Childs Nerv Syst DOI 10.1007/s00381-015-2698-2
ORIGINAL PAPER
Management of traumatic spinal injuries in children and young adults Neriman Özkan 1 & Karsten Wrede 1 & Ardeshir Ardeshiri 1,4 & Zeynep Sariaslan 1 & Klaus Peter Stein 1 & Phillip Dammann 1 & Oliver Müller 1 & Adrian Ringelstein 2 & Ulrich Sure 1 & I. Erol Sandalcioglu 1,3
Received: 25 August 2014 / Accepted: 1 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Spinal injuries are rarely seen in pediatric patients and therapeutic options are still poorly defined. The present study is aimed to present our experience with a rather large series of children and young adults suffering from traumatic spinal injury. Patients and methods Between 1990 and 2010, 75 consecutive pediatric patients with spinal injuries were treated in our institution. Mean age was 15 years, ranging from 3 months to 21 years. Radiological findings, treatment strategies, and clinical outcome were evaluated retrospectively and compared with literature. Forty (53.3 %) patients were treated conservatively and 35 patients (47 %) surgically using anterior or posterior approaches. Subgroup analysis was performed depending on age groups, severity of neurological symptoms, and localization. Results Main trauma mechanisms were fall in 24 patients (38 %) and motor vehicle accidents in 21 patients (28 %). Complete neurological deficits were present in 17 individuals (23 %) and incomplete in 36 patients (48 %). Fractures were
most frequently localized at the cervical region (56 %) with predilection of the C 5/6 segment. Odontoid fractures were seen in 10 (13 %) patients. Fractures of the lumbar and thoracic region were rare. Level of injury or clinical course did not differ between the subgroups (≤15 years versus >15 years). Conclusion Nearly three fourths of all radiologically detected spinal injuries are located at the cervical spine. Complete neurological deficits after trauma was associated with a poor outcome, in particular for patients with injuries of the upper cervical spine. The use of autologous bone graft was associated with favorable long-term results and should be considered as the material of first choice for vertebral body and disc replacement. Keywords Pediatric neurosurgery . Injury mechanism . Spinal cord injury . Spinal instrumentation . Pediatric spine . Infant . Adolescence
Introduction
* Neriman Özkan [email protected] 1
Present address: Department of Neurosurgery, University Hospital of Duisburg-Essen, Essen, Germany
2
Institute of Radiology and Neuroradiology, University Hospital of Duisburg-Essen, Essen, Germany
3
Present address: Neurosurgical Department, Klinikum Nordstadt Hannover, Hannover, Germany
4
Present address: Clinic for Spinal Surgery, Schoen Clinic Hamburg Eilbek, Hamburg, Germany
Spinal injuries in children and young adults are rare with an incidence of 2.7 to 9 % of all spinal injuries [1–3]. Given the rarity of this entity, the current literature does not allow the introduction of clinical standards of diagnostics and treatment for these patients [4–7]. Thus, their management remains challenging in terms of radiological assessment, selection of the optimal treatment strategy, and surgical repair, if necessary [1, 8–10]. Pediatric spinal injuries are managed conservatively in most cases [11]. Surgery might only be indicated for unstable injuries with progressive neurological deficit, fractures with dislocation, or progressive deformations with compression of neural structures [2, 8, 10, 12–15].
Childs Nerv Syst
The present study was conducted to review our experience with a large series of pediatric patients, suffering from traumatic spinal injury, consecutively treated in our institution over the last 20 years. Radiological findings, treatment strategies, and clinical outcome were evaluated and compared with literature.
Patients and methods Patients and clinical data Clinical data of 75 consecutive patients suffered from traumatic spinal injury and treated at our institution between 1990 and 2010 were analyzed retrospectively. Patients with congenital spinal anomalies or vertebral body fractures due to tumorous lesions were excluded. Basic demographic data, neurological examination before and after treatment, radiological findings, surgical techniques, complications, and follow-up were assessed. Subgroup analysis was performed for children up to 15 years of age and for young adults between 16 and 20 years. Neurological evaluation The pre- and postoperative neurological status was classified, using the Frankel score in order to achieve a functional grading of impaired daily life activities and gait disturbances [16]. Thus, for each patient, outcome was classified as poor (grade A + B), fair (grade C), or good (grade D + E). The functional outcome was further analyzed according to the etiology, localization, extent, and severity of the spinal cord injury.
In cases of surgery different operative strategies were chosen alone or in combination. The dorsal access included dorsal decompression by hemilaminectomy or laminectomy, with or without additional dorsal instrumentation. Ventral cervical procedures included spondylectomy and stabilization with autologous bone graft or titanium-PEEK cages filled with bioactive material (ATHLET® with KAINOS®, Signus Medizintechnik, Alzenau, Germany) and ventral plate fixation (TOSCA®, Signus Medizintechnik, Alzenau, Germany or CASPARevolution®, Aesculap AG, Tuttlingen, Germany). The autologous bone graft was usually taken from the patients’ pelvis. Ondontoid fractures were treated by either ventral screw fixation or dorsal stabilization. Postsurgical treatment After surgery, an external stabilization with a Philadelphia® collar was utilized for the following 3–6 weeks and carefully mobilization. Halo fixation devices were necessary for postoperative stabilization in complex fractures for 4–8 weeks. CT scans were performed in all cases after surgery with instrumentation in order to evaluate the bony structures and the correct implant placement. Neurological rehabilitation was necessary especially in cases with neurological deficits in the early postoperative period. Statistical analysis Data was analyzed with the SPSS statistical software (SPSS statistical software for Windows release). For statistical analysis, Student’s t test for paired or unpaired variables and chisquare test was taken for normal data distribution. A p value
ORIGINAL PAPER
Management of traumatic spinal injuries in children and young adults Neriman Özkan 1 & Karsten Wrede 1 & Ardeshir Ardeshiri 1,4 & Zeynep Sariaslan 1 & Klaus Peter Stein 1 & Phillip Dammann 1 & Oliver Müller 1 & Adrian Ringelstein 2 & Ulrich Sure 1 & I. Erol Sandalcioglu 1,3
Received: 25 August 2014 / Accepted: 1 April 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose Spinal injuries are rarely seen in pediatric patients and therapeutic options are still poorly defined. The present study is aimed to present our experience with a rather large series of children and young adults suffering from traumatic spinal injury. Patients and methods Between 1990 and 2010, 75 consecutive pediatric patients with spinal injuries were treated in our institution. Mean age was 15 years, ranging from 3 months to 21 years. Radiological findings, treatment strategies, and clinical outcome were evaluated retrospectively and compared with literature. Forty (53.3 %) patients were treated conservatively and 35 patients (47 %) surgically using anterior or posterior approaches. Subgroup analysis was performed depending on age groups, severity of neurological symptoms, and localization. Results Main trauma mechanisms were fall in 24 patients (38 %) and motor vehicle accidents in 21 patients (28 %). Complete neurological deficits were present in 17 individuals (23 %) and incomplete in 36 patients (48 %). Fractures were
most frequently localized at the cervical region (56 %) with predilection of the C 5/6 segment. Odontoid fractures were seen in 10 (13 %) patients. Fractures of the lumbar and thoracic region were rare. Level of injury or clinical course did not differ between the subgroups (≤15 years versus >15 years). Conclusion Nearly three fourths of all radiologically detected spinal injuries are located at the cervical spine. Complete neurological deficits after trauma was associated with a poor outcome, in particular for patients with injuries of the upper cervical spine. The use of autologous bone graft was associated with favorable long-term results and should be considered as the material of first choice for vertebral body and disc replacement. Keywords Pediatric neurosurgery . Injury mechanism . Spinal cord injury . Spinal instrumentation . Pediatric spine . Infant . Adolescence
Introduction
* Neriman Özkan [email protected] 1
Present address: Department of Neurosurgery, University Hospital of Duisburg-Essen, Essen, Germany
2
Institute of Radiology and Neuroradiology, University Hospital of Duisburg-Essen, Essen, Germany
3
Present address: Neurosurgical Department, Klinikum Nordstadt Hannover, Hannover, Germany
4
Present address: Clinic for Spinal Surgery, Schoen Clinic Hamburg Eilbek, Hamburg, Germany
Spinal injuries in children and young adults are rare with an incidence of 2.7 to 9 % of all spinal injuries [1–3]. Given the rarity of this entity, the current literature does not allow the introduction of clinical standards of diagnostics and treatment for these patients [4–7]. Thus, their management remains challenging in terms of radiological assessment, selection of the optimal treatment strategy, and surgical repair, if necessary [1, 8–10]. Pediatric spinal injuries are managed conservatively in most cases [11]. Surgery might only be indicated for unstable injuries with progressive neurological deficit, fractures with dislocation, or progressive deformations with compression of neural structures [2, 8, 10, 12–15].
Childs Nerv Syst
The present study was conducted to review our experience with a large series of pediatric patients, suffering from traumatic spinal injury, consecutively treated in our institution over the last 20 years. Radiological findings, treatment strategies, and clinical outcome were evaluated and compared with literature.
Patients and methods Patients and clinical data Clinical data of 75 consecutive patients suffered from traumatic spinal injury and treated at our institution between 1990 and 2010 were analyzed retrospectively. Patients with congenital spinal anomalies or vertebral body fractures due to tumorous lesions were excluded. Basic demographic data, neurological examination before and after treatment, radiological findings, surgical techniques, complications, and follow-up were assessed. Subgroup analysis was performed for children up to 15 years of age and for young adults between 16 and 20 years. Neurological evaluation The pre- and postoperative neurological status was classified, using the Frankel score in order to achieve a functional grading of impaired daily life activities and gait disturbances [16]. Thus, for each patient, outcome was classified as poor (grade A + B), fair (grade C), or good (grade D + E). The functional outcome was further analyzed according to the etiology, localization, extent, and severity of the spinal cord injury.
In cases of surgery different operative strategies were chosen alone or in combination. The dorsal access included dorsal decompression by hemilaminectomy or laminectomy, with or without additional dorsal instrumentation. Ventral cervical procedures included spondylectomy and stabilization with autologous bone graft or titanium-PEEK cages filled with bioactive material (ATHLET® with KAINOS®, Signus Medizintechnik, Alzenau, Germany) and ventral plate fixation (TOSCA®, Signus Medizintechnik, Alzenau, Germany or CASPARevolution®, Aesculap AG, Tuttlingen, Germany). The autologous bone graft was usually taken from the patients’ pelvis. Ondontoid fractures were treated by either ventral screw fixation or dorsal stabilization. Postsurgical treatment After surgery, an external stabilization with a Philadelphia® collar was utilized for the following 3–6 weeks and carefully mobilization. Halo fixation devices were necessary for postoperative stabilization in complex fractures for 4–8 weeks. CT scans were performed in all cases after surgery with instrumentation in order to evaluate the bony structures and the correct implant placement. Neurological rehabilitation was necessary especially in cases with neurological deficits in the early postoperative period. Statistical analysis Data was analyzed with the SPSS statistical software (SPSS statistical software for Windows release). For statistical analysis, Student’s t test for paired or unpaired variables and chisquare test was taken for normal data distribution. A p value
