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Unstable Spinal Fractures In Children

M. Benzagmout *, A. Moussaoui*, M. Maaroufi #, S. Tizniti #,  K.Chakour*,FM. Chaoui*, S. Boujraf #**

* Department of Neurosurgery, University Hospital Hassan II; Fez, Morocco
#Department of Radiology, University Hospital Hassan II; Fez, Morocco
**Department of Biophysics and Clinical MRI Methods, Faculty of Medicine and Pharmacy, University of Fez

Address for Correspondence:
Dr. Saïd Boujraf
BP. 8589 Atlas 30003, Fez; Morocco.
Tel   : 00 212 67 780 442
Fax  : 00 212 35 944 789


Although rare, pediatric spinal injuries are associated to the highest mortality rate of all orthopedic injuries in children. We present a retrospective study of 15 children operated for unstable spinal fractures between October 2002 and November 2005. The mean age ranged from 7 to 14 years old with an average of 10.3 years old and the male/female ratio was 2. The causative etiologies were falls in 12 cases and motor vehicle accidents in 3 cases. 40% of the children sustained one or more associated injuries and 73.3% of patients had neurological deficits. The lumbar spine and the thoracolumbar junction were the predominant levels of trauma. For the surgical treatment, posterior approach was employed in 13 cases and a transpleural thoracotomy in 2 cases. Except patients with Frankel grade A, all others won at least 1 grade according to the grading of Frankel. There was no case of death. Consolidation, maintenance of alignment, and stable fixation after one year recessions were seen in all documented radiography of patients. Length of follow-up for these patients ranged from 1 to 4 years.
Keywords: child, unstable fractures, spine, surgery.

J.Orthopaedics 2007;4(2)e27



Fractures and severe injuries of the spine in children are relatively rare; it represents 1 to 10% of spinal injuries reported by various authors (1-8). Anatomic and biomechanical characteristics of the spine in the developing child explain the different patterns of injury occurring in the childhood comparatively to the adult population.  Therefore, the purpose of this paper is to describe the clinical and therapeutical particularities of spinal trauma in children and to compare our results to other series reported in the literature. 

Material and Methods :

This is a retrospective series of fifteen infants hospitalized at the neurosurgery department of the university hospital of Fez for injuries of the vertebral column or the spinal cord between October 2002 and November 2005. Only the unstable lesions were included in this study.

Hospital and clinic records for each patient were reviewed, noting demographic data, mechanism of injury, level involved, type of bony injury, presence of spinal cord injury, any associated injuries, treatment received, length of hospital stay, and outcome.

Results :

There were 123 cases of spinal traumatism admitted into our department during the same period (October 2002- November 2005). Eighteen Childs with spinal injuries were identified from the trauma registry, and fifteen medical records were available for review. There were ten boys and five girls; the male/female ratio was 2. The age of our patients was situated between 7 and 14 years; the mean age was 10.3 years.

Falls were the most common cause in this series (12 cases); Motor vehicular accidents were seen in 3 cases only. However, there were no documented cases of child abuse. The duration of admission varied from 2 hours to Three weeks.

Preoperatively, the neurological examination was normal in four patients. In contrast, 11 patients had spinal cord injury. The neurological deficit was classified according to the Frankel grading: seven patients had paraplegia (three of grade A and four of grade B), four patients had paraparesia (three of grade C and one of grade D).

All patients have systematically benefited of x-ray at the level of lesion and CT scan of the spinal cord. Injuries localized to the thoraco-lumbar junction (T11-L1) were predominant (6 cases). The cervical spine was affected in 4 cases and the lumbar spine in 3 cases. Only two patients had thoracic involvement. There wasn’t any patient with multiple spine level involvement. Patterns of vertebral column injury were divided into three types: Vertebral fracture without disco-ligamentous injuries (Figure 1) was seen in 11 cases (73.3%); subluxation or dislocation only was seen in one case (6.7%); and fracture with disco-ligamentous injuries or mixed injuries (Figure 2) were seen in 3 cases (20%). Excluding abrasions and minor lacerations, associated injuries were seen in six patients, five of them had associated lower limbs.  In addition, two patients had closed head injury and one patient had hemothorax.

Fig 1 Fig 2

No neurological deterioration was noted during any patient’s hospital stay. All patients underwent spinal surgery during their hospitalization. The posterior approach was employed in 13 cases. The remaining two patients underwent anterior decompression through a transpleural thoracotomy. For patients operated using posterior approach, a laminectomy in frontal of the involved level was practiced in 6 cases. Three patients underwent posterior stabilization alone; they had complete spinal cord injuries, with no signs of neurological improvement in the postoperative course. However, the remaining patients won at least 1 grade according to the Frankel grading. In our series, the mean length of hospitalization was 9 days ranging from 6 to 23 days.

The overall complication rate was 20% (3 patients).

Two of them developed ulceration at the supporting point; one of them was treated also for urinary tract infection with a favorable outcome. The osteosynthesis infection was deplored in one case by the tenth day after surgery; this required the removal of the osteosynthesis materiel and antibiotherapy according the favorable clinical evolution; considering the paraplegia, this patient benefited also of orthopedic treatment (Grade A de Frankel). No death was recorded in the studied series.

Consolidation, maintenance of alignment, and stable fixation as documented on radiographs at 1 year were seen in all patients. Length of follow-up for these patients ranged from 1 to 4 years.

Discussion :

Spine injury in the pediatric population remains uncommon, with reported frequencies of 1 to 10% (1-8). Comparing to the adult, the pediatric patient is anatomically and biomechanically different with more flexible and mobile spine (9). In fact, ligaments, discs, and surrounding soft tissue structures are more elastic and the musculature is less developed in children than in adults. These explain the relative resilience of the pediatric spine to injury as well as the different features of spinal injuries occurring in the childhood comparatively to the adult population.

In our series, the most common cause of injury was falls. This contrasts with the majority of previous reports in that the motor vehicle accidents were the principle causes (1, 4, 5, 10-12). Generally, 50% of children with spinal injuries have associated injuries. The most common extra spinal injury was in head (4, 13). This is in difference from our results where 33.3% of patients had associated orthopedic injuries.

Furthermore, the incidence of pediatric spinal injury increased with age (1-4, 14). This may be reflective of the protective effect of a flexible spine in the younger child. In previous reports, most of spinal injuries in children were located at the cervical spine (1-3, 5, 10, 11). In contrast, the lumbar spine and the thoracolumbar junction were the most involved levels in our series. This could be explained by the mechanism of the traumatism, where falls were predominant. The choc wave transmission during axial trauma is mainly achieved at the lumbar spine and the thoracolumbar charnel. Previous published works reported 11 to 16% incidence of multilevel spine involvement in children (5, 14). We haven’t recorded any multimodal lesion.

Generally, spinal cord involvement is observed in 19% of spine injury in children (10). Indeed, patients with a dislocation or fracture–dislocation had a higher incidence of neurologic injury than did patients with fracture alone. This is to be expected as dislocation causes larger degrees of displacement than pure fracture types, and the force required to produce such a displacement must be greater (10). In our series, a total of 11 patients had neurologic deficit; seven of them were paraplegic.

Ideally, the surgical treatment should be done in emergency. This permit neural decompression as well as good alignment of the spinal column and a satisfactory stabilization of the spine. As in previous studies, the majority of patients with partial injuries showed neurologic improvement in the postoperative course (9). This is attributable to plasticity and greater capacity for recovery of the immature spinal cord (10).

In our series, the overall complication rate was 20% and there wasn’t any case of death recorded. Previous reports in the literature showed a much high rate of mortality and complications (12, 15). We can explain these results by higher average age of our patients and the dominance of the thoracolumbar spinal lesions.

In fact, previous studies have shown that the more serious and fatal injuries occurred in children younger than 8 years (13, 16) and from cervical spine injuries (17).


Spinal injuries in children are relatively uncommon compared with adults. The spinal cord involvement is the greater risk. Optimal treatment requires a well understanding of the medical and spinal characteristic of this population. The prognosis depends on the rapidity of care, the spinal level of the lesion and the clinical profile of the associated lesions

Reference :

  1. Anderson JM, Schutt AH. Spinal injury in children: a review of 156 cases seen from 1950 through 1978. Mayo Clin Proc. 1980; 55: 499-504.

  2. Burke DC. Spinal cord injuries, 1976. Aust NZ J Surg. 1977; 47: 166-170.

  3. Dickman CA, Zabramski JM, Hadley MN, Rekate HL, Sonntag VK. Pediatric spinal cord injury without radiographic abnormalities: Report of 26 cases and review of the literature. J Spinal Disord 1991; 4: 296-305.

  4. Eleraky MA, Theodore N, Adams M, et al. Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg. 2000; 92: 12-17.

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  10. Carreon LY., Glassman SD., Campbell MJ. Pediatric Spine Fractures A Review of 137 Hospital Admissions. J Spinal Disord Tech 2004; 17: 477-482

  11. Cirak BB, Ziegfeld S, Knight VM et al. Spinal Injuries in Children. Journal of Pediatric Surgery 2004; 39 (4): 607-612.

  12. Kewalramani LS, Kraus JF, Sterling HM. Acute spinal-cord lesions in a pediatric population: epidemiological and clinical features. Paraplegia. 1980; 18: 206-219.

  13. Orenstein JB, Klein BL, Gotschall CS, et al. Age and outcome in pediatric cervical spine injury: 11-year experience. Pediatr Emerg Care. 1994; 10: 132-137.

  14. Hadley MN, Zabramski JM, Browner CM, et al. Pediatric spinal trauma: review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg. 1988; 68: 18-24.

  15. Hamilton MG, Myles ST. Pediatric spinal injury: review of 61 deaths. J Neurosurg. 1992; 77: 705-708.

  16. Orenstein JB, Klein BL, Oschenschlager DW. Delayed diagnosis of pediatric cervical spine injury. Pediatrics 1992; 89(6): 1185-1188.

  17. Nitecki S, Moir CR. Predictive factors of the outcome of traumatic cervical spine fracture in children. J Pediatr Surg 1994; 29(11): 1409-1411.


This is a peer reviewed paper 

Please cite as :M. Benzagmout : Unstable Spinal Fractures In Children

J.Orthopaedics 2007;4(2)e27





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