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Pediatric thoracolumbar injuries present multiple challenges for physicians
Spine surgeons should be prepared to address different problems in children who present with thoracolumbar injuries than those seen in adults.
NEW ORLEANS — Injuries that pediatric patients typically sustain during a car accident are associated with several complications that physicians who examine these patients need to be aware of and ready to address, according to a presenter at the Federation of Spine Associations Specialty Day Meeting, here.
According to Randal R. Betz, MD, “Lap belt injuries are the most common thoracolumbar injury we see in younger children. Most injuries are severe and usually occur with the child in the rear seat with a lap belt but no shoulder strap.” Many patients will have a “seat belt sign” — bruising over the pelvis or abdomen — and half the patients Betz studied had associated intra-abdominal injuries and a delay diagnosis of spine trauma. In many cases, these accidents were so severe that in 50% of the crashes a passenger in the car had died. Betz said.
Spinal cord injury incidence
Spine trauma in children is rare, but it does occur.
Randal R. Betz
Betz reported on a 2006 study by Stulik and colleagues of 15,646 children from birth to 18 years of age in which spine trauma accounted for 3.6% of the injuries. In a 2004 study by Carreon and colleagues 24 patients of 137 patients (18%) of children with spine trauma suffered injury to the spinal cord and ten of 144 injuries were noncontiguous, multiple spine fractures. Motor vehicle accidents were the most common cause of injury.
Intra-abdominal injury incidence
In 71% of children that Beaunoyer and colleagues studied in 2001 there were intra-abdominal injuries as well as the thoracolumbar injuries and attending physicians must be aware of this possibility, Betz said.
A plain radiograph, CT scan, and MRI show a lap belt injury at L2-3, but they missed some spine fractures.
Source: Betz RB
Posterior wiring and no fusion for a lap belt injury is a good option in young patients that allows further growth.
The sequelae of pediatric scoliosis is shown. When a lap belt injury occurs in a patient with scoliosis the risk of surgery is 67%, according to Randal R. Betz, MD.
“If you are a spine surgeon and you are called to see a spine fracture, remember the high incidence of intra-abdominal injuries and look for them,” Betz said. “On the flip side, if a child is rushed to the operating room for intra-abdominal injuries, you’ve got to try to stabilize the spine while not really knowing what’s going on. Too many children are neurologically intact before they reach the operating room (OR) only to become paralyzed from unprotected movement getting transferred to and from the OR table.”
Injuries with delayed symptoms
Diagnosing the extent of these injuries is difficult, Betz said, because often the injury cannot be readily seen with routine radiographic imaging. Plain radiographs, CT scans and tomograms can miss some spine fractures. Pediatric patients often have delayed presentation of spinal cord trauma, which only adds to the challenges the surgeon faces.
Another point he made was that physicians who care for pediatric patients with thoracolumbar injuries should keep in mind these children will continue to grow and are amenable to conservative treatment, such as casting or bracing. It is important to avoid a fusion if at all possible.
Betz described a child treated with a spinal fusion who recovered completely neurologically, but had a substantially shortened spine.
Physicians should be open to bracing or casting since fusion is often not necessary in young patients, according to Betz. – by Robert Linnehan
References:
Beaunoyer M. J Pediatr Surg. 2001;36:760-762.Betz RR. Presentation #20. Presented at: Federation of Spine Associations Specialty Day Meeting; March 15, 2014; New Orleans.
Carreon LY. J Spinal Disord Tech. 2004;17:477-482.
Stulik J. Acta Chir Orthop Traumatol Cech. 2006;73:313-320.