AUTHOR(S): Osenbach, Richard K., M.D.; Menezes, Arnold H., M.D. Division of Neurological Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa Neurosurgery 30; 385-390, 1992 ABSTRACT: Between January 1, 1970, and December 31, 1988, 179 children (birth to age 16) were treated for spinal cord and/or vertebral column injury by the Neurosurgical Service at the University of Iowa Hospitals and Clinics. Pediatric injuries accounted for 9% of all spinal trauma seen during this period. The mean age was 10.2 years. Sixty-two children were between birth and 8 years of age and 117 were between ages 9 and 16. The cause, distribution, type of injury, and severity of neurological injury varied with age. Neurological outcome was dependent on the severity of the initial neurological injury. Children with complete or severe incomplete myelopathy uniformly remained with severe neurological dysfunction; children with mild to moderate injuries recovered normal or nearly normal neurological function. Surgical versus nonoperative management had no bearing on neurological outcome. Twelve percent of the children with severe spinal cord injuries developed posttraumatic spinal deformity. We conclude that spinal injury patterns differ between preadolescent and older children. Most injuries can be successfully managed with nonoperative therapy. Prognosis is primarily correlated with the severity of the initial neurological insult. Finally, children with severe spinal cord injury must have close, long-term followup to monitor the development of posttraumatic spinal deformity. KEY WORDS: Pediatric spine; Spinal cord injury; Spinal fracture; Spine INTRODUCTION Injuries to the spinal cord and/or vertebral column are relatively uncommon in the pediatric population (birth to 16 years). The incidence ranges from less than 1 to 10% of all spinal injuries (2,3,9,18,21,22,29,32). The injury patterns seen in young children differ from those in adolescents and adults largely because of agedependent variations in the anatomical and biomechanical features of the spine (6,10,17,21,29). Young children sustain a greater proportion of cervical injuries, particularly injuries involving the upper cervical spine and craniovertebral junction (CVJ) (2, 17,18,24,28-30) . Children also have a higher incidence of complete spinal cord injury and spinal cord injury without radiographic abnormality (SCIWORA) (3,26, 27) . Pediatric spinal injuries can present special problems regarding external spinal immobilization
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and surgical intervention in a child with significant growth potential. We have retrospectively reviewed our experience with 179 consecutive pediatric spinal injuries at the University of Iowa Hospitals and Clinics for an 18year period. This report highlights the cause, distribution, types of injury, treatment, and functional outcome in this group of patients. PATIENTS AND RESULTS This series includes 179 children from birth to 16 years of age who sustained spinal cord and/or vertebral column injury between January 1, 1970, and December 31, 1988. Children with congenital spinal anomalies, which might predispose them to spinal column injury, were excluded. Data were retrieved from a detailed review of hospital and outpatient records and radiographic studies of each patient. Patients were divided into two age groups based on the age at which the pediatric spine attains most adult characteristics (14). There were 110 boys and 69 girls from birth to 16 years of age (mean age, 10.2 years). The age distribution of the entire group is shown in Figure 1. Group I (birth to 8 years) included 62 (35%) children, and the remaining 117 patients (65%) comprised Group II (9-16 years). The cause of injury varied with age (Table 1). Vehicular trauma was the most common cause of injury and accounted for 56% of all cases, and it was also the leading cause of injury in each group individually. Falls accounted for 17% of injuries and were nearly twice as frequent in younger children. Athletic and sports-related injuries (wrestling, football, diving, gymnastics, etc.) comprised 13% of all injuries and were more common in older children. Birth injuries accounted for 6% of the cases, whereas penetrating injuries (all gunshot wounds) were the cause of injury in only 4% of the patients. The site of injury was classified as follows: upper cervical (occiput to C3), lower cervical (C4-C7), thoracic (T1-T11), thoracolumbar junction (T12-L1), and lumbar (L1-L5). A single fracture of S1 was included with lumbar injuries. The distribution of injuries differed between the two groups (Table 2). The cervical spine was most frequently injured and accounted for 112 (63%) cases. Sixty-four of these injuries involved the upper cervical spine and CVJ, whereas 48 occurred between C4 and C7. Younger children sustained a higher percentage of cervical injuries (79%) than did older children (54%). Furthermore, upper cervical and CVJ injuries were twice as frequent in younger children. Lower cervical and thoracic injuries occurred with equal frequency in both groups, whereas thoracolumbar junction and lumbar injuries were more common in the older group. Patients were classified according to the severity of their motor deficit, as defined by Ducker et al. (13) and outlined in Table 3. This classification readily allowed comparison of neurological outcome to initial neurological status. Eighty-six children (48%) were neurologically intact on initial evaluation, whereas 93 (52%) had varying degrees of
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Neurosurgery 1992-98 March 1992, Volume 30, Number 3 385 Pediatric Spinal Cord and Vertebral Column Injury Experimental and Clinical Study
TREATMENT All patients were maintained with external spinal immobilization after initial presentation. Lifethreatening injuries were attended to immediately, and the spinal injury was dealt with as soon as feasible. All patients had plain radiographs of the entire spinal axis. Additional studies (polytomography, computed tomography, myelography, magnetic resonance imaging, or angiography) were performed depending on the clinical situation of each patient. In recent years, thin section computed tomography (CT) has been obtained in the majority of patients in whom a fracture was identified on plain radiographs. Patients
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with neurological deficit were evaluated with either myelography, CT-myelography, or, more recently, magnetic resonance imaging. Four patients with SCIWORA and thoracic levels of dysfunction underwent angiography to exclude vascular injuries although none was found. Management of the spinal injury was individualized based on the age, level and type of injury, degree of neurological dysfunction, and the presence of associated systemic injuries. One hundred twenty-two children (67%) were managed nonoperatively with a combination of bedrest and/or external immobilization. Fifty-nine children (33%) underwent surgical intervention for irreducible, unstable injuries. Eighty-three percent of the patients managed operatively were in the older age group. The thoracolumbar junction was the single location where surgery was preferred over nonoperative management. These injuries were often associated with extreme degrees of subluxation and were thought to be managed best surgically. OUTCOME Nine children (5%) died secondary to concurrent head injuries. The median follow-up for the 170 survivors was 30 months (1 mo to 12 yr). Neurological outcome was primarily dependent on the severity of the initial injury (Table 7). All patients neurologically intact at initial presentation remained so. Eighty-seven of 93 patients with neurological deficit survived; 63 (73%) of these patients sustained a complete or severe partial injury (Grades I and II). Twenty-five of 37 (68%) children with complete injuries remained unchanged; seven regained partial sensation but had no return of motor function. Four children with complete injuries improved two grades and recovered some motor function, albeit they were almost totally impaired. Only one patient with a complete lesion regained useful motor function in his lower extremities and was able to walk with assistance. Eleven of 26 (42%) children with severe, incomplete injuries remained unchanged. This group included eight children in Grade I and three in Grade II. Six patients initially in Grade I recovered minimal motor function, whereas two children improved to Grade III and were able to walk with assistance. Ten children were initially in Grade II. Seven of these children regained at least useful motor function and became ambulatory. No patient with a complete or severe partial injury regained full neurological function. The majority of children with moderate or mild injuries regained full neurological function. There was no difference in outcome between patients managed nonoperatively versus surgically. Nine children with severe cord injuries, all under 10 years of age, developed late posttraumatic spinal deformity (kyphoscoliosis). Five required surgical correction, whereas four were adequately managed with external bracing. Four children with cervical injuries had persistent spinal instability despite an adequate period of appropriate external immobilization, and they subsequently underwent surgical fusion. DISCUSSION
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neurological dysfunction (Table 4). Forty-two children (45%) had a complete transverse myelopathy, and 51 (55%) had a partial spinal cord injury. Six children sustained concomitant brachial plexus injuries. The incidence of neurological deficit was higher in the younger (62%) compared with the older group (47%) because of a greater percentage of complete injuries in the younger group. The risk of neurological deficit was correlated with the level of spinal injury (Table 5). Neurological deficit was most likely with injuries that involved the thoracolumbar junction, followed by the thoracic, cervical (upper and lower), and lumbar regions in descending order of frequency. When upper and lower cervical injuries were analyzed separately, the risk of neurological deficit was twice that encountered with upper cervical injuries. In contrast, lumbar injuries were least likely to result in neurological injury. All injuries were categorized into one of four groups based on radiographic appearance: 1) vertebral body and/or posterior element fracture alone (42%); 2) fracture combined with subluxation (28%); 3) subluxation without evidence of bony fracture (11%); and 4) SCIWORA (19%) (Table 6). Nondisplaced fractures were more frequent in the older group, whereas subluxation without fracture and SCIWORA occurred with higher frequency in younger children. Children with subluxation (with or without fracture) sustained spinal cord injury more often than children with fracture alone (46% vs. 17%). All injuries that involved subluxation alone (considered to be mainly ligamentous injuries) involved the cervical spine, and 84% occurred in the upper cervical spine. Similarly, the majority of children with fracture/subluxation (70%) and SCIWORA (76%) had injuries that involved the cervical spine. Fifty-eight (37%) children sustained concomitant systemic injuries that included closed head injury (n = 35, 20%); intraabdominal injury (n = 15, 8%), long bone fractures (n = 15, 8%), and blunt thoracic injuries (n = 7, 4%). There was a 60% incidence of head injury (35/58) among multiple trauma victims. Furthermore, 23 of the 35 (66%) head injuries occurred in conjunction with cervical spine injury. Similarly, 15 of the 22 thoracoabdominal injuries occurred in patients with injuries involving either the thoracic or lumbar spine.
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figures are somewhat lower than those of Kewalramani and Tori (21) who reported a 69% incidence of complete injury in their series of pediatric spinal cord injury. Nonetheless, these figures indicate that children are highly susceptible to severe spinal cord injury. The reasons for this are not completely clear, although it is possible that this vulnerability may be related to relative immaturity of the spinal cord microvasculature in young children. Neurological injury is closely correlated with the pattern of spinal injury (17). Injuries involving some degree of subluxation (with or without fracture) are more likely to result in neurological injury than nondisplaced fractures. However, neurological injury can occur in the absence of subluxation. It must be kept in mind that initial radiographic studies depict a static situation. It is quite plausible that the inherent elasticity and hypermobility of the pediatric spine allows transient subluxation to occur, after which elastic recoil returns the spine to a relatively normal anatomical alignment (15,28). This is one theory that has been proposed to explain the phenomenon of SCIWORA. Children with SCIWORA constitute an interesting subset of patients that deserve special mention. SCIWORA is most frequently seen in younger children and is associated with a high incidence of complete neurological injury. Interestingly, children with SCIWORA frequently develop neurological deficit in a delayed fashion (up to 2 days) after what is considered to be a trivial injury (1,11,26,27,31). Once initiated, there is often rapid evolution to severe and irreversible neurological injury. Although only 22% of our patients with SCIWORA presented in such a fashion, delayed presentation has been reported in as high as 67% of children with SCIWORA (27). Traumatic spinal injuries occur frequently in the setting of multisystem trauma. Head injury is a frequent concomitant of spinal injury, especially those involving the cervical spine (19). Of the 112 patients in this series who sustained cervical spine injuries, 23 (21%) suffered a significant head injury. Severe head injury may mask the presence of a spinal injury. Under these circumstances, it is critical to maintain a high index of suspicion and manage the patient as if a spinal injury were present (5). The majority of significant thoracoabdominal injuries occur in association with injuries to the thoracic and lumbar spine. The presence of significant systemic injuries frequently dictates the course of management of the spinal injury. Obviously, in these circumstances, management must be individualized, taking into account the overall condition of the child. The radiographic diagnosis of spinal injury proceeds in a stepwise fashion, using the complete armamentarium of contemporary imaging modalities. Because multiple levels of injury can occur, evaluation of the entire spinal axis is essential (20,24). Fractures identified on plain radiographs are delineated further by either thin-section CT or polytomography. Presently, all patients with neurological deficit undergo magnetic resonance imaging scans to exclude an acute surgical lesion, such as an extradural hematoma or herniated disc,
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Epidemiological studies estimate that each year in the United States there are approximately 11,200 new cases of spinal cord injury, of which 1065 involve children (21). During the period of this review, pediatric spinal injury accounted for 9% of all spinal injuries at this institution. This finding is within the 1 to 10% incidence reported in other series (2,3,9,17,18,21, 22,29,32) . The type and distribution of spinal injuries sustained by young children are fundamentally different from adolescents and adults. These differences are attributable to unique anatomical and biomechanical features of the infant and preadolescent spine (6,10,14). The fulcrum of cervical motion occurs at about C5-C6 in adolescents and adults; however, the relatively larger inertial mass of the head in the infant and young child shifts the fulcrum of motion rostrally (C2-C3), which increases the vulnerability of the upper cervical spine and CVJ to extreme flexion and extension forces (6,10,14,25,28). The facet joints, particularly in the upper cervical spine, are oriented in a relatively horizontal plane that allows excess translational motion in an anteroposterior direction (10). Wedge-shaped vertebral bodies and incompletely developed uncinate processes allow subluxation to occur with relative ease, especially with flexion forces (10,14,30). Finally, excessive motion occurs secondary to ligamentous laxity and immaturity of the paraspinous musculature, which does not become supportive until puberty (6,10,28). These features act in concert to render the pediatric spine inherently hypermobile. This mobility may actually buffer the spine from bony injury but cause it to be more susceptible to ligamentous injury and SCIWORA. The majority of spinal injuries in children involve the cervical spine (17-19,30). Upper cervical and CVJ injuries occur with higher frequency in younger children, whereas adolescents sustain a greater proportion of lower cervical injuries, similar to adults (17,29) . Similarly, injuries of the thoracic and lumbar spine are more prevalent in teenagers and adults than in young children. The patterns of injury vary between young children and adolescents. Teenagers most often sustain injuries that involve fractures of the vertebral body and/or posterior elements (with or without subluxation), whereas younger children are more prone to sustain purely ligamentous injuries (2, 17,29) . There is also a higher incidence of SCIWORA in younger children (8,26,27). Bony fractures do occur in young children although they are pathologically different from those in older children. Histological studies on cadaver spines have shown that fractures in young children most often occur through the cartilagenous vertebral endplates and thereby injure the active growth zones (4). Destruction of or injury to the growth plates may cause failure to attain normal vertebral height and ultimately contribute to asymmetric growth and delayed spinal deformity (24). The incidence of neurological deficit in this series (52%) is comparable to that reported by other authors (17,29) . Forty-two (24%) children suffered a complete neurological injury. These children accounted for 45% of patients with neurological deficit. These
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multilevel decompressive laminectomy should not be performed in a growing child, particularly if the injury primarily involves anterior structures because this will result in increased instability and potentially magnify the neurological deficit (30). If laminectomy is necessary, it should be accompanied by a posterior spinal fusion. We do believe that early stabilization followed by external immobilization in acrylic shells is beneficial in patients with thoracic and lumbar injuries. Although this treatment had little influence on the neurological outcome in our patients, it allowed for early mobilization and facilitated the rehabilitation process. No patient in this series received steroids, although recent data suggest that high-dose methylprednisolone may be beneficial if it is administered within 8 hours of injury (7). Consequently, we now administer high-dose methylprednisolone to all patients with spinal cord injury. There have been conflicting reports regarding prognosis of children with spinal cord injuries. Some authors have reported a good prognosis for neurological recovery in pediatric patients, whereas others have reported discouraging outcomes (2,13,17,21, 27) . It is apparent that functional outcome is strongly correlated with the severity of the initial neurological deficit. The majority of the patients with severe neurological injuries remained with severe functional impairment. Furthermore, outcome does not seem to be influenced whether the patient is managed surgically or nonoperatively. It should be kept in mind, however, that some children may show improvement up to 2 years after injury, and long-term follow-up is essential in detecting late improvement (17) . Lastly, a brief comment is in order regarding the cost of long-term care. Previous figures (1985) estimate the acute hospital cost for a child with a severe spinal cord injury to be approximately $250,000 to 300,000, with an annual expense of $50,000 per child. This sum translates into a staggering total annual cost of 75 to 125 million dollars (32). It is particularly troubling that many serious injuries might be potentially preventable through the implementation of effective childrestraint systems and educational programs. CONCLUSIONS Although spinal injuries are relatively uncommon in children, the economical, social, and emotional consequences of a severe spinal injury in a child are significant. The type of injuries sustained by children is age related, the result of unique anatomical features of the pediatric spine. The upper cervical spine is extremely vulnerable to injury in the young child. Younger children sustain more ligamentous injuries and SCIWORA, whereas older children and teenagers have a higher incidence of bony fractures. Neurological injury is frequent in children, with a particularly high incidence of complete myelopathy. The majority of injuries can be managed nonoperatively, with surgery reserved for those injuries that cannot be adequately reduced and stabilized nonoperatively. Children with mild
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although the latter is extremely uncommon in children (4). If magnetic resonance imaging is not readily available, CT-myelography is an acceptable alternative to exclude a surgical lesion (12). Patients with SCIWORA and thoracic levels of dysfunction underwent angiography to exclude the possibility of a thoracic aortic dissection although none was demonstrated. Many of the basic principles employed in treating adults with spinal injury are applicable in the pediatric age group. Most authors advocate conservative management of children with spinal column injury (15-20). Uncomplicated stable injuries without neurological compromise as well as many unstable injuries can be successfully managed nonoperatively with external immobilization alone. The method of immobilization chosen depends on the level and type of injury and the age of the child. For most cervical injuries, especially those involving the upper cervical spine and craniovertebral junction, the halo vest provides superior immobilization with minimal morbidity. There are occasional logistical and technical problems associated with the use of a halo in very young children. Nonetheless, we have successfully used this method in children as young as 1 year with minimal difficulty. In very young children, eight pins are used with a maximum of 1 to 2 pounds of torque applied to each pin. We have also used custom-molded braces that can be modified as necessary to accommodate growth. This type of brace has proven effective for stabilizing injuries of the lower cervical spine and cervicothoracic junction that are often difficult to stabilize adequately even in a halo vest. For injuries of the thoracic and lumbar spine, molded acrylic shells similar to those employed in adult patients are employed. Although nonoperative management is successful in most cases, a small number fail conservative therapy and require surgery for posttraumatic spinal instability (17,24) . Six of 120 patients (5%), all with cervical injuries, failed nonoperative therapy and required surgical stabilization. Children with severe spinal cord injury are also prone to develop spinal deformity as they grow and must be followed carefully (5,20,23, 24) . This deformity ranges from mild degrees of kyphosis that require no treatment or external bracing alone to severe degrees of deformity that require surgical correction. Although most injuries can be treated conservatively, early surgical intervention (within 2 wk of injury) is appropriate in selected cases. As in adults, there is disagreement regarding the indications for early surgical intervention in children with spinal injury. We believe the main indications for early surgical intervention include injuries that cannot be reduced and stabilized by external means and partial spinal cord injury with progressive neurological deficit (17,19,30). Extradural hematomas and herniated discs also constitute indications for acute surgical intervention, particularly in patients with incomplete injuries. In patients with a stable neurological examination, however, evidence is lacking that surgery results in a better neurological outcome than does nonoperative therapy (13,17). In particular,
Received for publication, July 22, 1991; accepted, August 20, 1991. Reprint requests: Richard K. Osenbach, M.D., Division of Neurosurgery, C42 General Hospital, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242.
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features of traumatic paraplegia in infancy. J Trauma 13:166-170, 1973. Hachen HJ: Spinal cord injury in children and adolescents: Diagnostic pitfalls and therapeutic considerations in the acute stage. Paraplegia 15:55-64, 1977. Hadley MN, Zabramski J, Browner CM, Rekate H, Sonntag V: Pediatric spinal trauma: Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg 68:1824, 1988. Henrys P, Lye ED, Lifton C, Salciccioli G: Clinical review of cervical spine injuries in children. Clin Orthop 129:172-176, 1977. Hill SA, Miller CA, Kosnik EJ, Hunt WE: Pediatric neck injuries: A clinical study. J Neurosurg 60:700-706, 1984. Hubbard DD: Injuries of the spine in children and adolescents. Clin Orthop 100:56-65, 1974. Kewalramani LS, Tori JA: Spinal cord trauma in children: Neurologic patterns, radiologic features, and pathomechanics of injury. Spine 5:11-18, 1980. Kewalramani LS, Kraus JF, Sterling HM: Acute spinal-cord lesions in a pediatric population: Epidemiological and clinical features. Paraplegia 18:206-219, 1980. Mayfield JK, Erkkila JC, Winter RB: Spine deformity subsequent to acquired childhood spinal cord injury. J Bone Joint Surg [AM] 63:1401-1411, 1981. McPhee IB: Spinal fractures and dislocations in children and adolescents. Spine 6:533-537, 1981. Menezes AH: Traumatic lesions of the craniovertebral junction, in Van Gilder JC, Menezes AH, Dolan K (eds): Textbook of Craniovertebral Junction Abnormalities. Mount Kisco, Futura Publishing Co., 1987, pp 9-27. Osenbach RK, Menezes AH: Spinal cord injury without radiographic abnormality in children. Pediatr Neurosci 15:168-175, 1989. Pang D, Wilberger JE: Spinal cord injury without radiographic abnormalities in children. J Neurosurg 57:114-129, 1982. Papavasilou V: Traumatic subluxation of the cervical spine during childhood. Orthop Clin N Am 9:945-954, 1978. Ruge JR, Sinson GP, McLone DG, Cerullo LJ: Pediatric spinal injury: The very young. J Neurosurg 68:25-30, 1988. Sherk HH, Schut L, Lane JM: Fractures and dislocations of the cervical spine in children. Orthop Clin N Am 7:593-604, 1976. Walsh JW, Stevens DB, Young BA: Traumatic paraplegia in children without contiguous fracture or dislocation. Neurosurgery 12:439-445, 1983. Wilberger JE Jr: Spinal Cord Injuries in Children. Mount Kisco, Futura Publishing Co., 1986, pp 7-11.
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neurological injuries have an excellent prognosis for recovery of full function. Unfortunately, the prognosis for children with complete or severe partial injuries remains discouraging. Nevertheless, we should continue to concentrate on both clinical and experimental investigation in search of the answers that may someday provide a breakthrough in the treatment of spinal cord injury.
COMMENT The authors present a large series of children, birth to 16 years old, with spinal cord or vertebral column injury seen at one institution. Their patient population is divided by age, level of spine or neurological injury, and whether the injury was complete. The authors emphasize the fact that the majority of the children can be managed nonoperatively with external immobilization and that the prognosis is independent of the need for surgical intervention. They also emphasize the important problem of spinal cord injury without radiographic abnormality, which appears to be most prevalent in the younger age group. This is an excellent review. It is well organized and comes to succinct and helpful conclusions. We expect that the majority of these rare injuries could be avoided when public health issues, such as child restraints, are taken more seriously.
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Harold L. Rekate Phoenix, Arizona
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Table 1. Cause of Spinal Injury
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Figure 1. Age distribution of children with spinal injury.
Table 3. Grading Scheme for Spinal Cord Injury
Table 4. Neurological Injury with Respect to Age
Table 5. Relationship of Neurological Injury to Level of Injury
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Table 2. Distribution of Pediatric Spinal Injuries
Table 7. Relationship of Initial Neurological Injury to Outcome
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Table 6. Classification of Spinal Injury
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and surgical intervention in a child with significant growth potential. We have retrospectively reviewed our experience with 179 consecutive pediatric spinal injuries at the University of Iowa Hospitals and Clinics for an 18year period. This report highlights the cause, distribution, types of injury, treatment, and functional outcome in this group of patients. PATIENTS AND RESULTS This series includes 179 children from birth to 16 years of age who sustained spinal cord and/or vertebral column injury between January 1, 1970, and December 31, 1988. Children with congenital spinal anomalies, which might predispose them to spinal column injury, were excluded. Data were retrieved from a detailed review of hospital and outpatient records and radiographic studies of each patient. Patients were divided into two age groups based on the age at which the pediatric spine attains most adult characteristics (14). There were 110 boys and 69 girls from birth to 16 years of age (mean age, 10.2 years). The age distribution of the entire group is shown in Figure 1. Group I (birth to 8 years) included 62 (35%) children, and the remaining 117 patients (65%) comprised Group II (9-16 years). The cause of injury varied with age (Table 1). Vehicular trauma was the most common cause of injury and accounted for 56% of all cases, and it was also the leading cause of injury in each group individually. Falls accounted for 17% of injuries and were nearly twice as frequent in younger children. Athletic and sports-related injuries (wrestling, football, diving, gymnastics, etc.) comprised 13% of all injuries and were more common in older children. Birth injuries accounted for 6% of the cases, whereas penetrating injuries (all gunshot wounds) were the cause of injury in only 4% of the patients. The site of injury was classified as follows: upper cervical (occiput to C3), lower cervical (C4-C7), thoracic (T1-T11), thoracolumbar junction (T12-L1), and lumbar (L1-L5). A single fracture of S1 was included with lumbar injuries. The distribution of injuries differed between the two groups (Table 2). The cervical spine was most frequently injured and accounted for 112 (63%) cases. Sixty-four of these injuries involved the upper cervical spine and CVJ, whereas 48 occurred between C4 and C7. Younger children sustained a higher percentage of cervical injuries (79%) than did older children (54%). Furthermore, upper cervical and CVJ injuries were twice as frequent in younger children. Lower cervical and thoracic injuries occurred with equal frequency in both groups, whereas thoracolumbar junction and lumbar injuries were more common in the older group. Patients were classified according to the severity of their motor deficit, as defined by Ducker et al. (13) and outlined in Table 3. This classification readily allowed comparison of neurological outcome to initial neurological status. Eighty-six children (48%) were neurologically intact on initial evaluation, whereas 93 (52%) had varying degrees of
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Neurosurgery 1992-98 March 1992, Volume 30, Number 3 385 Pediatric Spinal Cord and Vertebral Column Injury Experimental and Clinical Study
TREATMENT All patients were maintained with external spinal immobilization after initial presentation. Lifethreatening injuries were attended to immediately, and the spinal injury was dealt with as soon as feasible. All patients had plain radiographs of the entire spinal axis. Additional studies (polytomography, computed tomography, myelography, magnetic resonance imaging, or angiography) were performed depending on the clinical situation of each patient. In recent years, thin section computed tomography (CT) has been obtained in the majority of patients in whom a fracture was identified on plain radiographs. Patients
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with neurological deficit were evaluated with either myelography, CT-myelography, or, more recently, magnetic resonance imaging. Four patients with SCIWORA and thoracic levels of dysfunction underwent angiography to exclude vascular injuries although none was found. Management of the spinal injury was individualized based on the age, level and type of injury, degree of neurological dysfunction, and the presence of associated systemic injuries. One hundred twenty-two children (67%) were managed nonoperatively with a combination of bedrest and/or external immobilization. Fifty-nine children (33%) underwent surgical intervention for irreducible, unstable injuries. Eighty-three percent of the patients managed operatively were in the older age group. The thoracolumbar junction was the single location where surgery was preferred over nonoperative management. These injuries were often associated with extreme degrees of subluxation and were thought to be managed best surgically. OUTCOME Nine children (5%) died secondary to concurrent head injuries. The median follow-up for the 170 survivors was 30 months (1 mo to 12 yr). Neurological outcome was primarily dependent on the severity of the initial injury (Table 7). All patients neurologically intact at initial presentation remained so. Eighty-seven of 93 patients with neurological deficit survived; 63 (73%) of these patients sustained a complete or severe partial injury (Grades I and II). Twenty-five of 37 (68%) children with complete injuries remained unchanged; seven regained partial sensation but had no return of motor function. Four children with complete injuries improved two grades and recovered some motor function, albeit they were almost totally impaired. Only one patient with a complete lesion regained useful motor function in his lower extremities and was able to walk with assistance. Eleven of 26 (42%) children with severe, incomplete injuries remained unchanged. This group included eight children in Grade I and three in Grade II. Six patients initially in Grade I recovered minimal motor function, whereas two children improved to Grade III and were able to walk with assistance. Ten children were initially in Grade II. Seven of these children regained at least useful motor function and became ambulatory. No patient with a complete or severe partial injury regained full neurological function. The majority of children with moderate or mild injuries regained full neurological function. There was no difference in outcome between patients managed nonoperatively versus surgically. Nine children with severe cord injuries, all under 10 years of age, developed late posttraumatic spinal deformity (kyphoscoliosis). Five required surgical correction, whereas four were adequately managed with external bracing. Four children with cervical injuries had persistent spinal instability despite an adequate period of appropriate external immobilization, and they subsequently underwent surgical fusion. DISCUSSION
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neurological dysfunction (Table 4). Forty-two children (45%) had a complete transverse myelopathy, and 51 (55%) had a partial spinal cord injury. Six children sustained concomitant brachial plexus injuries. The incidence of neurological deficit was higher in the younger (62%) compared with the older group (47%) because of a greater percentage of complete injuries in the younger group. The risk of neurological deficit was correlated with the level of spinal injury (Table 5). Neurological deficit was most likely with injuries that involved the thoracolumbar junction, followed by the thoracic, cervical (upper and lower), and lumbar regions in descending order of frequency. When upper and lower cervical injuries were analyzed separately, the risk of neurological deficit was twice that encountered with upper cervical injuries. In contrast, lumbar injuries were least likely to result in neurological injury. All injuries were categorized into one of four groups based on radiographic appearance: 1) vertebral body and/or posterior element fracture alone (42%); 2) fracture combined with subluxation (28%); 3) subluxation without evidence of bony fracture (11%); and 4) SCIWORA (19%) (Table 6). Nondisplaced fractures were more frequent in the older group, whereas subluxation without fracture and SCIWORA occurred with higher frequency in younger children. Children with subluxation (with or without fracture) sustained spinal cord injury more often than children with fracture alone (46% vs. 17%). All injuries that involved subluxation alone (considered to be mainly ligamentous injuries) involved the cervical spine, and 84% occurred in the upper cervical spine. Similarly, the majority of children with fracture/subluxation (70%) and SCIWORA (76%) had injuries that involved the cervical spine. Fifty-eight (37%) children sustained concomitant systemic injuries that included closed head injury (n = 35, 20%); intraabdominal injury (n = 15, 8%), long bone fractures (n = 15, 8%), and blunt thoracic injuries (n = 7, 4%). There was a 60% incidence of head injury (35/58) among multiple trauma victims. Furthermore, 23 of the 35 (66%) head injuries occurred in conjunction with cervical spine injury. Similarly, 15 of the 22 thoracoabdominal injuries occurred in patients with injuries involving either the thoracic or lumbar spine.
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figures are somewhat lower than those of Kewalramani and Tori (21) who reported a 69% incidence of complete injury in their series of pediatric spinal cord injury. Nonetheless, these figures indicate that children are highly susceptible to severe spinal cord injury. The reasons for this are not completely clear, although it is possible that this vulnerability may be related to relative immaturity of the spinal cord microvasculature in young children. Neurological injury is closely correlated with the pattern of spinal injury (17). Injuries involving some degree of subluxation (with or without fracture) are more likely to result in neurological injury than nondisplaced fractures. However, neurological injury can occur in the absence of subluxation. It must be kept in mind that initial radiographic studies depict a static situation. It is quite plausible that the inherent elasticity and hypermobility of the pediatric spine allows transient subluxation to occur, after which elastic recoil returns the spine to a relatively normal anatomical alignment (15,28). This is one theory that has been proposed to explain the phenomenon of SCIWORA. Children with SCIWORA constitute an interesting subset of patients that deserve special mention. SCIWORA is most frequently seen in younger children and is associated with a high incidence of complete neurological injury. Interestingly, children with SCIWORA frequently develop neurological deficit in a delayed fashion (up to 2 days) after what is considered to be a trivial injury (1,11,26,27,31). Once initiated, there is often rapid evolution to severe and irreversible neurological injury. Although only 22% of our patients with SCIWORA presented in such a fashion, delayed presentation has been reported in as high as 67% of children with SCIWORA (27). Traumatic spinal injuries occur frequently in the setting of multisystem trauma. Head injury is a frequent concomitant of spinal injury, especially those involving the cervical spine (19). Of the 112 patients in this series who sustained cervical spine injuries, 23 (21%) suffered a significant head injury. Severe head injury may mask the presence of a spinal injury. Under these circumstances, it is critical to maintain a high index of suspicion and manage the patient as if a spinal injury were present (5). The majority of significant thoracoabdominal injuries occur in association with injuries to the thoracic and lumbar spine. The presence of significant systemic injuries frequently dictates the course of management of the spinal injury. Obviously, in these circumstances, management must be individualized, taking into account the overall condition of the child. The radiographic diagnosis of spinal injury proceeds in a stepwise fashion, using the complete armamentarium of contemporary imaging modalities. Because multiple levels of injury can occur, evaluation of the entire spinal axis is essential (20,24). Fractures identified on plain radiographs are delineated further by either thin-section CT or polytomography. Presently, all patients with neurological deficit undergo magnetic resonance imaging scans to exclude an acute surgical lesion, such as an extradural hematoma or herniated disc,
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Epidemiological studies estimate that each year in the United States there are approximately 11,200 new cases of spinal cord injury, of which 1065 involve children (21). During the period of this review, pediatric spinal injury accounted for 9% of all spinal injuries at this institution. This finding is within the 1 to 10% incidence reported in other series (2,3,9,17,18,21, 22,29,32) . The type and distribution of spinal injuries sustained by young children are fundamentally different from adolescents and adults. These differences are attributable to unique anatomical and biomechanical features of the infant and preadolescent spine (6,10,14). The fulcrum of cervical motion occurs at about C5-C6 in adolescents and adults; however, the relatively larger inertial mass of the head in the infant and young child shifts the fulcrum of motion rostrally (C2-C3), which increases the vulnerability of the upper cervical spine and CVJ to extreme flexion and extension forces (6,10,14,25,28). The facet joints, particularly in the upper cervical spine, are oriented in a relatively horizontal plane that allows excess translational motion in an anteroposterior direction (10). Wedge-shaped vertebral bodies and incompletely developed uncinate processes allow subluxation to occur with relative ease, especially with flexion forces (10,14,30). Finally, excessive motion occurs secondary to ligamentous laxity and immaturity of the paraspinous musculature, which does not become supportive until puberty (6,10,28). These features act in concert to render the pediatric spine inherently hypermobile. This mobility may actually buffer the spine from bony injury but cause it to be more susceptible to ligamentous injury and SCIWORA. The majority of spinal injuries in children involve the cervical spine (17-19,30). Upper cervical and CVJ injuries occur with higher frequency in younger children, whereas adolescents sustain a greater proportion of lower cervical injuries, similar to adults (17,29) . Similarly, injuries of the thoracic and lumbar spine are more prevalent in teenagers and adults than in young children. The patterns of injury vary between young children and adolescents. Teenagers most often sustain injuries that involve fractures of the vertebral body and/or posterior elements (with or without subluxation), whereas younger children are more prone to sustain purely ligamentous injuries (2, 17,29) . There is also a higher incidence of SCIWORA in younger children (8,26,27). Bony fractures do occur in young children although they are pathologically different from those in older children. Histological studies on cadaver spines have shown that fractures in young children most often occur through the cartilagenous vertebral endplates and thereby injure the active growth zones (4). Destruction of or injury to the growth plates may cause failure to attain normal vertebral height and ultimately contribute to asymmetric growth and delayed spinal deformity (24). The incidence of neurological deficit in this series (52%) is comparable to that reported by other authors (17,29) . Forty-two (24%) children suffered a complete neurological injury. These children accounted for 45% of patients with neurological deficit. These
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multilevel decompressive laminectomy should not be performed in a growing child, particularly if the injury primarily involves anterior structures because this will result in increased instability and potentially magnify the neurological deficit (30). If laminectomy is necessary, it should be accompanied by a posterior spinal fusion. We do believe that early stabilization followed by external immobilization in acrylic shells is beneficial in patients with thoracic and lumbar injuries. Although this treatment had little influence on the neurological outcome in our patients, it allowed for early mobilization and facilitated the rehabilitation process. No patient in this series received steroids, although recent data suggest that high-dose methylprednisolone may be beneficial if it is administered within 8 hours of injury (7). Consequently, we now administer high-dose methylprednisolone to all patients with spinal cord injury. There have been conflicting reports regarding prognosis of children with spinal cord injuries. Some authors have reported a good prognosis for neurological recovery in pediatric patients, whereas others have reported discouraging outcomes (2,13,17,21, 27) . It is apparent that functional outcome is strongly correlated with the severity of the initial neurological deficit. The majority of the patients with severe neurological injuries remained with severe functional impairment. Furthermore, outcome does not seem to be influenced whether the patient is managed surgically or nonoperatively. It should be kept in mind, however, that some children may show improvement up to 2 years after injury, and long-term follow-up is essential in detecting late improvement (17) . Lastly, a brief comment is in order regarding the cost of long-term care. Previous figures (1985) estimate the acute hospital cost for a child with a severe spinal cord injury to be approximately $250,000 to 300,000, with an annual expense of $50,000 per child. This sum translates into a staggering total annual cost of 75 to 125 million dollars (32). It is particularly troubling that many serious injuries might be potentially preventable through the implementation of effective childrestraint systems and educational programs. CONCLUSIONS Although spinal injuries are relatively uncommon in children, the economical, social, and emotional consequences of a severe spinal injury in a child are significant. The type of injuries sustained by children is age related, the result of unique anatomical features of the pediatric spine. The upper cervical spine is extremely vulnerable to injury in the young child. Younger children sustain more ligamentous injuries and SCIWORA, whereas older children and teenagers have a higher incidence of bony fractures. Neurological injury is frequent in children, with a particularly high incidence of complete myelopathy. The majority of injuries can be managed nonoperatively, with surgery reserved for those injuries that cannot be adequately reduced and stabilized nonoperatively. Children with mild
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although the latter is extremely uncommon in children (4). If magnetic resonance imaging is not readily available, CT-myelography is an acceptable alternative to exclude a surgical lesion (12). Patients with SCIWORA and thoracic levels of dysfunction underwent angiography to exclude the possibility of a thoracic aortic dissection although none was demonstrated. Many of the basic principles employed in treating adults with spinal injury are applicable in the pediatric age group. Most authors advocate conservative management of children with spinal column injury (15-20). Uncomplicated stable injuries without neurological compromise as well as many unstable injuries can be successfully managed nonoperatively with external immobilization alone. The method of immobilization chosen depends on the level and type of injury and the age of the child. For most cervical injuries, especially those involving the upper cervical spine and craniovertebral junction, the halo vest provides superior immobilization with minimal morbidity. There are occasional logistical and technical problems associated with the use of a halo in very young children. Nonetheless, we have successfully used this method in children as young as 1 year with minimal difficulty. In very young children, eight pins are used with a maximum of 1 to 2 pounds of torque applied to each pin. We have also used custom-molded braces that can be modified as necessary to accommodate growth. This type of brace has proven effective for stabilizing injuries of the lower cervical spine and cervicothoracic junction that are often difficult to stabilize adequately even in a halo vest. For injuries of the thoracic and lumbar spine, molded acrylic shells similar to those employed in adult patients are employed. Although nonoperative management is successful in most cases, a small number fail conservative therapy and require surgery for posttraumatic spinal instability (17,24) . Six of 120 patients (5%), all with cervical injuries, failed nonoperative therapy and required surgical stabilization. Children with severe spinal cord injury are also prone to develop spinal deformity as they grow and must be followed carefully (5,20,23, 24) . This deformity ranges from mild degrees of kyphosis that require no treatment or external bracing alone to severe degrees of deformity that require surgical correction. Although most injuries can be treated conservatively, early surgical intervention (within 2 wk of injury) is appropriate in selected cases. As in adults, there is disagreement regarding the indications for early surgical intervention in children with spinal injury. We believe the main indications for early surgical intervention include injuries that cannot be reduced and stabilized by external means and partial spinal cord injury with progressive neurological deficit (17,19,30). Extradural hematomas and herniated discs also constitute indications for acute surgical intervention, particularly in patients with incomplete injuries. In patients with a stable neurological examination, however, evidence is lacking that surgery results in a better neurological outcome than does nonoperative therapy (13,17). In particular,
Received for publication, July 22, 1991; accepted, August 20, 1991. Reprint requests: Richard K. Osenbach, M.D., Division of Neurosurgery, C42 General Hospital, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242.
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neurological injuries have an excellent prognosis for recovery of full function. Unfortunately, the prognosis for children with complete or severe partial injuries remains discouraging. Nevertheless, we should continue to concentrate on both clinical and experimental investigation in search of the answers that may someday provide a breakthrough in the treatment of spinal cord injury.
COMMENT The authors present a large series of children, birth to 16 years old, with spinal cord or vertebral column injury seen at one institution. Their patient population is divided by age, level of spine or neurological injury, and whether the injury was complete. The authors emphasize the fact that the majority of the children can be managed nonoperatively with external immobilization and that the prognosis is independent of the need for surgical intervention. They also emphasize the important problem of spinal cord injury without radiographic abnormality, which appears to be most prevalent in the younger age group. This is an excellent review. It is well organized and comes to succinct and helpful conclusions. We expect that the majority of these rare injuries could be avoided when public health issues, such as child restraints, are taken more seriously.
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Harold L. Rekate Phoenix, Arizona
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Table 1. Cause of Spinal Injury
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Figure 1. Age distribution of children with spinal injury.
Table 3. Grading Scheme for Spinal Cord Injury
Table 4. Neurological Injury with Respect to Age
Table 5. Relationship of Neurological Injury to Level of Injury
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Table 2. Distribution of Pediatric Spinal Injuries
Table 7. Relationship of Initial Neurological Injury to Outcome
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Table 6. Classification of Spinal Injury
