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4. Brown RL, Brunn MA, Garcia VF.Cervical spine injuries in children: a review of 103 patients
treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg. 2001;36:1107–14.
5. Montalbano M, Fisahn C, Loukas M, Oskouian RJ, Chapman JR, Tubbs RS. Pediatric
Hangman’s fracture: a comprehensive review. Pediatr Neurosurg. 2017;52(3):145–50.
6. Vaccaro AR, Koerner JD, Radcliff KE, etal. AOSpine subaxial cervical spine injury classica-
tion system. Eur Spine J. 2016;25(7):2173–84.
7. Johnson KT, Al-Holou WN, Anderson RCE, etal. Morphometric analysis of the developing
pediatric cervical spine. J Neurosurg Pediatr. 2016;18(3):377–89.
M. C. Kruyt and F. C. Öner
Thoracolumbar Spine Injuries
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inChildren
MehmetKaymakoglu andMuharremYazici
2.1 Definition
Pediatric spine injury constitutes a small percentage (4%) among all trauma cases,
and thoracolumbar injuries (30% to 40%) are even rarer compared to cervical injuries among all pediatric spine trauma [1]. Although most of the cases can be managed with conservative treatment, a careful physical exam and adequate knowledge
about the features of pediatric spine injury are essential to prevent devastating
complications.
Pediatric patients should not only be considered as “little adults” and it should be
taken into account that they have many anatomical and physiological differences.
This has also an importance in thoracolumbar injuries, and there are many differences in the management compared to adults (Chap. 7). The spinal column of children starts carrying adult properties at 8years of age, and the injury pattern changes
before and after that age. The children have a growing spine and the decision of
fusion should be made very carefully, as it diminishes the growing potential.
Additionally, the ligamentous laxity and the superior location of the pivot point of
the head, which is larger relative to the body, lead up to a higher risk for distraction
2
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_2).
M. Kaymakoglu
Department of Orthopedics and Traumatology, Bornova Turkan Ozilhan State Hospital, Izmir,
Turkey
M. Yazici (*)
Department of Orthopedics and Traumatology, Hacettepe University Faculty of Medicine,
Ankara, Turkey
e-mail: yazioglu@hacettepe.edu.tr
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_2
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injuries. More horizontal and immature facets and immature paraspinal muscles
also reduce the stability of the spinal column. Studies revealed that an elongation up
to 2cm is possible during trauma in children and this elongation protects the bony
structure from fracture but the spinal cord has more limited exibility up to 5–6mm.
Thus, a clinical entity called SCIWORA (spinal cord injury without radiographic
abnormality) with neurological symptoms may occur without any sign of radiological nding in the pediatric population, and this increases the importance of the
physical examination of the whole spine in the Emergency Department (ER).
SCIWORA syndrome can also have a delayed onset, up to 4days, and neurological
follow-up of patients is therefore important (Chap. 4).
M. Kaymakoglu and M. Yazici
2.1.1 Mechanism ofInjury
The main mechanisms of injury are distraction and compression. Besides more
elastic properties of the pediatric spine, high-energy trauma tends to damage the
vertebra through its relatively weak ossication centers such as vertebral endplates
and facet joints. Biomechanical studies showed that in case of high bending stresses,
Salter-Harris type 1 fracture occurs through the weakest point of the spinal column:
the growth plates. Motor vehicle accidents constitute the most common reason
(>50%) of pediatric spine trauma, especially in children older than 10years old.
Falling from height is also an important reason for those under 10years old. Since
the thoracic spine is biomechanically supported by the rib cage, the injury rate is
less than the cervical and lumbar regions [2].
2.2 Physical Examination
The management of pediatric spine trauma necessitates a multi-disciplinary trauma
team. After the evaluation of Glasgow Coma Score (GCS) (Appendix F) and
Advance Trauma and Life Support (ATLS) protocol for children, immobilization of
the spine and a cervical collar should be provided immediately. Neck hyperexion
should be avoided when using a spine board to prevent airway obstruction and spine
injury. A complete neurological examination must be performed (Video 2.4);
including motor and sensory evaluation, genital and rectal examination, and reexes.
Palpation of the entire spinal column should be made; and any abnormalities such
as bruising, step-offs, or open wounds should be noted. Fatal intra-abdominal and
head injuries often accompany pediatric spine trauma; thus, additional injuries
should be studied and excluded before any treatment intervention.
2.3 Imaging
Anterior-posterior (AP) and lateral “full spine” radiographs are mandatory for the
initial radiographic evaluation. Unlike the adults, in case of any neurological ndings or in the need for further evaluation, a full spine computed tomography (CT)
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scan is not recommended because of the excessive radiation exposure. Magnetic
resonance imaging (MRI) should be the preferred study in such cases. Furthermore,
MRI gives the clinician the advantage of the ability to assess the ligamentous structures (e.g., posterior ligamentous complex) and soft tissues around the spinal column. It also enables to classify the patients with SCIWORA according to MRI
abnormalities of the spinal cord. If the patient is unable to get in MRI, a very short
section CT for the suspected/injured spinal levels can be done for further evaluation.
2.4 Treatment Options
Most of the spinal injuries in children are managed conservatively, as bony fractures and neurological decits are rarely seen. The treatment algorithm is dependent on the neurological status of the patient and the degree of instability of the
spine as adults. The Thoracolumbar Injury Classication and Severity Score
(TLICS) system has been used for adults to provide better outcomes for both conservative and surgical management, and a new study approved its validation
among pediatric patients (Table 2.1) [4]. For those for whom surgical management is mandatory, the surgeon must be familiar with the possible effect of multilevel spinal fusion which disturbs the growth potential of the spine, especially in
children younger than adolescence [5]. It should be considered that spinal alignment of the spine evolves during the child’s growth, and a patient-specic sagittal
alignment should be restored. The Risser sign can be used for the remaining
growth and remodeling potential of the child (Appendix M). According to
Pouliquen etal., [6] stable compression fractures have excellent outcomes with
Table 2.1 Thoracolumbar injury classication and severity score system
Type of injury Points
Morphology
Compression 1
Burst 2
Rotation/translation
Distraction 4
Disruption of the posterior ligamentous complex
Intact 0
Suspected 2
Disrupted 3
Neurologic status
Intact 0
Nerve root 2
Cord, conus medullaris: complete 2
Cord, conus medullaris: incomplete 3
Cauda equina 3
The sum of all points: 0–3: Conservative management, ≥4: Surgical management. If the sum is
equal to 4, patient-specic management can be chosen (adapted from Vaccaro etal. [3])
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M. Kaymakoglu and M. Yazici
a
b
Fig. 2.1 A 7-year-old female patient with multiple proximal thoracic vertebral fractures was
treated conservatively (a). After more than 10years of follow-up, coronal and sagittal alignments
were restored despite mild scoliosis and vertebral heights were regained (b)
nonsurgical management, especially in children with Risser sign of 0–1. Another
study with 33years of mean follow-up showed that single-column compression
fractures in children have good remodeling potential with the ability to regain the
vertebral height (Fig.2.1) [7]. Fracture dislocations, injuries with neurological
decits, and unstable fractures according to the TLICS scoring system should be
managed with surgical intervention (Fig.2.2) (Video 2.4). High-dose corticosteroid treatment in children is controversial, and there is not any randomized trial
with a high level of evidence suggesting the use of corticosteroids.
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Fig. 2.2 An 8-year-old male patient with T6 fracture and posterior ligamentous complex injury.
Mechanical instability was treated with a short segment posterior instrumentation and fusion
(Video 2.3)
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2.5 Expected Outcomes
Outcomes of non-surgical and surgical treatment in neurologically injured patients
mainly depend on the initial severity of spine injury. Mild-to-moderate injuries
recover normal or nearly normal, whereas severe injuries are difcult to heal regardless of the choice of surgical or non-surgical treatment. Burst fractures without neurological injury can be treated with hyperextension bracing relying on the remodeling
potential of the canal in children. The surgical intervention seems to provide better
radiological outcomes, but there is not any difference in functional scores between
non-surgical and surgical groups. However, surgeons should consider the risk of
spinal deformity after mild spinal injuries or SCIWORA syndrome (Chap. 4) in
patients treated conservatively (Fig.2.3). Thus, the follow-up of pediatric patients
with deformity is crucial in conservative management and growth- sparing instrumentation has to be the treatment of choice if the patient has growth potential. Nonfusion spine stabilization as internal bracing is another treatment strategy in the
growing spine (Fig.2.4). Excellent radiological and functional outcomes have been
reported by several authors with internal bracing. The only disadvantage of this
technique is the need for the second stage to remove the hardware after 1 year.
In case of permanent neurological decit, the risk of developing paralytic scoliosis with/without pelvic obliquity is extremely high, close to 100%.
2.6 What Should Patient andFamily Know?
Spine fractures in children rarely need surgical intervention unless there is a highenergy trauma with fracture-dislocation or neurological decits. Outcomes are good
at experienced spine centers, and a growth-friendly strategy is considered if a
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M. Kaymakoglu and M. Yazici
Fig. 2.3 An example of possible complications in conservatively treated patients. A 16-year-old
female admitted to our hospital after 4years of a T12 burst fracture. Her kyphosis was corrected
with anterior corpectomy and posterior instrumentation and fusion (Video 2.3)
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a
b
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Fig. 2.4 Six-year-old female patient after a vehicle accident. L1–2 fracture-dislocation with an
incomplete neurological injury was managed with open reduction and xation without fusion (a).
Instruments were removed after 1year (b)
surgical intervention is needed. The neurological status at the initial trauma is the
main determinant of the treatment success.
Further Readings
1. Cirak B, etal. Spinal injuries in children. J Pediatr Surg. 2004;39(4):607–12.
2. Vialle LR and Vialle E. Pediatric spine injuries. Injury. 2005;36 Suppl 2: p. B104–12
3. Vaccaro A, Lehman RA, Hurlbert RJ, etal. A new classication of thoracolumbar injuries:
the importance of injury morphology, the integrity of the posterior ligamentous complex, and
neurologic status. Spine. 2005;30(20):2325–33.
4. Dawkins RL, etal. Thoracolumbar injury classication and severity score in children: a valid-
ity study. Neurosurgery. 2019;84(6):E362–e367.
5. Dede O, Yazici M.Pediatric spinal injuries: the rationale behind nonfusion management. Curr
Orthop Pract. 2013;24(4):433–40.
6. Pouliquen JC, etal. Vertebral growth after thoracic or lumbar fracture of the spine in children.
J Pediatr Orthop. 1997;17(1):115–20.
7. Karlsson MK, et al. A modeling capacity of vertebral fractures exists during growth: an
up-to- 47-year follow-up. Spine (Phila Pa 1976). 2003;28(18):2087–92.
Atlanto-Axial (C1–C2) Subluxation
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andDislocation
FedericoCanavese
3.1 Definition
Atlanto-axial dislocation (AAD) is the loss of stability between C1 (atlas) and C2
(axis), which can be secondary to traumatic, inammatory, idiopathic, or congenital
abnormalities, although the cause is most commonly multifactorial (Fig.3.1).
According to the direction and plane of the dislocation, AAD can be divided into
four types: anterior-posterior, rotatory (frequent in children), central, and mixed.
3.2 Natural History
If not diagnosed and treated in a timely and appropriate manner, AAD can cause
permanent neurologic decits and sagittal plane deformity.
In particular, sagittal deformity develops when upper cervical spine lordosis
decreases and, as a compensatory mechanism, sub-axial cervical lordosis increases.
Some patients with end-stage changes (mostly adults) can develop kyphosis at the
occipito-axial (C0–C2) segment together with severe sub-axial lordosis (C3–C6),
resulting in swan neck deformity.
3
Supplementary Information The online version contains supplementary material available at
(https://doi.org/10.1007/978- 3- 030- 80356- 8_3).
F. Canavese (*)
Department of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre
Hospital, Lille, France
Faculty of Medicine Henri Warembourg, Nord-de-France University, Lille, France
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_3
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Fig. 3.1 Atlanto-axial
dislocation (CT scan;
transverse section); patient
from GuangzZhou Women
and Children Hospital,
Guangzhou, China
F. Canavese
3.3 Physical Examination
Clinical presentation varies according to the type of injury, the underlying pathology, and the severity of the dislocation. Approximately 50% of patients present with
neck pain and/or neck movement restriction, 70% with weakness and/or numbness,
and 90% with pyramidal signs (Videos 3.4 and 3.9).
Some patients may also develop muscle weakness, dizziness, tinnitus, blurred
vision, sphincter disturbances, lower cranial nerve dysfunction, and respiratory
distress.
3.4 Imaging
Lateral exion-extension (dynamic) and anterior-posterior (AP) open mouth radiographs of the spine should be performed in all patients.
The atlas-dens interval (ADI) is an important radiographic parameter to evaluate
the severity and direction of dislocation. ADI is measured from a line projected
superiorly along the anterior border to the axis body to the anterior arch of the atlas,
and it does not change during exion-extension movements (normal values: 2–3mm
in adults, and 4–5mm in children). Increased ADI is suggestive of disruption of
transverse ligament of C1.
Three-dimensional computed tomography (CT) scan provides useful information about the osseous anatomy of C1–C2 while magnetic resonance imaging (MRI)
helps to assess soft tissues, joints, and the spinal cord. In particular, MRI is indicated when myelopathic symptoms are present or when plain radiographs show
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