Evaluation of Thoracolumbar Spine Trauma in Children

Examination

Spine precaution

• Spine precautions for suspected spinal injury: If spinal injury is suspected, the patient should be kept in spine precautions (cervical collar, spine immobilization, flat, log-roll), until injury is ruled out (9).

Physical examination

• ABCs: If compromised, the patient should have their airway, respiratory status, and cardiac status stabilized. Hypotension should be avoided.
• Motor and sensory: A complete motor and sensory examination should be performed.
• Other examinations: Rectal and genital examination should also be included. Reflex testing is performed as well.
• Thoracolumbar spine examination: A complete thoracolumbar spine examination has been shown to diagnose a fracture with a sensitivity of 81% and specificity of 68%.
• Symptoms: Tenderness is the most common physical exam finding, but also contusions, step-off deformity, and neurologic defect can be seen (18).
• Concomitant injuries: Patients often have concomitant thoracic/abdominal injuries (up to 42%), especially in MVC with seat belt across the lap (9). Patients may also have associated head injury or other non-contiguous spine injuries.

Radiologic Tests

High-velocity injury, chest/abdominal/pelvis injury, back pain/midline tenderness, local signs of thoracolumbar injury, abnormal neurologic signs, cervical spine fracture, Glasgow Coma Scale score>15, major distracting injury, and alcohol/drug intoxication are risk factors for thoracolumbar spine injuries and, when present, indicate that imaging of the thoracolumbar spine should be strongly considered (16,34).  Patients with thoracolumbar spine injuries should have the cervical spine imaged as well, because of the risk for noncontiguous spine injuries.

Regular x-rays

X-rays are often the initial imaging modality; however, CAT scan is becoming more common for suspected injuries or when further investigation after x-rays is needed. (See child page for images characteristic of injury types)

CAT scan

Significant splaying of posterior elements (spinous processes) or spine deformity on CAT scan suggests the need for surgical intervention.  (See child page for images characteristic of injury types)

MRI

MRI is generally reserved for those patients with concern for neurologic injury, in order to more fully evaluate compression of neural elements.  MRI can also show injury to the posterior ligamentous complex as well as injury in the spinal cord. (See child page for images characteristic of injury types)

Correlation of Tests

Correlating the patient’s neurologic examination with the morphology of the injury as described in imaging of the bone and surrounding soft tissues can be used to determine when surgery is indicated.  See TLICS,  AOSpine Injury Classification and Tips for Managing Thoracolumbar Spine Injuries in Children.