TRAUMATIC THORACOLUMBAR VERTEBRAL FRACTURES IN CHILDREN

Transcription

1 TRAUMATIC THORACOLUMBAR VERTEBRAL FRACTURES IN CHILDREN Review, and Considerations in Trauma Evaluation Kenneth Gundle, R1 Seattle Children s Hospital Pediatric General Surgery Rotation December 23rd, 2010

2 Epidemiology Spine fractures overall are rare. Only ~2-3% of pediatric injuries (Green NE, Swiontkowski MF, eds. Skeletal Trauma in Children. Mosby Elsevier: Philadelphia, Chapter 11.) 20% of these fractures have associated neurologic injury Mechanisms: Newborns: NAT Children and Teenagers: secondary to MVC, sports or recreational activities (i.e., horse riding) Akbarnia BA. Pediatric spine fractures. Orthop Clin North Am 1999;30: Note ~ Kids with Crohn s at higher risk (Semeao EJ, Stallings VA, Peck SN, Piccoli DA. Vertebral compression fractures in pediatric patients with Crohn's disease. Gastroenterology 1997;112: )

3 Anatomy: General Considerations Development - subaxial spine with 3 primary ossification centers: two neural arches and the body. Compared to adults, greater intervertebral disk water content - superior shock absorber to load (water content 88% at birth, 80% at 12, 70% at age 70) Greater capacity for growth and remodeling. Most adult features achieved by age 8, and all by 12. Mild Anterior Wedging A:P Ratio > 0.9 is within normal range (Gaca AM, Barnhart HX, Bisset GS, 3rd. Evaluation of wedging of lower thoracic and upper lumbar vertebral bodies in the pediatric population. AJR Am J Roentgenol 2010;194: )

4 Anatomy: The 3 Vertebral Columns Used to think about anatomy, to classify injury, and inform treatment. Anterior column: ALL, ant. 1/2 of vertebral body, ant. anulus fibrosus Middle column: post. 1/2 of vertebral body & anulus fibrosis, PLL Posterior column: ligamentum lavum, neural arch, facet capsules, interspinous ligaments

5 The 3 Vertebral Columns: Pathologic Correlation Compression fx - failure of anterior column, generally with intact middle column If multilevel compression or involves 2 columns, possible to have neuro compromise/instability. Burst fracture - failure under compression of both anterior and middle columns Potential for instability, as well as spinal canal narrowing. Key is presence/absence of posterior column compromise. Flexion-Distraction (Seatbelt Injuries) Fracture through vertebral bodies, exiting through arch/ pedicle Fracture-dislocation - all three columns fail, with distraction. Always unstable, requiring operation. Usually with neurologic deficit.

6 Evaluation in Trauma ABCs... History, PE (neuro/strength/sensation (LT&pain)/rectal) Radiographic Assessment: Goal is to determine alignment, displacement, and extent of canal compromise C-spine series generally obtained, and C-collar placed. In absence of distracting injury or decreased LOC, and not high mechanism, then image Thoracic or Lumbar spine only if tenderness to palpation. CT scans are of benefit if radiographs concerning for burst fracture or multicolumn injury, to show degree of canal compromise. Should discuss if other CTs required, to coordinate obtaining them with recons of T/L spine - or bony pelvis. MRI if looking for soft tissue component, and frequently used if neuro deficit. If considerating nonop treatment, some advocate standing/upright films to make sure that weight-bearing does not worsen deformity. Mehta JS, Reed MR, McVie JL, Sanderson PL. Weight-bearing radiographs in thoracolumbar fractures: do they influence management? Spine (Phila Pa 1976) 2004;29:564-7.

7 Example 17yoF in restrained high speed MVC. + ttp at Lumbar Spine + abdominal ttp, with skin findings. What is the next study of choice? Akbarnia BA. Pediatric spine fractures. Orthop Clin North Am 1999;30:

8 Example CT is superior for bony anatomy, and can be coordinated with abdominal imaging. Akbarnia BA. Pediatric spine fractures. Orthop Clin North Am 1999;30:

9 A few points in evaluation If seat-belt sign, think not only of duodenal hematoma, but also spine fracture (flexion-distraction type). [study where 4 of 9 were associated with severe abdominal injury] (Johnson D, Falci S: The diagnosis and treatment of pediatric lumbar spine injuries caused by rear seat lap belts. Neurosurgery 26: , 1990.) If calcaneal fracture, think of spine fracture. Children have relatively high rate of SCIWORA. Trigylidas T et al., Spinal cord injuries without radiographic abnormality at two pediatric trauma centers in Ontario. Pediatr Neurosurg (4):

10 Compression fractures - mainstay is pain control, bed rest, braces (e.g. TLSO), and PT. If <50% of body height loss, generally nonop but with longterm f/u for possible deformity. Operate for unstable fractures, progressive deformity, or worsening neurologic deficit. Treatment Burst fractures - operative treatment can correct and maintain alignment, prevent kyphosis, but in absence of neuro compromise surgical treatment is controversial (?? - A) Progressive neurologic deficit ---> emergency decompression. Unstable fractures generally urgent ORIF. Canal and Beaty: Campbell s Operative Orthopaedics,11th edition

11 Classification System Efforts to quantify or standardize treatment have been attempted.

12 Non-Op Outcomes for Compression Fractures most anterior compression fractures in children heal without sequelae Sagittal plane wedging/height loss usually reconstitutes. This restoration of height in children is partly the result of hypervascularity of the reparative response and stimulation of the physis. This probably accounts for the infrequent occurrence of kyphosis in children with multiple compression fractures. Some argue that operative treatment in a young child is indicated only in the presence of significant neurological involvement, persistent frank dislocation, or a block on the myelogram

13 Citations Canale ST, Beaty JE, eds. Campbell s Operative Orthopaedics. Mosby Elsevier: Philadelphia, Chapter 33. Green NE, Swiontkowski MF, eds. Skeletal Trauma in Children. Mosby Elsevier: Philadelphia, Chapter 11. Akbarnia BA. Pediatric spine fractures. Orthop Clin North Am 1999;30: Gaca AM, Barnhart HX, Bisset GS, 3rd. Evaluation of wedging of lower thoracic and upper lumbar vertebral bodies in the pediatric population. AJR Am J Roentgenol 2010;194: Semeao EJ, Stallings VA, Peck SN, Piccoli DA. Vertebral compression fractures in pediatric patients with Crohn's disease. Gastroenterology 1997;112: Denis F. The three-column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8:817, Mehta JS, Reed MR, McVie JL, Sanderson PL. Weight-bearing radiographs in thoracolumbar fractures: do they influence management? Spine (Phila Pa 1976) 2004;29: Johnson D, Falci S: The diagnosis and treatment of pediatric lumbar spine injuries caused by rear seat lap belts. Neurosurgery 26: , 1990 Trigylidas T et al., Spinal cord injuries without radiographic abnormality at two pediatric trauma centers in Ontario. Pediatr Neurosurg (4): Vaccaro AR, Zeiller SC, Hulbert RJ, et al. The thoracolumbar injury severity score: a proposed treatment algorithm. J Spinal Disord Tech 18:209, 2005.