Pediatric Traumatic Spinal Injury (TSI)
What is pediatric traumatic spinal injury?
Pediatric traumatic spinal injury (TSI) is damage to the spinal cord and/or the bones of the spinal column caused by impact or collision. TSI is more common in adults than in children, who represent approximately 5 percent of admitted patients with spinal injury.
(Hamilton MG and Mylk s ST, “Pediatric spinal injury: review of 174 hospital admissions,” JNS, 1992).
The long-term effects of traumatic spinal injury depend on the presence of spinal cord injury. If the spinal cord is damaged, appropriate rehabilitation can continue to improve the initial severity of the weakness in the affected limbs for as long as two years after the initial injury, sometimes even longer.
What are the causes and symptoms of pediatric traumatic spinal injury?
The vast majority of infant TSIs occur as a result of motor vehicle collisions. Because toddlers and small children have large heads relative to their body size, they are mostly at risk for TSI from falls. Adolescents and teenagers are mostly at risk from sports injuries, especially football, and from motor vehicle collisions. The impact from these collisions puts stress on the bones of the spine and the ligaments that hold the spinal column together. An unstable spinal column greatly increases the risk for spinal cord injury.
(Cirak B, et al. “Spinal injuries in children,” Journal of Pediatric Surgery, 2004).
Typically, patients with traumatic spinal injury have severe neck or back pain immediately after the impact or collision. They can also have weakness, numbness, paralysis or loss of bowel/bladder function.
How is pediatric traumatic spinal injury diagnosed?
When TSI is suspected, patients undergo appropriate imaging studies to evaluate the injury. Every patient with traumatic spinal injury should have a CT scan of the affected area to characterize the extent of the fracture and help determine the need for treatment. If a CT scan shows potential ligament or spinal cord damage, an MRI is used to better characterize the extent of the injury.
How is pediatric traumatic spinal injury treated?
The severity of the fracture and involvement of the ligaments that hold the spinal column together dictate the relative instability of the spinal column and the necessary treatment.
Rigid orthotic braces such as cervical collars or thoracolumbosacral orthotic (TLSO) braces are a treatment for injuries of the bones or ligaments that are deemed stable on X-ray and/or CT scan. Typically, a patient wears an orthotic brace for two to three months, depending on the extent of the injury. The benefits of the orthoses are that they are noninvasive, can be easily cleaned and work well for stable injuries.
Halo vest orthosis involves a carbon fiber ring affixed to the skull with four to six skin-penetrating pins. The ring is secured with rods to a vest that is worn by the patient. Typically, halo vest orthoses are used for injuries between the base of the skull and the upper bones of the spine in the neck. The halo ring is placed in the operating room under anesthesia and attached to the vest. During the procedure, X-rays are used to confirm good alignment of the spine.
The halo orthosis is typically worn for two to three months; X-rays or CT scans are done during that time to ensure good alignment and fusion. At the end of the orthosis period, young children may need repeat anesthesia for removal of the halo, while teenagers may be able to have the ring and vest removed in an outpatient procedure. The major benefit of the halo orthosis is that it is a mostly noninvasive tool that helps children with damage to the base of the skull and the top of the spinal column without the need for open surgery.
Open spinal fusion surgery involves placing rods, screws and plates to fix bones in place where unstable spine injuries are present. Spinal fusion can be done from the front and/or the back of the spinal column, depending on the severity and location of the injury within the spinal column and the presence of injury to the spinal cord.
Spinal fusion is done in the operating room under general anesthesia, using either intraoperative X-ray or CT guidance to ensure correct positioning of the screws, rods and plates and alignment of the spinal column. After spinal fusion surgery, children sometimes require a rigid orthotic brace to ensure adequate spinal fusion.
What follow-up care is needed?
A child who undergoes TSI surgery for stabilization of the spinal column needs to be followed by a neurosurgeon to make sure there is no degeneration of the spinal column near the injury.
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