Update on Spinal Injuries in the Growing Child



As our title suggests, the currently available case studies and review articles on the topic of pediatric spinal injuries was reviewed. A specific focus on nonfusion (surgical) treatment is included. As with other pediatric injuries that can also affect adults, spinal injuries in the very young aren’t the same as in the fully grown adult. There are different anatomical features to consider along with differences in healing responses to trauma.

Two of the most important factors that influence the management and outcomes of serious spinal injuries include the extensive bone and soft tissue remodeling that goes on and the fact that the child is still growing. The growth factor alone can make deformities and complications better or worse.

By “serious” spinal injury, the authors mean vertebral fractures with or without dislocation and/or with or without spinal cord injury. Spinal cord injury without radiographic abnormality (SCIWORA) is the term used to describe spinal cord injury without bone fracture. And one of the later developments of a spinal cord injury in children without apparent bone involvement is spinal deformity (scoliosis). This type of subsequent deformity can be very severe.

Car accidents, falls from a height, and sports trauma are the three most common causes of such serious injuries. The lack of strength, increased laxity and mobility, and decreased spinal stability in children (as compared with adults) are additional reasons why pediatric and adult spinal injuries differ.

In children, ligamentous laxity in the spine is greater than the ability of the spinal cord to stretch. In other words, the ligaments can stretch with the force of the distraction from the injury but the spinal cord only has so much give before it is injured as well.

Likewise, the growth plate (physis) can be damaged but the discs and bony vertebra remain unharmed. The result can be a spinal cord injury without fracture of the surrounding bone. This type of injury has been reported in children as young as six months old resulting in permanent paralysis.

Treatment of children with spinal cord injuries is not by a cookbook or cookie cutter approach. The authors recommend early surgery to stabilize a rapidly progressing spinal deformity. But if the child is still growing, they also advise waiting to do a spinal fusion until the spine has reached near maturity.

Whenever possible, a nonoperative treatment approach should be taken. This could involve bracing or growth-sparing (growing) rods. When the spine can’t be stabilized by conservative means, then nonfusion surgery may be appropriate. The surgeon lines everything up as normal as possible and uses instrumentation (pins, rods, wires, screws) to hold it in place. As soon as bone healing occurs (as seen on X-ray), the form of fixation used is quickly removed to avoid (spontaneous) spinal fusion.

Studies show that stable vertebral fractures treated conservatively (without surgery) can be successful. Long-term follow-up did not show any faster or greater disc degeneration in these children as adults (compared with other adults who never had this type of serious spine injury).

Individual case reports also suggest that conservative care of fracture-dislocations of the thoracolumbar vertebrae in young children can also be quite successful. It is possible to preserve normal spinal motion and spinal stability. In general, the results (and therefore prognosis) are quite good in children under the age of 10. They heal and recover quickly. The potential for remodeling and regaining normal vertebral height without deformity and without neurologic involvement is also greater in this age group. The exception is the child with a serious neurologic injury right from the start.

In summary, the authors provide surgeons with a very complete review of pediatric spinal injuries. They explain the ability to treat many spine traumas in this age group conservatively or with nonfusion (surgical) management. Major differences between children and adults are reviewed along with a presentation of results obtained so far (mostly for individual cases and sometimes as part of case series).