Overview
Spinal injuries are uncommon in children but carry a high risk of missed diagnosis and long-term deformity. Injury patterns depend on age. Before about 8 years of age, a large head-to-body ratio, ligamentous laxity, horizontally oriented facets and weak neck musculature place the fulcrum of motion at C2–C3. Injuries therefore cluster in the upper cervical spine and are often ligamentous. After about 10 years of age, injury patterns become adult-like. Thoracolumbar injuries occur mainly in adolescents. Lap-belt Chance fractures occur in children restrained without an appropriate booster seat, and non-accidental trauma must be considered in infants.
Clinical Presentation
History and examination are limited in young children. Neck pain, torticollis, refusal to move the neck, focal deficits, transient paresthesias and a high-risk mechanism should raise suspicion. Transient neurological symptoms after sports require MRI before return to play. Spinal cord injury without radiographic abnormality (SCIWORA) is characteristic of children younger than 8 years [5]. Neurological symptoms may be delayed by hours to days, and MRI often reveals ligamentous, disc or cord abnormalities. Children with SCIWORA are usually immobilized and restricted from sports for about 12 weeks to prevent recurrent injury.
In infants and toddlers, unexplained spinal fractures, multiple injuries of different ages or an inconsistent history should prompt evaluation for non-accidental trauma, including a skeletal survey and ophthalmological examination.
Imaging
Radiation exposure must be balanced against diagnostic yield. Validated pediatric decision rules, such as the PECARN cervical spine rule, help select children for imaging [1]. Radiographs remain the first-line study in low- and intermediate-risk children; flexion-extension views have a limited role in the acute setting. CT is reserved for high-risk mechanisms, inadequate radiographs or suspected fractures, and MRI for neurological symptoms, obtunded children and suspected ligamentous injury [2]. On CT, the condyle–C1 interval is a sensitive measurement for craniocervical dissociation in children.
Knowledge of normal variants prevents overtreatment:
• Pseudosubluxation of C2 on C3 (and C3 on C4), assessed with the Swischuk line
• Atlantodens interval up to 4–5 mm
• Increased prevertebral soft tissue in crying children
• Unfused synchondroses and secondary ossification centers mimicking fractures
• Loss of cervical lordosis in neutral position
Treatment
Young children should be immobilized with torso elevation or an occipital recess to avoid forced cervical flexion on a standard backboard (Figure 1) [3]. Most pediatric injuries are treated nonoperatively with cervical orthoses, Minerva braces or halo immobilization. In young children, halo application requires more pins, often 8–12, inserted at lower torque. Thoracolumbar compression fractures are treated with mobilization, and the growing spine has considerable remodeling potential. Osseous Chance fractures are treated with a hyperextension cast. Odontoid fractures through the dentocentral synchondrosis in children younger than about 7 years usually heal with closed reduction and immobilization.
Surgery is indicated for ligamentous instability, which heals poorly, such as occipitocervical dissociation, and for irreducible deformity or neural compression. Implant choice is guided by size on preoperative CT, and fusion should be as short as possible to preserve growth. Atlantoaxial rotatory subluxation recognized early usually responds to analgesia, a collar or halter traction, whereas chronic cases may require halo reduction or fusion.
Figure 1. Positioning and age-related biomechanics of the pediatric cervical spine. (A) On a standard backboard, the relatively large occiput of a young child forces the neck into flexion. (B) Torso elevation or an occipital recess restores neutral alignment. (C) The fulcrum of cervical motion lies at C2–C3 in children younger than about 8 years and at C5–C6 in adults.
Surgical Indications
• Occipitocervical dissociation and other unstable ligamentous injuries
• Irreducible or progressive deformity
• Neurological deficit with ongoing compression
• Unstable thoracolumbar injuries, such as ligamentous flexion-distraction
Prognosis
Most pediatric spinal fractures heal without long-term sequelae. Children with incomplete cord injuries generally recover better than adults. However, almost all children injured before the adolescent growth spurt develop progressive paralytic spinal deformity and need surveillance until skeletal maturity [4]. Long-term care should also address bladder, bowel and psychosocial needs during the transition to adulthood.
Differential Diagnosis
• Normal developmental variants (listed above)
• Atlantoaxial rotatory subluxation, including Grisel syndrome
• Congenital anomalies (os odontoideum, Klippel-Feil syndrome)
• Transient neurapraxia of the cord
References
1. Leonard JC, Harding M, Cook LJ, et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024;8(7):482-90.
2. Expert Panel on Pediatric Imaging; Kadom N, Palasis S, Pruthi S, et al. ACR Appropriateness Criteria® Suspected Spine Trauma-Child. J Am Coll Radiol. 2019;16(5S):S286-99.
3. Herzenberg JE, Hensinger RN, Dedrick DK, Phillips WA. Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. J Bone Joint Surg Am. 1989;71(1):15-22.
4. Mayfield JK, Erkkila JC, Winter RB. Spine deformity subsequent to acquired childhood spinal cord injury. J Bone Joint Surg Am. 1981;63(9):1401-11.
5. Pang D, Wilberger JE Jr. Spinal cord injury without radiographic abnormalities in children. J Neurosurg. 1982;57(1):114-29.