Cervical Spine Trauma in Children: A Review

Todd Mccall, MD; Dan Fassett, MD; Douglas Brockmeyer, MD

Disclosures

Neurosurg Focus. 2006;20(2):E5 

In This Article

Treatment Strategies

Most pediatric cervical spine injuries can be managed nonsurgically with external immobilization.[4,11,26,40,90] Even in cases of ligamentous instability, children can often heal with external immobilization and avoid surgery.[67,86] Nevertheless, with the development of improved surgical options for internal fixation and the frequent complications associated with halo immobilization devices, more surgeons are opting for early surgical treatment when indicated.[30,31,61]

External Immobilization

The pediatric cervical spine is more difficult to immobilize externally than adult spines because of its inherent elasticity and flexibility, and because in some cases adequate orthotic devices may not be commercially available. External immobilization of the cervical spine has two potential functions. The first and most common goal is to prevent movement and preserve cervical alignment. Second, some cases require traction to restore normal anatomical alignment.

Neonates can provide a unique challenge for immobilization because of their small body habitus. To address this difficulty, Pang and Hanley[69] described a thermoplastic, molded orthotic device for the occiput, neck, and thorax. In more recent years, commercial cervical collars have started to be produced specifically for infants and children. A custom-fitted Minerva orthosis can be a reasonable alternative to a halo device in preschool-aged children, providing adequate immobilization while not interfering with activities of daily living.[36] In a study of adults, a Minerva body jacket was superior to a halo immobilization device for preventing flexion and extension of each subaxial intervertebral level.[10]

As alluded to previously, halo devices have fallen out of favor because of the frequent complications related to their use. Children are more likely than adults to experience these complications,[9] probably because of the thinner scalps and calvariae in the former group of patients. In a series of 37 patients between 3 and 16 years of age treated with a halo, 68% of the children experienced a complication related to the device.[27] The most frequent complication is pin site infection, with others including pin loosening, dural or calvarial penetration, and supraorbital nerve injury.[9,27,65] Halo devices can also inhibit activity and physiotherapy. Because of the thinner calvaria, special consideration needs to be given before placing a child in a halo device. First, more pins need to be used, with children younger than 2 years of age requiring eight to 10 pins.[65] As children get older, fewer pins are required, and by the age of 4 to 5 years, only four pins are necessary. Second, the amount of torque applied to pins for fixation decreases with the patient's age. Table 1 summarizes the torque recommendations for pediatric patients.

Traction is indicated to restore cervical alignment when segmental subluxation is present. Factors that make placing a child in traction challenging include a less massive body to supply countertraction and more elastic ligaments and less musculature, which together increase the chance of overdistraction. The physician must be diligent and obtain a lateral radiograph with every change in the amount of weight used with the device, because small additions in weight can have very large effects. One pound per cervical level should be adequate in children younger than 4 years, and 2 lbs per level is sufficient if the child is 4 years of age or older. Weight must be removed if new symptoms develop or if overdistraction is noted. For very young patients, Gardner-Wells tongs should be avoided. Instead, bilateral paired parietal bur holes and steel wire or a halo ring can be used.[43]

Surgical Management

Approximately 25 to 30% of cervical spine injuries require surgery.[30,34] The goals of surgery are to improve stability of the vertebral column and to protect the spinal cord while limiting operative risks, repeated procedures, and morbidity. Indications for surgery include nonreducible deformities, unstable injuries requiring stabilization, progressive deformity, and decompression of neural structures.26,34, 54,75,82,83,90 The chief decision for the surgeon is usually whether to perform an anterior or a posterior approach. In general, the approach should be dictated by the column that is disrupted, so that additional damage to intact structures providing stability is minimized. This point is emphasized by findings in a series of 16 patients (including some children) with posterior ligamentous disruption who were all treated with anterior fusion and in whom postoperative deformity developed.[89] Anterior and posterior fusions both prevent flexion, extension, and translation. A combined anterior and posterior approach is sometimes required in cases of severe disability resulting from injury to both the anterior and posterior columns.

In children, special consideration needs to be given to other issues, including the growth potential of the pediatric spine and an assessment of whether the size of the spine is adequate to accept hardware. Surgical options include posterior onlay autograft with halo placement, posterior bone and wire fusion with halo immobilization, posterior lateral mass plate instrumentation, and anterior cervical discectomy and fusion with plate and screw fixation.

By 10 years of age, the cervical spine has almost reached adult height, and thus surgery is less likely to lead to kyphosis or lordosis.[7,85] Most of the growth potential is in the epiphysis of the VBs, with minimal potential in the posterior cervical spine. With an anterior approach, the disc and cartilaginous endplates can be removed, leading to an essentially equal ability of the anterior and posterior columns to increase in height and avoid kyphosis, even in patients younger than 10 years of age.

For children up to 4 years old, a posterior bone and cable fusion followed by external immobilization is preferred because of technical limitations of plate and screw fixation techniques in the very young. By age 5 years, anterior discectomy and fusion can be considered with an expectation of good fusion and alignment.[16,83] Specialized pediatric instrumentation such as the Synthes Short Stature Anterior Cervical Spine Locking Plate is well adapted for children because of its smaller profile, decreased radius of curvature, and reduced screw lengths. The surgeon needs to be cognizant of the small VB remaining once the cartilaginous end-plate has been removed. In patients between 5 and 10 years of age, posterior plate and screw fusion is usually avoided because of the bulk of the instrumentation, but after this age it is a reasonable alternative.

A final consideration for the surgeon is the use of autogenous bone graft or an allograft. The use of allograft should only be considered when the bone is under compression, such as with an anterior discectomy and fusion. Failure of allograft to develop solid bone union in children when used in a posterior construct has been well documented.[54,88] Both rib and iliac crest are suitable for autogenous bone graft substrate.[57,63]

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