Pediatric Spine Trauma in Arab Countries · It constitute: *1-5% of child trauma. *1-10% of spine...
Transcript of Pediatric Spine Trauma in Arab Countries · It constitute: *1-5% of child trauma. *1-10% of spine...
PEDIATRIC SPINE TRAUMA IN
ARAB COUNTRIES
DR ESSA AL ABDULGANI
CONSULTANT PEDIATRIC NEUROSURGEON
HEAD DEPARTMENT OF NEUROSUGERY
DAMMAM MEDICAL COMPLEX -KSA
Introduction
How common ?
Traumatic spine injuries(TSI) in children are relatively uncommon.
( rare)
It constitute: *1-5% of child trauma.
*1-10% of spine injury cases.
The mortality rate is higher in pediatric age group. Mostly related to organ injuries.
Which part of the spine?
Pediatric vertebral injuries occur 60-80% of the time in the cervical region VS (in adults cervical spine constitute 30-40% ).
Males are more frequently affected.
Literature review
No single study or review collecting all pediatric patients from different Arab countries
with spine injuries in one paper.
Only few scattered case reports where available.
No clear statistics available.
In Saudi Arabia there is 2 reviews , and few case reports.
-multicenter study.
Correspondence: Dr. Amro Al-Habib
- Department of Surgery ,King Saud University, Riyadh
- Retrospective chart review in a major trauma centers from May 2001 to May 2009.
- RESULTS:
- A total of 8941 trauma patients were identified during the study period, and 3796
of these patients were at or below 18 years of age.
- Of these younger patients, 120 had sustained a spine injury (3.2% of all pediatric
trauma cases).
Spine and spinal cord injury
Overall, the spine was most commonly affected at the cervical level (55.8%).
More than 1 spinal region was affected in 23.3%.
Most of the younger patients (<12 years) sustained cervical injuries (88%).
Older patient ----- thoracic .
SCI, alone or in combination with other injuries, was found in 23 patients (19.2%).
Neurological deficits at discharge were present in 6 of the SCI patients (26%), and the other SCI patients achieved full recoveries (74%).
M :F ratio
mechanism of spine
injury
MVC was the commonest
mechanism of spine injury
(60.8%).
pedestrian injuries
(20.8%).
fall-related injuries
(15%).
Mechanism of injury by age
The mechanisms of injury varied
significantly across the age
groups:
Patients younger than 12
years old experienced
pedestrian (40.6%) and fall-
related (34.4%) injuries.
Older patients (12-18 years),
injuries were mostly caused by
MVC (72.7%).
SCI (INTERNATIONAL VS KSA)
MOH in KSA Recorded one of the highest rate of spinal cord injuries in the world…. Mostly resulting from MVC.
Annual incidence rate of 62.37 and 38/million, in two different studies.
Compared with other countries :
North America at 40/ million
western Europe 16/……..
Australia 15/……..
Asia – central 25/ …….
Asia – south 21/ …….
Africa –central 29/ …….
Africa – east 21/ …….
Middle east, Jordan, Qatar, and turkey at 15/ million.
Fractures of the Thoracolumbar
Spine in Pediatric Patients
uncommon in pediatric patients.
most pediatric thoracolumbar injuries can be managed non surgically.
While the cervical segment is the most commonly injured region of the spine among
pediatric age groups, the thoracic and lumbar segments are involved in 25% to 53%
of all pediatric spine injuries.
Injuries to the thoracic spine becomes more frequent with advancing age.
Single-level injuries to the thoracolumbar spine are less common than multilevel
injuries.
Thoracolumbar junction is the most common site for single-level fracture.
T5 through T8 region is the most common area for multilevel fractures,
Overall, vertebral compression fractures are the most common types of fractures
found among pediatric spine injuries.
The plasticity and high vascularity of the vertebral cancellous bone of the pediatric
spine, along with its high proportion of cartilaginous components, allows it to provide
considerable shock absorption before compressing or bursting.
pediatric spine is more flexible than the adult spine as the result of a combination of
factors:
Ligamentous and facet capsule laxity
increased natural kyphosis from mild vertebral body wedging.
more elastic intervertebral disks due to a higher disk water content and less collagen
crosslinking.
greater mobility between vertebral segments as the result of more horizontally
oriented facets that allow greater flexion and pseudosubluxation
These elastic properties allow the pediatric vertebral column to lengthen by as much as 2 inches before dislocation occurs, as compared with the spinal cord, whose length can increase by only 0.25 inches before it ruptures.
explain why pediatric patients can sustain significant spinal cord injuries in the absence of any osseous injury to the spine (SCIWORA)
Thoracolumbar spine injuries
most common physical finding:
- Tenderness
- Bruising
other signs included:
- skin injuries
- Crepitus
- Stepoff or gaps between spinous processes
Thoracolumbar spine injuries
Neurologic deficits can be found in up to 19%.
complete spinal cord injuries (SCIs) are generally more common than incomplete
injuries.
The “lap belt” sign:
presence of skin bruising or abrasions
matching the pattern of an automobile
seatbelt.
associated with intra-abdominal injury
in 50% to 84%.
spinal fracture in 15% to 50%.
SCI in 11% to 50%.
Paediatric Classification
Type I: physeal injury of the superior growth plate associated with posterior lesion above the pedicle (soft tissue injury or superior facet fracture).
Type II: osseous type. Fracture through the vertebral body, pedicle, lamina and spinous process.
Type III: physeal injury of the inferior growth plate associated with posterior lesion below the pedicle (soft tissue injury or inferior facet fracture).
Type I
Physeal injury of the superior growth plate associated with posterior lesion
above the pedicle (soft tissue injury or superior facet fracture).
Type II
Osseous type. Fracture through the vertebral body, pedicle, lamina and spinousprocess.
Type III
Physeal injury of the inferior growth plate associated with posterior lesion below the pedicle (soft tissue injury or inferior facet fracture).
Chance Fractures
Unique to thoracolumbar spine (T10 – L2)
Variant of flexion-distraction injury
Due to lap belt injury without shoulder belt restraint
Fulcrum of flexion lies anterior to vertebral column allowing no compression of vertebral body
Flexion results in either ligamentous tear or combination of ligament, bone and disc injuries
Chance Fractures
15-42% chance intra-abdominal organ injury: pancreas, duodenum and prox small bowel
79% hollow viscus injury in New Zealand case series
25-83% neurologic deficit/vertebral injury
1/3 patients have Type II fracture
2/3 Type I or III fracture
96% patients bone and soft tissue injury, 4% soft tissue injury alone
Almost all patients have extensive soft tissue oedema and posterior osteo-ligamentous complex disruption
Management
ABC’s
Prevent secondary injury
High index of suspicion in patients restrained by lap seat belts
Regular reassessment for abdo injuries
Unstable fracture: requires immobilisation/ stabilisation
Management
Conservative: reduction of dislocation + application of TLSO 2-3
months
Surgical: failure to stabilize conservatively.
Cervical spine injury in children
Cervical spine injury (CSI) in
children is rare but can result in
mortality and significant morbidity.
Approximately 72% of spinal
injuries in children <8 years old
occur in the cervical spine.
Falls are the commonest cause of CSI in the younger population.
followed by pedestrian and MVC (passenger seat accidents) in the slightly older
group.
Sports related accidents are seen most commonly among adolescents.
Biomechanics – anatomical factors
The paediatric cervical spine is intrinsically susceptible to spinal cord injury.
The anatomical factors that account for this includes:
The relatively large child’s head
Weak neck muscles
lax spinal ligaments
pliable discs
In young children the fulcrum for
movement is located in the upper
cervical spine.
leading to a relatively high incidence
of injury in the upper cervical spine in
this age group.
In children over eight years the fulcrum
migrates caudally to C5/6.
conclusion
TSI in pediatric age group is rare( 1-5% of all pediatric trauma).
Pediatric Patients have different pathophysiology, and their management is different
from adults.
Most of the thoracolumbar spine injury can be managed conservatively.
The available data concerning TSI and SCI in pediatric age group is inadequate in
the developing countries, and a registry is lacking. This stimulate us to work hard
toward creating & maintaining a national registry.