Thoracic and Lumbar Spine Injuries
Andrew Jea MD
James M. Drake BSE, MBBCh, iMSc, FRCSC, FACS
EPIDEMIOLOGY
Spinal cord injury (SCI) in children is uncommon.
Spine fractures in children represent 1% to 2% of all pediatric fractures.8
The thoracic region (T2-T10) is most commonly injured followed by the lumbar region (L2-L5).9
Trauma to the lower thoracic or lumbar spine in children is rarely associated with spinal cord injury.8
Each year 1,000 new spinal cord injuries are reported in children.10
Adolescent boys are most affected.11
ANATOMY
Embryology of the thoracic and lumbar vertebrae.
Three main ossification centers:8
One each for the left and right sides of the neural arch.
One for the body.
Junction of the arches with the body occurs at the neurocentral synchondrosis.
Remains visible radiographically until 3 to 6 years old.
Lies just anterior to the pedicle base.
Often mistaken for a congenital anomaly or fracture in younger children.8
Secondary centers of ossification occur in flattened, disc-shaped epiphyses superior and inferior to each vertebral body.
Provides longitudinal growth.17
Ossification of these growth plates at age 7 to 8 years creates the radiographic impression of a groove at the corner of each vertebral body.
Ligaments and discs attach to this groove, which is an apophyseal ring.
The ring develops its own ossification center by the age of 12 to 15 and fuses with the remainder of the vertebra at skeletal maturity.18
Differences in the pediatric spinal column compared to adults predispose infants and small children to flexion and extension injuries.
Small children’s facet joints are more horizontally oriented.
Physiologic wedging of the vertebral bodies.
Particularly of the upper cervical spine.
Facilitates forward movement of the vertebra.
Hyperextension coupled with the hypermobility:
Results in momentary dislocation then spontaneous reduction.
EVALUATION
History
Back pain from a major accident or fall increases suspicion for spine injury.
Major accident includes significant vehicular damage, head-on, high-speed collision, rollover, or death at the scene.
Accidents involving the lack of seatbelts, prolonged extrication, airbag deployment, steering wheel or windshield damage, passenger ejection, or space intrusion can be associated with spine injuries.
Vehicle accidents involving motorcycles, bicycles, or pedestrians have a high association with spine injuries.
Transient or persistent symptoms include pain, weakness, numbness, and tingling.
Physical Exam
A seatbelt mark across the abdomen, or intra-abdominal injury, should increase suspicion for possible thoracic or lumbar fracture.8
Look for tenderness, swelling, ecchymosis, or a palpable defect posteriorly along the spinous processes.8
Lower thoracic and upper lumbar injuries (T11-L1) are associated with increased risk of gastrointestinal injury.
Lumbar and sacral injuries (L2-sacral) are associated with risks of orthopedic and gastrointestinal injuries.11
Accurately document any loss of sensation or motor function.8
Spinal cord injury above the T6 level can present with spinal or neurogenic shock (bradycardia and hypotension).23
Represents a loss of descending sympathetic tone.
Spinal shock must be recognized early.
Pure fluid and blood resuscitation may not be effective.
A vasopressor may be needed to restore adequate perfusion.
INITIAL MANAGEMENT
Spine Stabilization
The mainstay of spinal injury management is to immobilize the affected levels.
In the field, this means immobilizing the entire spinal axis.23
Use an appropriately sized cervical collar!
If proper collar is unavailable, blocks and tape are effective for immobilizing the head on the backboard.23
Children’s disproportionate large head places them in flexion when positioned on a neutral board.
Proper immobilization requires either:
A special board with a recess for the occiput, allowing the head to rest in line with the body.
Placement of a thin cushion under the torso relative to the head.23
See Chapter 9 on C-spine Injuries for details.
SPINAL IMAGING
Plain Radiographs
AP and lateral radiographs can detect most osseous injuries in children and give an excellent global view of the spine.23
Flexion/extension x-rays are important to rule out subluxation in any patient with reported transient neurologic symptoms.20
Paraspinous muscles will often “splint” the spine, rendering any subluxation undetectable in the acute setting.
Obtain follow-up x-rays 5 to 7 days after muscle spasm subsides.20
Computed Tomography
If plain films are negative but clinical suspicion remains high, high-quality CT scans may be obtained to identify an occult, and possibly surgically correctable, vertebral fracture or dislocation.20
CT seems less helpful in pediatric spine’s routine evaluation because children are more likely than adults to have ligamentous injury without fracture.
Magnetic Resonance Imaging
The modality of choice in the pediatric patient with apparent spinal cord injury but negative radiographic studies.
Sensitive at detecting ligamentous disruptions and instability not seen on plain radiographs.24
Demonstrates extent of actual spinal cord damage, ranging from mild hemorrhage and/or edema to cord transection.25
Findings are prognostic of patient outcome.25
A normal-appearing MRI suggests excellent recovery.
Findings of major hemorrhage or cord transection are associated with permanent cord injury.
MANAGEMENT
Assess in hospital using a systematic approach to spine fractures (Fig. 13-1).
Issue of immediate stability (e.g., whether or not there is a need for rigid immobilization at the time of presentation) based on the specific fracture type (Table 13-1).29
Definition of stability based on the injured spinal column’s remaining ability to bear normal physiologic loads without further neurologic compromise.29
Majority of thoracic and lumbar spine fractures in children and younger adolescents are minor, stable, and without neurologic deficit.8
Bed rest and gradual resumption of activities are generally sufficient for managing these injuries.8
In most instances, emergent decompression is unnecessary for the patient with a complete thoracic spinal cord injury associated with a spinal fracture.29,30
Thoracic spinal cord made up primarily of delicate white matter tracts.
T4-T8 levels represent the spinal cord’s primary vascular watershed zone.
Emergent decompression justified for:
Thoracic spinal cord compression by “sub-threshold” forces causing a rare, incomplete injury (e.g., bone fragment, hematoma, and/or herniated disc).
Compression of the conus medullaris at the thoracolumbar junction.
Compression of the cauda equina at the lumbar spine.29Related posts:
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