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Pediatric Spine and Spinal Cord Injuries

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PEDIATRIC SPINE AND SPINAL CORD INJURIES

Eric R. Trumble, MD

NEUROSURGEONS FOR KIDS

November 15, 2006

OBJECTIVES

 

SPINE INJURY

Introduction

Incidence

Types of Head Injury

Current Knowledge & Management

Long-term Sequellae

Prevention

INTRODUCTION

Motor vehicle crashes #1 cause of TBI, SCI, and seizures

600-700 children die each year

75,000 children are injured

INCIDENCE

Trauma is the leading cause of death in children

11,000 children die from trauma annually

Of those, >80% had a severe head injury

Of those, approximately 10% have a spinal cord injury

In children ages 1-15, more died from trauma than all other causes… COMBINED

IF YOU HAVE A BIG HEAD ON A SMALL BODY…

 

PEDIATRIC CONSIDERATIONS

Structural differences between pediatric and adult cervical spines alter injury patterns and cause distinct pathology in young children.

The more elastic intervertebral ligaments and more horizontally aligned facet joints in young children predispose them to subluxation of the cervical spine without bony injury.

Immature neck muscles and a proportionally large head further compound this effect, making pediatric cervical spines act like a fulcrum and increasing the chance of injury.

This fulcrum starts in the upper cervical levels and changes progressively to lower levels as the pediatric cervical spine matures, until it reaches adult levels at C5 and C6. Most injuries occur at the C1-C3 levels in children younger than 8 years.

BIRTH TRAUMA

More often brachial plexus injuries, e.g Erb’s palsy, than spinal cord injury

Incidence of Erb’s palsy 1:1000

Incidence of permanent disability from Erb’s palsy 1:10,000

Acute work-up includes cervical spine X-rays and shoulder/clavicular X-rays

MOTOR ASSESSMENT

Assess all extremities, as many muscle groups as possible

Grade strength using British Muscle Movement Scale

- 0  Flaccid

- 1  Tone but no joint movement

- 2  Able to move joint horizontally but not against gravity

- 3  Able to move joint against gravity but not against active resistance

- 4  Weak but able to overcome light active resistance

- 5  Normal

SENSORY ASSESSMENT

AUTONOMIC ASSESSMENT

Hypotension (Vasodilation)

Priapism

Lack of Sphincter

Reflexes (Absent in acute injury and lower motor neutron injury, increased in chronic upper motor neutron injury)

PROGNOSIS

Much worse prognosis if:

            Injury is complete (no function distal)

            Autonomic signs are present

            Hypotension

            Hypoxia

SUSPICIONS SHOULD BE RAISED REGARDING SPINAL CORD INJURY WHEN:

Child abuse

Vehicular ejection

Peds vs car

Child holding head rigid

Apnea following trauma

Any neurological deficit

Seatbelt sign

Subcutaneous emphysema

Crepitance about spinous processes

Heart rate <80 with hypotension (spinal shock)

RISK FACTORS FOR ERB’S PALSY

Macrosomia

Prolonged labor

Gestational Diabetes

Breech delivery

Cephalopelvic disproportion

STEROIDS

Start them as soon as there is a high level of suspicion for spinal cord injury

            High dose Solumedrol protocl

                        Bolus 30mg/kg given over 15 minutes

                        Wait 45 minutes

 Begin infusion of 5.4mg/kg/hr for total treatment time of 48 hours (barring  complications)

ERB’S PALSY

If the patient is still symptomatic and at least 3 months old, need to proceed to MRI of cervical spine and brachial plexus to rule out nerve root avulsion

If improving clinically, observe until at least 6-9 months of age.

If no improvement, consider surgical exploration/repair when 4-8 months old

 

*Laurent, Neurosurgical correction of upper brachial plexus birth injuries. J Neurosurg. 1993;79:197-203

OCCIPITO-CERVICAL DISLOCATION

Wackenheim’s Clival baseline

Powers ratio (distance from to the basion to the posterior arch of C1 divided by the distance from the opisthion to the anterior arch of C1)

More common in certain syndromes, e.g. Down’s syndrome*

 

*Trumble, Atlanto-axial Subluxation in a Neonate with Down’s syndrome. Pediatric Neurosurgery 21(1): 55-58, 1994.

 

C1-2 ROTATORY SUBLUXATION

More common in children due to ligamentous laxity and horizontal angle of C1-2 facets (until approximately 8yo)

Ligamentous injury seen by jumped facets at C1-2

Presents with acute onset of torticollis and neck pain, rarely with neurological deficit

Stable injury

Requires dynamic CT for diagnosis

 

C1-2 ROTATORY SUBLUXATION

 

 

TREATMENT OF C1-2 ROTATORY SUBLUXATION

Conservative, palliative

            Soft cervical collar

            Prn pain medications

            Scheduled muscle relaxants, e.g. Valium

            Rest

            Follow-up in 2-4 weeks with repeat dynamic CT*
 

* Myseros & Trumble, Conservative Treatment of Atlanto-Axial Rotatory Subluxation. Proceedings of AANS. 1995, 342.

 

OUTCOME

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ATLANTO-AXIAL SUBLUXATION

C2 is the most common site of spinal cord injury in children

            Anatomy is different

                        C2 synchondrosis(not completely ossified until 8 years old)

                        Similar to Type II odontoid fractures

                        Need to be immobilized

 

IMMOBILIZATION

If able to reduce fracture such that displacement of dens and C2 is <3mm, most will fuse with 3 months of Halo immobilization

If distraction is too great, or ligamentous injury too much to tolerate upright, will need surgical fixation

            Usually sublaminar wires with bony fusion

            If child large enough, may consider trans-articular or odontoid screws

 

AFTER IMMOBILIZATION

Need to confirm stability by supine and upright cervical spine films

Remember to re-torque the halo pins

(lower pressures for thinner skulls)

 

PEARLS

Most spinal column injuries in children, either ligamentous or osseous, can heal with external immobilization only

Outcome is most dependent on severity of injury

Speed of treatment/recognition of diagnosis is next most important variable