What do you think is the best way to treat a spinal cord injury in a youung child (five years old): body cast and then bracing or surgery straightaway? We’ve already made the choice but I’m curious to know what you would have recommended.

There was a recent review of studies done in this topic area. Two of the largest studies involving 122 and 179 children both showed significantly improved results in at least 80 per cent of the cases. Children with mild injuries and no neurologic damage are more likely to recover fully.

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.

“Serious” spinal injury in children is defined as vertebral fractures with or without dislocation and/or 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.

Treatment of children with spinal cord injuries is not by a cookbook or cookie cutter approach. Early surgery is recommended to stabilize a rapidly progressing spinal deformity. But if the child is still growing, experts 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.