Trauma-related Spine Conditions

The spinal cord is a long, tube-like structure that carries messages between the brain and the rest of the body. It runs in a canal/spinal column consisting of vertebrae that are divided into four sections of bones from top to bottom — cervical, thoracic, lumbar and sacral. 

Trauma-related spine conditions result in fractures, sprains and dislocations of bones in the spinal column.

While children rarely have spinal injuries and even less frequently have spinal cord injuries, certain activities do put children at risk for such injuries.

Some causes of trauma-related spine conditions include:

• Birth injuries
• Car accidents
• Falls
• Sports injuries — such as tackle football, wrestling and snowboarding
• Diving accidents
• Disease, including osteoporosis 
• Trampoline accidents
• Violence

Of the trauma-related spinal cord injuries in children, 60-75 percent occur in the neck or cervical area. Twenty percent of injuries occur in the chest region or upper back (thoracic region). The remaining 5-20 percent affect the spinal cord in the lower back (lumbar and sacral regions). Boys more frequently sustain spinal cord injuries than girls.

The location of the spinal trauma makes a significant difference in how the injury is treated and the long-term outcomes for children with these spinal injuries.

Because of the way the spinal cord functions and is organized, damage to the cord often produces specific patterns or symptoms based on where the damage occurred.

C1 atlas and C2 axis spine injuries occur at the first and second vertebrae, respectively. Lower cervical spine injuries (C3-C7) and other thoracic, lumbar and sacral injuries occur lower on the spine.

In general, the higher up the spinal column the injury occurs, the more problems a child will experience. For example, injury to the upper cervical spine results in loss of upper and lower extremity function, whereas with an injury to the thoracic spine, the upper extremity function is spared.

The following symptoms may occur in varying degrees in a child with spinal trauma:

• Muscle weakness
• Loss of sensation/inability to feel pain or temperature
• Breathing problems
• Inability to move arms or legs
• Neck or back pain
• Kyphosis — a forward curvature of the back bones (vertebrae) in the upper back, giving a child an abnormally rounded or "humpback" appearance
• Loss of bladder and bowel control
• Paralysis

Physicians often recognize a spinal cord injury based on its characteristic pattern of symptoms. A comprehensive physical examination and detailed family history help provide clues to the diagnosis.

For children older than age 9, a modified version of the Glasgow Coma Scale may be used to assess your child's consciousness level and determine whether the injury is mild, moderate or severe.

Cervical spine clearance is routine in alert patients with suspected spinal injuries at Children's Hospital of Philadelphia (CHOP). Children who do not have distracting injuries or neurological deficits can be cleared from cervical spine immobilization without imaging tests if they can complete a functional range-of-motion examination.

If your child has moderate to severe tenderness in the cervical spine area, clinicians recommend that you child continues to use an immobilization collar until after radiologic and imaging tests can be conducted.

At CHOP, we use the following imaging tests to help determine your child’s diagnosis and the potential cause of trauma-related spine injury.

• X-rays, which produce images of bones and internal organs on film and are a primary diagnostic tool for diagnosing spinal trauma. 
• Magnetic resonance imaging (MRI), which use a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
• Computed tomography (CT) scan, which use a combination of X-rays and computer technology to produce cross-sectional images ("slices") of the body including bones, muscles and organs.

Spine surgeons at CHOP have extensively studied the use of MRI in assessing cervical spine injuries, particularly for patients who are non-verbal or comatose. While MRI testing mirrored findings in X-rays in many cases, in others the MRI uncovered additional injuries and played a significant role in the child's ultimate treatment plan. Read the study abstract.

Treatment of your child's trauma-related spine injury will depend on your child's individual needs. Issues that will affect treatment include:

• Your child's age, overall health and medical history
• The type of injury
• The location of the injury
• The extent of the injury
• Your child's tolerance for specific medications, procedures or therapies

The most common injury occurs to the anterior (front) spine as vertebral body compression fractures. Commonly called a "crushing injury," this type of trauma-related spine condition often results from an automobile accident.

Depending on the number of vertebrae involved, your child might have varying levels of brain, deformity, or neurologic injury.

If two or three adjacent vertebrae are affected, your child may experience compression and wedge fractures which can be very painful and can cause kyphosis or other health problems. When a single vertebra is affected by the trauma, there are fewer related issues.

Injuries to the posterior (back) elements of the spine can affect the spinal cord and/or segmental nerve roots, causing pain.

Nonsurgical and surgical interventions

Single, mild compression fractures need observation only. Multiple adjacent compression fractures may require a halo vest or brace to immobilize your child's spine, avoid progressive kyphosis or control associated pain.

At CHOP, orthopaedic physicians work closely with the National Orthotics and Prosthetics Company (NOPCO) to fit patients with custom-designed halos or braces. Because NOPCO has a local office at CHOP, these braces can be measured, created and fitted in a short period of time. In the past 6 years, more than 100 patients at CHOP have received halos as part of their treatment.

For some children — such as those with fractures of the posterior elements of the spine may be associated with a risk for serious nerve problems. In these cases, nonsurgical interventions such as a brace or halo isn't sufficient treatment. Instead, they require surgery.

In most cases, spinal fusion surgery is recommended to stabilize the child's spine, relieve pressure on the nerves, and treat other injuries caused by the trauma. A careful work-up is required to evaluate the risk for neurologic injury.

If your child has not reached skeletal maturity, growing rods or vertical expandable prosthetic titanium ribs (VEPTR) may be recommended surgical treatments. Both growing rods and VEPTR can stabilize the spine, allow future lung and chest wall growth, and be expanded at regular intervals as your child grows.

Your child's physician will recommend the best surgical or nonsurgical treatment option for your child based on your child's specific condition and needs. 

Support services 

While surgery can dramatically improve trauma-related spine conditions, it can also be a stressful experience for both you and your child. At CHOP, we take every precaution to ensure safety in surgery. 

Our multidisciplinary approach helps us to address all aspects of your child’s care and treatment. We offer a wealth of ongoing support and services to your child and family including how to prepare your child for surgery and what to expect during surgery. 

Your child will have access to clinical services such as physical and occupational therapy, as well as psychosocial support from social workers and psychologists who can help your child deal with the emotional effects of the injury.

We also recognize your child's pediatrician or referring physician as an important part of your child's care team and provide regular updates about your child's progress. 

Recovery from any trauma-related spine injury requires regular medical evaluations and diagnostic testing to monitor progress. The clinical team at CHOP will continue to follow-up on your child's care at our Main Campus or one of our CHOP Care Network locations.

Our pediatric clinical professionals will follow your child until young adulthood, between the ages of 18 and 21, and help transition to adult orthopaedic care, if needed.

Long-term outcomes for children with trauma-related spine conditions vary from patient to patient. Much depends on the location and severity of the spinal injury and the child's other health issues. Children with trauma-related spine injuries tend to recover more fully than similarly injured adults.

Well-managed compression fractures generally have a good outcome, and even the less common posterior fractures often have a good prognosis.