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2. Treatment
a. Conservative
(1) Mild rotatory deformity
(a) Collar
(b) Analgesics
b. Surgical
(1) C1–C2 fusion if neurological symptoms present
(2) SAC 13 mm
G. Traumatic cervical injuries
1. Cervical spine fractures
a. Vertebral fractures account for 2 to 3% of all childhood injuries.
b. Fifteen percent of all spinal cord injuries occur in children.
c. Under 10 years, bony injuries are less common.
d. Patient positioning may be a problem in children under 5 years.
(1) Head is larger than the trunk.
(a) Back board may displace fracture.
(b) Keep the head lower than the chest.
2. Radiographic evaluation
a. Interpretation of cervical radiographs are more difficult.
(1) Incomplete ossification
(2) Normal anatomic variants
(a) Pseudosubluxation of C2–C3.
b. Spinal cord injury without radiographic abnormality
(1) Common in children under 10 years
(2) Magnetic resonance imaging (MRI) is helpful in identifying the
location and extent of injury.
3. Specific injuries
a. Occipitoatlantal instability
(1) Most injuries are fatal.
(2) Radiographs
(a) More than 1-mm increase in distance between odontoid tip
and basion
(b) Power’s ratio (distance from basion to posterior arch of
C1/distance from opisthion to anterior arch of C1)
(i) Greater than 1.0 is consistent with instability.
(3) Treatment
(a) Occiput-to-C1 fusion and halo brace
b. Jefferson fracture
(1) Axial loading injury mechanism
(a) Usually have an associated head injury
(b) More commonly recognized due to the increased use of
computed tomography (CT).
(2) Radiographic finding
(a) Widening between odontoid and lateral mass of C1
(b) Overhang of the lateral mass of C1 may be normal in child
due to differential ossification.
(c) CT scan is best in delineating fractures and helps to differ-
entiate
(i) Neurocentric synchondroses (fused by 6 years)
(ii) Posterior synchondrosis (fused at 5 years)
(iii) Irregular ossification
* Especially anterior arch may have multiple ossifica-
tion centers.
(3) Treatment
(a) Minerva orthosis or halo brace, depending on displacement
or rupture of the transverse ligament
c. Odontoid fractures
(1) Usually occur in children less than 4 years old as synchondrosis
is fused by 6 years.
(2) Os odontoidium is an unrecognized fracture of odontoid waist.
(3) Radiographs
(a) Angulation of odontoid with displacement
(b) Flexion-extension radiographs
(i) May demonstrate instability and displacement of the
fracture
(ii) Great caution should be taken during flexion and ex-
tension examination
(4) Treatment
(a) Reduction by posterior translation and mild extension
(b) Minerva or halo vest
(i) Nonunion (rare)
(ii) Malunion (common)
d. Hangman’s fracture—bilateral fracture of the C2 pedicles (traumatic
spondylolisthesis of C2 on C3)
(1) Mechanism of injury
(a) Extension or distraction
(b) Commonly associated with facial abrasions or fractures
(2) The majority are neurologically intact.
(3) Radiographs
(a) Fractures of the pedicles and displacement or angulation
may be significant.
(4) Treatment
(a) Closed reduction
(i) Posterior translation and slight extension
(b) Minerva orthosis or halo vest
e. Lower cervical spine injuries
(1) Bony injuries are less common in children under 10 years.
(2) Cervical dislocations should be reduced as soon as possible.
(3) Stabilization is performed using posterior spinous process
wires and fusion using iliac crest bone graft (Fig. 23–5).
d’Amato C. Pediatric spinal trauma: injuries in very young children. Clin Orthop Relat Res 2005;
432:34–40.
Dogan S, Safavi-Abbasi S, Theodore N, et al. Pediatric subaxial cervical spine injuries: origins, manage-
ment, and outcome in 51 patients. Neurosurg Focus 2006;20:E1–E7
McCall T, Fassett D, Brockmeyer D. Cervical spine trauma in children: a review. Neurosurg Focus
2006;20:E5–E11
Santiago R, Guenther E, Carroll K, et al. The clinical presentation of pediatric thoracolumbar fractures.
J Trauma 2006;60:187–192
Vialle LR, Vialle E. Pediatric spine injuries. Injury 2005;36(Suppl 2):B104–B112
Figure 23–5 Cervical kyphosis. (A) Lateral radiograph of a 17-year-old patient with cerebral palsy pre-
sented with severe thoracic lordosis and cervical kyphosis with progressive myelopathy. This patient
underwent anterior vertebrectomy and fusion and subsequent surgical procedures for correction of
his thoracic lordosis. (B) MRI of a 14-year-old boy with postlaminectomy kyphosis and myelopathy.
Anterior corpectomy and fusion were required for correction.
Index
Note: Page numbers followed by f and t indicate figures and tables, respectively.
251
A
ABCDE mnemonic, 85
abscess
epidural, 223–224
clinical presentation of, 223
diagnosis of, 224
etiology of, 223
treatment of, 224
soft tissue, 127
achondroplasia
and atlantoaxial instability, 247
and basilar invagination, 243
and kyphotic spinal deformity, 196
action potential(s), compound muscle,
58
Adams forward bend test, 181
ADI. See atlantodens interval
Adson’s test, 49
aggrecan, 116
aging
and anular tear, 138
and disk degeneration, 116–118
radiographic findings in, 54, 54f
airway, evaluation of, in trauma patient, 86
ala, sacral, 19
alar ligaments, 14, 15, 16f
ALIF. See anterior lumbar interbody fusion
Allomatrix™, 81
American Spinal Injury Association
spinal cord injury assessment form, 87f
standard of neurological testing, 86
4-aminopyridine, for spinal cord injury, 89t
amyotrophic lateral sclerosis, 127
anatomy. See also neuroanatomy
of anulus fibrosus, 115, 116f
of cervical spine, 125f
bony, 12–14
developmental, 240
ligamentous, 14–15
of intervertebral disk, 115, 116f
of lumbar pedicle, 75–76
of neuroforamen, 150, 150f
of spine
basic, 3–4
surgical, 12–21, 12f–13f
aneurysmal bone cyst, 209t
angina pectoris, 127
angiography, 52
with spinal tumor, 207t
ankylosing spondylitis
and basilar invagination, 243
clinical findings in, 236–237
degenerative cervical spine disorder in,
126
epidemiology of, 236
genetics of, 236
kyphotic spinal deformity in, 201–202
low back pain in, 159
lumbar disk disease in, 144
nonskeletal manifestations of, 237
pathogenesis of, 236
physical findings in, 236
252 Index
ankylosing spondylitis (Continued)
radiographic findings in, 237
spinal deformity in, 238
surgical treatment of, 238
treatment of, 238
anterior atlantoaxial ligament,
15, 16f
anterior caudal nerve, 11
anterior coccygeal plexus, 11
anterior cord syndrome, 7
anterior horn cell disease, and kyphotic
spinal deformity, 199
anterior longitudinal ligament, 15, 17
anterior lumbar interbody fusion, 163t,
164, 165f
anterior ramus/rami, 9, 11
anterior sacroiliac ligament, 19
anterior spinal artery, 7
anterior spinothalamic fasciculus, 7
anterior spinothalamic tract, 6, 6f
anterior ventral fissure, 6f
antibiotic therapy
for disk space infection, 224
for epidural abscess, 224
for osteomyelitis, 223
anulus fibrosus, 74
anatomy of, 115, 116f
cells of, 115
collagen of, 115
nociceptors on, 139
tear of
aging and, 138
imaging of, 56, 57f–58f
pathogenesis of, 138
pathology of, 142
signs and symptoms of, 144
apical ligament, 15, 16f
apportionment, in disability/impairment
determination, 93
arachnoid membrane, 8–9, 8f
artery of Adamkiewicz, 8
arthritis. See also ankylosing spondylitis;
rheumatoid arthritis
enteropathic, 239
facet joint, 92
in inflammatory bowel disease, 239
psoriatic, 144, 239
ascending pathways, 6f
ASIA. See American Spinal Injury
Association
astrocytoma, 212t
athlete(s), helmeted, prehospital
management of, 85
atlantoaxial articulation, 14, 15, 16f
kinematics, 60
ligaments of, 15, 16f
atlantoaxial impaction, in rheumatoid
arthritis, 231–232
atlantoaxial instability, 62–63
in pediatric patient
etiology of, 247
treatment of, 248
atlantoaxial interval, in pediatric patient,
240
atlantoaxial rotatory fixation, 96
atlantoaxial subluxation
in rheumatoid arthritis, 230–231, 230f
surgical stabilization in
indications for, 232–233
technique for, 234
atlantodens interval, 62–63
anterior, rupture of transverse ligament
and, 96
normal, 230
in pediatric patient, 241f
posterior
as predictor of paralysis, 231
prognostic significance of, 232
in rheumatoid arthritis, 230f, 231
in rheumatoid arthritis, 230–231, 230f
atlanto-occipital articulation, 14–15
atlanto-occipital dislocation, anterior,
Power’s ratio in, 62, 62f
atlanto-occipital fusion
with basilar invagination, 241
congenital, 246
associated disorders, 246
clinical findings in, 246
radiographic findings in, 246
treatment of, 246
atlanto-occipital membrane
anterior, 16f
posterior, 16f
atlas (C1), 13–14, 16f
bipartite superior articular surface of,
240
developmental anatomy of, 240
fractures of, 63, 96–97, 97f
classification of, 97f
hypoplasia of, with basilar invagination,
241
posterior arch of
absence of partial absence of, 240
bifid, 240
with basilar invagination, 241
pseudonotch of, 240
Index 253
autonomic dysreflexia, 12
autonomic systems, spinal, 11–12
axis (C2), 14, 16f
fractures of, 63
pseudosubluxation of, 240
spinolaminar line of, posteriorly
displaced, 240
traumatic spondylolisthesis of, 99–100,
99f. See also hangman’s fracture
azygos vein, 8
B
Babinski’s sign, 45f, 47t
in cervical myelopathy, 123
back pain. See also low back pain
acute
imaging of, 52
management of, 52
axial. See also low back pain
surgical management of, 158–166
discogenic, injection therapy for, 92
injection therapy for, 92
with lumbar disk disease, 137
in osteomyelitis, 219
prevalence of, 90
rehabilitation of, 90–92
balance, sagittal, 60
bamboo spine, in ankylosing spondylitis,
237
basilar invagination, 62
clinical findings in, 243–244
pathology of, 241
in pediatric patient, 241–244, 243f
primary, 241
in rheumatoid arthritis, 231–232
secondary, 241–243
treatment of, 244
types of, 241–243
Batson’s plexus, 8
biglycan, 116
biomechanics
of cervical spinal fusion, 67–69
of facet joints, 74
of intervertebral disk, 74
of lower cervical spine, 63–67
of lumbar transpedicular instrumentation,
75–76, 77f
of occiput–C1 instability, 61–62
of spinal deformity, 193
of spinal instability and instrumentation,
61–76
of spondylolisthesis, 74, 169
of thoracic spine, 69–70
of thoracolumbar kyphosis, 73
of thoracolumbar spine, 69–70
biopsy, open, in spinal infection, 222t
block vertebra, 182f
blood culture(s), in spinal infection, 222t
BMP. See bone morphogenetic protein(s)
Bohlman triple-wiring method, 64f
bone, formation of, 78
bone age, evaluation of, 181
bone disease, and lumbar spondylolisthesis,
176
bone graft(s)
allograft
for anterior cervical fusion, 80
for anterior thoracolumbar fusion,
80–81
incorporation, physiology of, 79
for posterior spinal fusion, 80
autograft
for anterior cervical fusion, 80
incorporation, physiology of, 78–79
for posterior spinal fusion, 80
enhancers, 80
extenders, 80
incorporation, physiology of, 78–79
substitutes, 79, 81–82
bone marrow, 81
stem cells in, 81
bone morphogenetic protein(s), 82
and disk metabolism, 118, 142
in treatment of disk degeneration, 118
bone scan/scintigraphy, 52, 53t
in disk space infection, 224
of spinal tumor, 207t
Bone Source, 81
bowstring sign, 46t
brace(s)
for kyphotic spinal deformity in
Scheuermann’s disease, 198
rigid cervicothoracic, 69
sterno-occipital-mandibular
immobilized, 69
brachial plexus, 11
breast cancer
metastases to spine, 206t
risk factors for, 206t
breathing, evaluation of, in trauma patient,
86
Brooks wiring, 63
Brown-Sequard syndrome, 7
bulbocavernosus reflex, 50f
burst fractures, thoracolumbar, 72, 107, 108,
108 f
254 Index
C
café au lait spots, 48
calmodulin, and idiopathic adolescent
scoliosis, 179
carotid sheath, contents of, 23, 23f
cauda equina, 11
spinal stenosis and, 149, 152
cell transplantation, for disk degeneration,
118
central cord syndrome, 7
ceramics
as bone graft substitutes, 81
calcium-based, 81
clinical uses of, 82
cerebral palsy
and kyphotic spinal deformity,
199, 250f
scoliosis in, 189–191
cerebrospinal fluid, in spinal cord, 6
cervical collar, 68
postoperative indications for, 130–131
cervical orthosis, 68–69
cervical plexus, 11, 12f
cervical spine. See also atlas (C1);
axis (C2)
anatomy of, 125f
bony, 12–14
developmental, 240
ligamentous, 14–15
anterior corpectomy, in smokers, 128
articulations, 14–15, 16f
C2–C7 articulation, 15
C3–C6 vertebrae, 14
C7 vertebra, 14
deformity, in rheumatoid arthritis,
230–232, 230f–231f
degenerative disorders, 122–131
differential diagnosis of, 126–127
imaging of, 124–125, 126f
discectomy, anterior, 128
extension, 48, 60–61
facet wiring and graft for, 68
flexion, 48, 60–61
fractures
of C3–C7 vertebral bodies, 102–103
clay-shoveler’s, 102
in pediatric patient, 248
of spinous process, 102
tear drop, 102
wedge compression, 102
fusion
anterior, 80, 128
biomechanics of, 67
biomechanics of, 67–69
posterior, biomechanics of, 68, 68f, 69f
in smokers, 128
immobilization, in trauma patient, 95
infections, 126–127
inflammation, 126
instrumentation
anterior, 128
posterior, 68, 68f, 69f
interspinous wiring of, 68
intervertebral foramina in, 9
kinematics, 60–61
laminectomy and fusion with
instrumentation, 128–129
laminoforaminotomy, 128, 129f
laminoplasty, 128, 130f
lateral bending, 48, 60–61
lower
biomechanics of, 63–67
compressive flexion injuries,
and instability, 67
injuries, in pediatric patient, 248
instability
bony disruption and, 67
ligamentous disruption and, 63
White and Panjabi checklist for, 63
laminectomy, biomechanics of, 67
laminectomy plus facetectomy,
biomechanics of, 67
surgical approach to, posterior, 21–22
vertical compression, and instability,
67
magnetic resonance imaging of, 54
manual in-line stabilization of, 86
middle, surgical approach to, anterior
medial, 22–24, 23f
muscles of, 15–17
normal variants of, 240
pediatric, disorders of, 240–250
associated abnormalities, 240
physical findings in, 240
radiographic evaluation of, 240
pedicle screw for, 68
posterior lateral mass screw/rod for, 68,
68f, 69f
postoperative management of, 130–131
rotation, 48, 60–61
spinal nerves, 9
spontaneous rotatory subluxation of
C1–C2
and atlantoaxial instability, 247
Fielding classification of, 247
Index 255
subaxial, kinematics, 61
surgical approach to, 21–29
anterior, 22–29, 23f
complications of, 129
indications for, 127–128
anterolateral retropharyngeal,
25–26
complications of, 129–130
lateral, 26
posterior, 21–22, 22f
complications of, 130
indications for, 128
tension signs, 46t
trauma, 95–103, 126
anatomical distribution of, 95
emergency department management
of, 95
epidemiology of, 95
evaluation of, 95
extension-acceleration injury in, 103
flexion-deceleration injury in, 103
incidence of, 95
in-field management of, 95
mechanism of injury in, 95
in pediatric patient, 248
radiographic evaluation of, 248
soft tissue injury in, 103
subaxial, 100
classification of (Allen), 100, 100t
tumors, 126
upper (C1–C2)
fixation of
anterior odontoid screws for, 63, 67f
C1 lateral mass screw/C2 pedicle
screw for, 63, 65f, 66f
Luque rods for, 63
Magerl’s transarcticular screw
technique, 63, 64f–65f
occiptocervical plates for, 63
posterior methods, 63, 64f–66f
sublaminar wiring technique,
63, 64f
subluxation, 96
surgical approach to
anterior retropharyngeal exposure
by McAfee, 25
anteromedial, by DeAndrade and
Macnab, 25
posterior, 21, 22f
transoral, 24–25, 24f
trauma to, 96
vascularity of, 7
vertebrae, cross-sectional view of, 125f
cervicothoracic brace(s), 69
cervicothoracic junction, surgical approach
to, 26–29
low cervical, 26
sternum-splitting, 27–29, 27f–31f
supraclavicular, 26
transthoracic, 26–27, 32f–36f
Charcot-Marie-Tooth disease, and kyphotic
spinal deformity, 199
Charite, 166
chondrocytes, 115
chondrosarcoma, 210t
chordoma, 210t, 216f
claudication
neurogenic, 148
vascular and neurogenic
coexisting, 152
comparison of, 156t
differentiation of, 152
claudication-like symptoms, in lumbar
spinal stenosis, 152
clay-shoveler’s fracture, 102
clonus, as myelopathic sign, 47t
Cobb angle, in idiopathic adolescent
scoliosis, 181
coccyx
spinal nerve of, 9
surgical anatomy of, 19–21
collagen
and idiopathic adolescent scoliosis, 179
of intervertebral disk, 115–116, 142
collagen disease, and kyphotic spinal
deformity, 196
Collagraft, 81
comma tract, 6f
compression fractures
osteoporotic, magnetic resonance
imaging of, 208t
thoracolumbar, 72
compression sign, 46t
computed tomographic myelography, 52,
53t
of cervical degenerative disorders, 124
of degenerative lumbar spondylolisthesis,
174
of lumbar disk disease, 144–145
of lumbar spine, 160
of thoracic spine, 132, 135f
computed tomography, 52, 53t
of adult scoliosis, 188
of ankylosing spondylitis, 237
of anular tear, 58f
of lumbar disk disease, 144–145
256 Index
computed tomography (Continued)
of lumbar spinal stenosis, 153
of lumbar spine, 57f, 160
of lumbar spondylolisthesis, 172
of spinal infection, 222t
of spinal tumor, 207t
of trauma patient, 88, 104
connective tissue, and idiopathic
adolescent scoliosis, 179
contralateral leg raise test, 46t, 143
conus medullaris, 4, 5f, 8
costotransverse ligament, 17
costovertebral ligament, 17
Cotrel-Dubousset hook system, 186
C-reactive protein, in spinal infection, 206,
222t, 223
CRP. See C-reactive protein
cruciform ligament, 14, 15, 16f
cytokine(s), proinflammatory, and
intervertebral disk matrix,
118, 142
cytokine blockers, in treatment of disk
degeneration, 118
D
DBM. See demineralized bone matrix
decorin, 116
degenerative disorders. See also disk
degeneration
cervical, 122–131
differential diagnosis of, 126–127
imaging of, 124–125, 126f
epidemiology of, 54
history-taking in, 42–45
plain radiographs in, 54, 54f
thoracic, 132–136
deltoid muscle, 12f, 13f
demineralized bone matrix, 81
dens
developmental anatomy of, 240
posteriorly angulated, 240
dentate ligament(s), 8f, 9
dermatome(s), 10–11, 10f
nerve roots innervating, 49t
descending pathways, 6f
diastrophic dysplasia, and atlantoaxial
instability, 247
dimples, midline, 48
disability
definition of, 93
determination of
apportionment in, 93
components of, 93–94
evaluation of, 92–94
and litigation, prognostic significance of,
90
partial, definition of, 93
disk degeneration
and adult scoliosis, 188
aging and, 116–118
biochemistry of, 116
imaging of, 56, 57f–58f
in lumbar/lumbosacral spine, 74
Modic end plate changes in, 56
morphological changes in, 138, 138f
pain relief in, 120
and spinal stenosis, 148, 149
stages of, 117f
treatment of
biologic disk regeneration in,
118–119
biologic strategies for, 118
disk herniation
biochemical pathology of, 142
cervical
epidemiology of, 124t
physical findings in, 124t
in cervical degenerative disease, 122
epidemiology of, 54
inflammatory response to, 142
injection therapy for, 92
locations of, 139, 140f, 141 f
lumbar
age and, 137
history-taking in, 142
neurological examination in, 143
physical findings in, 142–143
surgical treatment of, 146f, 147 t
morphology of, 139, 139t
recurrent, imaging of, 56
and spinal stenosis, combined, 148
thoracic, 132, 134f, 135–136, 135f
types of, 139, 139t
discitis, 219, 220f–221f
cervical, 126
and low back pain, 159
and lumbar disk disease, 144
discography, 52, 53t
of adult scoliosis, 188
of anular tear, 57f
in low back pain, 161
of lumbar disk disease, 145
disk pressure, 74
disk space infection(s)
clinical findings in, 224
epidemiology of, 224
Index 257
etiology of, 224
treatment of, 224
distraction test, 46t
dorsal column, 6f
dorsal ramus/rami, 9, 12f, 142
dorsal spinocerebellar tract, 6f
dorsal sulcus, 6f
Down’s syndrome, atlantoaxial instability
in, 247
Drummond technique, 186
Duchenne muscular dystrophy, scoliosis in,
191
dura mater, 8–9, 8f
Dynagraft™, 81
dysdiadochokinesia, 124
dysplasia. See also spondylolisthesis,
lumbar, congenital/dysplastic
and atlantoaxial instability, 247
and kyphotic spinal deformity, 196
E
edema, magnetic resonance imaging
of, 56
electrodiagnostic tests, 58–59
electromyography, 58–59
EMG. See electromyography
enthesitis, in ankylosing spondylitis,
236
eosinophilic granuloma, 209t, 213f
ependymal canal, 6
ependymoma, 212t
epidural space, 9
erector spinae muscle, 13f, 21
erythrocyte sedimentation rate
in disk space infection, 224
in spinal infection, 206, 222t, 223
esophagus, 23, 23f, 24
ESR. See erythrocyte sedimentation rate
Ewing’s sarcoma, 210t
external abdominal oblique muscle,
12f, 13 f
F
facet joint(s), 4
arthritis of, 92
biomechanics of, 74
dislocations, cervical
with herniated disk, 101
unilateral or bilateral, 100–101,
101f, 102 f
injection therapy, 161
indications for, 92
and spinal stenosis, 149
facet joint pain syndrome, 92
facet syndrome
lumbar, 144
signs and symptoms of, 144
facial asymmetry, 240, 243
far-out syndrome, 150, 156
fasciculus cuneatus, 6, 6f, 7
fasciculus gracilis, 6, 6f, 7
femoral stretch, 46t
fever, in osteomyelitis, 220
FGF. See fibroblast growth factor
fibroblast growth factor, and disk
metabolism, 118
fibromodulin, 116
fibrositis, and lumbar disk disease, 144
finger escape sign, 44f, 47t
flatback syndrome, 202
flip test, 143
fluorosis, 149
fracture(s)
of atlas (C1), 63, 96–97, 97f
classification of, 97f
of axis (C2), 63
burst, thoracolumbar, 72, 107,
108, 108f
of C3–C7 vertebral bodies, 102–103
cervical spine
in pediatric patient, 248
of spinous process, 102
tear drop, 102
wedge compression, 102
clay-shoveler’s, 102
compression
imaging of, 56
thoracolumbar, 72
hangman’s, 63, 99–100, 99f
types of, 99f, 10 0
Jefferson, in pediatric patient,
248–249
occult, in ankylosing spondylitis,
237
odontoid. See odontoid fractures
pathologic, imaging of, 56
thoracolumbar, 104–110
instrumentation for, 72, 73f
types of, 72
fracture/dislocation, thoracolumbar, 72,
106–107, 108, 110f
Frajersztajn sign, 46t
Frankel Impairment Scale, 86, 88t
Friedreich ataxia, and kyphotic spinal
deformity, 199
functional spinal unit, 60