If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Spinal injuries in children contribute to the highest mortality and morbidity among all pediatric injuries. Fortunately, these injuries are a rare clinical entity but pose a difficulty in diagnosis due to challenges in neurological evaluation of a child and varied radiological presentation. Anatomical and biomechanical aspects of developing musculoskeletal system, relative plasticity of the pediatric spine make children vulnerable to spine injuries. Though motor vehicle collisions are common, children also suffer non-accidental trauma, falls and sports injuries. More chances of cervical spine involvement, higher susceptibility of spinal cord to tensile forces and associated multisystem injuries result in devastating consequences in children compared to adults. Injuries like SCIWORA, vertebral apophyseal injuries, birth-related spinal cord injuries are more specific injuries in pediatric age group. A vigilant clinical, neurological and radiological evaluation is mandatory in all children with suspected spinal injuries. Normal radiological features like ossification centers, pseudosubluxation and physiological vertebral wedging should be carefully noted as they could be misinterpreted as injuries. While CT scans help in better understanding of the fracture pattern, Magnetic Resonance Imaging in children is beneficial especially in detecting SCIWORA and other soft tissue injuries. Management principles of these pediatric spinal injuries are similar to adults. Literature evidences support conservative management in injuries like SCIWORA, unless there is an ongoing spinal cord compression. As in adults, the role of high dose methylprednisolone is still controversial in pediatric spinal cord injuries. Stable spinal injuries can be managed conservatively using orthosis or halo. Instrumentation by both anterior and posterior techniques has been described, but it is challenging due to smaller anatomy and poor implant purchase. In addition to pedicle screw instrumentation, wiring techniques are very beneficial especially in younger children.
of all spinal injuries which is much less than adult spinal trauma. Though uncommon, PSI are different from adult spinal injuries in terms of incidence, mechanism of injury, clinical presentation, diagnosis and management. Typically PSI are more commonly noted in the cervical spine due to the large head-torso ratio. The higher magnitude of injuries necessary to cause PSI also makes the children susceptible to multi-organ injuries. Accurate clinical neurological examination is difficult in children and a low threshold to apply radiological investigations for diagnosis is warranted. We have presented a narrative review to describe certain normal anatomical variations, physiological susceptibility of the pediatric spine, injury presentation, and loopholes in radiological evaluation with specificities of managing pediatric spinal trauma.
2. Methods
A detailed search on PubMed database was made using the following keywords and Boolean operators - “pediatric OR “children” AND “spine fracture” OR “vertebral injury”. Totally 54 English language full text articles were retrieved and all articles specific to the management of spine fractures in pediatric age (age <15 years of age) were included (n = 37). Further, a detailed narrative review of previously published literature on pediatric spinal injury was performed to include the epidemiology, mechanism and principles of intervention of pediatric spinal trauma. Being a narrative review, further additional screening based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines laid out for systematic review was not performed to select the articles.
2.1 Anatomical characteristics of pediatric spine
The levels of injury and injury pattern in the pediatric age group are quite different from the adult population. This is because of the difference in anatomical and biomechanical characteristics of the spine. Cervical spine is the most common site of pediatric spinal injury accounting for more than 80% cases,
In pediatric age group, this is attributable to the large size of the cranium and hyper mobility of the cervical spine (Fig. 1). The larger head to body ratio in children leads to a higher incidence of occipito-cervical and upper cervical injuries. In a study by Leonard et al., among 167 children (age <8 years) with cervical spinal injuries, 63% had Atlanto-axial injuries and these injuries were about 2.5 times more common in children than adults.
Fig. 1Lateral radiograph of cranium with cervical spine and thorax of a 3 year old child (a) and a 17 year old adult (b) showing the difference in their head-trunk ratio between the pediatric and adult population.
Secondly, nucleus pulposus in the discs are more hydrophilic in pediatric age group and act as shock absorbers to distribute the forces effectively under compressive loads (Fig. 2). Antonio et al.,
The human lumbar intervertebral disc: evidence for changes in the biosynthesis and denaturation of the extracellular matrix with growth, maturation, ageing, and degeneration.
in their cadaveric study of twenty five lumbar spine specimens observed that the hydration in human discs usually peaks around the age of 2–5 years. The cartilaginous nature of the spinal column also improves the elasticity of the spine and hence the traumatic force is dissipated to the surrounding soft tissue structures like ligaments, discs and muscles, making bony injury less common in younger children. Due to the flexibility of the spinal column, children are also prone for a specific pattern of injury termed “SCIWORA- Spinal cord injury WithOut Radiological Abnormality”. Ahmann et al. suggested that the injury to the spinal cord in SCIWORA is caused by ischemia or contusion due to temporary occlusion of the vertebral arteries resulting from the stretching effect.
Biomechanically, the fulcrum of flexion moment is at a higher cervical level especially till the age of 8 years, after which it shifts below to C5–C7 levels as in adult population.
Horizontal orientation of the cervical facets, poorly developed uncovertebral joint (Fig. 3), lax ligaments, poor protective reflexes and relatively weaker neck muscles make them vulnerable to subluxation-dislocation type injuries.
However, the relative smaller size of the spinal cord to canal dimensions allow a greater degree of canal compromise tolerated by pediatric patients without neurological injury than adult population.
Fig. 2(a)Mid-sagittal T2W Magnetic Resonance Image of Lumbar spine of a 4 years old child showing thick, well hydrated discs; (b)Lateral lumbo-sacral spine radiograph of the child showing well-maintained disc height.
Fig. 3(a-b)Parasagittal CT cervical spine showing shallow facets (white arrow)in a child; (b)Coronal CT cervical spine of the same patient showing under-developed uncus (∗); (c-d)Note the deeper, well articulated facet joints and uncovertebral joint in 38 years old male patient.
in their review article suggested that, the presence of multiple ossification centers and synchondroses in pediatric spine (Fig. 4) should be observed carefully as they could be misdiagnosed as fractures. Physiological wedging of the anterior vertebral bodies can mimic compression fractures. A difference of height less than 3 mm between anterior and posterior vertebral cortices is considered physiological wedging.
Fig. 4(a)Axial CT scan image of Atlas showing unfused apophysis of the anterior arch (white arrows); (b)Midsagittal CT scan image of a 5 years old child showing apophysis between dens and body of C2 (∗); (c)Thoracic Axial CT scan image of the same child showing unfused ossification centers between the neural arches and vertebral body (thick white arrow).
Similarly, excessive mobility due to ligamentous laxity can result in physiological subluxation of cervical vertebra, commonly seen at C2 over C3. It is termed as “pseudosubluxation” and typically less than 2 mm (Fig. 5). Shaw et al.,
evaluated the prevalence of pseudosubluxation in 138 polytraumatized patients with age less than 16 years. They noted an incidence of 21.7% at the C2–C3 level and suggested the importance of identifying this physiological variant in radiographs. Swischuk et al. proposed that a line drawn on the lateral cervical radiograph from the anterior aspect of posterior arch of C3 to C1 is normally within 1 mm to the posterior arch of C2.
If the distance is > 2 mm, then further evaluation is mandatory as pseudosubluxation is less likely. The Spinolaminar line is also intact in patients with pseudosubluxation. Several skeletal dysplasias and metabolic abnormalities like mucopolysaccharidosis, achondroplasias alter the shape of the vertebral body which could be misinterpreted as fracture (Fig. 6). Alteration in the width of the pre-vertebral soft tissue shadow in the neck is considered as an indirect evidence of cervical spine injury (Fig. 7).
However, in children, these soft tissue shadows could show physiological variability depending of the degree of inspiration and a prominent cervical lymphatics and adenoid (Fig. 7).
Fig. 5Lateral cervical radiograph of a 6 year old child showing mild subluxation of C2 over C3 (white arrow); Note the ‘Spinolaminar line’ (line connecting the junction of lamina and spinous process in the cervical spine) is intact (∗) indicating C2–C3 “pseudosubluxation”.
Fig. 6Lateral radiograph of dorsal with lumbosacral spine of a 3 year old child with mucopolysaccharidosis showing anterior beaking of vertebral bodies (white arrow). Also, note the flattening of the vertebral body-platyspondyly (∗).
Fig. 7(a)Lateral cervical spine radiograph of a 25 year old male showing C5 Burst fracture with increased Pre-vertebral soft tissue shadow (white line) following a trauma due to fall from height; (b) Lateral C- spine radiograph of a 2 year old child showing increase in the pre-vertebral shadow without any injury mechanism. The widening of soft tissue shadow is due to cry of the baby.
in a study 103 pediatric cervical spine injuries, observed that sports related injuries were exclusively seen in adolescent patients with a mean age of 13.8 years. Boys are injured twice more than girls above the age of 8 years. Ugalde et al.,
performed a retrospective analysis of blunt pediatric cervical injury in a level I trauma centre and observed a male predominant (every 2 in 3 patients were males) pattern. Because of the anatomical characteristics of the spine, cervical spine injuries in children can occur even with low energy mechanisms like simple falls,
while thoracic and lumbar spine injuries most often result from high impact forces (Fig. 8). Hence, Chest and abdominal injuries are more commonly associated with thoracolumbar trauma. Ceran et al. attributed higher incidence of chest injuries to the pliable ribs in children. In the review article by Roche et al., it was noted that the small bowel injuries are particularly associated with “Seatbelt” fractures of thoracolumbar spine.
observed that in addition to improper positioning of the children beneath the seat belt, poorly developed abdominal musculature and underdeveloped bony structures like iliac crest contribute to abdominal injuries. A study by Leonard et al.
in their study of 662 pediatric spine injury patients observed that head injury was the most commonly associated injury (24.9%) followed by chest injury in 11.4%. Cervical spine was involved in 80.7% of these head injury patients. It is also reported that three-fourths of children with non-accidental spinal trauma also have concomitant head injury.
Hence a thorough clinical examination is mandatory to avoid missed injuries. The incidence of contiguous vertebral fractures is also higher in children (Fig. 9) than adult population as traumatic force is spread to multiple adjacent levels due to the relative flexibility of the spine.
reported a rare case of pediatric transverse sacral fracture presenting with cauda equina syndrome. However, as in case of adults, the neurological injury associated with sacral fractures is very less.
Fig. 8(a)Antero-posterior radiograph of a 6 years old child showing reduced disc space at T2-T3 level following a motor vehicle collision; (b)Mid-sagittal CT scan image showing dislocation at T2-T3 level with fracture of the spinous process; (c)T2W mid-sagittal MRI scan showing significant spinal cord compression at T2-T3 level.
Fig. 9(a–b) Mid-sagittal Computed Tomography and T2W Magnetic Resonance Imaging of a 12 years old child who sustained a road traffic accident. Note contiguous vertebral fractures at T3, T4, T5 and T6 levels.
These are Salter-Harris Type I injuries of the inferior endplate with apophysis and are also called limbus injuries. Ossification of ring apophysis occurs between 4 and 6 years of age and fusion of the ossified apophysis with vertebral body happens by 17–20 years. This attachment between vertebral apophysis and vertebral body is relatively weaker till the osseous union occurs.
These limbus injuries represent bony fractures of the vertebral rim at the site of attachment of Sharpey fibres of the intervertebral disc and are more common in the lumbar spine (Fig. 10). Commonly reported mechanism of injury is by lifting heavy weights, twisting injuries or falls.
They can be associated with disc extrusion in the spinal canal presenting with symptoms that mimic acute disc herniation. Reported incidence of these injuries is about 19–42%.
Yen et al., in their study on apophyseal ring fractures noted that three-out of four adolescent patients were obese or overweight and suggested a strong association with these injuries.
SCIWORA (Spinal Cord Injury WithOut Radiological Abnormality)
Fig. 10(a–b) Lateral spine radiograph and midsagittal CT scan image of an adolescent male showing avulsion of the inferior endplate of L4 vertebra. Note the irregularities at the posterior aspect of L4 inferior end plate; (c)Midsagittal T2W MRI showing significant spinal canal narrowing and thecal sac compression; (d)Axial MRI image showing endplate defect (white arrow) at L4.
and is a clinical entity, where there is a spinal cord injury without notable findings on radiological examination including plain X-rays and CT scans (Fig. 11). These injuries were described in the pre-MRI era and overall incidence varies between 5 and 65%.
in a study of 297 pediatric patients with SCIWORA demonstrated that overall, the most common cause was sports injuries (41%), followed by motor vehicle collisions (26%), falls (14%), and assault (4%). They are common in the cervical spine, but have also been reported in the thoracic spine. Ren et al.
reported 12 cases of pediatric thoracic SCIWORA following a traumatic event during dance practice. 91.7% patients in the study were less than 8 years old. Because of the elasticity of pediatric spine, even a higher traumatic force can result in excessive mobility and stretching of the spinal column. At the same time, a stretch in the spinal cord can result in significant injury resulting in neurological deficits. Cadaveric studies have shown that a neonatal spinal column could be stretched to about 2 inches without injury, but cervical cord ruptures if stretched beyond 1/4th inch.
performed a literature review on the incidence of SCIWORA after the advent of MRI and it was reported to be 3–32%. They also suggested the term “SCIWONA – Spinal Cord Injury WithOut Neuroimaging Abnormality”, in patients who were categorized as SCIWORA but had a normal MRI findings.
3)
Spinal trauma in child abuse
Fig. 11(a–b) Antero-posterior and lateral Whole Spine radiographs of a 3 years old child, who presented with history of fall while playing showing no significant abnormality; (c) Computed Tomography of the upper dorsal spine showing no obvious bony injury; (d) T2W MRI showing hyperintense signal changes in the spinal cord at T1-T2 level; (e) Hypointense signal is noted at the same level in T1W imaging indicating a contused spinal cord.
A high index of suspicion is mandatory when the child presents with multiple skeletal fractures in different stages of healing. Anterior compression of vertebral body causing wedging, endplate notching are common injuries in child abuse.
Most often the symptoms are subtle and neurological injury is not seen often. In the original description of spinal fractures in battered baby syndrome by Swischuk, six out of seven children, had only spine injury without injury to the spinal cord while one child had injuries at two spinal levels due to violent shaking mechanism resulting in spinal cord injury.
Mechanism and the level of injury are different in breech and cephalic presentation. Longitudinal traction with a hyper-extended neck is the mechanism of injury in breech presentations and the patients are more prone for a lower cervical injury. Mackinnon et al.
in their study of 22 neonates with SCI, observed that upper cervical cord injury was seen in all patients with cephalic presentation. Similarly, Menticoglouet al.,
reported forceps delivery in all 15 cephalic presentation patients with SCI. Neonates with birth-related SCI injury present with symptoms of apnea, flaccid quadriplegia. Injuries can result in focal spinal cord hemorrhages to spinal root avulsions and brachial plexus injuries.
2.4 Radiological evaluation of pediatric spine trauma
The standard radiographic views of an adult trauma (Antero-Posterior, lateral) is also routinely recommended in pediatric trauma. Open mouth view in patients with suspected cervical spine injuries is difficult to obtain in young children especially due to shorter neck, the need to open their mouth on command and a partially ossified odontoid process limits the detection of displaced fractures in children especially less than 5 years of age. Silva et al.,
in their analysis of 234 pediatric cervical spine radiographs observed that the lateral view has been shown to have a negative predictive value of about 97% for cervical spine trauma in children (Fig. 12). Knowledge about the Ossification centers of the vertebra is essential for appropriate interpretation of spinal imaging. Neural arches of Atlas (C1) are ossified at birth and by the age of 3 years they fuse posteriorly. Fusion with the anterior arch happens by the age of 7 years.
Axis (C2) is formed from six ossification centers (one for the vertebral body, one each for the neural arches, two for the odontoid process and one for the odontoid tip). Odontoid fuses with the C2 body around the age of 5–7 years. Ossification centre for the odontoid tip occurs by 7 years and they fuse with the dens by 12 years.
Subaxial cervical spine (C3–C7) have similar pattern of embryological development. They have an ossification centre for the vertebral body, one each for the lateral mass and neural arches which fuse in the midline around 2–4 years. Neurocentral synchondrosis of C3–C6 occurs between 3 and 6 years.
Fig. 12(a) Open mouth radiograph in a toddler could not give a clear visualization of the cervical spine; (b) Lateral view of cervical spine shows better details of the vertebrae.
Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.
reported the applicability of NEXUS criteria in the clearance of cervical spine injuries in 3065 pediatric patients. They noted that those patients, who met all the 5 low risk criteria, did not have any cervical spine injury in radiographic imaging. However, patients less than 2 years of age where not included in their study. Leonard et al.
in 2010 analyzed the Pediatric Emergency Care Applied Research Network (PECARN) data and reported 98% sensitivity with eight clinical predictors of cervical spine injury (neck pain, torticollis, focal neurological deficit, altered mental status, predisposing medical condition, substantial torso injury, diving, and high-risk motor vehicle crash) in pediatric patients of all age categories.
CT scan has the advantage of delineating the bony anatomy better and has a sensitivity of 93% in detecting cervical spine injuries
(Fig. 13). But it poses the risk of ionizing radiation to young children and hence not recommended for cervical spine clearance in pediatric population. Indications for CT as the primary modality of evaluation include children who have experienced polytrauma, obtunded, or at high risk owing to their mechanism of injury.
analyzed the sensitivity of x-rays and CT scans in cervical spine injury in a pediatric cohort of 1296 patients. They concluded that 32% of significant injuries were missed in x-rays, while CT was highly sensitive. MRI is the most sensitive modality to detect spinal cord and ligamentous injuries, especially as SCIWORA is common in this age group. Spinal cord hemorrhage can be detected in gradient-echo MRI sequences. Tectorial membrane, alar ligaments and transverse ligaments are better visualized in proton-density-weighted or T2 weighted MRI sequences (Fig. 14). In a study by Flynn et al.,
it was shown that about 24% of children who had cervical spine clearance had occult injuries detected in MRI. Limitations of obtaining MRI in young children include longer imaging time, the need for sedation which may not be available in all the centers.
Fig. 13(a) Lateral Cervical radiograph of a 14 years old boy showing C5 fracture; (b-d)Sagittal, Coronal and Axial CT scan showing involvement of the posterior vertebral wall indicating burst type fracture pattern; (e)His Axial CT scan image showing C5 lamina fracture (white arrow); (f)Coronal CT scan image showing fracture also involving the left lateral mass of C5.
Management of spine injury patients starts at the scene of trauma. The primary aim of pre-hospital care is to stabilize and maintain neutral alignment of the spine. In children <8 years, as the head size relative to the torso is large, a routine spinal board would place the neck in flexion. Hence a spinal board with an occipital recess or elevation of the torso would place the cervical spine in neutral position by aligning the external auditory meatus in line with the shoulders.
they observed that an average elevation of torso by about 25 mm was essential to place the spine in neutral alignment. Application of rigid cervical collars for immobilization can be difficult in children due to significant pain. According to NICE guidelines, it is advisable to allow the child assume a comfortable position on the spine board and give in line manual stabilization. Blocks or rolled towels can be applied on either side of the head and taped to support the neck.
Adequate airway maintenance is more important in children than adults, as they can develop cardiac arrest resulting from respiratory failure due to hypoxia.
The metabolic demand of children is also higher than adults, but due to a smaller lung capacity, they could tolerate apnea for only 2–3 min, after which hypoxia causes acidosis resulting in coagulopathy.
Intravenous fluid administration has to be cautiously performed to avoid volume overload in traumatized children. Crystalloids are the initial fluid of choice and Pediatric Advanced Life Support guidelines recommend a first fluid bolus up to 60 ml/kg for initial resuscitation.
It is crucial to maintain adequate spinal cord perfusion to prevent secondary cascade of injury to the neural structures.
Once the child is stabilized as per the ATLS protocol, a thorough neurological evaluation must be performed. It is important to clinically examine the entire spine as fractures can extend to multiple levels. Though there are several tools for assessing the severity of neurological injury, American Spinal Injury Association (ASIA) scoring system and the ASIA Impairment Scale (AIS) are widely accepted.
The severity and levels of injury are identified using this scaling system but their usefulness is limited in very young children, patients with altered level of consciousness and multiple other injuries. Mulcaheyet al.,
validated the usage of the International Standards for Neurological Classification of Spinal Cord Injury in children and they found that the motor and sensory system examination was not reliable in children less than 4 years of age.
2.6 Definitive management of PSI
Pediatric patients with mild to moderate traumatic spinal cord injury (SCI) pose a better neurological recovery compared to adults. However, severe SCI have poor long term prognosis, especially following cervical spine injury.
Shin et al. in a retrospective analysis of trauma database over a period of 12 years observed that death rate was inversely related to age of the patient.
Various pharmacological agents like high dose methylprednisolone, Nalaxone, Nimodipine, Tirilazad Mesylate, Ganglioside has been used to reduce secondary cascade mechanisms of spinal cord injury. Methylprednisolone has been tested in various multicentric clinical trials, especially in adults, however in children; its role is less certain. Arora et al.,
in a study of 15 incomplete spinal cord injury patients observed that, 13 children recovered completely in 24 h of administration of high dose methylprednisolone. Wang et al.,
in his study in PSI patients, concluded that the usage of high dose methylprednisolone is controversial and could cause more deleterious effects in children.
Majority of pediatric cervical spinal injuries can be treated using a hard collar immobilization or a halo. Indications for surgery include unstable injury, irreducible fracture/dislocation, progressive neurological injury due to spinal cord compression.
Surgery in pediatric patients is challenging as the bony morphology is smaller and hence posterior fusion with wiring techniques have been performed in the early days. Mortazavi et al.
has reported occipito-cervical fixation with threaded contoured rods and wire has been performed in patients as young as 11 months of age. In young pediatric patients keel screws with C1 lateral mass and C2 pars screws have been reported.
Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 67 pediatric patients.
reported successful placement of the screws in children as young as 18 months old. In the sub-axial cervical spine, anterior low-profile plating with screws has been performed in patients as young as 3 years old.
reported placement of lateral mass and pedicle screws in 4 year old children. Posteriorly, bone grafting with wiring and immobilization is still a very useful option in very young children (Fig. 15). Surgical intervention in SCIWORA is less advocated in literature. In patients with normal or only intra-neural MRI findings (like cord edema/contusion without compression), surgery is not recommended. Immobilization with collar, avoidance of activities that may increase the risk of exacerbation or recurrent injury is the mainstay of treatment.
In the presence of MRI evidence of ligamentous injury, ongoing spinal cord compression, progressive neurological deficit, surgical decompression with stabilization is warranted.
Fig. 15(a-b)Lateral cervical spine radiograph and mid-sagittal CT scan image of a 2 year old child showing displaced Odontoid fracture following a non-accidental trauma; (c)Coronal CT scan image showing fracture line passing below the level of C1–C2 facet joint; (d-e)Anteroposterior and Lateral Post-operative radiographs showing reduction of the fracture and fixation using Sub-laminar wires.
In the thoracolumbar spine, compression fractures are common due to the physiological anterior wedging of vertebral bodies. These fractures can be treated conservatively using a TLSO brace for about 6–8 weeks and they show good healing potential. Burst fractures following axial loading can result in neurological deficits. Stable burst fractures with intact neurology can be treated with hyperextension casting or TLSO brace for 8–12 weeks. Unstable burst fractures and flexion-distraction injuries require surgical intervention (Fig. 16). Both posterior and anterior techniques of stabilization have been reported.
Circumferential fusion with anterior strut grafting and short-segment multipoint posterior fixation for burst fractures in skeletally immature patients: a preliminary report.
Minimally invasive pedicle screw instrumentation has shown satisfactory results in adults. However, the outcomes of this technique have not been reported in pediatric spinal trauma.
Fig. 16(a)Lateral radiograph of dorsolumbar spine of a 11 year old boy showing L1 Burst fracture; (b)CT scan and T2W MRI showing flexion distraction type injury with retropulsion of fractured vertebral body into the spinal canal; (d-e)Postoperative radiographs following D11-L3 pedicle screw instrumentation and L1 decompression.
recently reported the use of sublaminar braided polyester cable with posterolateral fusion in a 2 year old child with thoracolumbar dislocation injury. They suggested that the chances of spinal cord injury are less with use of polyester cable compared to stainless steel wires. Limbus fractures can be treated using anti-inflammatory medication and TLSO brace for about 8 weeks. In case of significant neurological compromise, wide decompression of the spinal cord with instrumented stabilization is required. Takata et al.
suggested the need for fusion in patients with a large avulsed bony fragment, and those undergoing laminectomy and discectomy that would result in instability. Patients with these healed limbus fractures have the risk of chronic back pain in adult life.
Pediatric patients with thoracolumbar trauma have to be followed till skeletal maturity because of the risk of increasing spinal deformity. Progressive deformity and sitting imbalance are indications for surgical correction.
Pediatric spinal injuries though a rare entity, can result in devastating physical, social and psychological consequences. As they are different from adult patterns of injury, a prompt recognition and appropriate management is critical in the management of these injuries.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
Authors' contributions declarations
All authors contributed equally towards the preparation of this manuscript.
Declaration of competing interest
All authors declare that there are no conflicts of interests.
The human lumbar intervertebral disc: evidence for changes in the biosynthesis and denaturation of the extracellular matrix with growth, maturation, ageing, and degeneration.
Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.
Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 67 pediatric patients.
Circumferential fusion with anterior strut grafting and short-segment multipoint posterior fixation for burst fractures in skeletally immature patients: a preliminary report.
00030-9&id=gr1.jpg){kind=link}
00030-9&id=gr2.jpg){kind=link}
00030-9&id=gr3.jpg){kind=link}
00030-9&id=gr4.jpg){kind=link}
00030-9&id=gr5.jpg){kind=link}
00030-9&id=gr6.jpg){kind=link}
00030-9&id=gr7.jpg){kind=link}
00030-9&id=gr8.jpg){kind=link}
00030-9&id=gr9.jpg){kind=link}
00030-9&id=gr10.jpg){kind=link}
00030-9&id=gr11.jpg){kind=link}
00030-9&id=gr12.jpg){kind=link}
00030-9&id=gr13.jpg){kind=link}
00030-9&id=gr14.jpg){kind=link}
00030-9&id=gr15.jpg){kind=link}
00030-9&id=gr16.jpg){kind=link}