Pediatric spinal cord and vertebral column injury

Clinical characteristics of pediatric traumatic spinal cord injury in China: A single center retrospective study

OBJECTIVE

To investigate the clinical characteristics of children with traumatic spinal cord injury (SCI) admitted to a research rehabilitation center between 2011 and 2020, with a view to generate crucial data for understanding and prevention of pediatric traumatic SCI.

DESIGN

Retrospective cohort study.

SETTING

The National Rehabilitation Research Center of China, Beijing, China.

PARTICIPANTS

Medical records and imaging data of children with traumatic SCI admitted to the rehabilitation research center from 2011 to 2020.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Data on age, sex, cause of injury, neurological level of injury, impairment scale of SCI and details of spine fracture or dislocation were all collected and analyzed.

RESULTS

A total of 351 patients were included in the study, including 133 males (37.9%) and 218 females (62.1%). There were 231 cases (65.8%) without spine fracture or dislocation. SCI without fracture or dislocation (SCIWORA) was the most common in children between the age of 5 and 14 years (77.9%), and injuries caused by sports were the most common in girls (90.8%). Among sports injuries, those due to a special dance movement called "Xia-Yao" in Chinese, which involves hyperextension of the trunk, constituted the majority, with the neurological level of injuries located predominantly in the middle (34.6%) and lower (44.2%) thoracic levels.

CONCLUSION

Girls between the ages of 5 and 14 years constituted the majority of SCIWORA injuries at the thoracic levels, which were caused mainly by "Xia-Yao". Overall, careful attention should be paid to prevent this kind of injury in children.

Pediatric spinal instrumentation

This article reviews the evolution of spinal instrumentation in the pediatric age group, starting with the cervical spine and atlantoaxial area and ending with the lower spine. The congenital and the acquired conditions which require instrumentation are described. The technical details regarding pediatric instrumentation are alluded to, and finally an attempt is made to predict the future of spinal instrumentation in this age group.

Pediatric spinal cord injury with radiographic abnormality: the Beijing experience

BACKGROUND CONTEXT

Spinal cord injury (SCI) without radiographic abnormality (SCIWORA) is a syndrome that usually occurs in children primarily because of the unique biomechanics of the pediatric spine. We recently found that the histopathological and behavioral effects of SCI with radiographic abnormality (SCIWRA) and SCIWORA are very different from each other in animal models. Although numerous studies were conducted to understand the epidemiological and clinical characteristics of the overall pediatric SCI population and the pediatric SCIWORA population, the characteristics of the pediatric SCIWRA population and their differences from those of the SCIWORA population are poorly understood.

PURPOSE

To describe the epidemiology and clinical outcomes of pediatric patients with SCIWRA and their differences from those with SCIWORA.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

A total of 47 pediatric SCIWRA patients.

OUTCOME MEASURES

Epidemiological characteristics, injury severities, functional deficits, and management and recovery outcomes.

METHODS

Review of all cases with SCIWRA at Beijing Children's Hospital between July 2007 and December 2019 and comparison between the present data and our previous SCIWORA data.

RESULTS

Of the 187 pediatric SCI patients, 47 had SCIWRA (age: 7.06 ± 3.75 years, male-to-female ratio: 3:2). Main causes of SCIWRA were fall (38%) and traffic accidents (38%). Lesions were often located at multiple levels (62%). Incubation period was 3 ± 18 hours. According to the American Spinal Injury Association impairment scale (AIS), many SCIWRA patients had incomplete impairment (AIS B, 9%; AIS C, 9%; AIS D, 32%). Specifically, many of them had abnormal upper and lower limb muscle powers (55% and 60%), upper and lower limb muscle tones (34% and 49%), sensation (38%), and knee, ankle, and abdominal reflexes (47%, 34%, and 36%). 72% of SCIWRA patients were treated with methylprednisolone, dexamethasone, or both. 81% of them showed neurological improvement before discharge. There was no association between corticosteroid therapy and neurological improvement. Moreover, functional outcomes of their upper and lower limb muscle powers were significantly associated with functional outcomes of their upper and lower limb muscle tones (p < 0.01), respectively. In comparison to the SCIWRA population, the SCIWORA population had a higher ratio of younger and female patients of sports-related thoracic injuries with long incubation period leading to lower-body deficits and complete impairment (p<0.05 or p<0.01). Despite all the differences, their neurological improvement was similar (p>0.05).

CONCLUSIONS

Demographic differences exist in the SCIWRA population. Corticosteroids do not appear to be effective in the different types of pediatric SCI. Limb muscle tone may be used to evaluate the functional status of limb muscle power. The epidemiological and clinical characteristics of SCIWRA and SCIWORA are very different from each other. It is important to formulate tailor-made prevention, evaluation, and management strategies for the pediatric population to optimize the SCI outcomes.

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.

Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel

OBJECTIVES

The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel.

METHODS

A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol.

RESULTS

The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful.

CONCLUSIONS

Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.

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.

Temporary Internal Bracing for Pediatric Odontoid Synchondrosis Fracture

Children are predisposed to injuries of the upper cervical spine given their relatively immature osteology, ligamentous laxity, underdeveloped musculature, and larger ratios of head to body mass. Odontoid process fractures involving the synchondroses are among the most common of these injuries. Though many of these fractures can be treated conservatively with external bracing, fractures with significant displacement that are unable to be reduced require operative management. In these cases, most patients undergo C1-2 posterior fusion with arthrodesis with permanent limitation to atlantoaxial range of motion (ROM). Here, we present a novel operative approach to manage odontoid synchondrosis fractures with temporary internal bracing via C1-2 posterior instrumentation without arthrodesis. We saw a three-year-old female who presented after a motor vehicle collision with a displaced odontoid synchondrosis fracture that was unable to be adequately reduced in a closed fashion. In an attempt to preserve maximal atlantoaxial ROM, temporary internal bracing was carried out with excellent results.

An arrow that missed the mark: a pediatric case report of remarkable neurologic improvement following penetrating spinal cord injury

Penetrating spinal cord injuries are rare in children but result in devastating impacts on long-term morbidity and mortality-with little known about the recovery capacity in this age group. We present the case of an eight-year-old child who sustained a penetrating injury through the right anterior thorax. Thoracic CT showed the arrow tip extending through the spinal canal at T6. Neurologic examination revealed no motor or sensory function below T6. The arrow was surgically removed without complications through an anterior-only approach. MRI on post-operative day (POD) 4 showed focal T2 hyperintensity at the T6 spinal cord. Patient was discharged on POD33 with an American Spinal Injury Association (ASIA)-D score and trace voluntary control over bowel and bladder function. Remarkably, four months later, he had near normal bowel and bladder function, with near-intact lower extremity strength and self-sustained ambulation. Follow-up imaging revealed hemicord formation at the level of injury. We review our case of penetrating spinal cord injury in a child and similar reports in the literature. Penetrating thoracic spinal cord trauma portends poor clinical outcomes, particularly when employing available adult prognostic spinal cord injury scoring metrics. Incomplete spinal cord injury, and often-associated spinal shock, can mimic a complete injury-as in our patient, which improved to near-complete motor and sensory restoration of function and resulted in the formation of a split hemicord. This case represents a unique penetrating spinal cord injury with remarkable neurologic recovery, which would advocate against definitive early prognostication in the pediatric population.

Cobbler's Awl Causing a Rare Pediatric Paraspinal Injury Managed Using 3D CT

Pediatric spinal injuries are very uncommon, accounting for a small percentage of all spinal injuries. Domestic accidents such as falling and bumping are frequent events during childhood. In this case report, we present a rare penetrating trauma by a cobbler’s awl at the paraspinal level. The patient was referred to the ED after a needle became impaled into his back due to an accident that occurred at home. The patient’s neurologic assessment was normal. A radiologic study of the patient showed a cobbler’s awl penetrating the paravertebral muscle at the fourth lumbar vertebra level. The needle was removed promptly after an emergency surgical procedure. Postprocedure no complications occurred.

Acute traumatic unilateral cervical C4-C5 facet dislocation in pediatric toddlers

Background

The present study is to highlight the challenges in managing cervical spine injuries in toddlers (less than 4 years of age) without neurological deficit. Cases of unilateral cervical C4–C5 facet dislocation in toddlers are very rare.

Case presentation

A 3-year-old girl suffered cervical spine injury after a motor vehicle collision with unilateral C4–C5 facet dislocation without neurological deficit. Magnetic resonance imaging (MRI) showed no spinal cord injury, Frankel grade E. Initial management was cervical spine protection. Definite treatment and complication were discussed with the patient’s parents before closed reduction maneuver with minerva cast was applied under sedation. The patient showed no complication after closed reduction and the cervical spine had aligned well in radiographs. The minerva cast was removed at 8 weeks, at which point neck muscle stretching rehabilitation program started. At one-year follow up, the child was asymptomatic, had full active cervical motion and good function. In radiographs, the cervical spine had normal alignment and was healed.

Conclusions

Unilateral cervical facet dislocation in toddlers is very rare. Closed reduction maneuver and the minerva cast applied were optional in this case. The parents were highly satisfied with the effective treatment and outcome.

[Development and first application testing of a new protocol for preclinical spinal immobilization in children : Assessment of indications based on the E.M.S. IMMO Protocol Pediatric]

BACKGROUND

To protect the spine from secondary damage, spinal immobilization is a standard procedure in prehospital trauma management. Immobilization protocols aim to support emergency medicine personnel in quick decision making but predominantly focus on the adult spine; however, trauma mechanisms and injury patterns in adults differ from those in children and applying adult prehospital immobilization protocols to pediatric patients may be insufficient. Adequate protocols for children with spinal injuries are currently unavailable.

OBJECTIVE

The aim of this study was (i) to develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) to perform a first analysis of the quality of results if the protocol is used by emergency personnel.

MATERIAL AND METHODS

Based on a structured literature search a new immobilization protocol was developed. Analysis of the quality of results was performed by a questionnaire containing four case scenarios in order to assess correct decision making. The decision about spinal immobilization was made without and with the utilization of the protocol.

RESULTS

The E.M.S. IMMO Protocol Pediatric was developed based on the literature. The analysis of the quality of results was performed involving 39 emergency medicine providers. It could be shown that if the E.M.S. IMMO Protocol Pediatric was used, the correct type of immobilization was chosen more frequently. A total of 38 out of 39 participants evaluated the protocol as helpful.

CONCLUSION

The E.M.S. IMMO Protocol Pediatric provides decision-making support whether pediatric spine immobilization is indicated with respect to the cardiopulmonary status of the patient. In a first analysis, the E.M.S. IMMO Protocol Pediatric improves decision making by emergency medical care providers.

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

CONTEXT

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

EVIDENCE ACQUISITION

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

RESULTS

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

CONCLUSION

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

Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database

Background

The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database.

Methods

The Kids' Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ² for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P < .05.

Results

A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P < .001).

Conclusions

Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines.

Level of Evidence

III.

Clinical Relevance

Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Radiographic morphology of normal ring apophyses in the immature cervical spine

BACKGROUND

The ring apophyses of the cervical spine have a variable appearance that changes with age. The times at which they appear and fuse at each level are not fixed. In this study, we aim to detail normal ranges of appearance of these ossification centers for each age group.

MATERIALS AND METHODS

One hundred and eighty patients under the age of 21 attending the Royal Stoke University Hospital for cervical spine radiographs were retrospectively identified. The presence or absence of ring apophyses at each cervical level and whether these had undergone fusion was reported, as were the thickness, length, and craniocaudal and anteroposterior distance of the apophysis from the vertebral body. The angulation of the apophysis relative to the endplate was also noted.

RESULTS

The youngest patient in which apophyses were seen was aged 3, but apophyses were otherwise rarely seen before the age of 6. All apophyses were present from age 14, and the superior apophyses fused by the age of 18, although unfused inferior apophyses were still seen in the 20-year age group. It was observed that apophyses were rarely separated from the vertebral body by greater than 1 mm in craniocaudal distance (1%) or 2.5 mm in anteroposterior distance (2.6%) and the anterior apophysis was angulated towards the endplate in only 1% of cases.

CONCLUSIONS

We have detailed the range of normal appearances of the ring apophyses of the developing cervical spine. Cervical spine apophyseal injury is thought to be rare, but knowledge of normative morphological features should help in this diagnosis.

Neurophysiological monitoring of displaced odontoid fracture reduction in a 3-year-old male

Introduction

Odontoid fractures in young children are rare. Most authors advocate for closed reduction and external stabilization as first line treatment. Unlike adults, young children are much less amenable to an awake reduction for real-time assessment of neurological function. We used spinal cord monitoring, as used in spine surgery, to assess the function of the spinal cord during the closed reduction in our 31-month-old patient.

Case presentation

A 31-month-old male presented with a displaced odontoid fracture and ASIA C spinal cord injury. Given his age, closed reduction and halo application were completed under general anesthesia guided by neuromonitoring. A less-than-ideal reduction initially was accepted due to a decline in motor-evoked potentials. Subsequently, there was no change in neurological status. The reduction was repeated under anesthesia, with monitoring, a number of times until good correction was achieved. Ultimately, a surgical fusion was required due to ligamentous instability. The child achieved a very good neurological outcome and a stable spine.

Discussion

Neuromonitoring is an important adjunct to closed reductions when complete and reliable neurological assessment is not possible.

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.

Imaging and surgical approach to a pediatric penetrating intradural wooden splinter: case report

Penetrating spinal injuries by wood are infrequently reported. They are particularly rare in children. Only 6 cases of wooden fragments causing penetrating intradural spinal injury have been reported. The authors report a case of a 3-year-old girl who suffered a penetrating wound on her lower back after sliding on a wood floor. A portion of the extraspinal part of the wooden splinter was removed prior to presentation; however, a high suspicion for retained foreign body was maintained. Findings on CT were equivocal, but the diagnosis was confirmed on MRI. An incomplete cauda equina syndrome was noted on examination. She was taken to the operating room for removal of the wooden foreign body, repair of a durotomy, and repair of a CSF leak. At 8 months after surgery, the patient had fully recovered without sequelae. The roles of imaging modalities, prophylactic antibiotics, and surgery are discussed.

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.

What are the trends and demographics in sports-related pediatric spinal cord injuries?

OBJECTIVES

Pediatric spinal cord injury (PSCI) is a devastating injury that can cause significant long-term consequences. The purpose of this study is to calculate and report the prevalence of PSCI, identify risk factors for sports-related PSCI, and evaluate associated factors.

METHODS

The data sets of the Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID) from 2000-2012 were analyzed using ICD-9-CM external cause of injury codes to identify the mechanism of injury contributing to PSCI hospitalization. We then extracted demographic data on each admission including age, gender, race, and year of admission. We further stratified the data by sports-related cases of injury. Multivariate logistic regression analyses were used to identify independent risk factors.

RESULTS

Of our study population, 0.8% had a documented diagnosis of spinal cord injury (SCI). The most common documented external cause of injury code was motor vehicle accidents, representing roughly half of all cases in patients 0-9 years-old (p = 0.001). PSCI due to sports as an external cause of injury was more prevalent in patients 10-17 years old, and was especially prevalent in the 10-13 year-old age category in which sports-related PSCI reached a high of 25.6%. Risk factors for traumatic PSCI after a sports-related external cause included being of older age, male, and white.

CONCLUSIONS

The prevalence of SCI increased with age. Given the popularity of youth sports in the United States, parents and sports officials should be aware of the increased risk of sports-related PSCI among patients 10-17 years old.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Posttraumatic Spinal Cord Injury without Radiographic Abnormality

“Spinal Cord Injury without Radiographic Abnormality” (SCIWORA) is a term that denotes objective clinical signs of posttraumatic spinal cord injury without evidence of fracture or malalignment on plain radiographs and computed tomography (CT) of the spine. SCIWORA is most commonly seen in children with a predilection for the cervical spinal cord due to the increased mobility of the cervical spine, the inherent ligamentous laxity, and the large head-to-body ratio during childhood. However, SCIWORA can also be seen in adults and, in rare cases, the thoracolumbar spinal cord can be affected too. Magnetic resonance imaging (MRI) has become a valuable diagnostic tool in patients with SCIWORA because of its superior ability to identify soft tissue lesions such as cord edema, hematomas and transections, and discoligamentous injuries that may not be visualized in plain radiographs and CT. The mainstay of treatment in patients with SCIWORA is nonoperative management including steroid therapy, immobilization, and avoidance of activities that may increase the risk of exacerbation or recurrent injury. Although the role of operative treatment in SCIWORA can be controversial, surgical alternatives such as decompression and fusion should be considered in selected patients with clinical and MRI evidence of persistent spinal cord compression and instability.

Triage tools for detecting cervical spine injury in pediatric trauma patients

BACKGROUND

Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population.

OBJECTIVES

To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma.

SEARCH METHODS

We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility.

SELECTION CRITERIA

We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy.

MAIN RESULTS

Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity.

AUTHORS' CONCLUSIONS

There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.

Treatment of cervical subaxial injury in the very young child

INTRODUCTION

Infant's cervical spine has serious differences compared to other pediatric age groups and adults. Anatomical and biomechanical constitution of an infant is unique, and the pediatric spine gradually begins to resemble the structure of the adult spine after age 10. In addition, clinical presentation of the cervical spinal traumas has many distinctions from birth to the end of adolescence. In young children, cervical spine traumas are mainly localized in the upper cervical region. Trauma localized in subaxial cervical region and fracture-dislocations are rare in infants.

CASE REPORT

Here, we present a case history of a 7-month-old infant with surgically treated severe subaxial flexion-distraction injury. Neurologic examination revealed complete loss of motor function below C5. A whole-body CT was taken and we observed that C5-6 dislocated anteriorly approximately one vertebra size and also unilateral facet joint was locked. The patient was intubated and closed reduction was attempted with fluoroscopy under general anesthesia, but it was unsuccessful. Whereupon C5-6 microdiscectomy was performed with the anterior approach and fixation was provided with the craniofacial miniplate. Despite anterior stabilization, exact posterior alignment could not been achieved so, posterior approach was added to the surgery. At 12 month follow-up, the patient improved from quadriparesis to paraparesis and we achieved a satisfactory radiological outcome.

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.

Craniovertebral junction injuries in children. A Review

The craniovertebral junction (CVJ) is the most complex and dynamic region of the cervical spine. The wide range of movements possible at this region makes it vulnerable to injury and instability. The special anatomical features make children more prone to injuries of CVJ than adults where lower cervical spine is involved more frequently. The classical clinical manifestation in CVJ injury patients are pyramidal signs including weakness and spasticity, stigmata of CVJ anomalies (short neck, low hair line, facial or hand asymmetry, high arched palate, ), torticolis and neck movement restriction. The history of transient loss of consciousness or sudden neurological deterioration following minor trauma may be elicited. Most authors advocate conservative management (in form of immobilization) of CVJ injuries in children as is true in adults. Halo vest provides superior immobilization in upper cervical and CVJ injuries and can be used in a child as young as 1 year of age with minimal difficulty. Early surgical intervention, i.e. within 2 weeks of injury include is indicated in injuries that cannot be reduced and stabilized by external means, partial spinal cord injury with progressive neurological deficit and in children with extradural hematoma.

Utility of plain radiographs and MRI in cervical spine clearance in symptomatic non-obtunded pediatric patients without high-impact trauma

PURPOSE

The optimal imaging modality for evaluating cervical spine trauma and optimizing management in the pediatric population is controversial. In pediatric populations, there are no well-established guidelines for cervical spine trauma evaluation and treatment. Currently, there is virtually no literature regarding imaging and management of symptomatic pediatric patients who present with cervical spine trauma without high-impact mechanism. This study aims to establish an optimal imaging strategy for this subgroup of trauma patients.

METHODS

We performed a retrospective review of pediatric patients (aged below 18 years) who were admitted to Monash Medical Centre, Melbourne, Australia between July 2011 and June 2015, who did not suffer a high-impact trauma but were symptomatic for cervical spine injury following cervical trauma. Imaging and management strategies were reviewed and results compared.

RESULTS

Forty-seven pediatric patients were identified who met the inclusion criteria. Of these patients, 46 underwent cervical spine series (CSS) plain radiograph imaging. Thirty-four cases underwent magnetic resonance imaging (MRI) and 9 patients underwent CT. MRI was able to detect 4 cases of ligamentous injury, which were not seen in CSS imaging and was able to facilitate cervical spine clearance in a further two patients whose CSS radiographs were abnormal.

CONCLUSION

In this study, MRI has a greater sensitivity and specificity when compared to CSS radiography in a symptomatic pediatric low-impact trauma population. Our data call in to question the routine use of CSS radiographs in children.

Management and Outcome Analysis of Pediatric Unstable Thoracolumbar Spine Injury: Large Surgical Series with Literature Review

Pediatric thoracolumbar spine fractures are considered rare injuries with paucity of publication across the globe. Further, spine injuries in children are comparatively rarer, and pediatric spine differs from adults, both biomechanically and anatomically; so, adult spine management strategy cannot be applied to pediatric cases, and exact guidelines for management of pediatric spinal injury is lacking. The current study is undertaken to study epidemiology, surgical management, and outcome of pediatric dorsolumbar unstable spine injury. A total of 25 pediatric patients were analyzed retrospectively with thoracic, thoracolumbar junction and lumbar spine injuries, who were managed surgically at our institute since June 2008, formed the cohort of the present study. There were 19 males and six females with a mean age 14.8 years. Clinically, complete spinal cord injuries were observed in 11 (44%), and rest 14 had incomplete injury. Most common mode of injury was fall (76%) in contrast to the western countries and the thoracolumbar junction was the most common affected site. Among all patients who underwent surgical intervention, 68% cases had posterior decompression and pedicle screw fixation. Mean duration of hospital stay was 18 ± 31 days. The mean follow-up period was 13.83 ± 5.97 months. In incomplete neurological injury group, a total of 13 patients showed neurological improvement, out of which four cases improved by two Frankel grades, eight patients improved by at least 1 grade, and rest one by Grade 3 (Frankel Grade B to E). Neurological outcome was statistically significant in relation to the level of fracture (P - 0.03) and preoperative Frankel grade, however, other factors, for example, gender, mode of injury, type of fracture, various surgical approaches with instrumentation, and correction of kyphotic deformity were found to be statistically nonsignificant. Surgical management of unstable pediatric dorsolumbar spine is a safe and an effective procedure which can provide good neurological outcome. The current study is one of largest series of cases managed surgically in this part of the world.

Classification and Management of Pediatric Subaxial Cervical Spine Injuries

Appropriate management of subaxial spine injury in children requires an appreciation for the differences in anatomy, biomechanics, injury patterns, and treatment options compared with adult patients. Increased flexibility, weak neck muscles, and cranial disproportion predispose younger children to upper cervical injuries and spinal cord injury without radiographic abnormality. A majority of subaxial cervical spine injuries can be treated nonoperatively. Surgical instrumentation options for children have significantly increased in recent years. Future studies of outcomes for children with subaxial cervical spine injury should focus on injury classification and standardized outcome measures to ensure continued improvement in quality of care for this patient population.

Traumatic spinal injuries in children at a single level 1 pediatric trauma centre: report of a 23-year experience

BACKGROUND

With a reported incidence of up to 10% compared to all spinal trauma, spinal injuries in children are less common than in adults. Children can have spine fractures with or without myelopathy, or spinal cord injuries without radiological abnormalities (SCIWORA).

METHODS

We retrospectively reviewed the cases of children with spinal injuries treated at a level 1 pediatric trauma centre between 1990 and 2013.

RESULTS

A total of 275 children were treated during the study period. The mean age at admission was 12 ± 4.5 years, and the male:female ratio was 1.4:1. Spinal injuries were more common in children of ages 12-16 years, with most injuries among ages 15-16 years. The top 3 mechanisms of spinal injury were motor vehicle-related trauma (53%), sports (28%) and falls (13%). Myelopathy occurred in 12% and SCIWORA occurred in 6%. The most common spine levels injured were L2-sacrum, followed by O-C2. Associated injuries, including head injuries (29%), and fractures/dislocations (27%) occurred in 55% of children. Overall mortality was 3%. Surgical intervention was required in 14%.

CONCLUSION

The creation of a pediatric spinal injury database using this 23-year retrospective review helped identify important clinical concepts; we found that active adolescent boys had the highest risk of spine injury, that noncontiguous spine injuries occured at a rate higher than reported previously and that nonaccidental spine injuries in children are underreported. Our findings also emphasize the importance of maintaining a higher index of suspicion with trauma patients with multiple injuries and of conducting detailed clinical and radiographic examinations of the entire spine in children with a known spinal injury.

Epidemiology of spinal cord injury without radiographic abnormality in children: a nationwide perspective

PURPOSE

To characterize the epidemiology and costs associated with spinal cord injury without radiographic abnormality (SCIWORA) based on patient age.

METHODS

An analysis of data complied for 2012 in the Healthcare Utilization Project KID database (HCUP-KID), which represents a nationwide database of pediatric admissions, was performed. An initial search identified all children diagnosed with SCIWORA based on International Classification of Diseases, 9th edition (ICD-9) codes. Only data on patients aged <18 years were included in the analysis. The associated codes were then searched to identify the cause of injury. Pertinent epidemiologic data were collected from the database, including age, gender, and racial group. Injury level and pattern were determined from the associated ICD-9 codes, as were associated injuries. Hospital data included length of stay, in-hospital mortality, total hospital charges, and primary payer. All data were compiled and stratified based on patient age into three groups: group 1, age 0-3 years; group 2, age 4-10 years; group 3, age 11-17 years. These data were compared using Student's t test and Chi-squared analyses.

RESULTS

A total of 297 patients were identified who met the inclusion criteria. There was a slight predominance of females among the youngest patients (53 %) with a significant dominance of males in the oldest group (72 %) (p < 0.001). The most common race among the patients studied was white (50 %) followed by Hispanic (14 %), Black (12 %), Asian/Pacific Islander (4 %), and Native American (1 %). Overall, the most common cause of injury was sports injuries, which were responsible for 122/297 (41 %) injuries, followed by motor vehicle collisions (26 %). Mechanisms of injury were significantly varied based on age group, with motor vehicle collisions the most common cause in the youngest two age groups and sports injuries the most common in the oldest age group (p < 0.05). The most common location injured was the cervical spine (46 %), with the upper cervical spine most commonly injured, particularly in the younger age groups. Additional injuries were found in 158/297 (53 %) of patients, and these were more common among younger patients. Head trauma was the most common associated injury in all age groups, but the highest rate was found the youngest age groups (p < 0.0001). The average hospital stay for all patients was 13 days, with longer stays seen in younger age groups (p < 0.05). In-hospital mortality was uncommon among these patients and occurred in only 6/297 (2 %) of patients. Hospital charges were highest in the younger age groups, with an average charge of $210,772 for those in the youngest age group, decreasing to $72,178 for those in group 3 (p < 0.0005). The most common payer was public insurance/medicaid in the youngest age group and private insurance in groups 2 and 3 (p < 0.0001).

CONCLUSIONS

SCIWORA is an uncommon but potentially devastating injury in children. As with many pediatric injuries, this injury is heterogeneous between children of differing ages. This analysis of a nationwide series of children with such injuries identified significant differences in injury location, causes of injury, associated injuries, and hospital charges associated with this diagnosis.

Retirement-from-sport considerations following pediatric sports-related concussion: case illustrations and institutional approach

The decision to advise an athlete to retire from sports following sports-related concussion (SRC) remains a persistent challenge for physicians. In the absence of strong empirical evidence to support recommendations, clinical decision making must be individualized and should involve a multidisciplinary team of experts in concussion and traumatic brain injury. Although previous authors have advocated for a more conservative approach to these issues in child and adolescent athletes, there are few reports outlining considerations for this process among this unique population. Here, the authors use multiple case illustrations to discuss 3 subgroups of clinical considerations for sports retirement among pediatric SRC patients including the following: those with structural brain abnormalities identified on neuroimaging, those presenting with focal neurological deficits and abnormalities on physical examination, and those in whom the cumulative or prolonged effects of concussion are suspected or demonstrated. The authors' evolving multidisciplinary institutional approach to return-to-play and retirement decision making in pediatric SRC is also presented.

Peculiarities and Patterns of Cervical Spine Injuries in Children and Adolescents: A Retrospective Series of 84 Patients from a Single Institute

Cervical spine injuries occur infrequently in children but are associated with significant disability and mortality. A retrospective analysis was performed of 84 consecutive pediatric spine injuries treated at our institute from January 2002 to December 2011. The mean age was 14.7 years. There were 18 patients (21%) in group A (0-12 years) and 66 patients (79%) in group B (13-18 years). Overall, injury was more common in boys (ratio of 6:1). Trivial fall was the predominant cause in group A and fall from height in group B. There were 30 children (36%) with injuries of the upper cervical spine, 53 (63%) with injuries of the lower cervical spine and 1 patient (1%) with a combined injury of upper cervical spine and thoracic spine. Overall, 22% of the group A children and 67% of the group B patients had more severe injuries (Frankel grades A, B and C); 21% (18/84) were treated by surgical fusion. Where follow-up was available, 17 out of 22 children (77%) had good outcome (Frankel grade >C). In conclusion, mechanisms and patterns of injury in children are age related and the majority of the children had good outcome.

Spine trauma in very young children: a retrospective study of 206 patients presenting to a level 1 pediatric trauma center

BACKGROUND

The immature spine has anatomic and biomechanical properties that differ from the adult spine and result in unique characteristics of pediatric spinal trauma. Although distinct patterns of spinal injury have been identified in children younger than 10 years of age, little research has explored the differing characteristics of spinal trauma within this age group, particularly in the very young. The purpose of this study is to identify differences in the epidemiology and characteristics of spinal trauma between children under the age of 4 years and those between 4 and 9 years of age.

METHODS

A review of all patients treated for spinal injury at a single large level I pediatric trauma center between 2003 and 2011 was conducted. Demographic data, injury mechanism, neurologic status, and details of any associated injuries were compiled. Radiographic studies were used to determine injury location and fracture classification. The patient population was divided into 2 groups: the infantile/toddler (IT) group (ages 0 to 3 y) and the young (Y) group (ages 4 to 9 y). Data were compared between these groups using the χ2 test and the Student t test to identify differences in injury characteristics.

RESULTS

A total of 206 patients were identified. Fifty-seven patients were between 0 and 3 years of age and 149 were between 4 and 9 years old. Although motor vehicle collision was the most common cause of injury in both the groups, nonaccidental trauma was responsible for 19% of spine trauma among patients aged 0 to 3 years. Cervical spine injuries were much more common in the youngest patients (P<0.05) with injuries primarily in the upper cervical spine. Children in the IT group were more likely to sustain ligamentous injuries, whereas Y patients had more compression fractures (P<0.05). Neurologic injury was common in both the groups with IT patients more often presenting with complete loss of function or hemiplegia and Y patients sustaining more spinal cord injuries (P<0.05). IT patients had a 25% mortality rate, which was significantly higher than that of the Y group (P=0.005).

CONCLUSIONS

This study shows many significant differences in characteristics of spinal injury in infants/toddlers when compared with older children. These differences can help guide diagnostic evaluation and initial management, as well as future prevention efforts.

LEVEL OF EVIDENCE

Level III.

Highly unstable cervical spine injury in an infant: a case report

Although the rate of surgical intervention for pediatric cervical spine injuries has risen, none of these instrumentation techniques has been reported in children less than 1 year of age. Additional consideration with placement of wires or cables is not safe because of the presence of cartilaginous bone and poor bone strength. The authors report a technique of internal fixation without fusion using nonabsorbable synthetic suture in an infant with unstable cervical injury.

METHODS

A 5-month-old girl was transported to emergency department and computed tomography showed severe distraction injury at the C6-7 level with total disruption of the facet joints bilaterally. To improve her general condition, she was placed in a customized occipito-cervical brace until surgical stabilization could be performed. After 1 month, surgical fixation was performed. After removing all soft tissues at the appropriate level, a hole was made in the center of the superior articular process of C6. A nonabsorbable suture (2-0 Ethibond; Ethicon, Somerville, NJ, USA) was passed from the superior articular process to the facet joint. The suture was passed into the spinous process of the lower level, and it was progressively tightened and radiographs were taken until anatomic reduction was achieved.

RESULTS

After surgery, solid fusion was achieved. She was able to sit up in a stroller after 6 months.

CONCLUSION

As surgical treatment of pediatric cervical spine injuries is unsuitable for infants, the Ethibond sutures are strong enough to hold and stabilize the spine. This suturing technique can be used as an alternative treatment for cervical injury in infants.

Operative management of traumatic cervical spine distraction and complete cord transection in a 3-year-old patient

This report describes the presentation and operative treatment of a 3-year-old boy who survived a motor vehicle accident that resulted in a C6-7 distraction injury, complete avulsion of the spinal cord, and gross spinal instability. Only 5%-10% of all spinal cord and vertebral column injuries occur in children. Survival after such an injury is exceptionally rare in very young patients and is associated with severe neurological deficits. The authors discuss the substantial ethical challenges involved in the care of a patient with this injury. To their knowledge, only two other cases of survival have been reported in pediatric patients following motor vehicle trauma resulting in complete injury to the lower cervical spinal cord.

Disabling Orthostatic Headache after Penetrating Stonemason Pencil Injury to the Sacral Region

Penetrating injuries to the spine, although less common than motor vehicle accidents and falls, are important causes of injury to the spinal cord. They are essentially of two varieties: gunshot or stab wounds. Gunshot injuries to the spine are more commonly described. Stab wounds are usually inflicted by knife or other sharp objects. Rarer objects causing incidental spinal injuries include glass fragments, wood pieces, chopsticks, nailguns, and injection needles. Just few cases of penetrating vertebral injuries caused by pencil are described. The current case concerns a 42-year-old man with an accidental penetrating stonemason pencil injury into the vertebral canal without neurological deficit. After the self-removal of the foreign object the patient complained of a disabling orthostatic headache. The early identification and treatment of the intracranial hypotension due to the posttraumatic cerebrospinal fluid (CSF) sacral fistulae were mandatory to avoid further neurological complications. In the current literature acute pattern of intracranial hypotension immediately after a penetrating injury of the vertebral column has never been reported.

Characteristics of spinal injuries secondary to nonaccidental trauma

BACKGROUND

Nonaccidental trauma (NAT) is considered an uncommon cause of spine trauma in the pediatric population. Little has been published on such injuries and no large series is available in the literature. The purpose of this study is to describe the incidence and characteristics of spine trauma secondary to NAT.

METHODS

An IRB-approved retrospective review of all patients presenting to a single level 1 pediatric trauma center with a spinal injury between 2003 and 2011 was performed. Patients were identified using our institution's trauma registry. Medical records were reviewed to identify all spine injuries that occurred as a result of NAT. These cases were reviewed for details regarding injury mechanism, type and location of injury, associated injuries, and the treatment. Our institution's NAT database was also queried to identify the total number of patients formally determined to have sustained any injury as a result of NAT during the same period.

RESULTS

NAT was the cause of 11/342 (3.2%) spine injuries diagnosed during the study period. A total of 726 cases of NAT were identified, with spine injury present in 1.5%. All patients with spine trauma secondary to NAT were under the age of 2 years with an average age of 7 months. Among patients below 2 years with spinal trauma, NAT was tied as the most common mechanism, resulting in 38% of injuries. Eight of the 11 patients' spine injuries were cervical and 7 of these injuries were in the atlanto-occipital and atlantoaxial regions. Multilevel spine trauma was present in 64% of patients. Associated head and thoracic trauma was present in 73% and 36% of patients, respectively. Neurological injury was found in 54% of patients. The majority of injuries were treated nonoperatively and 1 patient required surgical management.

CONCLUSIONS

NAT represents a very common yet often overlooked cause of spinal trauma in children under the age of 2 years. Because of its frequency in this age group, clinicians should consider including an assessment of the spine in all young NAT patients. Patients with spinal trauma sustained as a result of NAT must undergo a thorough evaluation for associated injuries remote to the spine, neurological deficit, and multilevel spine injury.

SUMMARY

NAT is a common mechanism of spinal injury in patients below 2 years of age.

Fracture of the anterior arch of atlas after minor trauma of the immature spine postlaminectomy

Torticollis is a common complaint in the pediatric emergency department. Here, we report what we believe to be the first example in a young child of a fracture of the anterior arch of the atlas associated with an acquired, postsurgical defect of the posterior arch. A brief review of pediatric cervical spine injuries and fractures is presented. Atlas laminectomy may predispose patients to isolated atlas fractures even with minor trauma. Those fractures, however, are stable and treated by hard cervical orthosis.

Severe spinal cord injury in craniocervical dislocation. Case-based update

BACKGROUND

Craniocervical distraction injuries, including atlanto-axial dislocation (AAD) and atlanto-ocipital dislocation (AOD), are often associated with severe spinal cord involvement with high morbidity and mortality rates. Many patients with these injuries die at the accident scene, but advances in emergency resuscitation and transport permit that many patients arrive alive to hospitals.

DISCUSSION

Children with craniocervical distraction injuries usually present with a severe cranioencephalic traumatism that is the most relevant lesion at admission. After resuscitation and hemodynamic stabilization, the spinal cord damage appears as the main lesion. Apnea and quadriparesis, or quadriplegia, are usually present at the onset. Early diagnosis and management perhaps decrease life-threatening manifestations of the spinal lesion. But even so, the primary spinal cord insult is often irreversible and precludes obtaining a satisfactory functional outcome.

PATIENTS AND METHODS

We report the findings of four children with craniocervical distraction injuries (AOD and AAD) who presented with severe spinal cord damage. All patients were admitted with respiratory distress or apnea together with significant brain injuries. The medical records pertaining to these patients are summarized in regard to clinical features, management, and outcome.

CONCLUSIONS

In spite of timely and aggressive management, craniocervical injuries with spinal cord involvement continue to have a dismal prognosis. Outcome is closely related to the severity of the initial brain and spinal cord damage and is nearly always fatal in cases of complete spinal cord transection. Priority should be given to life-threatening complications. Ethic issues on indications for surgery deserve a detailed discussion with the children's parents.

Developmental biomechanics of neck musculature

Neck mechanics is central to head injury prevention since it is the musculoskeletal neck, which dictates the position and movement of the head. In the US, traumatic injury is the leading cause of death for children; however prevention is hampered by the lack of data concerning the mechanics of the immature head-and-neck. Thus, the objective of this study was to quantify neck muscle strength and endurance across the maturation spectrum and correlate these with head-and-neck anthropometry. A factorial study was performed on 91 human subjects measuring head-and-neck anthropometry and neck strength and endurance in three bending directions (flexion, extension, and lateral) as a function of age (6-23 years). Using a custom device, neck maximum voluntary contraction (MVC) force was measured in triplicate. Next, neck muscle endurance (sustained effort) was measured as the subjects' ability to maintain 70% of peak force over 30s. Linear regression of peak force and endurance as a function of age revealed each direction to significantly (p<0.0001) increase with age. The MVC force, averaged across all directions and normalized to the adult values, exhibits the following maturation curve: %MVC Force=-0.0879(age)(2)+6.018(age)+8.120. Neck muscle strength, similar between young males and females, becomes disparate in adolescence and adulthood with males exhibiting greater strength. Bending direction differences were also found with extension strength being the greatest regardless of age and sex. Furthermore, neck circumference appears predictive of neck strength and endurance in children. Together, these relationships may facilitate improved design of injury prevention interventions.

Spinal injuries in children

About 5% of spinal injuries occur in children – however the consequences to the society are devastating, all the more so because the cervical spine is more commonly affected. Anatomical differences with adults along with the inherent elasticity of the pediatric spine, makes these injuries a biomechanically separate entity. Hence clinical manifestations are unique, one of which is the Spinal Cord Injury Without Radiological Abnormality. With the advent of high quality MRI and CT scan along with digital X-ray, it is now possible to exactly delineate the anatomical location, geometrical configuration, and the pathological extent of the injury. This has improved the management strategies of these unfortunate children and the role of surgical stabilization in unstable injuries can be more sharply defined. However these patients should be followed up diligently because of the recognized long term complications of spinal deformity and syringomyelia.

Age, sex, and socio-economic status affect the incidence of pediatric spinal cord injury: an eleven-year national cohort study

BACKGROUND

Few studies focus on pediatric spinal cord injury (SCI) and there is little information regarding the cause, anatomic level, and high risk population of SCI in children. This study aims to investigate the incidence and risk factors of pediatric SCI.

METHODS

A nationwide cohort of 8.7 million children aged<18 years in an 11-year period was analyzed for causes, age at injury, anatomic sites, disability, and familial socio-economic factors. Incidence rates and Cox regression analysis were conducted.

RESULTS

A total of 4949 SCI patients were analyzed. The incidence rates of cervical, thoracic, lumbar, and other SCI were 4.06, 0.34, 0.75, and 0.85 per 100,000 person-years, respectively. The proportional composition of gender, age, and socio-economic status of SCI patients were significantly different than those of non-SCI patients (all p<0.001). Male children were significantly more likely to have SCI than females in both the cervical and the other SCI groups [Incidence rate ratio (IRR) = 2.03 and 1.52; both p<0.001]. Young adults and teenagers were also significantly more likely to have SCI than pre-school age children in the cervical SCI (IRR = 28.55 and 10.50, both p<0.001) and other SCI groups (IRR = 18.8 and 7.47, both p<0.001). Children in families of lower socio-economic status were also significantly more likely to have SCI (p<0.05).

CONCLUSIONS

In the pediatric population, the overall SCI incidence rate is 5.99 per 100,000 person-years, with traumatic cervical SCI accounting for the majority. The incidence rate increases abruptly in male teenagers. Gender, age, and socio-economic status are independent risk factors that should be considered.