Management of Pediatric and Adolescent Traumatic Thoracolumbar Spondyloptosis
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.360921
Source of Support: None, Conflict of Interest: None
Keywords: Adolescent, pediatric, rehabilitation spondyloptosis, surgical reduction and fixation, thoracolumbar spine trauma
Spinal injuries are relatively uncommon in the pediatric age group accounting for 2.7 to 9% of all spine injuries.,,, Cervical spine injuries constitute 40–60% of injuries,, while the majority of pediatric thoracolumbar spine trauma occurs in children above 14 years of age.
Thoracolumbar injuries in children usually present with endplate fractures with superior endplate being more common., The pediatric spine is more elastic than adults owing to the shallow facet joints and stretchable ligaments and joint capsules., Thus, trauma to the spine would commonly produce neurological deficits rather than fracture-dislocations. It would require an enormous high-velocity injury to cause three-column injury and subluxation of vertebral bodies thus making spondylolisthesis a rare phenomenon in children with only sporadic case reports of pediatric traumatic spondyloptosis.,,
Complete fracture-dislocation and greater than 100% subluxation of adjacent vertebral bodies in the coronal or sagittal plane is defined as grade V spondylolisthesis or spondyloptosis.,,, The upper vertebral body may be displaced anteriorly, laterally, or posteriorly to the caudal vertebra resulting in sagittal/coronal plane spondyloptosis.,,,, According to Denis classification, spondyloptosis is a fracture-dislocation type of injury with the severance of all three columns of the spine. Vaccaro's thoracolumbar injury classification and severity (TLICS) system acknowledges it as the most severe and unstable form of spine injury.
Spinal spondyloptosis often results in complete cord injury, especially in the thoracic spine, where there is the dearth of space around the neural elements.,, Spondyloptosis in children present unique surgical challenges as reduction and spinal column realignment requires precise planning and execution.,
In this series, we describe the clinical history and radiological characteristics of seven pediatric and adolescent cases of traumatic spondyloptosis involving the thoracolumbar vertebrae, their surgical management and outcomes in a health care setting wherein specialized rehabilitation centers are lacking.
Retrospective data analysis over the last 9 years (2008–2016) was done from the departmental database at our center. Records of all patients, aged 18 years or less, with thoracolumbar injuries having a diagnosis of “listhesis” were retrieved to figure out cases of spondyloptosis. As this was a retrospective analysis of the data of patients operated using standard surgical techniques and no new treatment algorithm or procedure was proposed, ethical clearance was not sought. Spondyloptosis was described on computed tomography (CT)/magnetic resonance (MR) scans as complete subluxation (>100%) of the adjacent vertebra. On axial CT slice, it was described as a “double vertebral sign.”
All patients aged 18 years or less whose spinal deformity was in agreement with the criterion of spondyloptosis were incorporated in the study. The clinical records and radiological data were evaluated to determine the neurological status and severity of injury in terms of the American Spinal Injury Association (ASIA) grading and TLICS scale, respectively.
The surgical vs conservative management plan was decided by the treating neurosurgeon. All patients had clinical and radiological follow-up via outdoor appointments.
A total of six boys and one girl, ranging in age from 9 to 18 years (mean 15.1 years), were included in the study. The girl sustained an injury due to wall collapse over her back. Two boys were involved in high-velocity road traffic accidents while two presented with fall from height. One patient was run over by a tractor while another patient suffered dorsal spine injury when he fell in a mortar mixing machine [Table 1].
One patient sustained chest injury resulting in multiple rib fractures and hemothorax. All seven patients had spondyloptosis >100% subluxation of adjacent vertebra. All patients underwent CT or MR imaging or both. Five patients had an injury at the thoracolumbar junction, that is, from T-11 to L-2 while one each at lumbar and dorsal spine. The TLICS score for all the patients was 8 (3 each for fracture morphology and posterior ligamentous complex and 2 for neurological deficit). Neurologically, each patient presented with ASIA A grade.
Six patients underwent single-stage posterior surgical reduction and fixation while one patient opted against surgery when prognosticated regarding the injury and chances of neurological improvement. The mean interval between the time of injury and surgery was 13.5 days (3–29 days). The number of levels of fixation was the surgeon's personal decision which varied from two to three levels above and below the fracture level.
Intraoperatively, cord transection was seen in five patients while one patient had a severely compressed cord. In cases of cord transection, the proximal end was ligated with purse-string suture and reinforced with fibrin glue. Complete reduction and alignment with the restoration of the height of the spine could be achieved in four patients, out of whom two patients underwent corpectomy of an irreducible posteriorly displaced vertebral body with mesh cage placement. In the remaining two cases, the spinal height was reduced by one vertebra as the impacted adjacent vertebra could not be aligned and the spine fixation was done minus the irreducible corpectomy vertebral body.
The mean postoperative stay was 14.3 days (4–48 days) with the longest stay of 48 days required by the patient with associated lung injury for which he had to be tracheostomized and ventilated for a prolonged duration. No incidence of decubitus ulcer or deep vein thrombosis was noticed during the hospital stay. All patients were educated about home-based rehabilitation before discharge. The mean follow-up period was 17 months (1–36 months). In the course of follow-up, one patient expired 2½ years post-surgery due to complications arising from bedsores. All patients remained neurologically the same, that is, ASIA A during the follow-up. There was no evidence of pseudoarthrosis or implant failure during follow-up.
Illustrative case 1 [[Table 1], Case 3—Able to achieve normal spinal column alignment].
A 15-year-old male presented with a history of injury sustained while working at a construction site wherein he fell in a mortar mixing machine. On arrival, the patient was paraplegic with power 0/5 at all joints of bilateral lower limbs and loss of bladder and bowel sensations. Thus, he suffered from ASIA grade A spinal cord injury (SCI). Thoracolumbar CT scanning showed spondyloptosis at the T12-L1 level with a complete displacement of the L1 vertebral body with respect to T12. [Figure 1] There were no other associated injuries.
Surgery: The patient underwent a single-stage posterior spinal stabilization procedure 5 days after admission. On exposure, the L1 vertebral body was seen impacted posterior to the T12. The thecal sac was lacerated and the cord was completely transected. Pedicle screws were placed bilaterally from T10 to L3.
The displaced T12 and L1 vertebral bodies could not be reduced with distraction. No further maneuvers were attempted to avoid any collateral damage to the adjacent structures. Therefore, L1 vertebrectomy was done to reduce and align the L2 vertebra under the T12 vertebral body. The autograft bone fragments from corpectomy L1 vertebra were placed over the decorticated posterolateral surfaces of instrumented vertebrae and space between T12 and L2 to achieve bony fusion. The thecal sac was identified and the purse-string suture was applied at both ends with 4-0 prolene ensuring watertight closure to avoid any cerebrospinal fluid (CSF) leak which was confirmed intraoperatively by Valsalva maneuver. The closed ends were covered with fat and reinforced with fibrin glue. The final construct consisted of 10 pedicle screws with contoured rod fixation spanning from T10 to L3 minus the L1 vertebra thus reducing the total spinal column height. The autograft bone fragments harvested from corpectomy of the L1 vertebra were placed between the T12 and L2 vertebral bodies and over the decorticated posterolateral surfaces of instrumented vertebrae to achieve bony fusion [Figure 2]a and [Figure 2]b.
Postoperative Course: The patient had an uneventful postoperative recovery. He was discharged on the 9th postoperative day for home-based rehabilitation. At 9 months follow-up, the patient remained neurologically the same and ambulatory in a wheelchair. A follow-up CT scan showed good alignment of the spine with evidence of bony fusion [Figure 2]c.
Illustrative case 2 [[Table 1], Case 4—Not able to achieve normal spinal column alignment].
An 18-year-old male presented to us with a road traffic accident, when the vehicle he was traveling in collided with an animal. Neurologically, he had ASIA grade A SCI. Imaging showed a L1-L2 lateraloptosis. [Figure 3]a, [Figure 3]b, [Figure 3]c There were no other associated injuries.
Surgery: The patient underwent a single-stage posterior spinal stabilization procedure 7 days after admission. On exposure, there was L1-L2 rotatory spondyloptosis. The thecal sac was lacerated, there was nerve root herniation and the cord was completely transected. Pedicle screws were placed in T12, L1, L3, and L4 vertebral bodies on the left side and in T12, L1, and L4 bodies on the right side. The displaced L1 and L2 bodies could not be reduced after distraction. So, a partial corpectomy of L2 was done in order to partially reduce L1 vertebral body over L3. The thecal sac was managed similarly as above. The screws were connected using rods and bilateral posterolateral fusion was done using autograft bone chips. An interconnecting rod was placed to provide additional stability [Figure 3]d and [Figure 3]e.
Postoperative Course: The patient had an uneventful postoperative recovery. He was discharged on 5th postoperative day for home-based rehabilitation. A follow-up CT scan after 1 year showed evidence of bony fusion [Figure 4]. He had no postoperative improvement of neurological status.
Anatomical considerations of the pediatric spine
Traumatic spinal fractures are rare in the pediatric population but the incidence increases in adolescence. The adolescent spine achieves speedy skeletal maturity with rapid growth changes in anatomic, biomechanical, and radiographic properties. The majority of pediatric thoracolumbar spine fractures occur in the teenage group especially those aged between 14 and 16 years. In our study, five out of seven patients (71.43%) were teenagers, which is in accordance with the literature. The pediatric spine differs from that of an adult in various aspects. The juvenile spine has horizontal and partially ossified facets thus resulting in enhanced spinal mobility. The mature configuration is achieved by 8 years of age but the adult pattern of the obliquity of joints is seen only after 15 years of age. The fusion of endplate begins at around this time and is accomplished by the age of 21–25 years. Aufdermaur, in his anatomic studies showed that fractures of the juvenile spine pass through the growth zone of physis, thus, having supreme healing capacity unlike a similar fracture in adults.
The three main mechanisms of spinal injury in the pediatric group are flexion with or without compression, distraction, and shear with hyperflexion injuries being the most common., Shear injuries result in fracture-dislocations and subluxation of vertebral bodies with failure of all three columns described by Denis and is often associated with SCIs.
Special features of managing pediatric and adolescent spondyloptosis
Spondyloptosis which is the severest form of spine trauma was first described as grade V spondylolisthesis or subluxation of more than 100% of L5 vertebra over sacrum by Neugebauer in 1882. This term is now used for all spinal levels with more than 100% subluxation of adjacent vertebra.,,,, Such injuries are caused by the shear-type mechanism of injury caused by a high-velocity force. Pediatric thoracolumbar traumatic spondyloptosis has been scantily reported in the literature,, [Table 2]. Prior to the current series, only three such cases of pediatric spondyloptosis have been described in the literature.
The present series reports seven cases of pediatric spondyloptosis with complete neurological injury. The documented incidence of complete neurological injury in adult spondyloptosis series is 80%, while in the current series all the patients presented with a complete injury. The most common mode of injury has been described as high-speed road traffic accidents,, while the present study had a variety of causes of spine injury with only two patients (28.57%) each presenting with a history of road traffic accident and fall from height. All the seven injuries were the aftermath of the impact by vectors with tremendous force. Males are more commonly affected population with a reported incidence of 60% which is less than the current series which had six male subjects out of seven (85.7%).
Spinal trauma is many a time associated with other system injuries such as intra-abdominal and thoracic injuries, head injuries, and long bone fractures.,,, The impact of an injury-causing spondyloptosis is immense, resulting in multisystem collateral damage. Head injury is the most commonly associated injury, but none of our patients suffered any head injury. One patient sustained rib fractures with hemothorax requiring chest tube drainage. The thoracic spine has been documented as the most affected region in pediatric thoracolumbar fractures followed by the lumbar and thoracolumbar junction,, while thoracolumbar junction has been described as the most common location for spondyloptosis.
Most of the pediatric spinal injuries (except spondyloptosis) can be managed conservatively contrary to adults., With advancements in the spinal disorders therapeutics, the treatment guideline for pediatric patients is the same as that in adults. Most of the surgeons now consider surgical treatment in view of the risks associated with braces and prolonged immobilization., Surgery is usually indicated for neural elements decompression, grossly unstable injuries with progressive neurological deficit, nonreducible dislocations, and progressive deformities.,,,,,
Thoracolumbar instrumentation with pedicle screws has been well-described for pediatric traumatic spine fractures., The healing is evident with noticeable callus formation with no complications. Long segment fixations are usually shunned for preserving the growth potential of the pediatric spine.
Various approaches such as anterior, posterior,,, and combined anterior-posterior, have been reported for the management of spondyloptosis. Gressot et al. in their case report on congenital spondyloptosis recommended posterior only approach for circumferential decompression and fusion in children. All patients in the current series underwent a single-stage posterior fixation of the spine. The elementary aim of surgery is a reduction with spinal realignment and stabilization, to enable early mobilization and rehabilitation of the patient. After exposure, the pedicle screws were placed under C-arm/O-arm guidance.
Based on reducibility by distraction, spondyloptosis can be divided into reducible and irreducible cases. In spondyloptosis, the adjacent vertebral bodies are almost glued to each other and the distraction force required to reduce and align them is exorbitant. Any attempt to do so may needlessly risk injury to nearby vital structures and should be avoided.
Gitelman et al., in his review of 22 patients of thoracic fracture-dislocation, could not achieve complete reduction and alignment in 31.3% patients. In the current series, four cases of spondyloptosis were irreducible, hence, alignment of the vertebral column was achieved after the corpectomy of the dropped out vertebra. Out of these, the spinal column got shortened in two cases where cage could not be placed in spite of maximum possible but safe distraction whereas in two cases, the mesh cage was placed and the spinal height was restored.
The documented complication rate is 35–60%. The various complications reported are deep vein thrombosis (DVT), pneumonia, septicemia, CSF leak from the surgical wound and prolonged intubation.
Highlighting the need for postoperative rehabilitation
Although the incidence of spinal injury in the pediatric age group is low as compared to adults, it is associated with a higher mortality rate with a ratio of 2.5:1 (28% vs 11%). Mortality due to bedsore complications in one patient is suggestive of the inadequacy of home-based care and probably unavailability/unaffordability of proper rehabilitation facilities in developing countries.
There is a strong relationship between functional status and whether the injury is complete or not complete, as well as the level of the injury., As in spondyloptosis, injury is complete; it creates more problems in rehabilitation. SCI children have special needs because of their potential for physical, intellectual, psychological, and social growth. It not only causes damage to independence and physical function but also leads to many complications from the injury such as neurogenic bladder and bowel, urinary tract infections, pressure ulcers, orthostatic hypotension, fractures, deep vein thrombosis, spasticity, autonomic dysreflexia, pulmonary and cardiovascular problems, and depressive disorders. Moreover, the treatment and rehabilitation period is long, expensive, and exhausting in SCI as well as it requires patience and motivation of the patient and relatives.
The overriding goal for comprehensive medical rehabilitation is to provide services required by the child for maximal recovery and to compensate for lost or impaired function while permitting the fullest development of potential in all areas. Rehabilitation involves the child and his family, a hospital-based and rehabilitation center-based team, and a school. Every effort must be made to prevent medical and/or physical complications that could interfere with rehabilitation or lead to greater disability. Family counseling and education are of paramount importance. By fostering the achievement of new adaptive skills, motivation can be maintained with consequent psychological benefit. Various factors which are needed to be taken care of are therapy training in mobility, personal care, and daily living activities; prevention and control of deformities and bedsores; bowel and bladder regulation; control of painful spasms; control of vasomotor dysfunction; prevention, control, and treatment of renal complications; maintenance of good nutrition without obesity. Also, introduction to recreational activities, return to home and chosen school, promotion of educational pursuits with training for future work and independent living options, and adaptation of housing and vehicles are important for proper rehabilitation. An interdisciplinary approach is essential in rehabilitation, which includes a team led by a physiatrist and consists of the patients' family, physiotherapist, occupational therapist, dietician, psychologist, speech therapist, social worker, and other consultant specialists as necessary.
This is the first series to date on pediatric and adolescent traumatic thoracolumbar spondyloptosis. The aim of surgery should be stabilization of the spine without further collateral damage to other vital structures. Patient and their families should be counseled regarding the dismal prognosis and adequately sensitized to the need for rehabilitation, which remains the most crucial but neglected segment. The dearth of rehabilitation centers inflicts high mortality and morbidity rates in developing countries.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]