A Review of Pediatric Lumbar Spine Trauma

Neurosurg Focus 37 (1):E6, 2014 ©AANS, 2014

A review of pediatric lumbar spine trauma

*Christina Sayama, M.D., M.P.H.,1 Tsulee Chen, M.D.,2 Gregory Trost, M.D.,3 and Andrew Jea, M.D.1 1Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children’s Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; 2Division of Pediatric Neurosurgery, Akron Children’s Hospital, Akron, Ohio; and 3Division of Spinal Surgery, Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin

Pediatric spine fractures constitute 1%–3% of all pediatric fractures. Anywhere from 20% to 60% of these fractures occur in the thoracic or lumbar spine, with the lumbar region being more affected in older children. Younger children tend to have a higher proportion of cervical injuries. The pediatric spine differs in many ways from the adult spine, which can lead to increased ligamentous injuries without bone fractures. The authors discuss and review pediatric lumbar trauma, specifically focusing on epidemiology, radiographic findings, types and mechanisms of lumbar spine injury, treatment, and outcomes. (http://thejns.org/doi/abs/10.3171/2014.5.FOCUS1490)

Key Words • pediatric spine trauma • lumbar • fracture

ediatric spine fractures are usually the result of bodies and have underdeveloped neck musculature.26,30 high-speed and impact injuries such as a motor They also have inherent ligamentous laxity, elasticity, vehicle accident or a fall from great height. Spine and incomplete ossification.23,25,30,31 Their facet joints are fracturesP in children represent 1%–3% of all pediatric small and more horizontally oriented, resulting in greater fractures.1,34 The incidence of pediatric spine injuries mobility and less stability.23–25,32 Because of these biome- peaks in 2 age groups; children < 5 years old and children chanical differences, younger children (0–8 years) tend to > 10 years old. There is a seasonal peak of pediatric spinal have fewer fractures and greater incidence of SCIWORA injuries from June to September, during summer break. (spinal cord injury without radiographic abnormality). There is another seasonal peak in the 2 weeks surrounding Hyperextension coupled with the hypermobility of the pe- the Christmas holiday. diatric spine can result in momentary dislocation followed The mechanism of injury in the pediatric population by spontaneous reduction, resulting in a damaged spinal varies with age. In young children ages 0–9 years, the pre- cord but a radiographically normal–appearing vertebral dominant cause of injury is falls and automobile-versus- column.20,24,26 Although SCIWORA has been reported to pedestrian accidents (> 75%). In children ages 10–14 years, occur at rates as high as 20% in children, it falls dramati- motor vehicle accidents (40%) are the major cause of lum- cally to < 1% in adults. A more adult-like vertebral column bar fractures, and falls and automobile-versus-pedestrian (9–16 years) with sturdier osseoligamentous formation accidents are less prevalent. In children 15–17 years of provides better protection of the spinal cord and therefore age, motor vehicle and motorcycle accidents become the less severe spinal cord injury (SCI) in this age group com- leading cause of spine injuries (> 70%), and there is also pared with the younger age group. When subjected to high an increase in sports-related spine trauma. stress, the adult spine is more likely to suffer breakage of The pediatric spinal column is different from the bones and frank rupture of ligaments in comparison with adult spine in many ways, and this can predispose infants the pediatric spine, in which deformation and return to and small children to flexion and extension injuries. They normal alignment is more common. have proportionally larger heads compared with their

Abbreviations used in this paper: ALL = anterior longitudinal lig- Lumbar Spine Radiographic Findings and ament; AP = anteroposterior; PLL = posterior longitudinal ligament; Evaluation rhBMP-2 = recombinant human bone morphogenetic protein–2; SCI = spinal cord injury; SCIWORA = SCI without radiographic abnor- Imaging studies are often used as an adjunct in evalu- mality; TLSO = thoracolumbosacral orthosis; VB = vertebral body. ating and diagnosing injury in trauma. Findings can be * Drs. Sayama and Chen contributed equally to this work. misinterpreted as pathological in the setting of an imma-

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Unauthenticated | Downloaded 10/04/21 09:08 PM UTC C. Sayama et al. ture spine. Knowledge of the various stages of growth and the corresponding age of the patient are imperative for ac- curacy of diagnosis. Vertebral formation occurs in 3 stages: membranous proliferation, chondrification, and ossification. Although ossification begins in the womb, it is completed decades after birth. There are 3 ossification centers in the vertebra: the centrum of the vertebral body (VB), and right and left centers in the posterior arch (Fig. 1). At approximately 10 weeks of gestation, ossification of the centrum begins in the thoracolumbar region and proceeds in both direc- tions. Evidence for ossification of the neural arches has been documented as early as 9 weeks of gestation in the cervical regions and progresses in the cranial-to-caudal direction.32 The neurocentral synchondrosis delineates the junction where the centrum and both arch centers fuse. During the mid- to late teenage years, secondary ossification centers present in the transverse and spinous processes, and the ring apophyses fuse with the primary ossification centers. During the midteenage years endplates begin to fuse, and this is completed at approximately 21– 25 years of age (Fig. 2). Fig. 1. Axial CT of the spine obtained in a 5-month-old baby. Arrows Radiographic imaging of the pediatric spine is lim- delineate the synchondroses that separate the centrum, right, and left ited by the concern for radiation exposure to a maturing primary ossification centers. spine. Whereas an adult trauma evaluation may include a “pan scan” of the entire spine, evaluation of the pediatric patient relies heavily on a combination of the mechanism and acute bone injury represented by marrow changes in of injury and physical examination. Other factors such as a series of T1-weighted, T2-weighted, and STIR images “breath arrest” at the time of injury can be helpful in de- can aid in delineating true injury from false positives and termining the likelihood of a VB fracture in the thoracic 17 acute versus chronic findings. However, the MRI modality region. can show false-negative findings in detecting neural arch When imaging studies are obtained, there can be find- fractures. ings that may be misconstrued as pathological that in fact Although imaging studies have their usefulness in are normal in children. The neurocentral synchondrosis evaluating the pediatric trauma patient, knowledge of the can still be visible at 3–6 years of age. Radiographically, natural progression in growth of the immature spine is this can appear as a groove at the corner of each VB. Until critical in correctly interpreting results. If the mechanism the endplates fully fuse in the mid-20s, these areas may be of injury and physical examination are suspicious for misinterpreted as VB fractures. spine trauma, then AP and lateral plain radiographs are “Wedging” of the VBs is sometimes read as a compression fracture. Gaca et al.9 performed a retrospective warranted. From there, a CT scan is helpful if a fracture radiographic review looking at the occurrence and degree is detected on radiographs or if the results of physical ex- of wedging of the VB from T-10 to L-3 based on anterior/ amination do not match the imaging findings. An MRI posterior VB height measurements. Although the previ- scan is useful in the setting of neurological deficit. ously reported ratio of 0.95 was used as the cutoff for concern about compression fracture,12 their study revealed Types of Lumbar Spine Injuries that patients without spine injury can have an anterior/ posterior ratio of as low as 0.893.15 Several classification systems exist to describe lum- All imaging modalities have their advantages and bar fractures systematically. The most comprehensive limitations. Plain radiographic films are useful in evalu- and accurate is probably the AO fracture classification. ating for gross evidence of misalignment both in the an- However, this system is cumbersome to apply in practice. teroposterior (AP) and lateral views. Findings such as a Instead, most authors extrapolate from Denis’s 3-column trapezoidal shape to the VB, scoliosis, or offset spinous model, originally described for fractures at the thoraco- processes should raise the level of suspicion of acute inju- lumbar junction. This model divides the spine into 3 col- ry. Following plain radiographs, CT scanning has repeat- umns: anterior (ventral half of the VB and intervertebral edly been shown to be superior in identifying acute bone disc including the anterior longitudinal ligament [ALL]); injury. In the pediatric population, the concern for radia- middle (dorsal half of the VB and intervertebral disc in- tion exposure sometimes influences the practitioner to be cluding posterior longitudinal ligament [PLL]); and poste- judicious in obtaining a CT scan. Additionally, distraction rior (pedicles, lamina, facet joints, spinous processes, and and apophyseal injuries are difficult to determine on CT interspinous and supraspinous ligaments). Depending on imaging alone. Magnetic resonance imaging studies are which combination of columns are injured, Denis labeled useful in determining spinal cord and soft-tissue injury these fractures as compression, burst, seat belt, or frac- (ligamentous, edema, and so on). Hemorrhage, edema, ture-dislocation. This classification system has thus been

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Fig. 2. Axial CT scans demonstrating the primary (medium blue arrows, dot) and secondary (light blue lines, dots) ossification centers of the L-4 vertebra as they change over a lifespan from an infant to an adult. There are 5 secondary ossification centers: 1 at the tip of the spinous process, 1 at the tip of each transverse process, and 2 ring epiphyses. yo = years old. extrapolated to the thoracic spine, the lumbar spine, and The VB is partially or completely comminuted and there the pediatric spine. Treatment approaches were then sug- is disruption of the posterior wall. There are often frag- gested by the type of fracture. ments that break into the spinal canal and there may be (SCI). Compression Fractures The patient in Case 2 was a 15-year-old male unre- strained passenger involved in a motor vehicle accident Compression fractures are the most frequently seen who presented with back pain and bilateral ankle pain. fractures in the lumbar spine and usually occur as a result On CT imaging his lumbar spine demonstrated an L-1 of an axial compression load in flexion. This is a stable burst fracture with approximately 19° of kyphotic defor- injury in which the posterior column is intact. Spinal cord mity and disruption of the PLL with retropulsion of VB injury has not been documented in this type of fracture, fragments posteriorly (Fig. 4A). An MRI study was per- and spinal canal compromise does not occur. Kyphotic formed, which demonstrated an associated contusion of angulation can occur because there is more reduction in the conus medullaris, disruption of the ALL and PLL, and height of the VB anteriorly. A long-term increase in de- no ongoing spinal cord compression (Fig. 4B). The patient formity can occur when there is an associated kyphosis was noted to have decreased strength in his bilateral lower of > 30%. extremities; his physical examination was limited due to The patient in Case 1 was a 16-year-old girl who fell pain but he was able to wiggle his toes bilaterally. The from a horse and was thrown over, landing on her but- patient did have bowel and bladder dysfunction as well as tocks. She presented to the emergency department with some associated dysesthetic pain. Conservative treatment back pain and left wrist pain. She was found to have an in a brace was attempted because there was no ongoing L-2 compression fracture in addition to a left wrist frac- compression of the spinal cord on MRI or worsening of ture. She was neurologically intact. A CT scan of the findings on his neurological examination; however, the pa- lumbar spine showed an L-2 compression fracture with tient had intractable back pain and increased kyphosis on approximately 19° of loss of height anteriorly. She was upright lumbar spine radiographs (26° in brace; Fig. 4C). treated conservatively in a brace and did well with con- Therefore, the decision was made to perform posterior servative management, with improved back pain (Fig. 3). spinal stabilization and fusion from T-11 to L-3 (Fig. 4D). Postoperatively the patient did well, and after 2 weeks in Burst Fractures the hospital was transferred to an inpatient rehabilitation Burst fractures occur with axial load without flexion, center. He has been seen in a 3-month follow-up visit and and affect the anterior and middle columns. This type of at that time he was ambulatory, with a left orthotic foot fracture makes up 15%–20% of all major VB fractures. brace and a walker.

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neurological sequelae. There may be disruption of the facets as well as narrowing of the spinal canal. It is the most unstable and severe of all the injury mechanisms. The patient in Case 3 was a 9-year-old girl who was a restrained passenger in a motor vehicle accident in which she had no loss of consciousness. On presentation to the emergency department she complained of back, neck, and abdominal pain. She was neurologically intact with full strength and sensation in her bilateral lower extremities. A CT scan of her lumbar spine demonstrated an L-1 seat belt–type fracture with anterior VB wedging and a fracture through the bilateral facets and the T-12 spinous process (Fig. 5A). The patient had layering fluid in her abdo- men and, due to concern for bowel injury, she was initially taken to the operating room by pediatric surgery for an exploratory laparotomy and small-bowel resection. She was kept on strict spinal precautions with no alteration in findings on her neurological examination. Lumbar spine MRI studies demonstrated mild compression of L-1 with STIR signal extending through both pedicle and pars with disruption of the interspinous ligaments and the ligamen- tum flavum (Fig. 5B). Because this injury was unstable, the patient was taken to the operating room for a T10–L3 posterior spinal fusion. Postoperatively she did well and was discharged home on postoperative Day 5. On 6-week follow-up the patient was doing well and thoracolumbar radiographs were obtained, which showed intact hardware and stable alignment (Fig. 5C). Apophyseal Ring Fractures The apophyseal ring is attached to the anulus fibro- sus; it ossifies between 4 and 6 years of age and fuses at 18 years of age. There is an osteocartilaginous portion that exists between the VB and apophyseal ring that is rela- Fig. 3. Case 1. Sagittal CT scan of the lumbar spine showing an L-2 tively weak and susceptible to repeated stresses. Apophy- compression fracture with 19° loss of height anteriorly. seal ring fractures often result from lifting a heavy object, but may also occur from falls or twisting injuries. Many patients with apophyseal ring fractures describe a “pop” Anterior and Posterior Element Injuries (3-Column Injuries) at the time of injury, which is then followed by radiculopathy. Diagnosis is confirmed with MRI and/or CT studies This type of injury pattern is inherently unstable and to pinpoint the exact location and configuration of the le- is characterized by failure of all 3 columns. These account sion. In the pediatric spine the growth zone in the VBs is for approximately 20% of all spinal injuries and are asso- found in the endplates. Disruption of this zone can easily ciated with the highest likelihood of SCI. Approximately occur with moderate shearing forces. This fracture is typi- 75% of patients with fracture-dislocation injuries have cally seen in the adolescent or young adult and presents some neurological deficit and 50% of these have complete just like a herniated disc with a radiculopathy.33 Yen et al. SCIs. reported 4 adolescent cases and noted a strong associa- There are different types of injury patterns in 3-col- tion of adolescent apophyseal ring fractures with a slipped umn injuries: those with distraction and those with rota- capital femoral epiphysis and overweight/obesity.35 tion. The first (with distraction) is a flexion-distraction The patient in Case 4 was a 13-year-old girl who fell type injury where the flexion force vector is acting around on her tailbone while playing volleyball and developed an anteriorly placed axis of rotation and the posterior ele- acute onset of back pain with radicular pain down her left ments are distracted. This is commonly seen in association posterior extremity to the dorsum of her left foot. A CT with motor vehicle–associated seat belt injuries. Seat belt scan was done, which demonstrated a posterior detached injuries are often associated with intraabdominal trauma, fragment at the superior S-1 endplate and a defect in the and neurological injury is infrequent. The second type of bone adjoining the fracture site (Fig. 6A and B). Lumbar injury (with rotation) usually occurs with falls from great spine MRI demonstrated a left eccentric disc herniation heights or with heavy objects falling onto a body with a with impingement on the exiting left S-1 nerve root (Fig. bent torso. On CT scans, this is best appreciated on axial 6C and D). Her clinical picture and radiographic imaging views where one can see rotation of the superior and in- was consistent with an apophyseal ring fracture and as- ferior VBs. This type of injury has a high propensity for sociated L5–S1 disc herniation causing an S-1 radiculopa-

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Fig. 4. Case 2. A: Sagittal lumbar spine CT scan showing an L-1 burst fracture with 19° of kyphosis. B: Axial and lateral MRI studies of the lumbar spine demonstrating the L-1 burst fracture with moderate narrowing of the canal and a contusion of the conus medullaris, without signs of ongoing compression. C: Lateral thoracolumbar radiograph obtained with the patient in a TLSO brace showing increased kyphotic deformity. D: AP and lateral thoracolumbar spine radiographs showing the postoperative fusion construct with improvement in kyphotic deformity at L-1. thy. Five months of conservative management, with rest, Treatment Options NSAIDs, steroids, and physical therapy, was attempted; however, she continued to have debilitating activity-lim- Different classification schemes exist for thoracic and iting pain. Therefore, surgery was recommended and she lumbar spine fractures. The Thoracolumbar Injury Clas- underwent a minimally invasive left L5–S1 microdiscec- sification and Severity Score has commonly been applied tomy. She did well postoperatively and on 3-month follow- in the adult population with trauma to help determine non- up was pain free. operative versus operative management of thoracolumbar

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Fig. 5. Case 3. T12–L1 Seat belt injury. A: Sagittal CT scan of the lumbar spine showing L-1 anterior wedging with distraction and fracture (red arrow) through the posterior elements. B: Sagittal MRI study of the lumbar spine demonstrating STIR signal abnormality (arrow with dashed line) with disruption of the posterior ligamentous complex. C: Postoperative AP and lateral thoracolumbar radiographs demonstrating a stable construct on 6-week follow-up. fractures.16 It has subsequently been studied and applied to reported.4,17,18 We previously reported the early safety and thoracic fractures and/or lumbar fractures alone. A score efficacy of rhBMP-2 use for posterior spinal fusions in the is calculated based on injury mechanism, neurological sta- pediatric population (mean follow-up of 11 months).8 tus, and integrity of the posterior ligamentous complex; a Lumbar compression fractures are treated with bed score of ≤ 3 suggests nonoperative treatment, a score of 4 rest, with gradual resumption of activities as tolerated suggests nonoperative or operative treatment, and a score when the kyphotic wedge of the vertebra is < 10°. Howev- of ≥ 5 suggests operative treatment.15 The Thoracolum- er, when the kyphotic deformity is > 10° in the immature bar Injury Classification and Severity Score has recently spine, immobilization in hyperextension is recommended been studied retrospectively in the pediatric population, for 2 months, followed by bracing for ≥ 1 year. Surgery and Garber et al. report excellent validity of this scoring with posterior and/or anterior stabilization is recommend- system in their pediatric cohort (unpublished data). ed in adolescents who are near skeletal maturity with > As a basic rule of thumb, many stable fractures can be 30° of kyphosis,5,28 or if the patient has had a prior lami- treated conservatively, whereas unstable fractures require nectomy. Stabilization and correction of the deformity can surgical stabilization. There are many different braces that be accomplished with pedicle screw constructs, a univer- can be used to obtain thoracic and lumbar immobilization sal segmental fixation system, or the Harrington rod dis- for conservative management. The thoracolumbosacral traction system. orthosis (TLSO) or the Jewett brace (used if hyperexten- Burst fractures may be treated conservatively when sion is desired) both can be used to achieve this result. there is no neurological injury. Conservative treatment For upper thoracic spine fractures between T-1 and T-4, usually consists of hyperextension casting for 2–3 months a SOMI (sterno-occipito-mandibular immobilizer) brace and bracing for an additional 6–12 months. Surgical in- is used in conjunction with a TLSO brace for treatment. tervention is relatively indicated with > 50% loss of body Duration of bracing therapy depends on the injury and height, > 50% canal compromise from retropulsed bone neurosurgeon, but is typically at least 3 months. fragments, or > 30° of kyphosis. Absolute indications for Surgical stabilization for unstable lumbar fractures surgical decompression and/or fusion include neurologi- can often be managed via a posterior approach. Adoles- cal deficits or progressive kyphosis.2,5 In the presence of cents can often be stabilized with adult-type instrumen- multiple nerve root palsies or SCI, anterior decompression tation; the pediatric spine reaches adult maturity at ap- must be considered. proximately 9 years of age. Younger children, however, Unstable injuries, such as the 3-column fractures have smaller pedicles, and thus pedicle screw placement mentioned above, are most often operative injuries. The may be challenging. They also have smaller spinal canals, only situation that can be treated conservatively is when so placement of sublaminar hooks is not safe. Stereotactic there is fracture-dislocation with minimal displacement guidance has helped with placement of instrumentation in and the fracture line goes through the bone (a “bony these cases. Also, rhBMP-2 has been used in young pa- chance fracture”). In this case, conservative management tients to promote bone fusion because they routinely have a consists of case immobilization for 8–10 weeks followed very limited amount of bone autograft available. Although by bracing thereafter.34 Surgical stabilization is indicated the FDA has only approved the use of rhBMP-2–soaked with progressive neurological deficit or displacement > absorbable collagen sponges for use in adult anterior in- 17° of kyphosis or when the predominant injury is dis- terbody lumbar fusion, “off-label” applications have been coligamentous instead of bony. Three-column injury with

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Fig. 6. Case 4. Apophyseal ring fracture with L5–S1 disc herniation. Preoperative AP (A) and lateral (B) lumbar spine CT scans demonstrating a posterior detached fragment at the superior S-1 endplate and a defect in the bone adjoining the fracture site eccentric to the left near the left S-1 nerve root (red arrows). Preoperative AP (C) and lateral (D) lumbar spine MRI studies demonstrating a left eccentric disc herniation with impingement on the exiting left S-1 nerve root. rotation is the most unstable and is uniformly treated with Erfani et al. have described the results of thoracic surgery. The procedure consists of posterior instrumenta- and lumbar instrumentation for pediatric traumatic spine tion and fusion 1 or 2 levels above and below the level of fractures over a 10-year period. Of 102 individuals, L-1 injury.11,19,21 was the most frequently injured vertebra (31 patients), Conservative management for apophyseal ring frac- followed by L-2 (19 patients), L-3 (18 patients), T-12 (16 tures consists of rest, analgesics, physical activity modifi- patients), and L-4 (10 patients), and the remainder of verte- cation, and physical therapy; however, it is rarely success- bral levels had < 5 patients each. Twenty patients required ful and surgical excision of the limbus fragment is usually surgical stabilization; however, only 15 patients partici- required. Surgery is done via a posterior approach to re- pated in follow-up (mean 49 months). Eight (53.3%) of the move the offending fragments with or without an inter- 15 patients had lumbar spine fractures, and all underwent laminal laminectomy.13,35 Typically these are not unstable posterior spinal instrumentation and fusion alone. Three injuries, and thus fusion is not necessary and outcomes patients with lower thoracic or thoracolumbar fractures are usually favorable. underwent an anterior followed by a posterior approach (those with delay in diagnosis). Four patients with SCI (2 Outcomes with cauda equina and 2 with incomplete SCIs) had return A majority of lumbar spine fractures in children and of baseline neurological function. They reported no post- younger adolescents are minor, stable, and do not present operative complications and all patients were functionally with neurological deficit. One must approach pediatric independent at follow-up.7 spine fractures in a systematic way, taking into consid- Dogan et al. also reviewed a series of 89 pediatric eration immediate stability, the need for neurological de- patients with traumatic thoracolumbar fractures, 23 of compression, and late stability and propensity for healing. whom underwent surgery. Of these fractures, 19.2% were Because children have more laxity of the spine, physicians at the thoracolumbar junction and 29.8% were somewhere must keep a high suspicion for SCIWORA and therefore between L-2 and L-5. Of the 23 patients who underwent order and proceed with more imaging (such as MRI) operation, 14 (60.9%) had lumbar spine fractures. The when clinically indicated. Previous reports estimate that mean follow-up was 17.2 months, and all patients had a anywhere between 7.5% and 30% of patients with thora- stable fixation, visible callus formation, and maintenance columbar fractures require operative intervention.6,15,23,29 of alignment.6 Twenty-nine patients with mild lumbar or

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Unauthenticated | Downloaded 10/04/21 09:08 PM UTC C. Sayama et al. sacral injuries were treated successfully with bed rest 2. Andreychik DA, Alander DH, Senica KM, Stauffer ES: Burst alone and gradual resumption of activities. There have fractures of the second through fifth lumbar vertebrae. Clini- been several previous studies that have reported success- cal and radiographic results. J Bone Joint Surg Am 78:1156– 1166, 1996 ful fusion associated with normal thoracolumbar growth 3. Black BE, O’Brien E, Sponseller PD: Thoracic and lumbar and good alignment after both anterior and posterior ap- 3,6,7,10,22,27 spine injuries in children: different than in adults. Contemp proaches for pediatric lumbar trauma. Orthop 29:253–260, 1994 Many pediatric fractures are managed conservatively, 4. Carlisle E, Fischgrund JS: Bone morphogenetic proteins for and children have been noted to have a high propensity for spinal fusion. Spine J 5 (6 Suppl):240S–249S, 2005 healing. Karlsson et al. observed and reported on the abil- 5. Crawford AH: Operative treatment of spine fractures in chil- ity of the pediatric spine to remodel after traumatic frac- dren. Orthop Clin North Am 21:325–339, 1990 ture in the thoracolumbar spine.14 The authors followed a 6. Dogan S, Safavi-Abbasi S, Theodore N, Chang SW, Horn EM, 24-patient observational cohort of children with thoracic Mariwalla NR, et al: Thoracolumbar and sacral spinal injuries in children and adolescents: a review of 89 cases. J Neurosurg or lumbar fractures for up to 47 years (range 27–47 years, 106 (6 Suppl):426–433, 2007 mean 33 years). Twenty-one patients had simple compres- 7. Erfani MA, Pourabbas B, Nouraie H, Vadiee I, Vosoughi AR: sion fractures, and all fractures were treated conserva- Results of fusion and instrumentation of thoracic and lumbar tively. There were 17 thoracic fractures and 7 lumbar frac- vertebral fractures in children: a prospective ten-year study. tures. The most notable result from this study is that they Musculoskelet Surg [epub ahead of print], 2014 found a significant improvement in the ratio of the anterior 8. Fahim DK, Whitehead WE, Curry DJ, Dauser RC, Luerssen height/posterior height (from 0.75 at time of injury to 0.87 TG, Jea A: Routine use of recombinant human bone morpho- at follow-up) in patients < 13 years old. This improvement genetic protein-2 in posterior fusions of the pediatric spine: in wedging of the VB demonstrates the potential of VB safety profile and efficacy in the early postoperative period. Neurosurgery 67:1195–1204, 2010 remodeling during growth when a fracture is encountered 9. Gaca AM, Barnhart HX, Bisset GS III: Evaluation of wedging in a younger patient. This is a stark contrast to adults, in of lower thoracic and upper lumbar vertebral bodies in the pe- whom we usually see increased posttraumatic kyphosis. diatric population. AJR Am J Roentgenol 194:516–520, 2010 In terms of quality of life measures, Erfani et al. re- 10. Gambardella G, Coman TC, Zaccone C, Mannino M, Ciurea ported a 33.3% incidence of occasional back pain in the AV: Posterolateral approach in the treatment of unstable ver- long term.7 They also reported near complete improvement tebral body fractures of the thoracic-lumbar junction with in- in all 4 patients with neurological injury in their series. In complete spinal cord injury in the paediatric age group. Childs another study by Moller et al., 5 (21.7%) of 23 patients had Nerv Syst 19:35–41, 2003 postoperative pain at long-term follow-up. They also re- 11. Gumley G, Taylor TK, Ryan MD: Distraction fractures of the ported predominantly favorable long-term outcomes with lumbar spine. J Bone Joint Surg Br 64:520–525, 1982 22 12. Hegenbarth R, Ebel KD: Roentgen findings in fractures of the no or minor neurological deficits. Dogan et al. noted that vertebral column in childhood examination of 35 patients and all neurologically intact patients remained so at follow-up its results. Pediatr Radiol 5:34–39, 1976 and that 75% of the patients with incomplete SCIs recov- 13. Ishihara H, Matsui H, Hirano N, Tsuji H: Lumbar intervertebral ered completely.6 disc herniation in children less than 16 years of age. Long-term follow-up study of surgically managed cases. Spine (Phila Pa Conclusions 1976) 22:2044–2049, 1997 14. Karlsson MK, Moller A, Hasserius R, Besjakov J, Karlsson Pediatric lumbar spine fractures constitute approxi- C, Ohlin A: A modeling capacity of vertebral fractures ex- mately 1%–3% of all pediatric fractures. Because of the ists during growth: an up-to-47-year follow-up. Spine (Phila differences in the pediatric spine, the incidence of SCI- Pa 1976) 28:2087–2092, 2003 [Erratum in Spine (Phila Pa 1976) 30:2237, 2005 and Spine (Phila Pa 1976) 31:72, 2006] WORA is much higher than in adults. Conservative versus 15. Kraus R, Stahl JP, Heiss C, Horas U, Dongowski N, Schnettler surgical management of different types of fractures de- R: [Fractures of the thoracic and lumbar spine in children and pends on the stability of the fracture, the neurological sta- adolescents.] Unfallchirurg 116:435–441, 2013 (Ger) tus of the patient, and his/her injury-healing ability. When 16. Lee JY, Vaccaro AR, Lim MR, Oner FC, Hulbert RJ, Hed- surgical intervention is indicated it is safe and effective in lund R, et al: Thoracolumbar injury classification and sever- the pediatric population, and outcomes in terms of fusion ity score: a new paradigm for the treatment of thoracolumbar and neurological status are good. spine trauma. J Orthop Sci 10:671–675, 2005 17. Leroux J, Vivier PH, Ould Slimane M, Foulongne E, Abu- Amara S, Lechevallier J, et al: Early diagnosis of thoracolum- Disclosure bar spine fractures in children. A prospective study. Orthop Dr. Trost is a consultant for Medtronic. Traumatol Surg Res 99:60–65, 2013 Author contributions to the study and manuscript preparation 18. Lu DC, Sun PP: Bone morphogenetic protein for salvage fusion include the following. Conception and design: Jea. Acquisition of in an infant with Down syndrome and craniovertebral instabil- data: Sayama, Chen, Jea. Analysis and interpretation of data: Sayama, ity. Case report. J Neurosurg 106 (6 Suppl):480–483, 2007 Chen, Jea. Drafting the article: Sayama, Chen, Jea. Critically revising 19. Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S: A com- the article: all authors. Reviewed submitted version of manuscript: prehensive classification of thoracic and lumbar injuries. Eur Sayama, Trost, Jea. Approved the final version of the manuscript on Spine J 3:184–201, 1994 behalf of all authors: Sayama. 20. Marar BC: Hyperextension injuries of the cervical spine. The pathogenesis of damage to the spinal cord. J Bone Joint Surg References Am 56:1655–1662, 1974 21. McCormack T, Karaikovic E, Gaines RW: The load sharing 1. Akbarnia BA: Pediatric spine fractures. Orthop Clin North classification of spine fractures. Spine (Phila Pa 1976) 19: Am 30:521–536, x, 1999 1741–1744, 1994

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22. Moller A, Hasserius R, Besjakov J, Ohlin A, Karlsson M: Ver- fractures in children: does age, mechanism of injury, or gender tebral fractures in late adolescence: a 27 to 47-year follow-up. play a significant role? Pediatr Radiol 33:776–781, 2003 Eur Spine J 15:1247–1254, 2006 31. Roche C, Carty H: Spinal trauma in children. Pediatr Radiol 23. Mortazavi MM, Dogan S, Civelek E, Tubbs RS, Theodore N, 31:677–700, 2001 Rekate HL, et al: Pediatric multilevel spine injuries: an institu- 32. Skórzewska A, Grzymisławska M, Bruska M, Lupicka J, tional experience. Childs Nerv Syst 27:1095–1100, 2011 Woźniak W: Ossification of the vertebral column in human 24. Pang D, Pollack IF: Spinal cord injury without radiographic foetuses: histological and computed tomography studies. Folia abnormality in children—the SCIWORA syndrome. J Trau- Morphol (Warsz) 72:230–238, 2013 ma 29:654–664, 1989 33. Swischuk LE, Swischuk PN, John SD: Wedging of C-3 in in- 25. Pang D, Wilberger JE Jr: Spinal cord injury without radio- fants and children: usually a normal finding and not a fracture. graphic abnormalities in children. J Neurosurg 57:114–129, Radiology 188:523–526, 1993 1982 34. Vialle LR, Vialle E: Pediatric spine injuries. Injury 36 (Suppl 26. Pang D, Zovickian JG: Vertebral column and spinal cord in- 2):B104–B112, 2005 juries in children, in Winn HR (ed): Youmans Neurologi- 35. Yen CH, Chan SK, Ho YF, Mak KH: Posterior lumbar apophy- cal Surgery, ed 6. Philadelphia: Elsevier Saunders, 2011, pp seal ring fractures in adolescents: a report of four cases. J Or- 2293–2332 thop Surg (Hong Kong) 17:85–89, 2009 27. Parisini P, Di Silvestre M, Greggi T: Treatment of spinal fractures in children and adolescents: long-term results in 44 patients. Spine (Phila Pa 1976) 27:1989–1994, 2002 Manuscript submitted March 12, 2014. 28. Pouliquen JC, Kassis B, Glorion C, Langlais J: Vertebral Accepted May 19, 2014. growth after thoracic or lumbar fracture of the spine in chil- Please include this information when citing this paper: DOI: dren. J Pediatr Orthop 17:115–120, 1997 10.3171/2014.5.FOCUS1490. 29. Puisto V, Kääriäinen S, Impinen A, Parkkila T, Vartiainen E, Address correspondence to: Christina Sayama, M.D., M.P.H., Jalanko T, et al: Incidence of spinal and spinal cord injuries Division of Pediatric Neurosurgery, Department of Neurosurgery, and their surgical treatment in children and adolescents: a pop- Texas Children’s Hospital, Baylor College of Medicine, 6621 Fan- ulation-based study. Spine (Phila Pa 1976) 35:104–107, 2010 nin St., CCC 1230.01, Houston, TX 77030. email: cmsayama@ 30. Reddy SP, Junewick JJ, Backstrom JW: Distribution of spinal texaschildrenshospital.org.

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