Injuries to the thoracic and lumbar spine in pediatric patients are less frequent than injuries of the cervical spine, although they are not rare.

Injuries are typically described using adult classifications and may be broadly divided into four groups: compression, burst, flexion-distraction, and fracture-dislocation.

Treatment is dictated by the mechanism of injury, neurologic status, and associated injuries.

Growth and ossification patterns are important for understanding potential fracture planes and for distinguishing normal anatomic variations from bony injury.

Development of the thoracic and lumbar vertebrae is similar to development of the lower cervical vertebrae.

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  A single primary ossification center develops during fetal life in the vertebral centrum (body) and in each neural arch ( Fig. 25-1 ).

  
  

  
  

  
  

  

  
  

  
  

  Developmental anatomy of an idealized vertebra within the thoracolumbar spine. A, Line diagram illustrating the vertebral body (B) and the neural arches (N) . The gray centers indicate primary ossification centers. Everything colored in black indicates secondary centers of ossification, including the ring apophysis (RA) , the transverse processes, and the spinous processes. The arrows indicate synchondroses. B, MRI of T6 vertebra in a 1-year-old girl shows the location of the neurocentral synchondroses (arrows) .

  
  

  
  

  

  
  
  
  
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  A neurocentral synchondrosis, the bidirectional physis between the primary ossification centers, closes between 3 and 6 years of age.

  
  
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  The neural arch ossification centers fuse between 2 and 4 years.

  
  
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  A vertical lucency on anteroposterior radiographs suggestive of a failure of fusion defect before age 2 years is normal.

Secondary ossification centers form at various times during puberty at the tips of the spinous, transverse, and mammillary processes (see Fig. 25-1 ).

The ring apophysis, the cartilaginous superior and inferior margins of the vertebral body, begins ossification during puberty as well but appears simultaneously throughout the spine ( Fig. 25-2 ; see Fig. 25-1 ).

Ossification of the ring apophysis (arrows) in a thoracic vertebra of a 10-year-old girl.

The vertebral body enlarges circumferentially by perichondral and periosteal apposition.

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  Vertical growth is through endochondral ossification at the vertebral endplates, which are essentially growth plates.

  
  
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  The ring apophysis, which is a cartilaginous structure contiguous with the vertebral endplate physes, does not contribute to the vertical growth of the spine.

  
  
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  The growth of the vertebral body is typically complete by the bone age of 14 years in girls and 16 years in boys, although the canal diameter is well formed by 5 years of age.

Ligamentous stability of the thoracic vertebrae and lumbar vertebrae is a function of longitudinal ligaments running along the anterior and posterior aspects of the vertebral bodies, the facet joint capsules, and the interspinous and supraspinous ligaments. Additional stability is conferred to the thoracic spine by the surrounding ribs.

An adequate history may be difficult to obtain at the initial evaluation.

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  Most of the initial information may come from medical personnel at the site of the injury.

  
  
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  For all patients, it is important to gather information on the time from injury and method of immobilization because this may suggest potential medical interventions for patients with a spinal cord injury.

Thoracic and lumbar spine injuries in infants and young children should raise suspicions for child abuse.

Motor vehicle accidents are the most common mechanism of thoracolumbar spine injury in all age groups.

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  A lap belt without a shoulder strap or shoulder harness in a car seat predisposes to flexion-distraction–type injuries as the thoracolumbar spine flips over the restraint, causing anterior compression of abdominal contents.

Motor vehicle accidents, sports injuries, and falls from a height can produce an axial loading mechanism that results in a burst fracture or a compression fracture, depending on the degree of spine flexion at the time of impact.

A spine fracture in a child that results from a low-energy mechanism may suggest an insufficiency fracture of bone secondary to iatrogenic causes (steroid use), primary lesions of bone (aneurysmal bone cyst, Langerhans cell histiocytosis), or infection.

Communicative patients sometimes can describe neurologic deficits such as loss of sensation or motor function in the extremities. However, this history is often absent in young, uncooperative, or obtunded patients.

Multiple mechanistic and injury-related associations with spine fractures can help guide additional evaluations or treatments.

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  A spine fracture at one level is a high risk for having a spine fracture at another level.

  
  
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  A lap-belt mechanism can be associated with intra-abdominal injury.

  
  
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  Abdominal injuries are present in 50% of patients with Chance fractures.

Initial management of a child with a potential spine injury is appropriate immobilization in the field. The cervical spine should be immobilized in a neutral position with access to the airways, while the remainder of the patient is placed on a rigid board.

The relatively larger head in a child younger than 8 years places the child’s neck in relative flexion when on a typical adult rigid board.

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  The head size requires that a cut-out for the head or a split-mattress technique be used to prevent excessive cervical or upper thoracic flexion.

After appropriate evaluation of the cardiorespiratory system using the ABCs, the spine examination is performed with appropriate spinal precautions observed.

Examination of the back is performed by logrolling the patient. Areas of swelling, ecchymosis, and tenderness should be identified. The overall sensitivity of the physical examination for detecting thoracolumbar spine fracture is 87%.

A complete neurologic examination is sometimes difficult in a pediatric patient.

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  The initial examination including strength, sensation, proprioception, rectal sphincter tone, bulbocavernosus reflex, and perianal sensation should be documented.

  
  
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  The examination is serially repeated, and any improvement or deterioration is noted.

A neurologic deficit with normal computed tomography (CT) scan or plain radiographs does not exclude the possibility of a spinal cord injury with associated spinal column instability in a child.

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  Spinal cord injury without radiographic abnormality (SCIWORA) may be present in a child secondary to the relatively greater elasticity of the spinal column compared with the spinal cord.

  
  
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  Magnetic resonance imaging (MRI) is the study of choice to detect ligamentous or bony injury that is not apparent on plain radiographs or CT.

X-ray

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  Alert, cooperative patients without a significant injury mechanism, without reported pain or tenderness, and with a normal neurologic examination do not require further imaging.

  
  
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  Plain films of the thoracolumbar spine are required in patients who are obtunded, who have spinal tenderness, or who have a distracting injury (e.g., long bone fracture, cervical spine injury, head injury) in the setting of a significant injury mechanism (e.g., motor vehicle accident, fall from >10 feet).

  
  
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  Initial radiographs should include supine anteroposterior and lateral views of the thoracolumbar spine. This film series should also be standard in any patient with a cervical spine injury. Evaluation of the films should be systematic.

  
  
  
  
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    Anteroposterior radiographs—coronal plane malalignment; increase in soft tissue shadows laterally suggesting paravertebral hematoma; loss of height in the vertebral bodies suggesting compression or burst; increased interpedicular space, such as found in a fracture; increased interspinous distance from any injury causing kyphosis

    
    
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    Lateral radiographs—sagittal plane malalignment, specifically any areas of focal kyphosis; anterior vertebral wedging suggesting compression; posterior element distraction or fracture

  
  

CT

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  CT scan has become standard in the evaluation of trauma patients and invariably provides a more detailed view of any fracture pattern.

  
  
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  CT scan is necessary only as an additional study if plain radiographs are abnormal because the CT scan information assists with decisions regarding final treatment. CT is more sensitive and more rapidly obtained than plain radiographs and helps distinguish acute from old injuries.

  
  
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  The higher sensitivity of CT relates to the detection of small, stable injuries. CT scan does not identify unstable injuries with any higher degree of accuracy than plain radiographs.

  
  
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  Axial images evaluate the integrity of the spinal canal, as in the case of a burst fracture or fracture-dislocation. The degree of spinal canal compromise is correlated with the probability of a neurologic deficit.

  
  
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  Sagittal images detail vertebral body compression and posterior element distraction or fracture.

MRI

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  MRI evaluates all the soft tissue components of the spine and has an excellent correlation with the intraoperative findings of soft tissue disruption.

  
  
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  MRI is required in a pediatric patient with a neurologic deficit. MRI allows localization of the specific cord injury level and any soft tissue or ligament injury that is not readily apparent on plain radiographs or CT scan.

  
  
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  The posterior ligamentous complex may be evaluated in burst fractures, compression fractures, and flexion-distraction injuries to understand the stability of the injury.