Treatment of Spine Injuries in Children – Stable vs. Unstable Fractures

Atlanto-Occipital Dislocations

• Highly unstable, requiring internal fixation: Atlanto-occipital dislocations are unstable and require internal fixation and fusion. A rigid cervical collar is inadequate for immobilization. If surgical stabilization cannot be performed quickly because of other trauma, then halo immobilization is recommended pending internal fixation.

Atlanto-Axial Dislocation

• Unstable, usually requiring internal fixation: For ligamentous injury or fractures involving ligament attachments, immediate external immobilization is required. Usually a hard collar is sufficient, but occasionally a halo may be preferred in cases of severe instability or patient noncompliance. Some unstable fractures may heal in a hard collar, but most of these injuries require internal surgical stabilization.

Atlanto-Axial Rotary Subluxation

• Early presentation (within 1 month): Analgesia, muscle relaxants, and hard cervical collar are used in the first instance. It is essential that patients are monitored to ensure that symptoms resolve. If pain and torticollis resolve, no further treatment is indicated; however, if torticollis persists, treatment needs to be escalated.
  Late presentation (greater than 1 month).For late-presenting cases or where initial conservative treatment has failed, treatment must be escalated.
• Closed reduction: A period of halo traction or manipulation under anesthetic with image intensifier screening will permit reduction of atlanto-axial rotary subluxation in the majority of cases. Good immobilization in a well-fitting hard collar or halo-body orthosis are then required for up to 6 weeks because the early recurrence rate is high (37,48).
• Open reduction and fixation: Where closed methods have failed, and atlanto-axial rotary subluxation has recurred, then C1-C2 arthrodesis is indicated. Instrumented fixation provides immediate stability and a good long-term outcome in most cases. In younger children (less than five years), instrumentation can be difficult because of the patient’s small size. Sublaminar cables and bone graft provide an alternative method of fixation in this age group.

Jefferson Fracture

• Many stable: A Jefferson fracture may be stable if the transverse ligament is intact. Fractures that include disruption of the transverse ligament are unstable.
• Collar or halo: Stable fractures may be treated with a cervical collar, although some practitioners prefer the use of a halo.

Odontoid Fractures

• Type I – stable: Type I odontoid fractures are usually treated with a rigid collar fixation.
• Type II – unstable: The transverse ligament is rendered incompetent. Good reduction is essential. The mode of fixation will depend on age. In the young child, posterior C1/C2 wiring with graft may suffice. In older children, instrumented fixation should be preferred (odontoid screw or C1-C2 screw fixation.)
• Type III – variable stability: When an odontoid fracture is stable, it may be treated with halo immobilization or possibly a rigid collar. If unstable, its treatment requires halo immobilization, although some cases may be treated by fixation with an odontoid screw.

Hangman’s Fracture

• Stable if well aligned.
• Collar, orthotic vest and collar, or halo: If the fracture is well opposed and C2 is not significantly displaced on C3, then a rigid cervical collar may be adequate. Occasionally, a SOMI or Minerva  orthosis is preferable for patients with behavioral issues. For fractures with significant C2-3 displacement or distraction, a Minerva or halo is indicated.

Teardrop Fracture

• Unstable: By definition, the teardrop fracture is a two-column injury and therefore is unstable.

Cervical Compression Fractures

• Variable stability: Cervical compression fractures can be either stable or unstable, depending on the amount of fracturing of the vertebral body and degree of involvement of posterior elements.
• Collar fixation: If the fracture is stable, it may be treated with a rigid cervical collar.

Ligamentous Injury

• Variable stability: Some injuries that involve only minor ligamentous disruption may be stable and can be treated with a rigid cervical orthosis. Any severe injury or trauma involving both the disk space and posterior elements should be considered unstable and requires fixation and fusion.