Spine injuries are uncommon in children, accounting about 2–3% of spinal trauma cases. Trauma may result from falls, auto accidents, sporting activities, and nonaccidental injury.
Most injuries involve the cervical spine because of greater mobility in the child and a relatively large head and less muscular support. Most injuries cause hyperflexion with compression injuries. Other injuries result from restraints in vehicular accidents such as seat-belt fractures. The flexibility of the spine accounts for cord injury without apparent skeletal trauma. It has been estimated that the spine can be distracted as much as 5 cm without apparent cord injury.
A careful neurologic examination is essential. Spinal shock with flaccid paralysis and total loss of all reflexes may follow severe spine trauma. This may cloud the examination.
AP and lateral radiographs are made on the stretcher. Be aware that transport and lateral radiographs should be made with compensation for the relatively larger head of the child. Place a pad under the trunk to neutralize the position of the neck. Include the entire spine, as multiple fracture sites are not uncommon.
CT scans, MRI, and other studies can be done as necessary. Carefully image the upper cervical spine, especially if the child has a head injury, neck pain, or muscle spasm.
Anatomic variations are relatively common and may cause confusion.
Retropharyngeal swelling may result from venous engorgement due to crying. In the quiet child, the retropharyngeal space is normally less than 7 mm and the retrotracheal space less than 14 mm.
Pseudosubluxation of C2–C3 level Up to 4 mm of pseudosubluxation is within the normal range for the child.
Atlanto-dens interval (ADI) The normal range is 3–5 mm, which is 1 mm greater than in adults.
Odontoid discontinuity may be due to a growth plate rather than a fracture.
Anterior wedging of the cervical vertebra is often seen in normal infants and younger children.
Spinal cord injury without radiographic abnormality is one of the unique spinal injuries of childhood. SCIWORA is due to the elasticity of the skeletal system, which allows the spinal column to elongate as much as 5 cm without disruption—far greater than the inelastic spinal cord. The condition occurs in children under the age of 8 years. Recurrent injury may occur because of instability. Evaluate with MRI.
Seat-belt injuries are due to a flexion distraction mechanism causing compression fractures of the lumbar vertebrae thought to be due to the elasticity of the posterior ligamentous structure present in children. Suspect this mechanism if contusions are present over the abdominal wall. These fractures vary widely in pattern. Often CT scans are necessary to establish the fracture pattern. Half will have associated abdominal injuries.
These injuries are through the vertebral end plate and can take many forms. Posterior physeal fracture with displacement may simulate disc herniation.
Because these injuries usually occur in infants and show varied patterns of injury, they may require CT or MRI studies for adequate evaluation.
Acute Rotatory Subluxation
Rotatory atlanto-axial subluxation may result from mild trauma, infection, or surgical procedures. The child shows acute torticollis. Early diagnosis is important. Evaluate by plane radiographs and CT scans with head maximally rotated in each direction. These CT scans show fixation of the first and second cervical vertebrae. If the duration is less than 1 week since onset, manage with a cervical collar and bed rest for a week. If not improved, hospitalize for traction.
These fractures occur in children with generalized osteopenia or with lesions such as eosinophilic granuloma.
Injuries with Neurologic Deficit
Children generally do better than adults. Most have only incomplete lesions, and about 20% of those with complete lesions show improvement. Manage with assessment by MRI and treatment with steroids.