Courtesy: Dr Rishi Kanna, Dr Ashok Shyam, Ortho TV

General Principles

Children are not small adults.

• Anatomy, biomechanics, and injury patterns differ significantly.
• Diagnosis is challenging because of normal anatomical variants, difficult clinical examination, and subtle radiological findings.

Incidence and Distribution

• Pediatric spine injuries account for approximately 1 to 2 percent of pediatric trauma.
• Cervical spine injuries account for about 70 to 75 percent of pediatric spinal injuries.
• Adults have cervical involvement in approximately 30 to 35 percent of cases.
• Children younger than 8 years commonly sustain upper cervical spine injuries (C1 to C3).
• Children older than 8 to 10 years have injury patterns similar to adults.

Anatomical and Radiological Differences

• Synchondroses between ossification centers may mimic fractures.
• Normal anterior vertebral wedging may resemble compression fractures.
• Pseudosubluxation is common, particularly in the cervical spine.

Vertebral Ossification

Each vertebra has three primary ossification centers.

• One centrum.
• Two neural arches.

The 1, 3, 6 rule

• Ossification centers appear at 1 year.
• Neural arches fuse posteriorly by 3 years.
• Neural arches fuse with the vertebral body by 6 to 7 years.

Axis (C2)

• Odontoid synchondrosis fuses at approximately 6 years.
• Can mimic a fracture.
• Represents a weak point prone to injury.

Biomechanics

Children younger than 8 years

• Large head with a small torso.
• Increased ligamentous laxity.
• Horizontal facet joints.
• Fulcrum of motion is in the upper cervical spine.
• Greater risk of instability, neurological injury, and head injury.

Children older than 8 years

• Spine behaves like the adult spine.
• Stronger ligaments.
• Fused synchondroses.
• Fulcrum shifts to the lower cervical spine.

Prehospital and Emergency Care

• Avoid standard flat spine boards in young children.
• Large head causes neck flexion during immobilization.
• Elevate the torso or use an occipital recess to maintain neutral cervical alignment.

Indications for Cervical Spine Imaging

Image the cervical spine in patients with

• Neck pain or tenderness.
• Neurological deficit.
• Altered consciousness.
• Distracting injuries.
• Inconsolable child.
• Unconscious patient.

Pseudosubluxation

• Common at C2 to C3.
• Must be distinguished from true instability.

Swischuk line

• Drawn along the spinolaminar junctions.
• Normal alignment forms a smooth continuous line.
• Disruption suggests true cervical injury.

SCIWORA

Spinal Cord Injury Without Radiological Abnormality

• Common in children younger than 8 years.
• Represents 20 to 40 percent of pediatric spinal cord injuries.

Mechanism

• Flexible vertebral column stretches without fracture.
• Less elastic spinal cord sustains injury.

Diagnosis

• MRI is essential.

Management

• Usually nonoperative.
• Prognosis depends on the initial neurological status.

Imaging Strategy

X ray

• First line investigation.

CT scan

• Best for suspected bony injuries.

MRI

• Required when X rays or CT scans are normal but suspicion remains high.
• Essential for diagnosing SCIWORA.
• Evaluates ligaments, soft tissues, and the spinal cord.

Injury Patterns

Children younger than 8 years

• Upper cervical injuries predominate.
• Higher incidence of neurological deficits.
• Higher mortality.

Children older than 10 years

• Adult type fracture and dislocation patterns.

Endplate Avulsion Injury

• Occurs in adolescents after flexion or twisting injuries.
• Can mimic lumbar disc prolapse on MRI.
• CT scan demonstrates a bony endplate avulsion.

Key Clinical Points

• Recognize normal anatomical variants before diagnosing fractures.
• C2 to C3 pseudosubluxation is a common normal finding.
• MRI is essential when neurological deficits are present or diagnosis remains uncertain.
• Management should be individualized based on age, injury pattern, and neurological status.

Exam Pearls

• Pediatric cervical spine injuries are more common than thoracolumbar injuries.
• Upper cervical injuries predominate in children younger than 8 years.
• MRI is the investigation of choice for SCIWORA.
• Swischuk line helps distinguish pseudosubluxation from true cervical instability.
• Odontoid synchondrosis normally fuses at approximately 6 years.
• Large head and ligamentous laxity predispose young children to upper cervical injuries.