PEDIATRIC SPINE TRAUMA IN

ARAB COUNTRIES

DR ESSA AL ABDULGANI

CONSULTANT PEDIATRIC NEUROSURGEON

HEAD DEPARTMENT OF NEUROSUGERY

DAMMAM MEDICAL COMPLEX -KSA

Introduction

How common ?

Traumatic spine injuries(TSI) in children are relatively uncommon.

( rare)

It constitute: *1-5% of child trauma.

*1-10% of spine injury cases.

The mortality rate is higher in pediatric age group. Mostly related to organ injuries.

Which part of the spine?

Pediatric vertebral injuries occur 60-80% of the time in the cervical region VS (in adults cervical spine constitute 30-40% ).

Males are more frequently affected.

Literature review

No single study or review collecting all pediatric patients from different Arab countries

with spine injuries in one paper.

Only few scattered case reports where available.

No clear statistics available.

In Saudi Arabia there is 2 reviews , and few case reports.

-multicenter study.

Correspondence: Dr. Amro Al-Habib

- Department of Surgery ,King Saud University, Riyadh

- Retrospective chart review in a major trauma centers from May 2001 to May 2009.

- RESULTS:

- A total of 8941 trauma patients were identified during the study period, and 3796

of these patients were at or below 18 years of age.

- Of these younger patients, 120 had sustained a spine injury (3.2% of all pediatric

trauma cases).

Spine and spinal cord injury

Overall, the spine was most commonly affected at the cervical level (55.8%).

More than 1 spinal region was affected in 23.3%.

Most of the younger patients (<12 years) sustained cervical injuries (88%).

Older patient ----- thoracic .

SCI, alone or in combination with other injuries, was found in 23 patients (19.2%).

Neurological deficits at discharge were present in 6 of the SCI patients (26%), and the other SCI patients achieved full recoveries (74%).

M :F ratio

mechanism of spine

injury

MVC was the commonest

mechanism of spine injury

(60.8%).

pedestrian injuries

(20.8%).

fall-related injuries

(15%).

Mechanism of injury by age

The mechanisms of injury varied

significantly across the age

groups:

Patients younger than 12

years old experienced

pedestrian (40.6%) and fall-

related (34.4%) injuries.

Older patients (12-18 years),

injuries were mostly caused by

MVC (72.7%).

SCI (INTERNATIONAL VS KSA)

MOH in KSA Recorded one of the highest rate of spinal cord injuries in the world…. Mostly resulting from MVC.

Annual incidence rate of 62.37 and 38/million, in two different studies.

Compared with other countries :

North America at 40/ million

western Europe 16/……..

Australia 15/……..

Asia – central 25/ …….

Asia – south 21/ …….

Africa –central 29/ …….

Africa – east 21/ …….

Middle east, Jordan, Qatar, and turkey at 15/ million.

Fractures of the Thoracolumbar

Spine in Pediatric Patients

uncommon in pediatric patients.

most pediatric thoracolumbar injuries can be managed non surgically.

While the cervical segment is the most commonly injured region of the spine among

pediatric age groups, the thoracic and lumbar segments are involved in 25% to 53%

of all pediatric spine injuries.

Injuries to the thoracic spine becomes more frequent with advancing age.

Single-level injuries to the thoracolumbar spine are less common than multilevel

injuries.

Thoracolumbar junction is the most common site for single-level fracture.

T5 through T8 region is the most common area for multilevel fractures,

Overall, vertebral compression fractures are the most common types of fractures

found among pediatric spine injuries.

The plasticity and high vascularity of the vertebral cancellous bone of the pediatric

spine, along with its high proportion of cartilaginous components, allows it to provide

considerable shock absorption before compressing or bursting.

pediatric spine is more flexible than the adult spine as the result of a combination of

factors:

Ligamentous and facet capsule laxity

increased natural kyphosis from mild vertebral body wedging.

more elastic intervertebral disks due to a higher disk water content and less collagen

crosslinking.

greater mobility between vertebral segments as the result of more horizontally

oriented facets that allow greater flexion and pseudosubluxation

These elastic properties allow the pediatric vertebral column to lengthen by as much as 2 inches before dislocation occurs, as compared with the spinal cord, whose length can increase by only 0.25 inches before it ruptures.

explain why pediatric patients can sustain significant spinal cord injuries in the absence of any osseous injury to the spine (SCIWORA)

Thoracolumbar spine injuries

most common physical finding:

- Tenderness

- Bruising

other signs included:

- skin injuries

- Crepitus

- Stepoff or gaps between spinous processes

Thoracolumbar spine injuries

Neurologic deficits can be found in up to 19%.

complete spinal cord injuries (SCIs) are generally more common than incomplete

injuries.

The “lap belt” sign:

presence of skin bruising or abrasions

matching the pattern of an automobile

seatbelt.

associated with intra-abdominal injury

in 50% to 84%.

spinal fracture in 15% to 50%.

SCI in 11% to 50%.

Paediatric Classification

Type I: physeal injury of the superior growth plate associated with posterior lesion above the pedicle (soft tissue injury or superior facet fracture).

Type II: osseous type. Fracture through the vertebral body, pedicle, lamina and spinous process.

Type III: physeal injury of the inferior growth plate associated with posterior lesion below the pedicle (soft tissue injury or inferior facet fracture).

Type I

Physeal injury of the superior growth plate associated with posterior lesion

above the pedicle (soft tissue injury or superior facet fracture).

Type II

Osseous type. Fracture through the vertebral body, pedicle, lamina and spinousprocess.

Type III

Physeal injury of the inferior growth plate associated with posterior lesion below the pedicle (soft tissue injury or inferior facet fracture).

Chance Fractures

Unique to thoracolumbar spine (T10 – L2)

Variant of flexion-distraction injury

Due to lap belt injury without shoulder belt restraint

Fulcrum of flexion lies anterior to vertebral column allowing no compression of vertebral body

Flexion results in either ligamentous tear or combination of ligament, bone and disc injuries

Chance Fractures

15-42% chance intra-abdominal organ injury: pancreas, duodenum and prox small bowel

79% hollow viscus injury in New Zealand case series

25-83% neurologic deficit/vertebral injury

1/3 patients have Type II fracture

2/3 Type I or III fracture

96% patients bone and soft tissue injury, 4% soft tissue injury alone

Almost all patients have extensive soft tissue oedema and posterior osteo-ligamentous complex disruption

Management

ABC’s

Prevent secondary injury

High index of suspicion in patients restrained by lap seat belts

Regular reassessment for abdo injuries

Unstable fracture: requires immobilisation/ stabilisation

Management

Conservative: reduction of dislocation + application of TLSO 2-3

months

Surgical: failure to stabilize conservatively.

Cervical spine injury in children

Cervical spine injury (CSI) in

children is rare but can result in

mortality and significant morbidity.

Approximately 72% of spinal

injuries in children <8 years old

occur in the cervical spine.

Falls are the commonest cause of CSI in the younger population.

followed by pedestrian and MVC (passenger seat accidents) in the slightly older

group.

Sports related accidents are seen most commonly among adolescents.

Biomechanics – anatomical factors

The paediatric cervical spine is intrinsically susceptible to spinal cord injury.

The anatomical factors that account for this includes:

The relatively large child’s head

Weak neck muscles

lax spinal ligaments

pliable discs

In young children the fulcrum for

movement is located in the upper

cervical spine.

leading to a relatively high incidence

of injury in the upper cervical spine in

this age group.

In children over eight years the fulcrum

migrates caudally to C5/6.

conclusion

TSI in pediatric age group is rare( 1-5% of all pediatric trauma).

Pediatric Patients have different pathophysiology, and their management is different

from adults.

Most of the thoracolumbar spine injury can be managed conservatively.

The available data concerning TSI and SCI in pediatric age group is inadequate in

the developing countries, and a registry is lacking. This stimulate us to work hard

toward creating & maintaining a national registry.