3% in developed countries and 4.5% in developing countries. • The etiology of TSCI in pediatric cases differs between developing and developed countries. In developed countries, transport injuries are the most prevalent cause of pediatric TSCI, while falls are the least common cause. Conversely, in developing countries, falls are the leading cause of pediatric TSCI.

Imaging Evaluation for Thoracic Spine Fractures in Pediatric Trauma Patients: A Single-Center Experience at an Academic Children's Hospital

BACKGROUND

Imaging workup for evaluating thoracic spine fracture (TSF) in pediatric blunt trauma is variable.

PURPOSE

The aim of the study was to determine the number of TSFs missed by radiography and identified on computed tomography (CT) or magnetic resonance imaging (MRI) that required intervention or resulted in a change in management.

METHODS

A retrospective review of children with TSFs was performed. Diagnostic images and reports for these patients were reviewed. Data regarding demographics, clinical presentation, management, and outcomes were extracted from institutional electronic medical records. Use of radiographs, CT, and MRI for evaluation of TSF was quantified. Incidence of TSFs was calculated and stratified by mechanism. The number of TSFs and complicating factors missed on radiography but identified on subsequent CT or MRI were quantified.

RESULTS

Three thousand two hundred sixty-five trauma patients 18 years or younger were reviewed. Of these, 3.3% (90/3265) had TSFs (36 females, 54 males; mean age, 10.80 ± 4.4 years). The most common mechanism of injury was fall (43% [39/90]) followed by motor vehicle collisions (30% [27/90]). The most common fracture was simple compression fracture 64%, which occurred most frequently in the mid thoracic spine, followed by transverse process fractures 19% and spinous process fractures 7%. Almost half of all TSFs diagnosed on CT and/or MRI were missed on initial radiographs. While all fractures that required operative management were identified on radiographs, 13 of the 19 fractures that required nonoperative intervention were missed.

CONCLUSIONS

Approximately 50% of TSFs diagnosed on CT or MRI were not identified on preceding radiographs. This is similar to studies in adult populations that show poor sensitivity of radiographs.

Acupuncture acupoints of spine and lower limb for pediatric backbend-induced thoracic spinal cord injury: Four case reports and literature review

BACKGROUND

Backbend-induced pediatric thoracic spinal cord injury without radiologic abnormality (BBPT-SCIWORA) in children is rare in clinical practice and leads to lower limb motor dysfunction. There are few clinical studies on BBPT-SCIWORA and even fewer on treatments for BBPT-SCIWORA-induced lower limb motor dysfunction.

OBJECTIVE

To explore the therapeutic effect of acupuncture at bilateral spine acupoints combined with lower limb acupoints in BBPT-SCIWORA.

CASE PRESENTATION

This study reported four cases of BBPT-SCIWORA after dancing, two of which received a unique medium-frequency electroacupuncture treatment. They were all females aged between 5 and 12 years old. They were diagnosed with BBPT-SCIWORA by magnetic resonance imaging (MRI), transferred to the rehabilitation department for lower limb dysfunction, and received rehabilitation treatments and acupuncture. Cases 1 and 2 received acupuncture treatment for lower limb acupoints, while Cases 3 and 4 received acupuncture treatment at the bilateral spine acupoints beside the lesion and lower limb acupoints. Cases 3 and 4 achieved better American spinal injury association (AIS) grades and lower extremity motor scores (LEMS) than Cases 1 and 2 after treatment.

CONCLUSION

Acupuncture treatment of beside bilateral spine acupoints plus lower limb acupoints therapy might facilitate early lower limb motor function recovery in children with BBPT-SCIWORA.

Iatrogenic atlantoaxial rotatory subluxation after thyroidectomy in a pediatric patient: A case report

BACKGROUND

Atlantoaxial rotatory subluxation (AARS) is an uncommon disease with a greater prevalence among children than adults, and it is mostly associated with trauma. Iatrogenic spinal injury accounts for a low percentage of injuries. However, in AARS, 20%-40% of cases are associated with surgery, and 48% are caused by infection. Here, we describe our experience with a case of iatrogenic AARS after general anesthesia.

CASE SUMMARY

A 12-year-old girl presented with right-sided torticollis and cervical motion limit. The patient had undergone thyroidectomy 2 mo ago. Computed tomography revealed AARS with bilateral locked facets. Following the failure of repeated external reduction under general anesthesia, the patient underwent an open surgical reduction. The patient gained atlantoaxial alignment without any complications. Follow-up radiographs showed a normal appearance without instability. The cervical spine of children is more predisposed to injury due to anatomical and biomechanical differences. AARS secondary to infection and surgery is known as Grisel's syndrome, which involves non-traumatic AARS. Several cases of AARS after surgery and other procedures with no evidence of inflammation have been reported. Our experience shows that surgery requiring hyperextension of the neck after general anesthesia should also be included as a risk factor.

CONCLUSION

Surgeons and anesthesiologists should be careful not to excessively extend the neck during pediatric surgery. Moreover, clinicians caring for pediatric patients with recent head and neck procedures must be aware of common AARS presentations.

Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study

OBJECTIVES

The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy.

MATERIALS AND METHODS

Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years).

RESULTS

A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92).

CONCLUSIONS

The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically.

Clinical characteristics and treatment of spinal cord injury in children and adolescents

Pediatric and adult spinal cord injuries (SCI) are distinct entities. Children and adolescents with SCI must suffer from lifelong disabilities, which is a heavy burden on patients, their families and the society. There are differences in Chinese and foreign literature reports on the incidence, injury mechanism and prognosis of SCI in children and adolescents. In addition to traumatic injuries such as car accidents and falls, the proportion of sports injuries is increasing. The most common sports injury is the backbend during dance practice. Compared with adults, children and adolescents are considered to have a greater potential for neurological improvement. The pathogenesis and treatment of pediatric SCI remains unclear. The mainstream view is that the mechanism of nerve damage in pediatric SCI include flexion, hyperextension, longitudinal distraction and ischemia. We also discuss the advantages and disadvantages of drugs such as methylprednisolone in the treatment of pediatric SCI and the indications and timing of surgery. In addition, the complications of pediatric SCI are also worthy of attention. New imaging techniques such as diffusion tensor imaging and diffusion tensor tractography may be used for diagnosis and assessment of prognosis. This article reviews the epidemiology, pathogenesis, imaging, clinical characteristics, treatment and complications of SCI in children and adolescents. Although current treatment cannot completely restore neurological function, patient quality of life can be enhanced. Continued developments and advances in the research of SCI may eventually provide a cure for children and adolescents with this kind of injury.

Clinical course of pediatric gunshot wounds involving the spine and spinal cord: the Miami experience

OBJECTIVE

Civilian gunshot wounds (GSWs) involving the skeletal spine and spinal cord in pediatric patients are fortunately rare. Nevertheless, their presentation mandates judicious evaluation, and their clinical outcomes remain poorly defined. Thus, the authors aimed to characterize the clinical course of this traumatic presentation in the pediatric population based on their institutional experience.

METHODS

A retrospective review of a level I trauma center database was performed for the period 2011-2021. Clinical data were included for patients aged ≤ 18 years who had presented with radiographic and clinical evidence of a GSW to the spine and had at least one documented follow-up at least 6 months after injury. The primary outcomes of the study were the categorization of gunshot injuries and the results of neurological and functional examinations.

RESULTS

A total of 13 patients satisfied the study selection criteria. The mean patient age was 15.7 ± 1.6 years, and all presentations were assault in nature. Most of the patients were male (n = 12, 92%) in gender, Black in race (n = 11, 85%), and from zip codes with a median household income below the local county average (n = 10, 77%). All patients presented with a minimum Glasgow Coma Scale score of 14. Examination at presentation revealed American Spinal Injury Association Impairment Scale (AIS) grade A in 3 cases (23%), grade B in 2 (15%), grade C in 1 (8%), grade D in 2 (15%), and grade E in 5 (38%). Gunshot injury involved all regions of the spine, most commonly the cervical and thoracic spine (n = 6 for each, 46%). In terms of skeletal injury, the most common injuries were to the facet (n = 10, 77%) and the pedicle (n = 8, 62%), with evidence of intracanal injury in 9 patients (69%). Neurosurgical intervention was pursued in 1 patient (8%). Overall, 7 patients (54%) experienced a complication during admission, and the median length of hospitalization was 12 days (range 1-88 days) without any mortality events. Within 90 days from discharge, 2 patients (15%) were readmitted to the hospital for further care. The mean follow-up was 28.9 months (range 6-74 months), by which only 1 patient (8%) had an improved AIS examination; all other patients remained at their initial AIS grade.

CONCLUSIONS

Pediatric GSWs involving the spine are typically nonfatal presentations, and their long-term functional outlook appears contingent on clinical examination findings at initial presentation. Although neurosurgical intervention is not necessary in most cases, judicious evaluation of radiographic and clinical examinations by a neurosurgical team is strongly recommended to optimize recovery.

Application of postmortem MRI for identification of medulla oblongata contusion as a cause of death: a case report

Whiplash injury is common in traffic accidents, and severe whiplash is characterized by cervical spinal cord injuries with cervical dislocation or fracture, that can be diagnosed by postmortem computed tomography (PMCT), postmortem magnetic resonance (PMMR), or conventional autopsy. However, for cervical spinal cord injury without fracture and dislocation, PMMR can be more informative because it provides higher resolution of soft tissues. We report the case of a 29-year-old male who died immediately following a traffic accident, in which the vehicle hit an obstacle at a high speed, causing deformation of the bumper and severe damage of the vehicle body. PMCT indicated no significant injuries or diseases related to death, but PMMR showed patchy abnormal signals in the medulla oblongata, and the lower edge of the cerebellar tonsil was herniated out of the foramen magnum. The subsequent pathological and histological results confirmed that death was caused by medulla oblongata contusion combined with cerebellar tonsillar herniation. Our description of this case of a rare but fatal whiplash injury in which there was no fracture or dislocation provides a better understanding of the potentially fatal consequences of cervical spinal cord whiplash injury without fracture or dislocation and of the underlying lethal mechanisms. Compared with PMCT, PMMR provides important diagnostic information in forensic practice for the identification of soft tissue injuries, and is therefore an important imaging modality for diagnosis of whiplash injury when there is no fracture or dislocation.

Pediatric Cervical Spine Injuries

Objective  Pediatric cervical spine injuries are rare and account for 1 to 2% of all pediatric spine injuries. There is a paucity of data on pediatric cervical spine injuries in developing countries like India. The purpose of this study is to review and analyze our 5 years of experience with pediatric cervical spine injuries. Methods  All the available medical records over the 5 years were reviewed retrospectively. The data was analyzed to know the epidemiology, mechanism of injury, injury patterns, management, and outcome. The patients were divided into two groups: 0 to 9 years and 10 to 18 years. Results  Seventy-five eligible records were included in our study. The incidence of cervical spine injuries was significantly lower in younger children than the older ones ( p  < 0.042). The most common mechanism of injury was fall from height: 33 (44%) patients followed by road traffic accidents: 27 (36%) patients. The involvement of the upper cervical spine was significantly higher in younger children ( p  < 0.001). Fractures with subluxation were the most common pattern of injury, observed in 35 (47%) patients. However, fractures with subluxation were uncommon in younger children compared with older children ( p  < 0.04). Spinal cord injury without radiographic abnormality (SCIWORA) was observed in 42% of younger children compared with 8% of older children ( p  < 0.02). Thirty (40%) patients were managed surgically; anterior cervical corpectomy with fusion was the most commonly performed procedure in 19 (63%) patients. The overall mortality was 20%. Conclusion  The results of our study revealed predominant involvement of the upper cervical spine in children younger than 10 years of age. SCIWORA was documented in both the age groups with a significantly higher incidence in younger children. The instrumentation and fusion techniques in children are safe; however, developing pediatric spine needs special considerations.

A case report on a child with fracture and dislocation of the upper cervical spine accompanied by spinal cord injury

RATIONALE

This study describes an 8-year-old boy with a C2 fracture and dislocation with a left C2-C3 articular process interlocking and spinal cord injury who underwent open reduction and internal fixation using the posterior cervical approach and achieved satisfactory results.

PATIENT CONCERNS

An 8-year-old boy underwent an emergency transfer from a previous hospital after a car accident.

DIAGNOSES

Axial fracture and dislocation with spinal cord injury (American Spinal Injury Association grade C), traumatic shock, brain contusion, intracranial hemorrhage, mandibular fracture, pulmonary contusion and hemorrhage, left vertebral artery stenosis, and multiple fractures throughout the body. Radiological examination revealed a fracture of the lower edge of the C2 vertebral body, fourth-degree anterior spondylolisthesis of the C2 vertebral body, interlocking of the left C2-C3 articular processes, widening of the C2-C3 vertebral space, and occlusion of the V1 and 2 segments of the left vertebral artery.

INTERVENTIONS

The boy was immediately intubated and transferred to the pediatric intensive care unit for rescue treatment. However, the reduction was unsuccessful with 2 weeks of cranial traction. Thus, an open reduction was performed under general anesthesia. One month after the surgery, the boy was discharged from the hospital on foot after rehabilitation treatment.

OUTCOMES

The boy was discharged from the hospital 1 month after surgery. At the 8-month follow-up, a radiological examination showed that the corrected C2 vertebral body fracture and dislocation were satisfactorily reduced, and the spinal cord was adequately decompressed. The internal fixation position was also good, and the spinal sequence had recovered well. In summary, except for the muscle strength of the right upper limb, which was slightly worse, the other clinical symptoms were significantly improved.

LESSONS

In treating cervical fracture and dislocation with unilateral facet lock, the posterior open reduction of pedicle screw and lateral mass screw internal fixation achieved satisfactory results. Consequently, treating complex cervical spine injuries in children requires an accurate diagnosis and careful treatment strategy.

Artificial intelligence for radiological paediatric fracture assessment: a systematic review

BACKGROUND

Majority of research and commercial efforts have focussed on use of artificial intelligence (AI) for fracture detection in adults, despite the greater long-term clinical and medicolegal implications of missed fractures in children. The objective of this study was to assess the available literature regarding diagnostic performance of AI tools for paediatric fracture assessment on imaging, and where available, how this compares with the performance of human readers.

MATERIALS AND METHODS

MEDLINE, Embase and Cochrane Library databases were queried for studies published between 1 January 2011 and 2021 using terms related to 'fracture', 'artificial intelligence', 'imaging' and 'children'. Risk of bias was assessed using a modified QUADAS-2 tool. Descriptive statistics for diagnostic accuracies were collated.

RESULTS

Nine eligible articles from 362 publications were included, with most (8/9) evaluating fracture detection on radiographs, with the elbow being the most common body part. Nearly all articles used data derived from a single institution, and used deep learning methodology with only a few (2/9) performing external validation. Accuracy rates generated by AI ranged from 88.8 to 97.9%. In two of the three articles where AI performance was compared to human readers, sensitivity rates for AI were marginally higher, but this was not statistically significant.

CONCLUSIONS

Wide heterogeneity in the literature with limited information on algorithm performance on external datasets makes it difficult to understand how such tools may generalise to a wider paediatric population. Further research using a multicentric dataset with real-world evaluation would help to better understand the impact of these tools.

Radiation dose levels of thoracic-lumbar spine CT in pediatric trauma patients and assessment of scan parameters for dose optimization

BACKGROUND

CT is frequently used for assessing spinal trauma in children.

OBJECTIVE

To establish the local diagnostic reference levels of spine CT examinations in pediatric spinal trauma patients and analyze scan parameters to enable dose optimization.

MATERIALS AND METHODS

In this retrospective study, we included 192 pediatric spinal trauma patients who underwent spine CT. Children were divided into two age groups: 0-10 years (group 1) and 11-17 years (group 2). Each group was subdivided into thoracic, thoracolumbar and lumbar CT groups. CT acquisition parameters (tube potential, in kilovoltage [kV]; mean tube current-time product, in milliamperes [mAs]; reference mAs; collimated slice width; tube rotation time; pitch; scan length) and radiation dose descriptors (volume CT dose index [CTDI_vol] and dose-length product [DLP]) were recorded. The CTDI_vol and DLP values of spine CTs obtained with different tube potential and collimated slice width values were compared for each group.

RESULTS

CTDI_vol and DLP values of thoracolumbar spine CTs in group 1 and lumbar spine CTs in group 2 were significantly lower in CTs acquired with low tube potential levels (P<0.05). CTDI_vol and DLP values of thoracolumbar spine CTs in both groups and lumbar spine CTs in group 2 acquired with high collimated slice width values were significantly lower than in corresponding CTs acquired with low collimated slice width values (P<0.05).

CONCLUSION

Pediatric spine CT radiation doses can be notably reduced from the manufacturers' default protocols while preserving image quality.

Spine Fractures in Children and Adolescents—Frequency, Causes, Diagnostics, Therapy and Outcome—A STROBE-Compliant Retrospective Study at a Level 1 Trauma Centre in Central Europe

The aim of this study was to present the frequencies and characteristics of paediatric spine fractures, focusing on injury mechanisms, diagnostics, management, and outcomes. This retrospective, epidemiological study evaluated all patients aged 0 to 18 years with spine fractures that were treated at a level 1 trauma centre between January 2002 and December 2019. The study population included 144 patients (mean age 14.5 ± 3.7 years; 40.3% female and 59.7% male), with a total of 269 fractures. Common injury mechanisms included fall from height injuries (45.8%), with an increasing prevalence of sport incidents (29.9%) and a decreasing prevalence of road incidents (20.8%). The most common localisation was the thoracic spine (43.1%), followed by the lumbar spine (38.2%), and the cervical spine (11.8%). Initially, 5.6% of patients had neurological deficits, which remained postoperatively in 4.2% of patients. Most (75.0%) of the patients were treated conservatively, although 25.0% were treated surgically. A small proportion, 3.5%, of patients presented postoperative complications. The present study emphasises the rarity of spinal fractures in children and adolescents and shows that cervical spine fractures are more frequent in older children, occurring with a higher rate in sport incidents. Over the last few years, a decrease in road incidents and an increase in sport incidents in paediatric spine fractures has been observed.

Traumatic Spinal Injury Associated with All-Terrain Vehicle (ATV) Accidents: A 10-Year Retrospective Analysis of the Coachella Valley

Objective

The use of all-terrain vehicles (ATVs) and associated injuries have significantly increased in the last decade. This study aimed to determine the frequency of ATV-associated spinal cord injuries (SCIs) in the Coachella Valley, California, and provide recommendations for data reproducibility in other areas with a similarly substantial level of ATV usage and injuries.

Methods

This retrospective analysis included data obtained through screening the trauma database of a level II trauma center for ATV-related injuries between January 1, 2010 and January 1, 2020.

Results

Our data suggest that more than one-third of patients admitted to the trauma center over a 10-year period suffered from spinal injury. Injuries to the spine were further categorized as including the spinal cord (radiographically or clinically) or only including the bony or ligamentous elements of the spine. Injury was more common in men and predominantly located in the thoracic spine. Injuries such as epidural hematoma, vertebral artery, and cord contusion were common, with many patients requiring neurosurgical intervention.

Conclusion

Highlighting the implicit dangers of ATV accidents on the spine could help identify outcomes and variables predictive of spinal injuries and spinal cord injuries necessary for patient management. Additionally, our study sets the framework by which legislating bodies could replicate the study for proper legislation and recommendations that may help prevent such injuries.

American football is the youth sporting activity most commonly associated with acute vertebral fractures

OBJECTIVES

Athletics confer cardiovascular fitness and improved cognitive processing in pediatric populations. However, one risk of sports participation is acute vertebral fracture, an injury with significant morbidity. It is currently unknown which sports represent the highest risk of acute vertebral fracture in pediatric populations. This study seeks to identify the youth sporting activities most commonly associated with acute vertebral fractures presenting to United States (U.S.) emergency departments (EDs).

METHODS

This cross-sectional, retrospective study queries the National Electronic Injury Surveillance System database to report national weighted estimates and demographic characteristics of pediatric patients with acute vertebral fractures presenting to U.S. EDs.

RESULTS

The mean annual incidence of estimated acute vertebral fractures over the study period was 1,672 (C.I. 1,217-2,126). From 2000-2001 (N = 4,030; C.I. 2,934-5,125) to 2016-2017 (N = 2,559; C.I. 1,681-3,438), there was no significant change in the estimated rate of sports-related acute vertebral fractures in pediatric patients (p = 0.09). American football was identified as the sport most frequently associated with acute vertebral fractures (23.4%; C.I. 17.6-29.3%). We found no appreciable change in the rate of football-related acute vertebral fractures over time, with 48.2% (C.I. 37.3-59.0%) occurring from 2000 to 2008 and 51.8% (C.I. 41.0-62.7%) from 2009 to 2017.

CONCLUSIONS

While sports-related acute vertebral fractures remain rare injuries in pediatric populations, we identify youth football as the sport associated with the highest risk of such injuries. Despite decreasing football participation rates over our study period, the annual incidence of football-associated acute vertebral fractures has not exhibited a proportional decline. Our findings raise concern that the relative risk of acute vertebral fracture associated with youth football has not significantly decreased over time. Elimination of dangerous tackling technique, improvement in helmet fit and technology, and availability of on-site medical care may contribute to decreased estimates in the future.

Thoracolumbar spinal fracture in children: Conservative or surgical treatment?

PURPOSE

Spinal thoracolumbar fractures represent 10-14% of pediatric fractures. Most children concerned by such fractures are above 10 years of age. No guidelines presently exist. Analysis of spine pathophysiology and of the various common therapeutic attitudes led us to conduct a review of the different therapeutic approaches in pediatric thoracolumbar fracture.

METHODS

A review of the literature was carried out using the Medline and Embase databases with the search-term "pediatric thoracic lumbar spine fractures".

RESULTS

The systematic review identified 44 studies, 24 of which were selected, and 19 were included for analysis. Physiological age was categorized on Risser's classification. In Risser 1 with Magerl A1 fracture, surgical treatment was not necessary and functional (rest and analgesics) or conservative treatment (bracing for 6 weeks) was sufficient. In Risser 1 with Magerl A2, A3 or B fracture, conservative treatment (bracing for 3 months) was the first-line option. In Risser 2-4, conservative treatment with bracing for 3 months was possible in the absence of instability, with kyphosis>20° and canal compression>33%; otherwise, treatment should be surgical. Subsequently, in case of onset of secondary instability, surgical treatment can be proposed. We highlight the importance of MRI assessment for diagnosis of thoracolumbar fracture and associated lesions of the intervertebral discs and posterior ligament complex. Children classified as Risser 5 can undergo the same treatment as adults.

CONCLUSION

Two main parameters should be assessed in treatment decision-making for thoracolumbar fracture: the Risser scale and the Magerl classification.

Spinal Injury in Indian Children: Review of 204 Cases

STUDY DESIGN

Retrospective study.

OBJECTIVE

The purpose of the study was to analyze the epidemiological parameters and associated factors after spinal cord injury (SCI) in children, in the last 14 years admitted at a tertiary care center (Indian Spinal Injury Centre [ISIC], New Delhi, India).

METHOD

The demographic and injury-related data was analyzed descriptively. The incidence, type, and level of injury were compared across the age groups using a χ² test. Wherever appropriate, Fisher exact test was used.

RESULTS

There were 1660 pediatric trauma cases admitted at ISIC from 2002 to 2015, where 204 cases presented with spine injuries. The average age of children sustaining spine injury was 15.69 years (3-18 years of range). There were 15 patients in the age group 0 to 9 years, 27 patients in the age group 10 to 14 years, and 162 patients in the age group 15 to 18 years. This difference in spine injury incidence among the age groups was statistically significant. Fall from height was a common mode of injury. In our sample, boys were 3 times more likely to be injured than girls. Burst fractures were common among the type of injuries.

CONCLUSION

Our study confirms the predominance of cervical spine injury and the high incidence of multilevel contiguous with a lesser percentage of noncontiguous multilevel spinal involvement. SCIWORA (spinal cord injury without radiological abnormality) incidences were in a similar context to the literature available. There was a very low incidence of death. Neurological improvement was seen in 8 operated cases and 4 conservatively treated cases.

Epidemiology of spinal fractures in children: Cross-sectional study

INTRODUCTION

Epidemiological studies of fractures of the spine in children are all old, mostly single-centre, with series spanning periods of 5 to 20 years.

HYPOTHESIS

As lifestyle is constantly changing, notably with an increase in sports activities and improvements in the prevention of road and household accidents, epidemiology has likely changed.

OBJECTIVE

To update the description of spinal trauma in children and adolescents compared to the existing literature.

MATERIAL AND METHOD

A multicentre cross-sectional study of spinal fracture, dislocation and spinal cord injury without radiological abnormality (SCIWORA) in children was carried out in 15 French university hospital centres, for a period of one year (2016).

RESULTS

One hundred and sixty-five children were identified: 85 girls, 80 boys; mean age 11 years (range, 10 months-17 years); median, 12 years 6 months. One hundred and fifty-two children (92%) had fracture, 8 (5%) dislocation (including 7 C1-C2 rotary dislocations), and 5 (3%) SCIWORA. Fractures were multiple in 80 cases (49%), contiguous in 73 cases (91%) and non-contiguous in 7 (9%). Locations were cervical in 25 cases (15%), thoracic in 85 (52%), lumbar in 75 and sacral in 4 (2%). Fracture types comprised 234 vertebral compactions (78%), 25 burst fractures (8%), 5 chance fractures (2%), 2 odontoid fractures, and 33 other lesions. Causes comprised fall in 77 cases (47%), sports accidents in 56 (34%), road accidents in 29 (18%), and others in 3. In 52 cases (32%), there was ≥1 associated lesion: appendicular in 35 cases (67%), thoracic or abdominal in 31 (60%), and head in 16 (31%). Twenty-one cases had multiple lesions (40%). Eighteen cases showed neurological involvement (11%) including 5 SCIWORAs. Neurological complications were more frequent before 9 years of age.

CONCLUSION

The epidemiology of spine fractures in children has slightly changed. There are now fewer cervical lesions. Causes are less often road accidents and more often sports accidents. Multi-level lesions remain frequent and the rate of neurological complications is around 10%. Compaction fracture is the most common type.

Imaging of pediatric cervical spine trauma

While pediatric cervical spine injuries (CSI) are rare, they are associated with high morbidity and mortality and sometimes require expeditious surgical management. In this article, we aim to improve the diagnostic accuracy of pediatric CSI by reviewing normal pediatric cervical anatomy, typical pediatric CSI patterns, and common mimics of pediatric CSI. A literature review was conducted on pediatric CSI, its epidemiology, and the various imaging manifestations and mimics. The most common pediatric CSI occur in the upper cervical spine owing to the higher fulcrum and larger head at a young age, namely prior to age 9 years, while lower CSI occur more frequently in patients older than 9 years. While various craniocervical measurements may be utilized to identify craniocervical disruption, soft tissue injuries may be the only manifestation, thus making pediatric CSI difficult to diagnose on initial imaging. In the acute setting, CT cervical spine is an appropriate initial imaging modality for pediatric CSI evaluation. MRI serves as an additional tool to exclude or identify injuries when initial findings are equivocal. It is essential to recognize the unique anatomy and biomechanics of the pediatric spine and thus discern common pediatric CSI patterns and their mimics.

[Posttraumatic vertebral disc alterations after B and C type spinal injuries in childhood-Clinical and radiological 10-year results for two cases]

Pediatric traumatic vertebral injuries usually present as stable A (AOspine classification) fractures, whereas B and C injuries are relatively uncommon. In contrast to adults the appropriate treatment strategy in children remains an issue of debate.The data from two pediatric patients admitted with B and C type spinal injuries in 2007 and 2008 were retrospectively analyzed. The initial diagnostics were performed via computed tomography (CT) and an additional magnetic resonance imaging (MRI) was carried out in one case.The clinical and radiological follow-up controls were carried out after 77 and 66 months as well as 123 and 112 months, respectively. In both cases thoracolumbar MRI scans revealed degenerative alterations of the ventral half of the L1/L2 disc with a regular disc signal in the dorsal segment at the first follow-up and a progressive disc degeneration in one patient at the second follow-up.Surgical treatment of pediatric B and C type injuries via open reduction and temporary monosegmental posterior screw and rod instrumentation results in satisfactory clinical and radiological outcomes. In the absence of vertebral burst fractures, the function and stability of discoligamentous injuries in children can be restored without any additional osseous fusion.

[Diagnostics and treatment of cervical spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]

BACKGROUND

Severe cervical spine injuries in children under the age of 17 years are rare. Recommendations or even guidelines for the diagnostics and treatment of such injuries in children are currently not available.

OBJECTIVE

The aim of the study was to formulate recommendations for diagnostics and treatment of injuries of the cervical spine in pediatric patients.

MATERIAL AND METHODS

First, a search of primary and secondary literature on the topic complex of diagnostics and treatment of cervical spine injuries in children was carried out. An appropriate internal literature database was defined and maintained. Second, within the framework of 9 meetings from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) systematically formulated recommendations for the diagnostics and treatment of injuries of the cervical spine in pediatric patients by a consensus process.

RESULTS

Recommendation for the diagnostics and treatment for injuries of the cervical spine could be formulated for three age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). The diagnostic and therapeutic principles known from adult patients suffering from injuries to the cervical spine cannot be easily transferred to pediatric patients.

CONCLUSION

Injuries to the pediatric spine are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. Classification systems and therapeutic recommendations for injuries to the cervical spine known from adult patients could also be used for adolescent patients. This is not possible for children under the age of 10 years. Only few classification systems exist for this age group. Basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical relationships as well as the protection of all neural structures.

[Pediatric spine trauma-Results of a German national multicenter study including 367 patients]

BACKGROUND

In general, pediatric spinal injuries are rare. No reliable data on the epidemiology of spinal injuries in pediatric patients in Germany are available. Especially in pediatric patients, for whom the medical history, clinical examination and the performance of imaging diagnostics are difficult to obtain, all available information on a spinal injury must be taken into account.

OBJECTIVE

The aim of this study was to provide epidemiological data for pediatric patients with spinal trauma in Germany in order to enhance future decision-making for the diagnostics and treatment of these patients.

MATERIAL AND METHODS

Within the framework of a national multicenter study, data were retrospectively obtained from 6 German spine centers for 7 years between January 2010 and December 2016. In addition to the demographic data, the clinical databases were screened for specific trauma mechanisms, level of injury as well as accompanying injuries. Furthermore, diagnostic imaging and the treatment selected were also analyzed.

RESULTS

A total of 367 children (female: male = 1:1.2) with a total of 610 spinal injuries were included in this study. The mean age was 12 years (±3.5 years). The most frequent trauma mechanisms were falls from <3 m and traffic accidents. The imaging diagnostics were only rarely carried out with the child under anesthesia. Younger children (0-9 years old) suffered more injuries to the cervical spine, whereas injuries to the thoracic and lumbar spine were more frequently found in older children (>10 years old). The children frequently showed accompanying injuries to the head and the extremities. Accompanying spinal injuries mostly occurred in adjacent regions and only rarely in other regions. Around 75% of the children were treated conservatively.

CONCLUSION

The results were different from the knowledge obtained from adult patients with spinal trauma and describe the special circumstances for pediatric patients with spinal trauma. Despite certain limitations these facts may help to enhance future decision-making for the diagnostics and treatment of these patients.

[Diagnostics and treatment of thoracic and lumbar spine trauma in pediatric patients : Recommendations from the Pediatric Spinal Trauma Group]

BACKGROUND

Spinal injuries in pediatric patients are overall very rare. Current reference studies including large patient numbers that enable the formulation of evidence-based recommendations on diagnostics and treatment of these injuries do not exist.

OBJECTIVE

The aim of the current study was to formulate recommendations on the diagnostics and treatment for injuries of the thoracic and lumbar spine in pediatric patients.

MATERIAL AND METHODS

Firstly, a search for primary and secondary literature on the topic of diagnostics and treatment of spinal injuries in children was carried out. From this, a literature database was established and maintained. Secondly, within the framework of 9 meetings in the time period from April 2017 to December 2019 the members of the Pediatric Spinal Trauma Group of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU) documented recommendations on diagnostics and treatment of injuries of the thoracic and lumbar spine in pediatric patients by a consensus process.

RESULTS

Recommendations on the diagnostics and treatment of injuries of the thoracic and lumbar spine could be given for 3 age groups (age group I: 0-6 years; age group II: 7-9 years; age group III: 10-16 years). Diagnostic and therapeutic principles known from adult patients suffering from injuries to the thoracic or lumbar spine cannot easily be transferred to pediatric patients.

CONCLUSION

Spinal injuries in childhood are rare and should be treated in specialized spine centers. Pediatric patients with a stable cardiopulmonary status should undergo magnetic resonance imaging (MRI) if a spinal trauma is suspected. The basic principles of the treatment of spinal trauma in children is the restoration of spinal stability and correct anatomical parameters as well as the protection of all neural structures. The potential for correction and regeneration of the individual spinal sections depending on the age of the patient must be considered for deciding between operative vs. conservative treatment. Whenever operative treatment is needed, it should be performed by minimally invasive techniques as a sole instrumentation without spondylodesis. An early removal of the screw-rod-system should be performed.

Evaluation and management of paediatric and adolescent back pain: Epidemiology, presentation, investigation, and clinical management: A narrative review

This narrative review will summarise a clinical approach to the investigation of back pain in children and adolescent patients, including a discussion of the epidemiology, presentation, investigation and clinical management of back pain in children and adolescents. This will assist the prompt and accurate diagnosis of spinal disorders that require significant medical intervention. Existing evidence suggests a relatively high incidence of non-specific back pain among young people; 27-48% of presentations of back pain in children and adolescents are attributed to non-specific back pain. Low back pain among schoolchildren is often linked to psychosocial factors and only occasionally requires medical attention, as pain is benign and self-limiting. Nonetheless, those young patients who seek medical assistance exhibit a higher incidence of organic conditions underlying the major symptom of spinal pain. A cautious and comprehensive strategy - including a detailed history, examination, radiographic imaging and diagnostic laboratory studies - should be employed, which must be accurate, reliable, consistent and reproducible in identifying spinal pathologies. A specific diagnosis can be reached in 52-73% of the cases. For cases in which a specific diagnosis cannot be made, re-evaluation after a period of observation is recommended. At this later stage, minor symptoms unrelated to underlying pathology will resolve spontaneously, whereas serious pathologies will advance and become easily identified.

Surgical Management of Pediatric Spine Trauma: 12 Years of Experience

OBJECTIVE

Spine trauma management in children varies from one team to another, and to date, no clear consensus has been reached. The goal of this study was to describe the epidemiology of spine trauma in children and evaluate the timing and techniques of surgery when it was required.

METHODS

A retrospective review of all patients admitted to our pediatric trauma center for spine traumas that required surgical management, between 2005 and 2016, was performed. All patients were followed with clinical and radiologic examination to evaluate the quality of fusion and realignment.

RESULTS

Seventy-three children, with a mean age of 14.1 years, were admitted. Spinal injuries were more common in the teenage group (14-18 years). The predominant etiology of spine injuries was motor vehicle collision (36%). The spinal level of injury varied according to the age group: young children presented more cervical traumas (P < 0.01), while teenagers presented more lumbar traumas. There were more fractures alone in the teenage group (P < 0.005), while there were more luxations alone in the school-age group (P < 0.05). Median timing for surgical intervention in patients with neurologic deficits was 1 day. Patients with posterior wall recession >5 mm underwent surgical management quicker than patients with no posterior wall recession (P < 0.03). At follow-up, out of the 37 patients with initial neurologic deficits, 14 had improved (38%).

CONCLUSIONS

Diskoligament maturation is an essential concept in spine traumas in children, as well as in surgical management. Surgical procedures should be carried out as soon as possible when patients present with neurologic deficits. At the thoracolumbar junction, a 2-level up-and-down fixation is recommended.

Spine Injuries in Child Abuse

BACKGROUND

Although rare, spinal injuries associated with abuse can have potentially devastating implications in the pediatric population. We analyzed the association of pediatric spine injury in abused children and determined the anatomic level of the spine affected, while also focusing on patient demographics, length of stay, and total hospital charges compared with spine patients without a diagnosis of abuse.

METHODS

A retrospective review of the Kids' Inpatient Database was conducted from 2000 to 2012 to identify pediatric patients (below 18 y) who sustained vertebral column fractures or spinal cord injuries. Patients with a documented diagnosis of abuse were identified using ICD-9-CM diagnosis codes. Our statistical models consisted of multivariate linear regressions that were adjusted for age, race, and sex.

RESULTS

There were 22,192 pediatric patients with a diagnosis of spinal cord or vertebral column injury during the study period, 116 (0.5%) of whom also had a documented diagnosis of abuse. The most common type of abuse was physical (75.9%). Compared with nonabused patients, abused patients were more likely to be below 2 years of age (OR=133.4; 95% CI, 89.5-198.8), female (OR=1.67; 95% CI, 1.16-2.41), and nonwhite (black: OR=3.86; 95% CI, 2.31-6.45; Hispanic: OR=2.86; 95% CI, 1.68-4.86; other: OR=2.33; 95% CI, 1.11-4.86). Abused patients also presented with an increased risk of thoracic (OR=2.57; 95% CI, 1.67-3.97) and lumbar (OR=1.67; 95% CI, 1.03-2.72) vertebral column fractures and had a multivariate-adjusted mean length of stay that was 62.2% longer (P<0.001) and mean total charges that were 52.9% higher (P<0.001) compared with nonabused patients. Furthermore, 19.7% of all pediatric spine patients under 2 years of age admitted during the study period belonged to the abused cohort.

CONCLUSIONS

Spine injuries are rare but can be found in the pediatric population. With an additional documented diagnosis of abuse, these injuries affect younger patients in the thoracolumbar region of the spine, and lead to longer lengths of stay and higher hospital costs when compared with nonabused patients. Because of these findings, physicians should maintain a higher level of suspicion of abuse in patients with spine injuries, especially patients under 2 years of age.

LEVEL OF EVIDENCE

Level III evidence-a case-control study.

Cervical and thoracic spine injury in pediatric motor vehicle crash passengers

OBJECTIVE

Motor vehicle occupants aged 8 to 12 years are in transition, in terms of both restraint use (booster seat or vehicle belt) and anatomical development. Rear-seated occupants in this age group are more likely to be inappropriately restrained than other age groups, increasing their vulnerability to spinal injury. The skeletal anatomy of an 8- to 12-year-old child is also in developmental transition, resulting in spinal injury patterns that are unique to this age group. The objective of this study is to identify the upper spine injuries commonly experienced in the 8- to 12-year-old age group so that anthropomorphic test devices (ATDs) representing this size of occupant can be optimized to predict the risk of these injuries.

METHODS

Motor vehicle crash cases from the National Trauma Data Bank (NTDB) were analyzed to characterize the location and nature of cervical and thoracic spine injuries in 8- to 12-year-old crash occupants compared to younger (age 0-7) and older age groups (age 13-19, 20-39).

RESULTS

Spinal injuries in this trauma center data set tended to occur at more inferior vertebral levels with older age, with patients in the 8- to 12-year-old group diagnosed with thoracic injury more frequently than cervical injury, in contrast to younger occupants, for whom the proportion of cases with cervical injury outnumbered the proportion of cases with thoracic injury. With the cervical spine, a higher proportion of 8- to 12-year-olds had upper spine injury than adults, but a substantially lower proportion of 8- to 12-year-olds had upper spine injury than younger children. In terms of injury type, the 8- to 12-year-old group's injury patterns were more similar to those of teens and adults, with a higher relative proportion of fracture than younger children, who were particularly vulnerable to dislocation and soft tissue injuries. However, unlike for adults and teens, catastrophic atlanto-occipital dislocations were still more common than any other type of dislocation for 8- to 12-year-olds and vertebral body fractures were particularly frequent in this age group.

CONCLUSIONS

Spinal injury location in the cervical and thoracic spine moved downward with age in this trauma center data set. This shift in injury pattern supports the need for measurement of thoracic and lower cervical spine loading in ATDs representing the 8- to 12-year-old age group.

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.

Epidemiology of spinal injury in childhood and adolescence in the United States: 1997-2012

OBJECTIVE There has been no successful study of trends in population-based incidences of pediatric spinal injury in the United States. The goal of the current study was to develop robust data to correct this deficiency in contemporary trauma epidemiology. METHODS Discharges coded for spinal injury were extracted from the Kids' Inpatient Database for 1997, 2000, 2003, 2006, 2009, and 2012 for patients younger than 18 years. Childhood was defined as ages 0 through 14 years and adolescence as ages 15, 16, and 17 years. Denominator population data were taken from the website of the US Census. Annual incidences were estimated for hospitalization for spinal injury, spinal cord injury (SCI), and hospital death with spinal injury. Mechanistic and anatomical patterns of injury were studied. RESULTS The annual population-based incidences of hospitalization for spinal injury, SCI, and death with spinal injury trended downward from 1997 to 2012 for children and adolescents in the United States. Rates of SCI and death fell faster than overall hospitalization rates, suggesting lower thresholds for admission or greater diagnostic sensitivity to minor injuries over time. The incidence of hospitalization for spinal injury was roughly 8 times greater for adolescents than for children, and the incidence of SCI was roughly 6 times greater. Motor vehicle crash predominated among mechanisms for both children and adolescents, but penetrating injuries and sport injuries were more commonly associated with SCI. Lumbosacral injuries predominated in both children and adolescents, but injuries of the cervical spine were more commonly associated with SCI. CONCLUSIONS Further research is needed to identify the cause or causes of the observed decline in injury rates. Epidemiological data can inform and support prevention efforts.

Epidemiology of vertebral fractures in pediatric and adolescent patients

Spinal injuries in children and adolescents are rare injuries, but consequences for the growing skeleton can be devastating. Knowledge of accident causes, clinical symptoms and diagnostics should be part of every trauma department treating these patients. We retrospectively analyzed patients with radiographically proven vertebral fractures of the spine. After clinical examination and tentative diagnosis the fractures and injuries were proven with conventional X-ray, computed tomography (CT) scans or magnetic resonance imaging (MRI). The study included 890 fractures in 546 patients with an average age of 12.8±6.2 (6.6-19.4) years. Females had an average age of 13.7±6.3 (7.4-20.0) years, whereas males were on average 12.0 (6.0-18.0) years old. Fall from height (58%) was the main cause of accident and the most common region of fracture was the thoracolumbar spine with a shift towards the thoracic spine the more fractures occurred. Merely 3.7% of all patients required operative treatment. If a vertebral fracture is found in children and adolescents, it is highly recommended to exclude synchronous additional spine fractures in other levels; prevention should concentrate on fall and traffic accidents.

Instrumented cervical spinal fusions in children: indications and outcomes

PURPOSE

To report indications, outcomes and complications of instrumented cervical spinal fusion in a consecutive series of children at major university hospitals.

METHODS

A retrospective, single surgeon series identified 35 consecutive children with a mean follow-up (FU) of 2.5 years undergoing instrumented cervical spinal fusion between 2005 and 2015.

RESULTS

The main indications were skeletal dysplasia and trauma associated cervical instability. Surgical complications were observed in 12 (34%) patients with multiple complications in four (11%). Four (11%) children required at least one revision surgery, three for nonunion and one for graft dislodgement. All were fused at FU. Surgical complications were more common in children undergoing occipitocervical (OC) fusion than in those avoiding fusion of the OC junction (60% versus 24%) (p = 0.043). Complications were found significantly more in children operated on under the age of ten years than above (50% versus 18%) (p = 0.004). The risk of complications was not dependent on the indications for surgery (skeletal dysplasia versus trauma) (p = 0.177).

CONCLUSION

Skeletal dysplasia associated cervical instability and cervical spine injuries represented the most common indications for instrumented cervical spinal fusion in children. Complications were observed in one-third of these children and 11% required revision surgery for complications. OC spinal fusion and spinal fusion before the age of ten years are associated with higher risk of surgical complications and increased mortality than non-OC fusions and cervical spinal fusions at an older age. We urge surgeons to employ caution to the patient, timing and procedure selection when treating paediatric cervical spine.

Imaging in paediatric spinal injury

Background

Paediatric spinal injury is rare and exhibits many unique features. Attending clinicians and radiologists often lack knowledge, expertise and experience in dealing with a potential injury to the paediatric spine. Within the paediatric age range itself there are different age-dependent mechanisms that can injure the paediatric spine. Moreover, the anatomical features and degree of osseous maturity of the developing paediatric spine determine the biomechanical characteristics which promote unique patterns of spinal injury in each paediatric age group.

Methods

An expert illustrated narrative review of the literature.

Results

Multiple factors make the imaging interpretation of the injured paediatric spine challenging. Each imaging modality has strengths and weaknesses in depicting spinal anatomy which vary with the type of spinal injury and age of the paediatric patient.

Conclusions

Attending doctors need to be familiar with the imaging appearances of the normal paediatric spine, its normal variants as well as the imaging features characteristics of paediatric spinal injury seen on radiographs, computed tomography and magnetic resonance imaging.

[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 thoracic SCIWORA after back bend during dance practice: a retrospective case series and analysis of trauma mechanisms

PURPOSE

The purpose of the study was to describe a unique type of low-energy traumatic pediatric thoracic spinal cord injury without radiographic abnormality (SCIWORA) after a back bend during dance practice and analyze the trauma mechanisms and treatment protocols.

METHODS

This was a retrospective case series from September 2007 to August 2016. The study was conducted at a tertiary medical center in Beijing, China (Xuanwu Hospital, China International Neuroscience Institute [China-INI], Capital Medical University). A total of 12 pediatric patients who had a clear traumatic history after back bend movements and had been diagnosed with thoracic SCIWORA were included. Clinical and imaging data were obtained for each patient. The follow-up data was analyzed. The traumatic mechanisms were investigated by analyzing the patients' medical history, spinal diffusion tensor imaging (DTI) and fiber tractography data.

RESULTS

Of the 12 patients, 11 (91.7%) were younger than 8 years old. The mean age of the patients was 6.6 years. All patients had a clear traumatic history of severe thoracic spinal cord injury after performing back bend movements. The mean follow-up time was 36.5 months. During the follow-up period, 1 patient (8.3%) recovered completely, and 11 patients (91.7%) had unfavorable prognoses, including 4 (33.3%) with incomplete recovery and 7 (58.3%) with no change. Two patients underwent spinal DTI, which showed rupture of the nerve fiber bundle in the section of the injury.

CONCLUSIONS

Back bend movements performed during dance practice may cause pediatric thoracic SCIWORA, particularly in children younger than 8 years old. We suggest that the mechanism of primary injury is the longitudinal distraction of the thoracic spine during back bend movements, which leads to violent distraction of the spinal cord and blunt injury of nerve axons, nerve cells, and small vessels. Spinal DTI may facilitate the diagnosis and prognostic evaluation of SCIWORA.