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Table of Contents    
NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS
Year : 2017  |  Volume : 65  |  Issue : 3  |  Page : 480-481

Pediatric thoracolumbar fractures: Salient points in management


Division of Spine Surgery, Department of Orthopedics, Sir Gangaram Hospital and Institute of Medical Sciences, New Delhi, India

Date of Web Publication9-May-2017

Correspondence Address:
Shankar Acharya
Division of Spine Surgery, Department of Orthopedics, Sir Gangaram Hospital and Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_318_17

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How to cite this article:
Acharya S. Pediatric thoracolumbar fractures: Salient points in management. Neurol India 2017;65:480-1

How to cite this URL:
Acharya S. Pediatric thoracolumbar fractures: Salient points in management. Neurol India [serial online] 2017 [cited 2019 Aug 19];65:480-1. Available from: http://www.neurologyindia.com/text.asp?2017/65/3/480/205918


The authors have documented the profile of pediatric thoracolumbar (TL) fractures presenting to their center from 2002 to 2014. Being a retrospective study, the paper only documents those cases of TL injuries with fracture dislocations and with spinal cord injuries with neurological deficit. Those without neurological deficit or radiological abnormalities, who have been given primary care and discharged from the casualty, are not documented. The authors stated that the aim of the study was to look into the epidemiology and study the risk factors responsible for pediatric TL fractures. However, neither of the two have been studied. At best, it can be described as a retrospective case series evaluation of pediatric TL fractures admitted to the authors' hospital from 2012 to 2014.[1]

Pediatric spine injuries are rare, and account for 2-5% of all spinal injuries, the majority of them being that of cervical spine.[2] They are different from the adult spine as the children's spine is more elastic and may tolerate more compression than the adult spine before fracturing or dislocating. Shallow facets and elastic ligaments permit up to 2 inches of vertebral column stretching, whereas the spinal cord can tolerate only 0.25 inches.[3] Physical injuries like Salter Harris type 1 (transverse fracture through the growth plate) may occur in children thus preserving the disc morphology, unlike the fractures seen in the adults. Thoracolumbar injuries in children should actually be analyzed in two age groups, those below 8 years, and those from 9 to 18 years (as fractures in patients below the age of 8 years behave differently from the fractures in children older than this age). In the present study by Babu et al., most of the children were between 15-18 (81%) years and only 4.4% were below 10 years of age. The occurrence of spinal cord injury without radiographic abnormality (SCIWORA) in children is of utmost importance, which can be as high as 36%, as reported in certain series.[3] The authors had only 2 cases of SCIWORA in their series. Most of the patients in their series had only radiographic and clinical assessment done, on the basis of which they were admitted or discharged from the accident and emergency department. Subtle injuries could have been missed, leading to the late presentation of deformity or neurological deficit. Syringomyelia is also an issue which should be kept in mind, especially in children with kyphosis.[4] In a retrospective magnetic resonance imaging (MRI) study, it was recorded that children with residual deformities can have 20-40% incidence of the development of a late syrinx.[5] I feel that all children who have undergone polytrauma, including injuries to the spine, should be followed up regularly in the outpatient department to pick up late or missed injuries.

The common cause of injuries in the published literature is motor vehicular accident;[6] the authors, however, have reported that the etiology in maximum number of their cases was due to a fall from height (71%). This may be due to the fact that most of the children in their series were between 15-18 years of age.

Classifying injuries is very important so as to have a standard plan of management, which is easily understood by all and is reproducible. Most authors agree that the adult thoracolumbar injury classification system (the Thoracolumbar Injury Classification and Severity [TLICS] score) has good reliability and validity in the adult group.[7] This classification is a scoring system based upon the severity of injury. The morphology of the fracture, the status of the posterior ligament complex (PLC) and the neurological status of the patient at presentation has a role in determining the severity of injury. The minimum score is 1 and the maximum score is 10. In patients with a score above 5, surgical intervention is favored. The authors have operated on 18 out of the 90 patients in their series. No classification system seemed to have been used and the decision to perform surgery had been dictated by the presence of neurological deficits and/or instability or deformity. They state that 50% of patients had only fusion without decompression, and the other 50% had a laminectomy or a corpectomy. According to the current literature, and also in my opinion, most of these fractures that are unstable and with or without neurological deficits, should be treated with posterior pedicular screw fixation systems. Smaller diameter pedicle screws can be used in children, and usually, tapping the screws and allowing the pedicle to expand helps to accommodate larger diameter screws in children. In most children, screws upto 5 mm in diameter can be used. Screw head prominence is important while choosing implants and the lowest profile screws should be used. Monoaxial screws should be preferred instead of polyaxial screws. In most fracture dislocations with instability, fusion with fixation is the treatment of choice. Only in selected cases can one fix without performing an additional fusion. Very rarely, anterior surgery is required, as almost all of the correction and decompression can be achieved by a posterior apporach. Neurological recovery in children is also better, as documented in several studies, and the recovery can be delayed until 18 months.[8] Follow up is essential for analyzing results. However, the present study has a follow up in only 23% patients. There is no mention of the correction of the deformity; the outcome of fusion; implant related failures; or, any surgery related failures.[1] At best, this study is a retrospective profiling of pediatric TL fractures presenting to the authors' institution from 2002-2014.

The important key points to be keep in mind while treating thoracolumbar fractures are as follows:

  • The morphological variations of the pediatric spine should be well understood by those treating these injuries
  • A high index of suspicion is required so as not to miss out SCIWORA. A MRI study should be done at the slightest suspicion. A screening study of the whole spine should always be done. Those children, after being discharged with only clinical and X-ray evaluation, should be closely monitored as outpatients, while ensuring a long-term follow-up. Late presentation of neurological deficits, persisting deformity or late kyphosis leading to a syrinx formation, should be avoided
  • The TLICS classification should be applied to each of these patients and they should treated according to its recommendations
  • Most children can be treated with posterior fixation and fusion. Harvesting bone grafts in children is an issue and alternative grafts like the rib or fibula should be considered. Allografts can also be used. Once fusion is achieved, the implants may be removed.


 
  References Top

1.
Babu RA, Arimappamagan A, Pruthi N, Bhat DI, Arvinda HR, Indira Devi B, Somanna S. Pediatric thoracolumbar spinal injuries: The etiology and clinical spectrum of an uncommon entity in childhood. Neurol India 2017;65:546-550.  Back to cited text no. 1
  [Full text]  
2.
Srinivasan V, Andrew Jea A. Pediatric thoracolumbar spine trauma. Neurosurg Clin N Am 2-017;28:103-114.  Back to cited text no. 2
    
3.
Pollack IF. Disorders of the pediatric spine. In: Spinal Cord Injury Without Radiolographic Abnormality (SCIWORA), Pang D, editor. New York: Raven Press. 1995, pp 509-16.  Back to cited text no. 3
    
4.
Saumyajit Basu. Spinal injuries in children. Front Neurol 2012; 96:1-8.  Back to cited text no. 4
    
5.
Abel R, Gerner H J, Smit C, Meiners T. Residual deformity of the spinal canal in patients with traumatic paraplegia and secondary changes of the spinal cord. Spinal Cord 1999;37:14-19.  Back to cited text no. 5
    
6.
Santiago R, Guenther E, Carroll K, Junkins EP Jr. The clinical presentation of pediatric thoracolumbar fractures. J Trauma 2006; 60:187-92.  Back to cited text no. 6
[PUBMED]    
7.
Savage JW, Moore TA, Arnold PM, Thakur N, Hsu WK, Patel AA, et al. The reliability and validity of Thoracolumbar Injury Classification System in pediatric spine trauma. Spine 2015; 40:E1014-E1018.  Back to cited text no. 7
[PUBMED]    
8.
Wang MY, Hoh DJ, Leary SP, Griffith PJ. McComb G. High rates of neurological improvement following severe traumatic pediatric spinal cord injury. Spine 2004;29:1493-97.  Back to cited text no. 8
    




 

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