Pediatric fractures of the cervical spine

Pediatric cervical spine trauma presents certain unique challenges. From a diagnostic standpoint, accepted protocols for cervical spine clearance are not as well validated in pediatric trauma patients as in the adult population.

Variation in vertebral size and degrees of ossification further hinder efforts to establish objective measurements for diagnosing pediatric cervical spine injuries.

Spinal cord injury without radiographic abnormality (SCIWORA) is most commonly seen in the pediatric population due to the elasticity of their spinal column. It accounts for up to 2/3 of cervical spine injuries in children less than 8 years of age. SCIWORA may be due to an unrecognized injury of the posterior ligaments, transverse atlantal ligament, or fracture through cartilaginous endplates, which, although radiographically invisible, can all be identified on MRI. However, in more than 1/3 of cases, the elasticity of the spine allows for spinal cord injury even in the absence of any recognizable musculoskeletal injury on MRI.

If a specific ligamentous injury is identified on MRI, it should be stabilized according to similar principles used in adults.

Stabilization may require atypical instrumentation due to size limitations.

In the absence of any musculoskeletal injury on MRI, treatment is limited to hemodynamic and respiratory support, followed by rehabilitation of spinal cord injury.

As with any pediatric fracture, the potential for child abuse should be evaluated.

Absence of T2 high-intensity cord signal change on MRI is associated with high likelihood of full neurological recovery.

Spinal cord signal change without significant hemorrhage has been correlated with good prognosis, with likelihood of either full recovery or relatively mild residual neurological deficits.

The presence of spinal cord hemorrhage or disruption is associated with severe permanent neurological deficits.