Operative management of traumatic cervical spine distraction and complete cord transection in a 3-year-old patient

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This report describes the presentation and operative treatment of a 3-year-old boy who survived a motor vehicle accident that resulted in a C6–7 distraction injury, complete avulsion of the spinal cord, and gross spinal instability. Only 5%–10% of all spinal cord and vertebral column injuries occur in children. Survival after such an injury is exceptionally rare in very young patients and is associated with severe neurological deficits. The authors discuss the substantial ethical challenges involved in the care of a patient with this injury. To their knowledge, only two other cases of survival have been reported in pediatric patients following motor vehicle trauma resulting in complete injury to the lower cervical spinal cord.

ABBREVIATIONSBSAER = brainstem auditory evoked response; SSEP = somatosensory evoked potential; tcMEP = transcranial motor evoked potential.

Abstract

This report describes the presentation and operative treatment of a 3-year-old boy who survived a motor vehicle accident that resulted in a C6–7 distraction injury, complete avulsion of the spinal cord, and gross spinal instability. Only 5%–10% of all spinal cord and vertebral column injuries occur in children. Survival after such an injury is exceptionally rare in very young patients and is associated with severe neurological deficits. The authors discuss the substantial ethical challenges involved in the care of a patient with this injury. To their knowledge, only two other cases of survival have been reported in pediatric patients following motor vehicle trauma resulting in complete injury to the lower cervical spinal cord.

Children younger than 16 years of age represent 5%–10% of those suffering from spinal cord and vertebral column injuries.1,16,27,28 While the cervical spine is the most commonly affected region in pediatric spinal trauma, the majority of injuries are incomplete insults to the upper cervical spine.2,5,10,11,21,24,26,28,29,32 Lower cervical spine trauma more frequently results in complete spinal cord injury than does trauma to the upper cervical spine.2,5,9,10,13,21,24,26,28,29,32 Survival among younger children with complete lower cervical cord injuries is rare.5,23,30

In this report we describe the presentation and operative treatment of a 3-year-old boy who survived a motor vehicle accident that resulted in a C6–7 distraction injury, complete avulsion of the spinal cord, and gross spinal instability. To our knowledge, only two previous cases of survival have been reported in pediatric patients following motor vehicle trauma resulting in complete injury to the lower cervical spinal cord.23,30

Case Report

History and Examination

The patient, a previously healthy 3-year-old boy, had partially freed himself from the upper harnesses of the 5-point restraint of his forward-facing car seat in the rear driver side position. The vehicle was traveling at approximately 40 miles per hour. While attempting to re-secure the child, the driver veered the vehicle into a stopped bus. Still partially restrained, the boy remained in his car seat and was not ejected during the collision.

He was pulseless at the scene and received approximately 2 minutes of cardiopulmonary resuscitation. Upon arrival to the emergency department, his Glasgow Coma Scale score was 3. On physical examination, he had a large forehead laceration, responsive pupils, abrasions and bruising of the abdomen, and priapism. Chest radiography revealed a 2.7-cm distraction injury at C6–7 (Fig. 1). Computed tomography angiography demonstrated that the vertebral artery injuries were limited to a blunt cerebrovascular injury Grade 2 injury of the left V1 segment and Grade 1–2 injury of the right V1 segment (Fig. 2).3,4 There was also a Grade 1 injury of the bilateral proximal internal carotid arteries. The patient was placed in halo-vest fixation without attempting to reduce the distraction, while we determined the full extent of his injuries and established the goals of care with his family. Magnetic resonance imaging confirmed complete transection of the cervical cord and edema in the spinal cord extending into the medulla (Fig. 3). There was no evidence of upper cervical bony or ligamentous injury requiring stabilization. Magnetic resonance imaging of the brain demonstrated only a small left cerebellar infarct as well as small amounts of intraventricular blood and scattered, thin subarachnoid hemorrhage. Electroencephalography demonstrated diffuse slowing, no epileptiform discharges, and mild hemispheric asymmetry.

FIG. 1.
FIG. 1.

Anteroposterior and lateral presentation radiographs of the chest (left) and cervical spine (right) demonstrating an approximately 2.7-cm distraction injury at C6–7.

FIG. 2.
FIG. 2.

Computed tomography angiogram demonstrating severe distraction injury at C6–7, Grade 2 injury of the left V1 segment, and Grade 1–2 injury of the right V1 segment. Vert = vertebral. Figure is available in color online only.

FIG. 3.
FIG. 3.

Sagittal T2-weighted MR image demonstrating spinal cord transection at C6–7 associated with an approximately 3-cm distraction of C6–7.

During the initial 48 hours of the patient's hospitalization, we described the severity and irreversibility of his neurological compromise to his parents. The discussion included our belief that, should he survive his acute injury, he would remain quadriplegic and ventilator dependent for the duration of his life. He would also require a multitude of surgical procedures, endure considerable psychological and physical insults, and potentially harbor substantial resentment regarding his quality of life. His parents very much wished to proceed with aggressive therapy, and with the input of the critical care service, we agreed to assess his clinical progress over a period of 48–72 hours. During this period, his cognitive function improved substantially. He began responding appropriately to verbal commands, and by hospital Day 6, he was communicating through facial expressions and blinking. Prior to initiating medical interventions that were more than supportive, we undertook two multidisciplinary care conferences, which included each of the clinical services involved in the patient's care. Despite the exceptionally grim prognosis and our concerns regarding the probable clinical course, the boy's parents felt very strongly that given his cognitive status, aggressive management was appropriate. In this context, we agreed to pursue surgical intervention to support activities of daily living and minimize deformity. We did not request an ethics consultation.

Closed Reduction With Neurophysiological Monitoring

In an effort to reduce the distraction and assess the potential for associated vascular compromise, the patient underwent closed reduction under neurophysiological monitoring on hospital Day 8. Under fluoroscopic guidance, the halo ring was loosened from the rods and gentle reduction was undertaken, followed by re-securing of the halo ring. With approximately 50% reduction of the C6–7 distraction, there were transient and slight decreases in the amplitudes of the brainstem auditory evoked responses (BSAERs). Fluoroscopy, however, demonstrated almost immediate regression of the C6–7 distraction to approximately 3 cm.

Anterior Procedure

On hospital Day 16, the patient underwent anterior instrumented fusion at C6–7, followed by posterior instrumented fusion from C-5 to T-2. The supine patient was secured on the operating table using the halo ring. Neurophysiological monitoring was used to evaluate brainstem function. Monitoring included BSAERs, transcranial motor evoked potentials (tcMEPs), and somatosensory evoked potentials (SSEPs), and its primary purpose was the evaluation of BSAERs during the reduction. We were concerned that rapid reduction of the injury could lead to the occlusion of major cervical arteries, which could manifest as a precipitous decrease in the amplitude or increase in the latency of these signals. In such a scenario, we would consider fusion without reduction, recognizing that the risk of fusion failure would be elevated. As expected, no tcMEPs or SSEPs were obtained. Rib autograft was obtained using standard techniques. A longitudinal anterior cervical incision and standard approach revealed the severely distracted C6–7 interspace with dural avulsion evidenced by CSF leakage. The C-6 segment was substantially retrolisthesed relative to C-7. The intervertebral disc was removed from the C-7 vertebral body. Reduction required the assistance of nursing staff translating the torso superiorly, toward the fixed skull. The C6–7 interspace could be reduced to approximately 7 mm, but this was lost with the release of upward force on the patient's torso. An appropriately sized fibular strut allograft was fashioned. A 16-mm Vectra-One anterior cervical plate (Synthes Inc.) was secured to the C-7 vertebral body. The fibular strut graft was held in position while the reduction was again achieved. At this point, the C-6 screw was placed. On two occasions, C-6 screw pullout resulted when the patient's torso was released. With the third attempt, the C-6 screw was positioned at the junction of the C-6 superior endplate and C5–6 disc space, and reduction was maintained (Fig. 4).

FIG. 4.
FIG. 4.

Intraoperative lateral fluoroscopic image demonstrating reduction of the injury with good position of an interbody graft and anterior cervical plate. The superior screw is positioned at the junction of the C-6 superior endplate and C5–6 disc space.

Posterior Procedure

The patient was turned prone, and we verified with fluoroscopy that the anterior construct remained stable. Through a significantly widened C6–7 interlaminar space, we identified dural avulsion and spinal cord transection. Using a freehand technique, we placed 4.5-mm pedicle screws bilaterally at T-1 and T-2. During this process, the transected spinal cord herniated posteriorly, consistent with interbody graft displacement. This was fluoroscopically verified (Fig. 5). The graft was removed, providing visualization of the C6–7 interbody space and anterior cervical plate. The avulsed portion of the spinal cord herniating posteriorly was cut sharply and discarded. A portion of the rib autograft was morselized, mixed with demineralized bone matrix putty, and packed into the C6–7 interspace and spinal canal at that level. We positioned 4.0-mm screws in the C-6 lateral masses and the left C-5 lateral mass. We could not position a screw in the right C-5 lateral mass; therefore, a sublaminar wire was used. Following standard decortication, the rib autograft was secured between the 4.0-mm titanium rods using sutures.

FIG. 5.
FIG. 5.

Intraoperative lateral fluoroscopic image demonstrating posterior displacement of the interbody graft into the spinal canal during placement of the posterior instrumentation. As a result of the traumatic spinal cord transection, the graft was removed posteriorly without additional neurological injury.

Postoperative Course

The patient was maintained in halo-vest immobilization for 6 months postoperatively. Computed tomography studies at that point demonstrated fusion (Fig. 6). At 22 months after surgery, the patient remained neurologically unchanged.

FIG. 6.
FIG. 6.

Sagittal plane reconstruction of a CT scan demonstrating fusion 6 months postoperatively.

Discussion

Survival after complete lower cervical spinal cord injury is uncommon among pediatric patients.2,5,17,21,23,24,26,28,30 Ramrattan and colleagues reviewed the case of a 15-month-old patient who had been treated with anteroposterior fusion following a complete discoligamentous disruption at C6–7.30 The patient had not presented with significant distraction, and initial imaging was read as normal. The injury was identified following a detailed neurological examination and MRI. Matsumoto and colleagues reported their experience with an 18-month-old girl who had survived following a complete discoligamentous disruption with cervical spinal cord transection at C5–6.23 She had also suffered bilateral vertebral artery injury and had probably survived as a result of collateral circulation through the circle of Willis.

In our case, the patient presented with a dramatic distraction injury. He probably survived the initial trauma because the injury occurred at C6–7, where the vertebral arteries were not tethered within the bony vertebral canals and could therefore stretch without avulsing. Thus, despite his catastrophic spinal cord injury, the boy did not suffer a fatal brainstem infarct or cervical hemorrhage. The debilitating, yet nonlethal, nature of his injury presented complex ethical challenges for his family and caregivers. These played a large part in delaying definitive surgical stabilization. The decision to proceed with aggressive management was influenced greatly by the consistent cognitive improvements the patient exhibited during the days following his injury. As described above, the clinical services agreed to undertake an aggressive management course only after a series of in-depth discussions and multidisciplinary care conferences with the patient's parents. While we believed that an ethics consultation was reasonable, we also believed that honoring their consistent and unified preference for aggressive management was most in keeping with current principles of ethical patient care.

While there is little formal literature regarding the role of ethical parameters in decision making for children with severe spinal cord injuries, the American Medical Association Code of Medical Ethics states that the decision of a family member regarding the care of a patient who is not competent to make his or her own medical decisions should generally be accepted by physicians, with the exception of 4 circumstances: “1) there is no available family member willing to be the patient's surrogate decision maker; 2) there is a dispute among family members and there is no decision maker designated in an advance directive; 3) a health care provider believes that the family's decision is clearly not what the patient would have decided if competent; and 4) a health care provider believes that the decision is not a decision that could reasonably be judged to be in the patient's best interests.”25 In such cases, an ethics committee review is often requested prior to turning to the legal system for resolution, if necessary. In our case, there was no dispute among the patient's family members. While the treating services harbored substantial misgivings, the decision to treat could be reasonably judged to be in the child's best interests. Given these circumstances and despite the treating teams' concerns regarding the longterm prognosis, we elected to proceed without a formal ethics consultation.

Once the decision to perform operative reduction and stabilization was made, we elected to conduct the anterior portion of the procedure before the posterior. This decision was made given concerns that discectomy and graft placement may be made more complex following reduction and posterior instrumentation. However, the stronger bone purchase of the posterior instrumentation could have facilitated reduction without substantially compromising the goals of the anterior approach. The posterior dislodgement of the interbody graft may have been less likely, and the position of the anterior screws may have been more favorable had alignment been established prior to the anterior portion of the procedure. Alternatively, identification and retrieval of a displaced interbody graft could have been more complicated with a posterior followed by an anterior approach.

During the 15 days between the boy's injury and definitive surgery, he was managed in a halo vest. An attempt to maintain some element of reduction using the halo vest was unsuccessful. Multiple groups describe the successful use of halo-vest fixation following pediatric subaxial cervical spine injury.12 However, recent guidelines aptly summarize the challenges associated with pediatric cervical spine immobilization, and this case emphasizes the limits of halo fixation in the context of highly unstable distraction injuries.18,31,33

Our patient faces significant medical challenges as he ages. Comorbidities, such as neurogenic bowel and bladder, pressure ulcers, thrombotic events, and ventilator-associated pneumonia, are frequent sequelae of spinal cord injury.23,24,28,29 Pediatric patients bear particular risk for global spine instability.14,20,22 Neuromuscular scoliosis is expected to develop in nearly all children with cervical spinal cord injuries, making spine alignment a unique consideration.14,20,22,23 Treatment implications are especially difficult for very young children who are at significant risk for pulmonary complications and high mortality if early thoracic posterior spine fusion is performed.15,19,30 Allowing the deformity to grow unchecked, however, places the child at risk for the development of thoracic insufficiency syndrome.6–8

For these reasons, continued monitoring for spinal deformity will be a mandatory component of follow-up for our patient. Bracing and growth-sparing spinal surgery may become necessary if severe scoliosis develops before adequate pulmonary function for adulthood has been achieved. His care is currently coordinated in a multidisciplinary clinic for children with myelomeningocele and other spinal defects.

Conclusions

To our knowledge, this patient represents the third reported case of the survival of a pediatric patient following lower cervical spinal cord avulsion from a motor vehicle accident.23,30 Surgical management of his case was undertaken as a consequence of the specific anatomical characteristics of the injury, specifically, the lack of damage to the large cervical arteries and brain. This case offers valuable learning points regarding the management of severe pediatric cervical spine injury.

Author Contributions

Conception and design: all authors. Acquisition of data: Garg, Hankinson. Analysis and interpretation of data: all authors. Drafting the article: Salazar Davern. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Salazar Davern. Administrative/technical/material support: Salazar Davern, Hankinson. Study supervision: Garg, Hankinson.

References

  • 1

    Age at injury in: The 2004 Annual Statistical Report for the Model Spinal Code Injury Care Systems Birmingham, ALNational Spinal Cord Injury Statistical Center2004. 5556(https://www.nscisc.uab.edu/PublicDocuments/reports/pdf/2004StatReport.pdf) [Accessed October 15 2014]

  • 2

    Apple DF JrAnson CAHunter JDBell RB: Spinal cord injury in youth. Clin Pediatr (Phila) 34:90951995

  • 3

    Biffl WLMoore EEOffner PJBrega KEFranciose RJBurch JM: Blunt carotid arterial injuries: implications of a new grading scale. J Trauma 47:8458531999

  • 4

    Biffl WLMoore EEOffner PJBurch JM: Blunt carotid and vertebral arterial injuries. World J Surg 25:103610432001

  • 5

    Brown RLBrunn MAGarcia VF: Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg 36:110711142001

  • 6

    Campbell RM JrSmith MD: Thoracic insufficiency syndrome and exotic scoliosis. J Bone Joint Surg Am 89:Suppl 11081222007

  • 7

    Campbell RM JrSmith MDMayes TCMangos JAWilley-Courand DBKose N: The characteristics of thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis. J Bone Joint Surg Am 85-A:3994082003

  • 8

    Campbell RM JrSmith MDMayes TCMangos JAWilley-Courand DBKose N: The effect of opening wedge thoracostomy on thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis. J Bone Joint Surg Am 86-A:165916742004

  • 9

    Carreon LYGlassman SDCampbell MJ: Pediatric spine fractures: a review of 137 hospital admissions. J Spinal Disord Tech 17:4774822004

  • 10

    Cirak BZiegfeld SKnight VMChang DAvellino AMPaidas CN: Spinal injuries in children. J Pediatr Surg 39:6076122004

  • 11

    Dearolf WW IIIBetz RRVogel LCLevin JClancy MSteel HH: Scoliosis in pediatric spinal cord-injured patients. J Pediatr Orthop 10:2142181990

  • 12

    Dogan SSafavi-Abbasi STheodore NHorn ERekate HLSonntag VKH: Pediatric subaxial cervical spine injuries: origins, management, and outcome in 51 patients. Neurosurg Focus 20:2E12006

  • 13

    Eleraky MATheodore NAdams MRekate HLSonntag VKH: Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg 92:1 Suppl12172000

  • 14

    Farley FAHensinger RNHerzenberg JE: Cervical spinal cord injury in children. J Spinal Disord 5:4104161992

  • 15

    Goldberg CJGillic IConnaughton OMoore DPFogarty EECanny GJ: Respiratory function and cosmesis at maturity in infantile-onset scoliosis. Spine (Phila Pa 1976) 28:239724062003

  • 16

    Hadley MNZabramski JMBrowner CMRekate HSonntag VKH: Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg 68:18241988

  • 17

    Hamilton MGMyles ST: Pediatric spinal injury: review of 61 deaths. J Neurosurg 77:7057081992

  • 18

    Hooley EChaput CDRahm M: Internal fixation without fusion of a flexion-distraction injury in the lower cervical spine of a three-year-old. Spine J 6:50542006

  • 19

    Karol LAJohnston CMladenov KSchochet PWalters PBrowne RH: Pulmonary function following early thoracic fusion in non-neuromuscular scoliosis. J Bone Joint Surg Am 90:127212812008

  • 20

    Kilfoyle RMFoley JJNorton PL: Spine and pelvic deformity in childhood and adolescent paraplegia: a study of 104 cases. J Bone Joint Surg Am 47:6596821965

  • 21

    Kokoska ERKeller MSRallo MCWeber TR: Characteristics of pediatric cervical spine injuries. J Pediatr Surg 36:1001052001

  • 22

    Lancourt JEDickson JHCarter RE: Paralytic spinal deformity following traumatic spinal-cord injury in children and adolescents. J Bone Joint Surg Am 63:47531981

  • 23

    Matsumoto TKawakami MAndo MYoshida M: Rare case of survival after traumatic disruption of the cervical spine with combined complete spinal cord injury and bilateral vertebral arterial breakdown in an 18-month-old patient. Eur J Orthop Surg Traumatol 24:Suppl 1S311S3142014

  • 24

    Oluigbo COGan YCSgouros SChapman SKay ASolanki G: Pattern, management and outcome of cervical spine injuries associated with head injuries in paediatric patients. Childs Nerv Syst 24:87922008

  • 25

    Opinion 220 - withholding or withdrawing life-sustaining medical treatment. American Medical Association (http://www.ama-assn.org/ama/pub/physician-resources/medicalethics/code-medical-ethics/opinion220.page) [Accessed October 15 2014]

  • 26

    Orenstein JBKlein BLGotschall CSOchsenschlager DWKlatzko MDEichelberger MR: Age and outcome in pediatric cervical spine injury: 11-year experience. Pediatr Emerg Care 10:1321371994

  • 27

    Osenbach RKMenezes AH: Pediatric spinal cord and vertebral column injury. Neurosurgery 30:3853901992

  • 28

    Parent SMac-Thiong JMRoy-Beaudry MSosa JFLabelle H: Spinal cord injury in the pediatric population: a systematic review of the literature. J Neurotrauma 28:151515242011

  • 29

    Patel JCTepas JJ IIIMollitt DLPieper P: Pediatric cervical spine injuries: defining the disease. J Pediatr Surg 36:3733762001

  • 30

    Ramrattan NNOner FCBoszczyk BMCastelein RMHeini PF: Cervical spine injury in the young child. Eur Spine J 21:220522112012

  • 31

    Rozzelle CJAarabi BDhall SSGelb DEHurlbert RJRyken TC: Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 72:Suppl 22052262013

  • 32

    Ruge JRSinson GPMcLone DGCerullo LJ: Pediatric spinal injury: the very young. J Neurosurg 68:25301988

  • 33

    Whitehill RRichman JAGlaser JA: Failure of immobilization of the cervical spine by the halo vest. A report of five cases. J Bone Joint Surg Am 68:3263321986

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Article Information

Correspondence Monica Salazar Davern, 13120 E. 19th Ave., Mail Stop C292, Aurora, CO 80045. email: monica.davern@ucdenver.edu.

INCLUDE WHEN CITING Published online November 21, 2014; DOI: 10.3171/2014.10.PEDS14242.

DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Dr. Garg is a consultant for DePuy Synthes Spine.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Anteroposterior and lateral presentation radiographs of the chest (left) and cervical spine (right) demonstrating an approximately 2.7-cm distraction injury at C6–7.

  • View in gallery

    Computed tomography angiogram demonstrating severe distraction injury at C6–7, Grade 2 injury of the left V1 segment, and Grade 1–2 injury of the right V1 segment. Vert = vertebral. Figure is available in color online only.

  • View in gallery

    Sagittal T2-weighted MR image demonstrating spinal cord transection at C6–7 associated with an approximately 3-cm distraction of C6–7.

  • View in gallery

    Intraoperative lateral fluoroscopic image demonstrating reduction of the injury with good position of an interbody graft and anterior cervical plate. The superior screw is positioned at the junction of the C-6 superior endplate and C5–6 disc space.

  • View in gallery

    Intraoperative lateral fluoroscopic image demonstrating posterior displacement of the interbody graft into the spinal canal during placement of the posterior instrumentation. As a result of the traumatic spinal cord transection, the graft was removed posteriorly without additional neurological injury.

  • View in gallery

    Sagittal plane reconstruction of a CT scan demonstrating fusion 6 months postoperatively.

References

1

Age at injury in: The 2004 Annual Statistical Report for the Model Spinal Code Injury Care Systems Birmingham, ALNational Spinal Cord Injury Statistical Center2004. 5556(https://www.nscisc.uab.edu/PublicDocuments/reports/pdf/2004StatReport.pdf) [Accessed October 15 2014]

2

Apple DF JrAnson CAHunter JDBell RB: Spinal cord injury in youth. Clin Pediatr (Phila) 34:90951995

3

Biffl WLMoore EEOffner PJBrega KEFranciose RJBurch JM: Blunt carotid arterial injuries: implications of a new grading scale. J Trauma 47:8458531999

4

Biffl WLMoore EEOffner PJBurch JM: Blunt carotid and vertebral arterial injuries. World J Surg 25:103610432001

5

Brown RLBrunn MAGarcia VF: Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg 36:110711142001

6

Campbell RM JrSmith MD: Thoracic insufficiency syndrome and exotic scoliosis. J Bone Joint Surg Am 89:Suppl 11081222007

7

Campbell RM JrSmith MDMayes TCMangos JAWilley-Courand DBKose N: The characteristics of thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis. J Bone Joint Surg Am 85-A:3994082003

8

Campbell RM JrSmith MDMayes TCMangos JAWilley-Courand DBKose N: The effect of opening wedge thoracostomy on thoracic insufficiency syndrome associated with fused ribs and congenital scoliosis. J Bone Joint Surg Am 86-A:165916742004

9

Carreon LYGlassman SDCampbell MJ: Pediatric spine fractures: a review of 137 hospital admissions. J Spinal Disord Tech 17:4774822004

10

Cirak BZiegfeld SKnight VMChang DAvellino AMPaidas CN: Spinal injuries in children. J Pediatr Surg 39:6076122004

11

Dearolf WW IIIBetz RRVogel LCLevin JClancy MSteel HH: Scoliosis in pediatric spinal cord-injured patients. J Pediatr Orthop 10:2142181990

12

Dogan SSafavi-Abbasi STheodore NHorn ERekate HLSonntag VKH: Pediatric subaxial cervical spine injuries: origins, management, and outcome in 51 patients. Neurosurg Focus 20:2E12006

13

Eleraky MATheodore NAdams MRekate HLSonntag VKH: Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg 92:1 Suppl12172000

14

Farley FAHensinger RNHerzenberg JE: Cervical spinal cord injury in children. J Spinal Disord 5:4104161992

15

Goldberg CJGillic IConnaughton OMoore DPFogarty EECanny GJ: Respiratory function and cosmesis at maturity in infantile-onset scoliosis. Spine (Phila Pa 1976) 28:239724062003

16

Hadley MNZabramski JMBrowner CMRekate HSonntag VKH: Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg 68:18241988

17

Hamilton MGMyles ST: Pediatric spinal injury: review of 61 deaths. J Neurosurg 77:7057081992

18

Hooley EChaput CDRahm M: Internal fixation without fusion of a flexion-distraction injury in the lower cervical spine of a three-year-old. Spine J 6:50542006

19

Karol LAJohnston CMladenov KSchochet PWalters PBrowne RH: Pulmonary function following early thoracic fusion in non-neuromuscular scoliosis. J Bone Joint Surg Am 90:127212812008

20

Kilfoyle RMFoley JJNorton PL: Spine and pelvic deformity in childhood and adolescent paraplegia: a study of 104 cases. J Bone Joint Surg Am 47:6596821965

21

Kokoska ERKeller MSRallo MCWeber TR: Characteristics of pediatric cervical spine injuries. J Pediatr Surg 36:1001052001

22

Lancourt JEDickson JHCarter RE: Paralytic spinal deformity following traumatic spinal-cord injury in children and adolescents. J Bone Joint Surg Am 63:47531981

23

Matsumoto TKawakami MAndo MYoshida M: Rare case of survival after traumatic disruption of the cervical spine with combined complete spinal cord injury and bilateral vertebral arterial breakdown in an 18-month-old patient. Eur J Orthop Surg Traumatol 24:Suppl 1S311S3142014

24

Oluigbo COGan YCSgouros SChapman SKay ASolanki G: Pattern, management and outcome of cervical spine injuries associated with head injuries in paediatric patients. Childs Nerv Syst 24:87922008

25

Opinion 220 - withholding or withdrawing life-sustaining medical treatment. American Medical Association (http://www.ama-assn.org/ama/pub/physician-resources/medicalethics/code-medical-ethics/opinion220.page) [Accessed October 15 2014]

26

Orenstein JBKlein BLGotschall CSOchsenschlager DWKlatzko MDEichelberger MR: Age and outcome in pediatric cervical spine injury: 11-year experience. Pediatr Emerg Care 10:1321371994

27

Osenbach RKMenezes AH: Pediatric spinal cord and vertebral column injury. Neurosurgery 30:3853901992

28

Parent SMac-Thiong JMRoy-Beaudry MSosa JFLabelle H: Spinal cord injury in the pediatric population: a systematic review of the literature. J Neurotrauma 28:151515242011

29

Patel JCTepas JJ IIIMollitt DLPieper P: Pediatric cervical spine injuries: defining the disease. J Pediatr Surg 36:3733762001

30

Ramrattan NNOner FCBoszczyk BMCastelein RMHeini PF: Cervical spine injury in the young child. Eur Spine J 21:220522112012

31

Rozzelle CJAarabi BDhall SSGelb DEHurlbert RJRyken TC: Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 72:Suppl 22052262013

32

Ruge JRSinson GPMcLone DGCerullo LJ: Pediatric spinal injury: the very young. J Neurosurg 68:25301988

33

Whitehill RRichman JAGlaser JA: Failure of immobilization of the cervical spine by the halo vest. A report of five cases. J Bone Joint Surg Am 68:3263321986

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