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Trauma to the Thoracic and Lumbar Spine in the Adolescent

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Trauma to the Thoracic and Lumbar Spine in the Adolescent Review Article Article de revue Trauma to the thoracic and lumbar spine in the adolescent Peter Clark, MD;* Mervyn Letts, MD† During adolescence the spine undergoes rapid growth and changes in anatomy and biomechanical prop- erties. Fractures of the adolescent spine are relatively uncommon but may give rise to serious problems. This review describes thoracolumbar fractures in adolescents with respect to epidemiology, anatomy, mechanisms of injury, clinical and radiologic assessment, and nonoperative and operative treatment. The treatment of these injuries follows many of the same principles as spinal fractures in adults but nonoper- ative treatment is used more frequently because there is less spinal instability and better tolerance of bed rest and spinal immobilization in this young population. La croissance de la colonne vertébrale est rapide et ses caractéristiques anatomiques et biomécaniques changent au cours de l’adolescence. Les fractures de la colonne au cours de l’adolescence sont relative- ment rares, mais elles peuvent entraîner de graves problèmes. Cette analyse critique décrit l’épidémiolo- gie, l’anatomie, les mécanismes traumatisants, l’évaluation clinique et radiologique, ainsi que le traite- ment chirurgical et non chirurgical de fractures de la colonne thoracolombaire chez des adolescents. Le traitement de ces traumatismes suit un grand nombre des mêmes principes que dans le cas de fracture de la colonne chez les adultes, mais on utilise plus souvent le traitement non chirurgical parce que la colonne de ces jeunes sujets est moins instable et tolère mieux le repos au lit et l’immobilisation vertébrale. njuries to the spine are rare in the adolescent thoracic and lumbar secondary to falls from a height and I young children but increase sig- spine will be outlined. to motor vehicle accidents. Neuro- nificantly in adolescence. From 12 to logic injury occurred in 14% with 17 years of age, the child’s spine un- Epidemiologic features multiple-level vertebral fractures dergoes rapid growth and change in noted in 35%. Hadley and associates2 its anatomic, radiographic and bio- Pediatric spinal fractures represent found that motor vehicle accidents mechanical properties as it ap- between 2% and 5% of all acute were the most common cause of proaches skeletal maturity. The pur- spinal injuries. The majority of thora- spinal fractures in children aged 10 pose of this article is to describe the columbar spine fractures in the pedi- to 16 years, followed by falls and epidemiologic characteristics of atric population occur in children sports injuries. spinal injuries in adolescents, their aged 14 to 16 years of age.1 The The following injury data were unique anatomic and radiographic most frequently injured area of the obtained from the database of the characteristics, the mechanisms of in- spine is T4 to T12, followed by T12 Canadian Hospitals Injury Reporting jury, and the clinical and radi- to L2.2,3 McPhee3 found that in chil- and Prevention Program (CHIRPP), ographic evaluation of these injuries. dren under 15 years of age, the ma- Health Canada, from 10 pediatric The principles of nonoperative and jority of spinal trauma occurred in and 6 general hospitals from across operative management of injuries to those over 12 years of age, usually the country. Data collection began in From the Division of Pediatric Orthopedics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ont. Accepted for publication May 12, 2000. Correspondence to: Dr. Mervyn Letts, Head, Division of Pediatric Orthopedics, Children’s Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Rd., Ottawa ON K1H 8L1; fax 613 738-4840. © 2001 Canadian Medical Association Canadian Journal of Surgery, Vol. 44, No. 5, October 2001 337 Clark and Letts April 1990. In April 1999 (the most heights were involved in 13%. Four- turity is possible across the adolescent current data available on adolescent teen percent of all spinal injuries oc- age group. The spine of a 12-year-old spinal injuries), the entire CHIRPP curred at home. Hospitalization was boy at a Risser stage of 0 differs database was searched for records of required in 60% of cases. Fractures greatly from that of a 13-year-old girl spine and spinal cord injuries suffered were documented in 67%, and 26% of Risser stage 4 to 5 who may be in by youths aged 12 to 17 years. Six- had an associated neurologic injury. the same school class. At a Risser hundred and ten cases were identi- Multiple injuries were sustained in stage 1, the iliac apophysis has not yet fied. There were no distinguishable 34% of patients seen in emergency formed and the spine is immature. At patterns of injury by the time of day, departments and in 43% of those a Risser stage 4 the entire apophysis day of the week, month or year of who were admitted to hospital. has formed but has not united with the injury. Injuries were most preva- the pelvis (Fig. 1). This stage corre- lent in those aged 14 to 16 years, Anatomy sponds to the end of spinal growth. and the majority occurred in boys Each vertebra has 3 ossification cen- (63%) (Table 1). Most injuries oc- The spine in the adolescent differs tres, a centrum and 2 neural arches curred during recreational or sport from that of an adult in numerous re- which normally fuse between the ages activities (53%) followed by motor spects. Children mature at variable of 2 and 6 years. If this fails to occur a vehicle accidents (26%). Falls from rates and a wide variety of skeletal ma- spina bifida occulta is seen. In the im- mature spine the facet joints are more horizontal and incompletely ossified, Table 1 which results in more spinal mobility. Age and Sex Distribution of Injuries They achieve a mature configuration No. of cases/ by 8 years of age, but the full, more Age, yr Cases, no. (%) 10 000 injuries* Male, % oblique adult pattern is not seen until 12 96 (15.7) 21.3 58.3 15 years of age. The vertebral bodies 13 95 (15.6) 21.4 60.0 may appear slightly wedged, particu- 14 136 (22.3) 33.0 62.5 larly in the thoracic spine because of 15 137 (22.4) 38.1 65.7 incomplete enchondral calcification at 16 98 (16.1) 41.2 56.1 the end plates. The epidural sac as- 17 48 (7.9) 30.4 62.5 Total 610 (100.0) 29.6 62.7 cends to its normal level opposite L1 *The number of spine and spinal cord injuries per 10 000 Canadian Hospitals Injury Reporting and Prevention Program injuries in the spinal canal by 1 year of age of all types with the age group indicated. and the spinal canal attains adult vol- ume by 6 years of age.1 The immature spine is growing and has physes that are part of the superior and inferior end plates. The end plate is composed of hyaline car- tilage adjacent to the nucleus and physeal cartilage adjacent to the bony vertebral body. The physes ap- pear radiographically between 8 and 12 years of age when the vertebral apophyseal ossification begins to de- velop in the periphery of the carti- laginous end plates (Fig. 2). Early in their development they appear as rings because they are thicker at the periphery than at the centre. The ring apophysis contributes to verte- bral body breadth and the physeal portion contributes to the vertical height. The end plates begin to fuse when the child is 14 to 15 years of age and may be confused with frac- FIG. 1. Risser stages of skeletal maturity. Risser stage I is illustrated on the left and tures until fusion occurs at 21 to 25 stage 4 on the right. years of age (Fig. 3). Following a 338 Journal canadien de chirurgie, Vol. 44, No 5, octobre 2001 Spinal trauma in adolescents vertebral fracture in children under ysis, healing potential is excellent, the bony vertebral body or the anulus 12 years of age, stimulation of verte- unlike a similar injury in the adult fibrosus and the disc space. bral growth with overgrowth and spine. The anulus does not fail in the complete reconstitution of normal Fractures of the lumbar vertebral immature spine. The immature inter- shape can occur. The amount of apophysis also occur and can herniate vertebral disc is more hydrophilic wedging that will remodel is limited into the spinal canal and present with than the mature disc, allowing it to to less than 20° το 30°. If the end low back pain and neurologic findings be a more effective shock absorber plate is damaged or changed, or par- similar to a disc protrusion seen in between the vertebral bodies. In chil- tially fused, an increase in deformity adults.5,6 Slipping of the vertebral dren the disc is a very firm structure may occur, especially during the apophysis occurs in the same age and much more resistant to injury rapid adolescent growth spurt (Fig. range as slipping of the capital femoral than the vertebral body. The verte- 4). Anatomic studies by Aufdermaur4 epiphysis, when these physes are bral body with its cancellous and vas- demonstrated that fractures of the thicker and weaker due to rapid cular centrum also acts as a shock ab- immature spine traverse the growth growth, and may also be associated sorber before compressing or zone of the physis similar to long with anterior lumbar end-plate com- bursting. Roaf8 in 1960 demon- bone physeal fractures. In flexion– pression or Scheuermann’s disease of strated that the cartilaginous end distraction type injuries of the spine a the lumbar spine in 38%.7 After phy- plate often fails first, allowing hernia- Salter–Harris type 1 injury may occur seal closure and cessation of spinal tion of the nucleus into the vertebral through the weaker physis.1 How- growth a weak zone no longer exists body creating Schmorl’s nodes rather ever, because it occurs through a ph- in the spine, and failure occurs through than herniating into the spinal canal FIG.
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