What is Pediatric Spine Trauma (Neck and Back Injury in Children)?
A spinal cord injury can severely disrupt a person’s life, often leading to serious and lasting disabilities. Young patients with multiple injuries are more likely to have spinal injuries. Despite being less common in children than adults, spinal injuries in children can have severe consequences if not managed correctly. Interestingly, a child’s spine is quite flexible and resilient, which can both help and hinder treatment. As children’s spines grow and mature, they can become more prone to certain types of injuries, such as spinal cord injuries without any visible abnormalities on an X-ray.
Also, children might not show the usual signs and symptoms of a spinal cord injury, making it crucial for doctors to be particularly vigilant when checking them. If a person has a head injury, there’s up to a 5% chance they might also have a spinal injury. That’s why it’s essential to act fast in such cases. Injuries can occur throughout the spine, but they’re most common in the neck area (55%), followed by the upper back (15%), and the point where the upper and lower back connect (15%) and the lower back and pelvic areas (15%).
Imaging tests like X-rays or MRI scans are vital for diagnosing spine trauma in children. However, care has to be taken to reduce the child’s exposure to radiation. MRI scans are particularly useful as they can show any damage to the soft tissues surrounding the spine.
Treating spine injuries in children needs a careful and meticulous approach to maintain the alignment of the spine, limit any neurological deficits, and ensure optimal growth and development. Implementing immobilization techniques early on, such as neck collars and other precautions, can prevent further injury. Surgery might be necessary in severe cases where there’s significant instability or neurological involvement. Rehabilitation plays an important role in helping the child recover to the best of their ability and improve their quality of life.
The spine is divided into five distinctive areas: the neck (cervical), upper back (thoracic), lower back (lumbar), and the pelvic (sacral) and tailbone (coccygeal) regions. Each part has its unique traits that affect the types of injuries that can occur and how they are treated.
The neck has seven vertebrae and supports the weight of the head while allowing a broad range of motion. The first two vertebrae are unique in that they aid head rotation. In children, the neck area can be more vulnerable to injury due to the disproportion between the size of the head and strength of the neck muscles.
The upper back has 12 vertebrae and forms the middle part of the backbone. The upper back vertebrae join with the ribs, providing support and protection for the organs in that area. Fractures and dislocations of the upper back bones are less common in children but can happen in high-energy trauma.
The lower back, made up of five vertebrae, carries most of the body’s weight. Lower back vertebrae are significantly larger and more robust than those in the neck and upper back, giving stability and support for to daily activities like walking and lifting. While injuries to the lower back are unusual in children, they might happen during certain sports or car accidents.
The pelvic region, consisting of the five joined vertebrae, connects with the pelvis to distribute weight from the spine to the legs. The tailbone, composed of four basic vertebrae, provides attachment points for pelvic muscles and ligaments. Injuries to the pelvic and tailbone areas are not common in children but can happen in incidents of direct trauma to the lower back or falls.
The spinal cord, located within the backbone, extends from the bottom of the brain to the lower back and is sectioned into areas matching the spinal sections. Encapsulated within protective layers, the spinal cord contains crucial nervous paths that control motor functions and facilitate sensation across the body. These paths can be damaged during a spinal cord injury, disrupting the sensation of touch, pain, temperature, vibration and position unless affected simultaneously.
Children’s spine structure, undergoing continuous growth and development, presents unique risks. Their vertebral bodies have areas of cartilage growth that make them prone to certain types of fractures. Also, the ligament flexibility and expansive movability of children’s spines potentially expose them to specific injuries that require thorough evaluation for diagnosis.
What Causes Pediatric Spine Trauma (Neck and Back Injury in Children)?
Spinal cord injuries can have numerous causes, but they’re mostly due to blunt force impacts. Car accidents are a top culprit behind these injuries, followed by falls, especially in kids under 8. As kids grow up, spinal cord injuries from sports become more common. Gun injuries and other types of violence can also cause spinal cord injuries in teenagers and young adults. Sadly, newborn babies can suffer spinal cord injuries from birth traumas.
Risk Factors and Frequency for Pediatric Spine Trauma (Neck and Back Injury in Children)
Every year, about 40 out of every million people experience a spinal cord injury. It’s estimated that adolescent boys are at the highest risk for these injuries. However, keep in mind that these numbers might actually be higher. This is because injuries that aren’t the result of an accident are often not reported. In fact, one study has found that a specific type of spinal injury, known as an atlantoaxial injury, is 2.5 times more common in children than adults.
Signs and Symptoms of Pediatric Spine Trauma (Neck and Back Injury in Children)
Trauma patients might arrive at the hospital unconscious, without a pulse, or having trouble breathing. These are dangerous signs and need immediate care. The first steps would typically involve checking the airway, breathing, circulation, disability, and exposure. After the patient’s condition is stabilized, further investigations can be done.
In young children with spinal trauma, symptoms could look quite different depending on the seriousness and location of the damage. Symptoms could include pain, trouble moving, difficulty standing or walking, weakness, numbness, tingling, urinary problems, and headaches. Heavy breathing problems can also be a sign of severe spinal trauma. It’s important to remember that patients with spinal trauma might also have injuries in other parts of the body. Emergency conditions like open fractures, pressure on the nerves and blood vessels, and heavy bleeding should be immediately checked for and treated if present.
Physical examination is key in young trauma patients, specifically if the doctor suspects multiple injuries. Certain signs like fast heart rate combined with low blood pressure could mean severe bleeding. Abnormal breathing rate and oxygen levels could point to lung injury. Other things the doctor would look for include open wounds, signs of head injury, tenderness in the neck, and pain or bruising in the chest and stomach area. The doctor would also look for signs of injury to the bones, muscles, blood vessels, and nerves.
Neurological assessment is a crucial part of the examination. The doctor would check things like mental status, cranial nerve function, motor strength, sensation, and reflexes to see if there is a spinal cord injury or any neurological deficits.
- They would check mental status using the Glasgow Coma Scale score.
- Try to determine the level of the spinal cord injury or level of sensory loss.
- Test for sensation of position, movement, or vibration to check the function of a part of the spinal cord.
- Check certain reflexes. If these are intact, it means the spinal cord injury is not complete.
- Check the entire spine if a neck injury is detected. Tenderness could be a sign of injury.
Sustaining a spinal cord injury can be classified into ‘complete’ or ‘incomplete’. A complete spinal cord injury means a complete lack of sensory and motor function below the level of injury, and an incomplete spinal cord injury means a patient has some level of sensory or motor function or both below the injury level. However, this distinction might not be possible immediately, as patients in spinal shock might lose all reflexes below the area of injury. It’s important to note that young patients with injuries in their neck and upper chest spinal cord are at risk for respiratory failure and neurogenic shock.
Testing for Pediatric Spine Trauma (Neck and Back Injury in Children)
In cases of a suspected injury to a child’s spine, several techniques are used to make a diagnosis. These techniques include X-rays, CT scans, and MRIs.
Plain X-rays
The X-rays used to check for spine injuries often focus on the neck area. They cover all seven neck vertebrae and the top of the chest. These pictures can spot about 90% of all bone injuries. Sometimes, if the physical exam isn’t enough, doctors use decision rules to help figure out if an X-ray is needed.
One useful rule, called the NEXUS standard, includes five guidelines that can suggest if a neck X-ray is necessary. These guidelines say that if a patient has no neck pain, normal alertness, no signs of being drunk, no focal neurological issue, and no significant secondary injury, like a severe fracture, then an x-ray might not be needed.
For kids, additional symptoms that might suggest the need for an x-ray include abnormal mental state, specific neurological issues, neck pain, twisted neck, severe upper body injury, or existing conditions that make spine injuries more likely. Also, if the initial x-rays aren’t clear, the spine should be kept still until a doctor can confirm that there are no injuries.
CT scan
CT scans are very good at detecting injuries to the neck, especially at the joint between the head and the neck and the place where the neck and chest meet. This is where plain x-rays can often miss something. CT scans are usually used for unconscious patients who have suffered severe trauma. In some cases, even if the CT scan shows no injury, an MRI may still be needed because in children, an absence of abnormality on the scan does not guarantee that there’s no injury. In fact, there’s a kind of injury known as SCIWORA seen in children below eight, which results from parts of the upper neck shifting due to force rather than breaking.
MRI
MRIs are known to be very effective at spotting spinal cord and ligament injuries, especially in children who are vulnerable to SCIWORA – an injury that occurs without any visible damage on an x-ray or CT scan. Different types of MRI sequences are best for spotting different injuries. For example, gradient-echo MRI sequences are great at spotting spinal cord bleeding, while proton-density-weighted or T2-weighted MRI sequences provide better images of structures like certain ligaments. Studies have shown that about 24% of children with a clear cervical spine show hidden injuries detectable by MRI. However, the need for longer imaging times and sedation may limit the use of MRIs in younger children.
Treatment Options for Pediatric Spine Trauma (Neck and Back Injury in Children)
Managing injuries to a child’s spine involves stabilizing the child, checking for damage to the spinal cord, and taking steps to prevent further harm and help the child recover. It’s crucial to quickly identify any injuries, intervene right away, and provide thorough, team-based care for the best possible outcome. Here’s a rundown of how this process works:
Pre-Arrival at the Hospital
Once a first responder arrives at the scene of an accident, they need to identify children who may have injured their spine, make sure their neck is immobilized to prevent further harm, and get them to the best facility for their injuries. Clear communication and coordination between first responders and the hospital team help ensure a smooth handover when the child arrives at the hospital.
At the Emergency Department
Spine injuries in children can be severe and life-threatening. Once they arrive at the hospital, healthcare professionals must quickly assess the child, focusing on:
* Airway: Ensuring the child can breathe and the neck is protected. If the child is not responsive, has a significant face/head injury, or has trouble breathing, they might need a tube placed into their trachea (intubation) to help them breathe.
* Breathing: Providing extra oxygen or helping them breathe if they are struggling.
* Circulation: Quickly establishing intravenous (IV) access. Some children with spine injuries can go into neurogenic shock, a type of shock resulting from nerve damage. Professionals also need to find and stop any bleeding.
* Disability: Carrying out a fast but in-depth examination of nerve function.
* Exposure: Taking off clothing to check for hidden injuries, and addressing any issues related to extreme cold or heat.
Where the injury is located can impact what kind of treatment is needed. For example, injuries above the C3 vertebra in the neck can lead to immediate inability to breathe, requiring swift intubation. During this procedure, the child’s neck must be held steady.
Vital signs like heart rate, blood pressure, breathing rate, and temperature are closely monitored. A tool called capnography might be used for tracking the patient’s breathing in the Emergency Department.
If a child with a spine injury has low blood pressure, it might result from neurogenic shock. But if they also have low blood pressure, doctors will consider if they are losing blood. Low blood pressure that’s not related to the injury (below 80 mm Hg systolic) is unusual and definitely warrants a thorough search for causes.
Children showing severe distress or with multiple injuries will need to be treated following the hospital’s trauma protocols, and help from several specialty doctors like orthopedic surgeons and neurologists may be required.
Corticosteroid Use
Sometimes, doctors might use a type of medication called corticosteroids to treat children with significant spine injuries. A study found that high doses of these drugs, given within 8 hours of injury, could help nerve function. However, children younger than 13, and those with penetrating injuries didn’t seem to benefit from these medications. Steroids can carry the risk of side effects, like internal bleeding and infections.
What else can Pediatric Spine Trauma (Neck and Back Injury in Children) be?
When trying to understand the cause of a spinal injury, doctors may consider several possibilities:
- Nonaccidental trauma: Severe spinal injury might happen alongside other grave injuries, like twisted limb fractures.
- Cancer: The patient might exhibit general symptoms, have a family history of cancer, or possess a genetic condition that makes them prone to developing cancers.
- Infection: The patients could have fever episodes and certain risk factors like exposed bone fractures and recent surgeries. Spinal tuberculosis should be considered in patients who are at higher risk, such as those with weakened immune systems or immigrants from countries where the disease is prevalent.
The following conditions should be excluded when assessing a spinal injury:
- Sudden neck stiffening (Acute torticollis)
- Nerve damage in the lower spine (Cauda equina and conus medullaris syndromes)
- Neck muscle strain (Cervical strain)
- Injuries from hanging or strangulation
- General neck trauma
- Infections in the spinal cord
- Damage to the spinal cord
A thorough physical examination and smart use of diagnostic tests can help doctors determine the accurate diagnosis and create an effective treatment plan for young patients with spinal injuries.
What to expect with Pediatric Spine Trauma (Neck and Back Injury in Children)
The severity of an injury to the spinal cord greatly affects the likelihood of recovery. Minor injuries tend to have a better outcome compared to severe ones. Sadly, only about 10% to 25% of patients fully recover after severe spinal cord injuries, but 64% show some level of recovery.
Kids who get spinal injuries before they have finished growing can develop a condition called scoliosis, which is a side-to-side curve in the spine. Recovery outlook for nerve injuries is generally better in children versus adults.
Possible Complications When Diagnosed with Pediatric Spine Trauma (Neck and Back Injury in Children)
After a spinal cord injury, there’s a possibility for numerous complications to arise. These might include:
- Spinal shock, where the body temporarily loses some function after the injury
- Neurogenic shock, a type of shock caused by changes in your nervous system
- Loss of control over bowel and bladder activity
- Bedsores, which are areas of skin that become damaged due to staying in one position for too long
- Pneumonia and atelectasis, which are lung-related issues
- Urinary infections
- Deep vein thrombosis and pulmonary embolism, which are blood clots related issues
- Scoliosis, a condition causing the spine to curve to one side
- Syringomyelia, a rare disorder where a fluid-filled cyst forms within your spinal cord
- Hip instability
In order to prevent these complications, it’s important to recognize and manage them early. This might involve measures like stabilizing the fracture, supporting breathing, and taking action to prevent bedsores and lung infections. It can also be beneficial to participate in comprehensive rehabilitation programs. These programs can work on strengthening muscles, improving movement and managing bladder and bowel activity. This in turn can help to minimize the risk of these complications after an injury to the spinal cord.
Preventing Pediatric Spine Trauma (Neck and Back Injury in Children)
To prevent children from experiencing spine injury, there are some precautions that can be taken even before an accident happens. It’s really important for both kids and their caregivers to understand how they can stay safe. For example, children should always wear helmets when they’re biking or playing sports and should stay away from potentially dangerous behaviors. Parents and caregivers also have a critical role to play. Using car seats and seat belts correctly, for instance, can help to prevent serious injuries from car accidents.
There are also precautions that can be taken to minimize the harm caused by an injury once it’s already happened. Recognizing an injury quickly and dealing with it effectively is key. In situations like a sports injury or a car accident, it’s crucial to follow safety rules, like learning the right way to play a sport and always wearing safety gear to lessen the chance of a serious spine injury. Also, medical attention should be sought as soon as possible. If doctors can diagnose and begin treating a spine injury quickly, they may be able to prevent it from getting worse or causing further problems down the line.
