Study Guide
Thoracolumbar Spine Fractures
Key Points:
- Most common cause of thoracolumbar spine trauma in pediatric patients is motor vehicle accidents accounting for up to 58% of all injuries.
- Compared with adults, pediatric patients have greater ligamentous flexibility and elasticity, shallower and more horizontal facets, and relative paraspinal muscle immaturity.
- AP and lateral plain radiographs are often favored for initial imaging, with the addition of MRI for children with neurologic deficits.
- The common fracture patterns include compression, burst, flexion-distraction, fracture dislocation injuries, apophyseal fractures/herniations, and spinous process and transverse process fractures.
- For stable injury patterns TLSO bracing for 6 – 8 weeks maybe sufficient, however when indicated instrumented stabilization with or without arthrodesis maybe necessary for unstable patterns.
Description:
Thoracolumbar spine trauma in pediatric patients is a rare entity. When it occurs, it can be potentially very devastating with a wide array of presentations. Treatment should be based on a strong understanding of the pediatric spine anatomy, biomechanics, and a thorough understanding of fracture pattern stability.Epidemiology:
Fractures of the thoracolumbar spine account for 1% to 2% of all pediatric fractures. The most common cause of pediatric spine trauma is motor vehicle accidents (even when seat belts are used), which lead to 33% to 58% of all injuries. Other mechanisms include fall from a height, sport related injuries, and child abuse. Football, rugby, and skiing are associated with thoracolumbar spine injuries. Additionally, sledding and all-terrain vehicle (ATV) use are also cited as high-risk activities for thoracolumbar spine injury as well.Clinical Findings:
Initial assessments should include a motor and sensory exam with reflex assessment if possible with the addition of a rectal and genital examination. Palpation of the spine for crepitation, ecchymosis and bony step-offs should be performed on survey. Thoracolumbar spine injuries may include associated internal organ injury in the thorax and abdomen. The incidence of concomitant abdominal or thoracic trauma is reported to be up to 42%. Keeping this in mind, the examiner should look for signs of pneumothorax in addition to a distended and painful abdomen if spine trauma is suspected. ATLS protocols should be maintained during initial assessment using pediatric spine board to elevate the child’s torso preventing neck hyperflexion when necessary. This is particularly important if children are less than 6 years.Imaging Studies:
Initial imaging should include AP and Lateral plain radiographs of the entire spine. If neurological deficits are noted MRI imaging would be the next imaging modality. MRI is also useful to determine if the posterior ligamentous complex of the spine is intact, helping guide therapy. CT scanning of the spine has widely been an accepted practice in adults, however risks associated with radiation exposure make it an unsafe screening tool in children. Some studies have shown that excess use of CT scan predispose children to an increased risk of thyroid cancer as they transition into adulthood. CT scan is a better modality at identifying osseous detail compared to MRI, however as stated previously the radiation exposure needs to be considered.Treatment:
For stable fracture patterns a thoracolumbosacral orthosis (TLSO) can be fashioned for the patient to allow for early mobilization. This must be maintained for 6 – 8 weeks with follow up imaging. Burst Fracture types with significant retropulsion (> 50%) into the canal and neurological compromise may necessitate decompression of the canal with anterior or posterior instrumentation arthrodesis. In Flexion-Distraction type injuries (Chance type) in which alignment cannot be maintained nonoperatively, surgical stabilization with posterior instrumentation fusion is treatment of choice. If there is a purely ligamentous injury with loss of integrity of the posterior ligamentous complex in older children, then these injuries are also treated as above. If apophyseal herniations result in significant neurological compression of the spinal cord or nerve roots, then surgical decompression may be required. Thoracolumbar fracture dislocations need to be stabilized with rigid instrumented constructs combined with arthrodesis with or without surgical decompression.Complications:
All operative interventions have risks for wound complications and infections and iatrogenic neurological injury. Families need to be made aware of this risk prior to undergoing surgical interventions. Pediatric patients with thoracolumbar neurologic injury have a risk of progressive skeletal deformity. There may be a role of prophylactic bracing even in curves < 10 degrees in this population. Curves > 20 degrees will likely progress despite bracing. Surgical deformity correction is an option for patients with large progressive curves or sitting imbalances. If progressive neurologic decline is noted, then MRI should be obtained to look for underlying spinal dysraphisms.Related Videos:
References:
- Daniels AH, Sobel AD. Pediatric Thoracolumbar Spine Trauma. Journal of the American Academy of Orthopaedic Surgery. 2013; 21(12); 707-16.
- Mahan ST, Mooney DP, Karlin LI, Hresko MT. Multiple Level Injuries in Pediatric Spinal Trauma. The Journal of Trauma: Injury, Infection, and Critical Care. 2009;67(3):537–542.
- Muchow RD, Egan KR, Peppler WW. Theoretical increase of thyroid cancer induction from cervical spine multidetector computed tomography in pediatric trauma patients. Journal of Trauma Acute Care Surg. 2012; 72(2): 403-9.
- Parent S, Dimar J, Dekutoski M. Unique Features of Pediatric Spinal Cord Injury. Spine. 2010;35(215):202–208.
- Sawyer J. Age-related Patterns of Spine Injury in Children Involved in All-Terrain Vehicle Accidents. Journal of Pediatric Orthopaedics. 2012;32(5):435–439.
- Vaccaro AR, Lehman RA Jr, Hurlbert RJ, et al: A new classification of thoracolumbar injuries: The importance of injury morphology, the integrity of the posterior ligamentous complex, and neurologic status. Spine (Phila Pa 1976) 2005;30(20):2325-2333.
- Vander Have KL, Caird MS, Gross S, et al. Burst fractures of the thoracic and lumbar spine in children and adolescents. J Pediatr Orthop. 2009;29(7):713–719.