Fractures of the Spine in Children Vahid Farsio , MD SINA HOSPITAL

Important Pediatric Differences Anatomical differences Radiologic differences Increased elasticity

Anatomy – C1 3 ossification centers at birth – body and 2 neurocentral arches Neurocentral synchondroses (F) fuse at about 7 years of age Copley. Cervical spine disorders in infants and children. J Am Acad Orthop Surg. 1998;6:204.

Anatomy – C2 4 ossification centers at birth – body, 2 neural arches, dens Neurocentral synchondroses (F) fuse at age 3-6 years Synchondrosis between body and dens (L) fuses age 3 – 6 years Thus no physis / synchondrosis should be visible on open mouth odontoid view in child older than 6 years Copley. Cervical spine disorders in infants and children. J Am Acad Orthop Surg. 1998;6:204.

Anatomy – Lower Cervical Vertebrae C3 – C7 Neurocentral synchondroses (F) fuse at age 3-6 years Ossified vertebral bodies wedge shaped until square at about age 7 Copley. Cervical spine disorders in infants and children. J Am Acad Orthop Surg. 1998;6:204.

Epidemiology of Spinal Trauma in Children Spinal injury is rare in children Pediatric vertebral injuries occur 60-80% of the time in the cervical region (30-40% of all vertebral injuries in adults) Overall incidence of spinal injury in children is 1-2% Motor Vehicle Accidents are the leading cause of pediatric SCI (60% of cases)…with falls and sports injuries (football and diving) thereafter M:F ratio of 2:1

Pediatric vs. Adult Spine Anatomy ……..Not just little adults! Children younger than 8yrs are more susceptible to C-spine injuries because; Larger head to body proportion Higher fulcrum……. “point of maximal mobility” (C2-3 at birth, C3-5 at 8-12yrs old to C5-6 at 12yrs old and adults) Weaker cervical musculature Increased ligamentous laxity leading to greater mobility of the c-spine Immature joints and Ossification centers Horizontal facet joints that facilitate sliding of the upper C-spine Spinal columns are more elastic than the spinal cord (tolerating more distraction before rupture……. Thus leading to SCIWORA

Key History and PE Components Cause…. MVA, Sports (Football/Diving), Falls Mechanism….. Hyperflexion (Clay shoveler’s or Teardrop Fx’s), hyperextension (Hangman’s Fx), Rotational (Jumped Facets), Compression or axial loading (Jefferson/Burst Fx) Symptoms….. Numbness, tingling, or weakness during any time since accident even if resolved Predisposing conditions….. 15% Down’s Syndrome pts have atlantoaxial instability, Achondroplasia (Cervicomedullary Junction stenosis) Physical Exam Testing for motor or sensory deficits and levels if present DTR’s and rectal tone High index for Multisystem trauma (40% of cases have associated intrabdominal injuries)

C Spine Immobilization for Transport in Children Large head will cause increased flexion of C spine on standard backboard Bump beneath upper T spine or cutout in board for head to transport child with spine in neutral alignment

Imaging Evaluation of Spine Injuries Are Xrays indicated? NEXUS Study Criteria Lateral, AP and Odontoid view Flexion-Extension views CT C-spine MRI

anterior wedging of vertebral bodies horizontal alignment of facet joints Children prone to anterior dislocation Young Child Mature

Alignment - Pseudosubluxation 24% C2 on C3 14% C3 on C4 (Age <7 years) Swischuk’s line: posterior arch of C1 to C3 – should come within 1 mm of post arch of C2

C2-3 Pseudosubluxation Look for significant prevertebral soft tissue Shaw. Pseudosubluxation of C2 on C3 in polytraumatized children: Prevalence and significance. Clin Radiol 1999;54: 377.

Dens Predental space – allow up to 5 mm in young children Subdental synchondrosis - lucency at base of dens Dens fuses with body of C2 between ages 4 - 6 years A thin lucency may be appreciable on the lateral view for many years (50% up to age 11) May have ossification centre at tip of dens os terminale

Prevertebral Soft Tissues Allowable thickness changes with age In general: Above glottis: ½ vertebral body Below glottis: 1 vertebral body Often falsely thickened 2° to neck flexion (big occiput) or expiration

L abnormal, R normalized with repositioning. Optimal if pt neck extended (and x ray taken at END inspiration – less false +).

Cervical Spine Injuries from Birth Trauma Can occur Upper cervical injuries may be a cause of perinatal death Newborn with C5/6 fracture dislocation

Os Odontoideum Usually asymptomatic Pain , mylopathy instability Fielding. Os odontoideum. J Bone Joint Surg Am 1980;62:376.

Atlanto-Occipital Dislocation 2.5 x more common in children than adults Due to small occipital condyles and horizontal atlanto-occipital joints Suspect if distance between occipital condyles and C1 is > 5mm at any point Usually have ++ soft tissue swelling

Dens Fracture Suspicious for dens fracture: widening of the synchondrosis anterior tilting of the odontoid Believed to have high miss rate – can lead to chronic problems

Hangman’s Fracture The hangman's fracture i Pseudosubluxation !!

Spinal Cord Injury Without Radiographic Abnormality SCIWORA Defined as traumatic myelopathy in the absence of findings on plain radiographs, flexion-extension radiographs and cervical CT scan mechanism is acceleration-deceleration or rotation injury 30-50% delayed onset of neurologic deficits from 30mins-4 days MRI should be done require immobilization Mild SCIWORA : Cervical cord neurapraxia

Thoracic Spine Fractures Less common spinal fracture in children than in more mobile regions Child abuse in very young Slotkin. Thoracolumbar spinal trauma in children. Neurosurg. Clin. N. Am. 2007;18:621.

Thoracolumbar Junction Injuries T11-L2 Classically lap-belt flexion-distraction injuries Chance fractures and variants High association with intraabdominal injury (50-90%) Neurologic injury infrequent but can occur Arkader. Pediatric chance fractures: a multicenter perspective. J Pediatr Orthop. 2011;31:741.

Seatbelt Injury Classification Rumball. Seat-belt injuries of the spine in young children. J Bone Joint Surg Br. 1992;74:571.

4 year Lap Belt Intraabdominal Injuries, Paraplegic

Lumbar Apophyseal Injuries Slipped Apophysis Compression-shear injuries Same age group as SCFE Typically adolescent males, inferior endplates of L4 or L5

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