Presentation of Thoracolumbar Spine Trauma in Children

Age-Dependent Anatomic distribution

• Age patterns for cervical spine injury: Cervical spine injuries are the most common in children <8 years old because of their large heads relative to body and neck size and less neck musculature (9,22,33).
• Age patterns for thoracolumbar spine injury: Thoracolumbar spine injuries are the most common in children between 8 and 20 years old because the ligaments stiffen, bones become stronger, and cervical musculature matures (9,22,33).

Mechanisms of Injury

• Falls: Fall is most common mechanism for spine injuries in younger children (18,31,33) whereas MVC is the most common mechanism for spine injury in teenage children (9,22).
• Other mechanisms: Other common causes of spine injury include all-terrain vehicle accidents, sport-related injuries, and child abuse (9). Fall from height has been reported as most common cause overall in some developing countries, such as India (2,30).

Symptoms and Signs

Patients with thoracolumbar spine injury can present with a range of findings from back tenderness to complete spinal cord injury.

• Tenderness: Tenderness in the back is the most common physical exam finding.
  Other symptoms: Common physical exam findings include contusions, step-off deformity, and neurologic defect (18).
  Concomitant injuries: Patients often have concomitant thoracic/abdominal injuries (up to 42%), especially in motor vehicle collision (MVC) with seat belt across the lap (20). Patients may also have associated head injury or other noncontiguous spine injuries.

Intervention at Presentation

Stabilization

• Cardiopulmonary instability: Cardiopulmonary stabilization may be necessary in a patient with trauma. This could include intubation for airway or respiratory support. Also, in patients with spinal cord injury, hypotension should be avoided. Blood pressure augmentation may be necessary in patients to address hypovolemic or neurogenic shock. Management of patients with an acute spinal cord injury in an intensive care unit or similar monitored setting is recommended (27).
• Spine stabilization: Spinal stabilization is necessary with thoracolumbar trauma. Until stability of the fracture is determined, precautions should be maintained (flat bedrest, log-roll, etc.)

Preparation for definitive intervention, nonemergent

• Systematic evaluation: Ensure that there are no other injuries to the patient that would prohibit intervention or need to be addressed prior to spine surgery.
• Steroids for acute signs of spinal cord injury: Steroids are not recommended for spinal cord injury treatment (17).
• Imaging: Plain films and MRI and CT scans of good quality and of the relevant anatomy are required.
• Consultations: Consultations may be obtained from neurosurgery, orthopedics, urology, or anesthesia depending upon the clinical circumstance.
• Prepare operating room for surgery: The surgical team is assembled, and communication of the unique needs of the surgery occurs (e.g., compatibility of anesthesia with monitoring needs, availability of monitoring personnel, availability of specialized equipment (instrumentation, drills, saws, allograft bone, and fusion augmentation substances such as bone morphogenetic protein)).

Preparation for definitive intervention, emergent

• Surgery within 24 hours: The same principles described above apply.

Admission Orders

• Positioning and activity: Typically, if a thoracolumbar fracture is determined to be unstable and in need of surgical treatment, the patient will remain in a collar or other protective device with flat bedrest and log roll maneuvers until surgery.
• Blood pressure parameters: Blood pressure parameters are not necessary unless spinal cord injury is present, in which case blood pressure elevation with fluids and pressors is desirable.