A brief review on paediatric spine injury

1. Pediatric spine injuries
Momen Ali Khan
Neurosurgery Resident
Department Of Neurosurgery
Dhaka Medical College Hospital

2. C1 (atlas)
Ossification centers: usually 3
 1 (sometimes 2) for body (not ossified at birth; appears on X-
ray during 1st yr.)
 1 for each neural arch (appear bilaterally ≈ 7th fetal week)
Synchondroses
 Synchondrosis of the spinous process: fuses by ≈ 3 yrs of age
 2 neurocentral synchondroses: fuse by ≈ 7 yrs of age
The ossification centers of C1 fail to completely close in 5% of
adults (usually posteriorly). When present, the rare anterior
defect is usually associated with a posterior defect.

3. C2 (axis)
Developmentally there are 5 ossification centers. The two halves of the odontoid fuse together
in the midline (dashed line ) at 7 months development.
So that at birth there are 4 primary ossification centers
 Odontoid process
 Vertebral body
 2 neural arches
Fusion time
 The posterior arches fuse together by 2–3 years of age.
 The anterior synchondroses normally fuse between 3 and 6 years of age.
 However, the dentocentral synchondrosis (AKA subdental synchondrosis) may be visible
on X-ray until ≈ 11 years of age.
 A secondary ossification center (os terminale) appears at the summit of the dens between
3 and 6 years of age, and fuses with the dens by age 12 years

5. C3–7
3 ossification centers at birth
 Vertebral body
 2 neural arches
Fusion
1. The 2 neural arches fuse together posteriorly by 2–3 years of age.
2. The neural arches each fuse to the body by 3–6 years of age.
Cervical bodies are normally slightly wedge-shaped in pediatric population
(narrower anteriorly).
Wedging decreases with age.

6. Synchondroses
Normal synchondroses may be mistaken for fractures, especially the dentocentral
synchondrosis of the axis which may be mistaken for an odontoid fracture.
Correlative sagittal CT from a 24-week-old child shows the synchondrosis between the odontoid and body of C2

7. Persistent Dentocentral Synchondrosis

8. Normal cervical spine radiographs 2-year-old

9. Normal CT cervical spine - pediatric

10. Pediatric cervical spine injuries
General information
1. Spinal cord injury is fairly uncommon in children
2. The cervical spine is the most vulnerable segment
3. In the age group ≤ 9 yrs, 67% of cervical spine injuries occur in the upper 3 segments of the
cervical spine (occiput-C2).
4. C2 is the most common vertebra injured in children.
5. C2 synchondrosis fractures are usually managed with halo traction.
6. Most stable fractures and ligamentous injuries may be treated nonsurgically
7. The fatality rate is higher with pediatric spine injuries than with adults (opposite to the situation
with head injury), with the cause of death more often related to other severe injuries than to the
spinal injury.
[Handbook of Neurosurgery 10th Greenberg 1121]

11. Injury Location Paediatric
Location Frequency
Cervical spine 42%
Thoracic spine 31%
Lumbar spine 27%
[Handbook of Neurosurgery 10th Greenberg 1121]

12. Ligamentous injuries are more common than actual fractures due to
1. Flexibility of ligamentous
2. A high head-to-body weight ratio
3. Immaturity of paraspinal muscles
4. The underdeveloped uncinate processes, these tend to involve e.g, SCIWORA
[Handbook of Neurosurgery 10th Greenberg 1121]

13. Spine/spinal cord injuries that are somewhat unique to the pediatric population
1. Atlantooccipital dislocation (AOD): a retroclival hematoma should raise the index
of suspicion for AOD
2. SCIWORA (spinal cord injury without radiographic abnormality)
3. Synchondrosis fractures: os odontoideum, C2 synchondrosis
4. Atlantoaxial rotatory fixation/subluxation
[Handbook of Neurosurgery 10th Greenberg 1121]

14. Evaluation of pediatric C-spine injuries
Do not perform C-spine imaging in children < 3
years of age with trauma who meet all of the
following conditions:
1. Have a GCS > 13
2. Are neurologically intact
3. Have no cervical midline tenderness (without
distracting injury)
4. Are not intoxicated
5. Do not have unexplained hypotension
6. Were not in a motor vehicle collision, a fall >
10 foot, or non-accidental trauma (NAT) as
the known or suspected mechanism of injury
Do not perform C-spine imaging in children > 3 years of
age with trauma who are:
1. Alert
2. Neurologically intact
3. Without posterior midline cervical tenderness (with no
distracting pain)
4. Not hypotensive without explanation
5. Not intoxicated
Use CT to assess the condyle-C1 interval (CCI) (AKA atlantooccipital interval) for pediatric patients with potential
atlantooccipital dislocation (AOD)

15.  Obtain cervical spine X-rays or high-resolution cervical CT in pediatric trauma
victims who do not meet either set of criteria above
 Obtain 3-position CT with C1–2 motion analysis to confirm and classify the
diagnosis for children suspected of having atlantoaxial rotatory fixation
(AARF)
[Handbook of Neurosurgery 10th Greenberg 1122]

16. Fracture through C2 dentocentral synchondrosis (odontoid epiphysiolysis).

17. Retroclival hematoma
1. Predilection for pediatrics, where it usually occurs with trauma (e.g., MVA)
2. Significant because it may be associated with atlantooccipital dislocation (AOD)
3. Usually managed conservatively with brace (e.g., halo or SOMI)
4. Outcome is usually good.
5. Death can occur usually from other causes
Predilection for pediatrics, possibly due to the-
1. Higher ratio of head to body weight
2. Flatter occipital condyles
3. Increased ligamentous laxity in children.

18. Retroclival hematoma association
1. Atlantooccipital dislocation
2. Occipital condyle fracture
3. Disruption of the apical odontoid ligament
4. Fracture of the clivus
5. Odontoid fracture
[Handbook of Neurosurgery 10th Greenberg 1102]

19. Retroclival epidural hematoma. 6-year-old with atlantooccipital dislocation (AOD) following motor vehicle accident.

20. Presentation
Neurologic findings may be due to stretching, compression, or contusion of adjacent brain parenchyma or
nerves.
Cranial nerve involvement reported includes:
1. Abducens (VI): the most commonly involved cranial nerve. May be unilateral or bilateral33
2. Optic (II)
3. Oculomotor (III)
4. Trigeminal (V)
5. Facial (VII)
6. Glossopharyngeal (IX)
7. Hypoglossal (XII)
8. Spinal accessory nerve (XI)
[Handbook of Neurosurgery 10th Greenberg 1102]
Other presentations include:
1. Hemiparesis
2. Quadriparesis
3. Hydrocephalus34
4. Occipitocervical instability

21. Management
Most cases are managed conservatively, usually with a brace (halo/vest, SOMI…).
Indications for surgical interventions include:
1. Fusion: may be considered as follows
a. Strong indication: ligamentous instability e.g., atlantooccipital dislocation meeting
AOD surgical criteria
b. Soft indication: cranial nerve deficits
2. Evacuation of hematoma: indicated on rare occasion for symptomatic brainstem
compression
3. Ventriculostomy/shunt: indicated for hydrocephalus
[Handbook of Neurosurgery 10th Greenberg 1103]

22. Surgical challenges pediatric spine
1. Finding hardware small enough for young children
2. The small size of c-spine lateral masses
3. Difficulty thoroughly removing disc material and cartilage
[Handbook of Neurosurgery 10th Greenberg 1121]