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|NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS
|Year : 2017 | Volume
| Issue : 3 | Page : 477-479
Surgical considerations in the management of pediatric thoracolumbar fractures
So Kato, Stephen J Lewis
Spinal Program, Krembil Neuroscience Center, Department of Orthopaedic Surgery/Neurosurgery, Toronto Western Hospital, University Hospital Network, The University of Toronto, Toronto, Ontario, Canada
|Date of Web Publication||9-May-2017|
Stephen J Lewis
Spinal Program, Krembil Neuroscience Center, Department of Orthopaedic Surgery/Neurosurgery, Toronto Western Hospital, University Hospital Network, The University of Toronto, Toronto, Ontario
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kato S, Lewis SJ. Surgical considerations in the management of pediatric thoracolumbar fractures. Neurol India 2017;65:477-9
Babu et al., share their experience with 90 patients with pediatric thoracolumbar spine trauma presenting over a 12-year period between 2002 and 2014. This represented 2% of all patients with spinal trauma presenting to their unit over this time-frame. The majority were those who sustained low velocity trauma, with 73% occurring from falls, and 14% with concomitant injuries. The injury types were 60% burst and 24% compression fractures. 75% of the cases were males, with over 80% in children 15 years and older. While 23% of cases were neurologically intact, 28% presented with ASIA A deficits. Surgical stabilization was performed in 20% of cases. Seven of the 20 patients presenting with neurological deficits did not improve at a mean follow-up of 5 months.
While this is one of the largest series of pediatric thoracolumbar fractures, many questions still remain unanswered. The indications for surgery were not clearly defined, the time to surgical treatment was not elaborated, and the fracture types were not classified in the accepted classification systems. Follow-up is notoriously difficult in this population, leaving limited information on prognosis for neurological recovery, clinical outcome, and complications related both to the surgically and non-surgically treated patients.
| » Classification|| |
The Denis classification of thoracolumbar fractures, divides the spine into 3 columns, and classifies the injuries into 4 types: Compression fractures (anterior column), burst fractures (anterior and middle column), seat belt injuries (posterior and middle column), and fracture dislocations (anterior, middle, and posterior column disruption). This classification describes a mechanism approach to the injuries, without offering treatment guidelines. The widely used Thoracolumbar Injury Classification and Severity (TLICS) system utilizes the injury morphology, the integrity of the posterior ligamentous complex, and the neurological status, to calculate a score to determine the need for surgical treatment. The reliability and validity of the TLICS system has been established in the pediatric population [Table 1].
| » Adult vs Pediatric Fractures|| |
Fracture patterns are similar between children and adult patients with thoracolumbar trauma. In this series with the majority of injuries occurring due to falls in older teenagers, a preponderance of compression fractures and burst fractures were observed. An injury more specific to children, as discussed in the paper, is the spinal cord injury without radiographic abnormality (SCIWORA). This involves a significant injury to the spinal cord without evidence of gross injury on computed tomographic (CT) or radiographic images. The elasticity and mobility of the child's ligamentous and disc structures allow for significant injury to the spinal cord at the time of impact. The mechanism is most likely a hyperextension injury, leading to an injury to the spinal cord, similar to the central cord syndrome seen in adult extension injuries. Magnetic resonance imaging (MRI) has been useful in identifying these lesions in patients with severe neurological deficits. However, due to the small size of the spinal cord and movement artifact secondary to breathing or motion, the regular sequence MRI scans may fail to demonstrate these lesions (SCI without neuroimaging abnormalities). The addition of diffusion weighted images sequences may be of benefit in better defining these injuries in these cases.
| » Management of Thoracolumbar Injury|| |
Non-surgical management ranges from recumbence to external immobilization. The mainstay of thoracolumbar immobilization is the application of a hyperextension brace such as Jewett brace, but casting can also be an option for young children. The duration of these treatments may vary but usually it takes up to 8 to 12 weeks before sufficient healing can be expected. A representative case is shown in [Figure 1]. There are many surgical approaches to treat thoracolumbar injuries. No specific treatment has been proven superior to the other, but optimal strategy should be considered on a case-by-case basis. From the posterior approach, pedicle screw fixation is the most commonly used technique in the current practice. The safety of screw insertion in pediatric patients has been established, but constructs by laminar hooks or spinous process wiring can be alternatives for very young children. Decompression can be achieved by laminectomy, with more severe compression requiring removal of the bony fragments through the transpedicular, costotransversectomy or anterior approaches. The advantages of anterior surgery include direct access to the bony compression and potentially shorter levels of fixation compared to posterior fixation. A representative case is shown in [Figure 2]. Usually, a short fusion consisting of one-level above and one-level below the level of fixation suffices except for very unstable three-column injuries, in which a longer construct may be considered. These constructs typically aim for bone fusion of the fixed segment. Screws, however, can be removed after fracture healing for immature patients with significant growth potential left, to maximize the mobility and axial growth and to avoid post-operative deformity. Late scoliosis in paralyzed immature patients has been described, occasionally necessitating delayed corrections.
|Figure 1: L2 burst fracture managed non-operatively. A 16-year-old male patient sustained an asymmetric L2 burst fracture after falling off the motorcycle (a and b). The patient was neurologically intact, and sagittal T2 MRI (c) confirmed the integrity of the posterior ligamentous complex. The patient was treated non-operatively with a hyperextension brace (d). Two years after the injury, the patient was pain free with no physical complaints. Imaging revealed 20° of focal scoliosis (e) and 16° of kyphosis (f)|
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|Figure 2: Operative management for L1 burst fracture. A 18-year-old male patient sustained an L1 burst fracture after falling from a tree (a and b: pre-operative CT). It was associated with an apophyseal ring avulsion at T12 (Salter-Harris type 2 fracture). The patient presented with bilateral lower extremity weakness, numbness and bladder dysfunction. MRI demonstrated the fracture fragment in the canal and signal intensity change of the distal spinal cord (c and d). The patient was treated with a posterior decompression and instrumented fusion from T12 to L2 (e and f)|
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| » Timing of the Treatment|| |
Optimal timing of the treatment for thoracolumbar injury has not been well established. Early decompression has shown improved neurological outcomes after spinal cord injury (SCI) in animal models, and it is the current recommendation in the surgical treatment of cervical SCI. While there is no high quality evidence in thoracolumbar injuries with regard to the surgical timing and neurological recovery, early surgical intervention has been shown to decrease the length of hospital stay and the morbidity rates. Our practice is to operate on those pediatric injuries requiring surgical intervention in an expedited fashion.
| » Conclusion|| |
Pediatric thoracolumbar fractures are relatively rare injuries, but can have significant impact on the quality of life of children in the growing age. Controversies exist related to surgical indications, construct length, timing and prognosis. Appropriate clinical examination and imaging are needed to properly identify the fracture patterns to determine the most appropriate management plan. While some fracture patterns are specific to children, operative treatment does not significantly differ from that of adults. Attention to future growth and healing potential should be made when considering surgical treatment in these patients.
| » References|| |
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[Figure 1], [Figure 2]