Spinal Injuries in Children

Epidemiology
Only 5% of spinal cord injuries occur in the paediatric age group.
4-14% of patients with any spinal injury are aged less than 15.
60% of patients with spinal trauma will have other injuries.
60-80% of injuries are in the c-spine region compared to 30-40% in adults.
Frequency of injury in upper c-spine (52%) is nearly twice that in the lower c-spine (28% C5-C7). 

Anatomy
In children:
- Interspinous ligaments and joint capsules are more flexible
- Vertebral bodies are wedged anteriorly and tend to slide forward with flexion
- The facet joints are flat
- The child has a relatively large head compared with the neck. Therefore, the angular momentum forces applied to the upper neck are relatively greater than in the adult.

Radiology
- Pseudosubluxation complicates the radiographic evaluation of a child's c-spine. 40% of children younger than 7 show anterior displacement of C2 on C3, and 20% of children up to 16 years. It is seen less commonly at C3 to C4.
- More than 3mm of movement may be seen when these joints are studied by flexion and extension maneuvers.
- Pseudosubluxation is made more pronounced by the flexion of the c spine. If you place the child in a neutral position and repeat the x-ray the pseudosubluxation should be corrected.
- Increased distance between the dens and the anterior arch of C1 appears in 20% of young children.
- Growth centres can resemble fractures.
- The odontoid synchondrosis appears as a radiolucent area at the base of the dens, especially in children <5 years old.
- Apical odontoid epiphyses appear as separations on the odontoid x-ray and are seen between the ages of 5-11


Clinical
C-spine injury can normally be identified from neurologic examination findings, and by detection of an area of soft tissue swelling, muscle spasm or a step deformity on palpation.

Features suggestive of SCI in an unconscious patient:
- Hypotension and bradycardia
- Flaccid areflexia
- Diaphragmatic breathing
- Loss of pain response below an identified dermatomal level
- Priapism
 -- Do a PR and assess the bulbocavernosus reflex - contraction of bulbocavernonsus muscle in response to squeezing the glans penis. No response if cord uninjured or patient has spinal shock.
   - Shouldn't we be imaging children under 11 at all?


Management
If history of clinical examination suggests a spinal cord injury, treat the patient as though they have an unstable injury even if imaging has been normal.
Remember to pad underneath the torso to elevate it, and allow the head to be in a neutral position.
Clearing the c-spine can be difficult in children.

SCIWORA
50% of c-cpine injured patients have SCIWORA due to transient vertebral displacement causing spinal cord injury but with subsequent realignment. Spinal cord injury and SCIWORA occur more frequently in young children. Multiple injuries and chest injuries increase the risk of fracture/dislocation and of cord injury. Reduced GCS and head injuries increase the risk of cord injury. Mortality rates are higher in younger children (<10 years) than in older children (30% vs 7%) but major neurological sequelae are uncommon in children who survive. Children can have their cord stretched 5cm before rupture. There is a case report here of SCIWORA in a child.
After 8 years old, the injury pattern is similar to in adults.


- SCIWORA is more common than in adults
- Normal c-spine in up to 2/3 of children who have suffered spinal cord injury
- Incomplete spinal cord injury may occur like in adults (anterior cord syndrome, central cord syndrome, brown sequard, posterior cord syndrome).