Pediatric Spine Trauma

Definition

• Traumatic injuries to the spinal column in patients with an immature skeleton

• Distinct from adults due to anatomical and biomechanical differences

• Higher risk of ligamentous injury without fracture

Epidemiology

• Accounts for a small percentage of pediatric trauma, but high morbidity

• Cervical spine injuries more common in younger children (<8 years)

• Thoracolumbar injuries increase with age (adolescent pattern approaches adults)

Unique Pediatric Features

• Large head-to-body ratio → increased cervical stress

• Ligamentous laxity

• Incomplete ossification

• More elastic vertebrae

• Horizontally oriented facet joints

Result: more soft tissue injury, less obvious fracture

Mechanism of Injury

• Motor vehicle accidents (most common)

• Falls

• Sports injuries

• Non-accidental trauma (consider in infants)

Classification

General Patterns

• Compression fractures

• Burst fractures

• Flexion-distraction injuries (Chance)

• Fracture-dislocations

Age-Based Injury Patterns

• <8 years

  • Upper cervical injuries (C1–C3)

  • High risk of ligamentous injury

• >8 years

  • Subaxial cervical and thoracolumbar injuries

  • Adult-like fracture patterns

SCIWORA (Spinal Cord Injury Without Radiographic Abnormality)

Definition

• Neurological deficit with normal X-ray and CT

Mechanism

• Stretch injury to spinal cord due to elastic spine

Diagnosis

• MRI required

Clinical Importance

• More common in children than adults

• Delayed neurological deterioration may occur

Clinical Presentation

• Neck or back pain

• Limited motion

• Neurological deficit:

  • Weakness

  • Sensory loss

  • Bowel/bladder dysfunction

• May be subtle in younger children

Imaging

X-ray

• First-line

• Alignment, vertebral height

CT

• Detailed bony anatomy

• Use cautiously (radiation concern)

MRI (critical)

• Ligamentous injury

• SCIWORA

• Spinal cord evaluation

Diagnosis

• Clinical suspicion + imaging

• Always assess:

  • Neurological status

  • Ligamentous stability

  • Mechanism of injury

Treatment

Nonoperative

Indications:

• Stable injury

• No neurological deficit

Management:

• Immobilisation (collar / brace)

• Observation

• Gradual mobilisation

Operative

Indications:

• Unstable injuries

• Progressive neurological deficit

• Failure of conservative management

Surgical Considerations

• Growth plates must be preserved

• Instrumentation adapted to smaller anatomy

• Avoid long fusions when possible

Complications

• Neurological deterioration

• Growth disturbance

• Spinal deformity (kyphosis/scoliosis)

• Missed injuries

Prognosis

• Variable

• Better outcomes in incomplete injuries

• SCIWORA → unpredictable recovery

Pits & Pearls

• Children ≠ small adults

• Normal X-ray does NOT exclude injury

• MRI is essential in:

  • Neurological deficit

  • Suspected ligament injury

• Always consider SCIWORA

• Maintain high suspicion in polytrauma

Pitfalls

• Missing ligamentous injuries

• Over-reliance on CT alone

• Failure to recognise SCIWORA

• Inadequate immobilisation

• Ignoring non-accidental trauma

Cervical Spine Clearance in Children (NEXUS vs PECARN)

Clearing the cervical spine in pediatric trauma is challenging due to communication limitations, subtle findings, and higher ligamentous injury rates.

1. NEXUS Criteria (Adapted for Pediatrics)

A child can be clinically cleared without imaging if ALL are present:

• No midline cervical tenderness

• No focal neurological deficit

• Normal level of alertness

• No intoxication

• No painful distracting injury

If all criteria are met → C-spine clearance without imaging

Limitations in Children

• Less reliable in:

  • <8 years old

  • Non-verbal children

• May miss ligamentous injuries (e.g., SCIWORA)

2. PECARN Cervical Spine Rule (More Pediatric-Specific)

Developed specifically for children to identify clinically important cervical spine injuries.

High-Risk Factors (→ CT recommended)

• Altered mental status

• Focal neurological deficit

• Severe mechanism of injury

• Signs of substantial torso injury

Intermediate Risk (→ X-ray ± MRI)

• Neck pain

• Limited range of motion

• Torticollis

Low Risk (→ No imaging)

• No pain

• Normal exam

• Low-risk mechanism

Imaging Strategy Summary

• Low risk (PECARN / NEXUS negative) → ❌ No imaging

• Intermediate risk → ✅ X-ray ± MRI

• High risk → 🔴 CT (consider MRI for soft tissue/cord)

Clinical Pearls

• PECARN is more sensitive for pediatric-specific injuries

• NEXUS is useful but less reliable in younger children

• MRI is essential when:

  • Neurological symptoms present

  • Suspected SCIWORA

• Avoid unnecessary CT → radiation risk in children