In the pediatric population, the occurrence of spinal injuries is rare with an overall incidence of 1.99 spinal cord injuries per 100,000 children in the United States. Only 10% of all children that suffer a spinal cord injury (SCI) are younger than 15 years. Cervical spine injuries comprise of 60% to 80% of these patients whereas 5.4% to 34% occur in the thoracolumbar spine.1–3 There is a distinct ethnic difference, African-Americans exhibit the highest rate of 1.53 spinal cord injuries per 100,000, followed by Native Americans (1.00), Hispanics (0.87), and Asians (0.36). With regard to gender, males are twice more likely to suffer this injury than females. Motor vehicle accidents are reported to be the most common cause spinal injuries accounting for 50% to 56%, whereas among these, 68% were not wearing seat belts at the time of the injury.4 Other frequently cited causes of pediatric spinal injuries occur as the result of birth injuries, falls, sports, diving, pedestrian injuries, and gunshot wounds.5–7
The main objective of this systematic review was to determine whether pediatric patients with SCI have specific characteristics regarding the use of spinal instrumentation, bracing to prevent curve progression, and clinical monitoring following SCI at a young age.
This was a systematic review of the literature followed by a modified Delphi consensus approach to make recommendations on 2 primary research questions using the GRADE system approach. The questions were determined by consensus through a panel of experts (Spinal Trauma Study Group members) and a comprehensive literature search was conducted using EMBASE and MEDLINE. The 2 questions are as follows:
- “What is the most effective means to achieve spinal stabilization in pediatric patients with a SCI?”
- “What is the most effective treatment of post-traumatic spinal deformities in pediatric patients with a SCI?”
All English articles published between 1950 and 2009 were included in this review. To meet the inclusion criteria, the population had to be representative of the pediatric age group (i.e., patients had to be of age 17 years or younger). In addition to randomized controlled trials, case series and reviews were included in this study. Case reports, adult age groups, and mixed pathology cohorts were excluded from this review. Search terms used for each question included the following:
- What is the most effective means to achieve spinal stabilization in pediatric patients with a SCI?
- Spinal cord injury,
- Internal fixators.
- What is the most effective treatment of post-traumatic spinal deformities in pediatric patients with a SCI?
- Spinal cord injury and
Abstracts of all articles that respected the inclusion/exclusion criteria were reviewed and, if deemed relevant, full text articles were obtained for further review. A GRADE system, proposed by Guyatt, and a modified Delphi approach were then used to grade the articles on the basis of the following recommendations:
- Pediatric patients with unstable fractures/fracture dislocations with or without neurological deficit should be stabilized surgically with instrumentation.
- Prophylactic orthotic treatment should be considered early after the appearance of spinal deformity to delay surgical correction of the deformity.
- Pediatric patients with SCI and a progressive spinal deformity should have their deformity corrected using modern surgical techniques similar to those used for neuromuscular scoliosis.
Medline returned 136 abstracts, and 281 abstracts were acquired from EMBASE (total 417) that were further reviewed for the first question, whereas 517 abstracts were reviewed for the second questions. After further assessment, 15 articles were selected regarding question 1 and 8 articles were chosen to explore question 2 (Tables 1 and 2). No level-1 or level-2 articles were found during this search.
Question 1. What Is the Most Effective Means to Achieve Spinal Stabilization in Pediatric Patients With a SCI?
The use of instrumentation to treat spinal fractures in the pediatric population has traditionally been controversial. This debate results from the paucity of published articles that address specifically the use of instrumentation in children. Unfortunately, most of the available studies concerned with pediatric spinal trauma are retrospective series that focus primarily on the patient's neurologic injury and combine both nonoperative and operative patients within their series.3,8–11 Although most of the series used adult instrumentation, they failed to establish a clear treatment algorithm to guide surgeons as to when it is important to surgically stabilize the fracture. Because of this lack of published evidence, adult treatment standards have generally been extrapolated to determine the treatment required for pediatric spinal fractures. The widespread adoption of this extrapolative technique results from the principle that children have better recovery rates after a SCI when compared with adults treated with similar methods. These methods include rapid emergent stabilization, traction, rigid orthotic treatment, and when necessary, rapid surgical decompression and stabilization through internal fixation. Recently, surgical stabilization of pediatric fractures has been facilitated by the development of small cervical pedicle and lateral mass screws, spinal cord monitoring techniques, and intraoperative guidance systems (Stereotactic and intraoperative computed tomography [CT] scans) to facilitate the identification of relevant anatomy.
There were following 26 relevant retrospective studies identified after a PubMed search that reported on the use of instrumentation in the pediatric trauma population: 16 retrospective patient series, 7 case reports, 1 review article, and 2 reports of radiographic analysis of the pediatric spine specifically addressing the issue of screw placement. There were 16 articles reporting the use of instrumentation in the pediatric cervical spine for instability, 1 cervical spine review article commenting on the use of instrumentation for instability in the pediatric spine,12 6 devoted only to thoracolumbar injuries, and 1 reporting on both anatomic areas.13 There were no randomized, prospective studies identified in the literature that evaluated the use of instrumentation for the stabilization of the pediatric spine after trauma. The primary indication, for the use of instrumentation in the pediatric spine, was instability resulting from trauma. Other indicators included rotatory subluxation, congenital spinal deformities/malformations, Down syndrome, tumors, prior surgery, os odontoideum, and systemic skeletal disease.8–10,14–16 The patients' age reported in this particular review ranged from 8 months to 18.9,17 Reports of pediatric instrumentation traditionally recommend the use of wires in children <3 years, and rigid instrumentation is reserved over the age of 10. Crostelli et al, in their series of 31 pediatric patients, reported that rigid instrumentation delivers satisfactory results without increased complications in children as young as 36 months. Moreover, the occurrence of complications suggested greater dependent on the patient's anatomic size.9 The spinal stabilization instrumentation methods used in these studies include the following: anterior odontoid screws, anterior cervical and thoracolumbar plates, posterior wiring techniques, posterior cervical C1–C2 transarticular, translaminar, and pedicle screws, lateral mass and pedicle screw rod or plate constructs, and thoracolumbar rod and screw constructs.8–10,14–17
Cervical Spine Instrumentation.
Two CT studies and 1 cadaveric anatomic study evaluated the anatomy of the cervical spine to assess the feasibility of using lateral mass, laminar and pedicle screws in the pediatric population.18–20 The authors concluded that a CT evaluation is essential for safe screw placement. The lateral mass of C1 and pedicles of C2 were identified as the preferred site from screw placement, and in children younger than 16 years, only 30.4% of laminae are adequate in size for translaminar screw placement—bringing to question the routine use of this technique in children.
Sixteen studies reported results of cervical spine instrumentation and fusion. The largest retrospective series by Anderson et al (95 patients), Gluf et al (67 patients), Eleraky et al (30 patients), and Brockmeyer et al (24 patients) correspondingly reported satisfactory stabilization, high fusion rates, and a low complication incidence after surgical stabilization.16,21–23 Anderson et al evaluated 95 pediatric patients having undergone a form of instrumentation, 25 patients were identified who did not have traditional wire fixation with concurrent halo/vest stabilization. In patients with a 3-month follow-up, 22 of 25 achieved a solid fusion, suffered no adverse events, and had clinical improvement.21 Gluf and Brockmeyer used C1–C2 transarticular screws in 67 children who were aged 1.7 to 16 years and reported a 100% fusion rate at 3 months postoperatively with a 10.4% complication rate, including 2 vertebral artery injuries. Their conclusion suggested safe and effective instrumentation was achieved if carefully planned and executed.22 Eleraky et al reported a 5-year follow-up on 30 surgical pediatric patients using a variety of instrumentation techniques on unstable pediatric spines. They described a 100% fusion rate, no deterioration of neurologic function, and no complications.23 Brockmeyer et al reported on 24 pediatric patients treated with various forms of screws, plates, and rod stabilizations. Results suggest no neurologic deterioration or fusion failures but did identify 2 complications: a superficial would infection that was treated with antibiotics and 1 instrumentation failure requiring reoperation.16 The remaining smaller retrospective series and single case reports (13 studies) show uniformly high fusion rates and a low complication rates. They also include the following: 1 patient with instrumentation failure, 1 requiring an extension of the fusion, and 2 patients with persistent dysphagia that had anterior odontoid screws placed.8,10,11,14,15,17,24–30 Finally, Anderson et al followed 17 patients treated with C1–C2 instrumented fusions over 5 years and found no long-term complications related to adjacent level degeneration, growth arrest, deformities, and/or instrumentation issues.31 All the previously explored articles, reporting on the use of instrumentation in pediatric cervical spines, are retrospective in nature, report on a wide variety of surgical techniques, do not compare the results of nonoperative treatment to surgical treatments, have no outcome measures, and are generally limited in their follow-up duration. Because of the lack of robust evidence contained in these studies, the conclusion of the expert authors is that there is low evidence (using the GRADE system) supporting the superiority of surgical treatment of cervical fractures with or without instrumentation over nonoperative treatment.
There were 6 retrospective articles identified that reported on the use of instrumentation in the pediatric population for thoracolumbar instability. These consisted of 3 case series and 3 case reports whereas only 1 article was reported on both cervical and thoracolumbar instrumentation. Santiago et al described 13 of 96 pediatric patients who underwent surgical stabilization without significant complications.32 Dogan et al reported that 23 of 89 patients with thoracolumbar fractures underwent instrumented fusions. After a 17.2-month follow-up, all patients had a visible callus formation and no instrumentation failure was observed. Complications included 1 case of meningitis from a cerebrospinal fluid leak, 2 cases of mild scoliosis, 1 posttraumatic syrinx, and no reports of instrumentation-related complications.3 Carreon et al reported on 24 of 126 pediatric patients who underwent fusion and stabilization after a spinal column fracture. Although the surgical location was vague, the author reported a callus formation in all patients after 12 months and a significantly higher (38%) complication rate in surgical patients when compared with the nonsurgical patients (12%). This elevated complication rate was attributed to the severity of the initial injury and not considered to be consequential of the surgery. Furthermore, they did not report any complications directly attributed to the instrumentation.13 The 3 remaining single case series reported successful instrumentation use in an 8-month old,17 in 6 patients following unstable fracture/dislocations of the thoracolumbar spine,28 and with lumbar Chance fracture/dislocations30 without instrumentation-related complications. As identified in the cervical spine, these studies demonstrate a clear lack of robust beneficial evidence to support the instrumentation of traumatic spinal instability. Therefore, in the strictest sense, there is low evidence (using the GRADE system) supporting the superiority of the surgical treatment of thoracolumbar fractures with or without instrumentation over the nonoperative treatment. However, there is an extensive body of literature outlining the safe and effective use of spinal instrumentation in the pediatric deformity population to correct the deformity by realigning the spine, holding the correction/reduction, and inducing significantly higher fusion success, all without a significant increase in instrumentation-related complications.33 With this in mind, a reasonable conclusion suggests at least moderate support exist regarding the instrumentation of unstable pediatric spinal fractures with the purpose of allowing realignment of the bony elements of the spinal column and protection of the neural elements.
Question 2. What Is the Most Effective Treatment of Post-Traumatic Spinal Deformities in Pediatric Patients With a SCI?
The treatment of trunk deformities is conventionally focused on progression prevention up until trunk growth plateaus around the age of 10 to 12 in females and 12 to 14 in males. Younger patients, further away from the adolescent growth spurt, are more likely of developing an augmented deformity. Moreover, nearly all patients that incur a SCI before the adolescent growth spurt develop scoliosis.34–37 As a result of such frequent observation, the multidisciplinary team should monitor closely the appearance of spinal deformities in SCI patients. After a spinal deformity is identified, prompt orthotic treatment should be initiated.
Brace management should be initiated before the aggravation of the deformity. If initiated on curves less than 10° of deformation, there is potential to avoid fusion, whereas when treatment is initiated after 20°, slowing of the potential progression may be anticipated. Mehta has contributed to several studies evaluating curve progression in relation to brace use. These studies along with those from the Shriner's Hospital Ross Hunter, recognize that the thoracolumbosacral orthosis does impair daily activities or independence; however, such shortcomings should be contrasted with the significant risks and expected complications of spinal fusion surgery.
Development of scoliosis in skeletally immature patients with a SCI has focused on structural issues related to index fractures and the development of secondary deformities resulting from paralysis and spasticity. Residual fracture deformities have been suggested to be an etiologic factor of paralytic scoliosis after pediatric SCI. Bergstrom et al38 conducted a retrospective observational study (weak evidence) on 76 of 766 eligible adult patients who incurred SCI during childhood. Patients were evaluated for the development of spinal deformities after SCI with the help of postinjury and follow-up radiographs. No relationship to residual fracture deformity and development of scoliosis, kyphosis, or hyperlordosis was noted. Demographics of eligible and studied patients were reported to be statistically equivalent. No functional evaluation or details regarding neurologic progression were reported.
Development of spasticity secondary to incomplete SCI, progressive cord apoptosis, and development of syringomyelia has been implicated as a causal factor of the paralytic deformity. Residual kyphosis and canal stenosis, also suggested etiologic factors of post-traumatic syringomyelia, have been proposed by several level IV quality studies. Abel et al39 have evaluated patients for residual kyphosis and stenosis retrospectively in selected referral centers. In this retrospective magnetic resonance imaging study, the development of post-traumatic syringomyelia was related to residual canal stenosis greater than 25% and focal kyphosis greater than 15°. These 2 parameters were20% to 40% related to the occurrence of post-traumatic syringomyelia.39
As mentioned earlier, spinal deformities will develop in nearly all patients if the injury occurs before the growth spurt.34,37 Only one article discussed prophylactic bracing after SCI in children.40 Bracing before 20° delays surgical correction and, before 10° may prevent scoliosis progression. On the basis of results of this study, aggressive prophylactic orthotic treatment for patients with paralytic SCIs seems warranted. Therefore, SCIs occurring before the adolescent growth spurt should be closely monitored due to the high risk of scoliosis development and progression. Patients with SCI in early childhood (i.e., before their growth spurt) should be closely monitored, and spinal deformities should be treated in a similar manner as neuromuscular scoliosis with modern correction surgical techniques when bracing fails to prevent progression. This recommendation was based on low evidence. On reviewing the studies discussed herein, the panel of experts believed that when these patients present with a progressive deformity, it should be rectified while emphasizing the realignment the spine while providing adequate sitting posture for wheel chair positioning.
There is no strong evidence to support the use of instrumentation in the pediatric population because of the low incidence of these injuries. The conventional evidence available supports the use of bracing and other conservative methods in the treatment of stable cervical and thoracolumbar injuries. However, this evidence is based on historical treatment paradigms that, likewise are lacking strong evidence to support their superiority over surgery for each particular type of injury. There is strong pre-existing evidence in the adult population that suggest that surgical stabilization should be performed with an unstable fracture/dislocation of the spine, which can be extrapolated to support a similar surgery strategy in the pediatric population. Moreover, extensive instrumentation experience exists in the pediatric deformity population that has shown excellent results in maintaining spinal corrective alignment with very low instrumentation complication rates. Although there is no strong evidence supporting the use of instrumentation for the treatment of pediatric spinal traumatic instability, the literature advises that the incidence of reported complications is remarkably low and the apparent success of fusion relatively high. In addition, there exists the intuitive need to stabilize the spinal column to protect neurologic function. Such justified intuition is based on extensive adult clinical experience and the fact that, even if a pediatric patient may have enhanced healing ability over adults, an unstable spine may still result in a catastrophic SCI during the vertebral healing process. This hypothesis is particularly applicable to a pediatric patient who suffers an incomplete SCI concurrent with an unstable bony spinal column injury. Available evidence has not reported any significant increase in morbidities associated with surgical treatment or the use of instrumentation in the pediatric population. Therefore, despite the lack of well-designed prospective studies to establish the efficacy of instrumentation in these cases, there still remains low to moderate evidence that supports the use of instrumentation in unstable pediatric spines to prevent neurologic injury and maintain spinal alignment.
Monitoring spinal deformity initiation and progression is an important role of the multidisciplinary team treating patients with SCI. Although the evidence regarding scoliosis development following SCI in children is low, the benefits of early bracing clearly outweigh the risks and complications associated with its use. Close monitoring should be initiated early to delay surgical correction as late as possible. There is a strong recommendation for the use of traditional neuromuscular spinal deformity treatment techniques for the treatment of progressive spinal deformities following a neurologic injury. There is very low evidence to support the use of surgery for the treatment of deformity following a SCI. There may be evidence suggesting that correction techniques used to correct neuromuscular deformities are useful and should be applied to this patient population.
To summarize, for the first question “What is the most effective means to achieve spinal stabilization in pediatric patients with a SCI?” there is a strong recommendation for the use of instrumentation in pediatric spinal fractures that are unstable to allow for the realignment of the bony elements of the spinal column and protection of the neural elements—low quality evidence.
For the second question “What is the most effective treatment of post-traumatic spinal deformities in pediatric patients with a SCI?” there is a strong recommendation for the use of traditional neuromuscular spinal deformity treatment techniques for the treatment of progressive spinal deformity following a neurologic injury—very low quality evidence.
- A systematic review of the literature was performed to identify the unique features associated with pediatric SCI. Two recommendations were formulated based on the available evidence.
- There is a strong recommendation for the use of instrumentation in pediatric spinal fractures that are unstable to allow for the realignment of the bony elements of the spinal column and protection of the neural elements (low quality evidence).
- There is a strong recommendation for the use of traditional neuromuscular spinal deformity treatment techniques for the treatment of progressive spinal deformity after a neurologic injury (very low quality evidence).
The authors thank Dr. Carlos Villenueva for his valuable input in the planning of this project.
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