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Dachling Pang and James E. Wilberger Jr.

spine appear to produce more serious neural injuries than extension forces. One explanation is that the pediatric spine is more resistant to extension forces than to flexion forces. However, if the ages of these patients were taken into consideration, it is clear that the three cases of complete cord transection due to hyperextension and the six cases of severe to complete cord injury due to flexion all occurred in children under 6 years. Thus, an alternative explanation may again be related to the aforementioned suggestion that the spines in infants and young

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Pediatric neck injuries

A clinical study

Stephen A. Hill, Carole A. Miller, Edward J. Kosnik and William E. Hunt

reviews of these features and the characteristics of pediatric spine lesions exist, 6, 21, 39, 53, 56, 66, 68 as do studies of the radiological subtleties of congenital anomalies and true injuries of the incompletely ossified cervical spine. 39, 40, 46, 53, 61, 66–68 The upper segments are susceptible to traumatic subluxations at the atlanto-occipital, 22 atlantoaxial, 16, 20, 24, 33, 44, 47, 67 and C2–3 levels, 37, 49, 58 but the most common injury to the spinal column itself is probably fracture of the odontoid 55 with or without cruciate ligament incompetency

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John R. Ruge, Grant P. Sinson, David G. McLone and Leonard J. Cerullo

frequent etiology of pediatric SCI as opposed to passenger-related MVA in adults. 2, 7, 9, 10, 21, 25, 27, 30, 31, 36, 39, 56, 57 Anatomical and biomechanical differences certainly exist between the adult and pediatric spine. Those differences that may play a role in SCI include the following: the infant's head is a disproportionately large mass and exposes the spine to different inertial forces; 20, 46, 47, 56 facets are shallowly angulated and the vertebral bodies are wedge-shaped, predisposing the spine to greater mobility; 6, 12, 17, 20, 23–25, 29, 45, 48, 53, 56

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Pediatric spinal trauma

Review of 122 cases of spinal cord and vertebral column injuries

Mark N. Hadley, Joseph M. Zabramski, Carol M. Browner, Harold Rekate and Volker K. H. Sonntag

✓ A review of 122 pediatric cases of vertebral column and spinal cord injuries is presented. These relatively uncommon injuries can be characterized by four distinct injury patterns: fracture only, fracture with subluxation, subluxation only, and spinal cord injury without radiographic abnormality. The immature pediatric spine has several anatomical and biomechanical features that distinguish it from the mature adolescent spine and, accordingly, the frequency of the injury type, the level of spine injury, and the incidence of neurological compromise were found to vary with the age of the patient. Follow-up data were obtained in 93% of the cases (median duration 44 months). No patient was made worse by treatment, 89% of the patients with incomplete myelopathy on admission were improved on their last examination, and 20% of the patients with a complete myelopathy had evidence of significant recovery of function. The authors conclude that the outcome after pediatric spinal trauma is good.

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Ian F. Pollack, Dachling Pang and Robert Sclabassi

✓ Spinal cord injury without radiographic abnormality is a well-known entity in the pediatric age group. Agerelated elasticity of the vertebral ligaments as well as immaturity of the osseous structures in the pediatric spine allow momentary subluxation in response to deforming forces. The resultant neurological injuries range from transient dorsal column dysfunction to complete cord transection. Between 1960 and 1985, 42 such injuries were treated at the Children's Hospital of Pittsburgh. Management of these radiographically occult spinal cord injuries consisted of cervical immobilization for 2 months in a hard collar and restriction of contact sports. Recurrent cord injury occurred in eight cases during the 2-month immobilization period. A clearly defined traumatic episode was identified in seven of the eight patients, although in four children the recurrent trauma to the spine was trivial. Five of the children removed their collars briefly before the second injury, and two children incurred reinjury with the hard collar in place. The remaining child was too young for hard-collar immobilization, and recurrent neurological deterioration occurred during sleep. Serial flexion-extension films failed to detect frank instability in any of the eight cases. The children most susceptible to reinjury were those who sustained mild or transient neurological deficits from an initial cord injury and who rapidly resumed normal activities. Radiographically occult spinal instability resulting from the initial injury to the vertebral and paravertebral soft tissues presumably made these children vulnerable to recurrent spinal cord injury, often from otherwise insignificant trauma. During the last 21 months, 12 additional children have been managed with a more stringent protocol combining neck immobilization in a rigid cervical brace for 3 months and restriction of both contact and noncontact sports, together with a major emphasis on patient compliance. With this new protocol, no recurrent cord injuries have been documented.

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Thomas A. Sweasey and Robert C. Dauser

to 1500 rads); 3, 5 however, it is now considered unnecessary by most authors. 13, 16 More controversy involves treatment of patients with neurological deficits. Some authors consider that immobilization with radiation therapy provides adequate treatment for these patients. 5 A major disadvantage of this treatment is the impairment of growth secondary to radiation destruction of vertebral endplates in the pediatric spine. 16 Others believe that the neural elements should be decompressed. If spinal instability occurs in the process of decompression, then fusion

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Mark G. Hamilton and S. Terence Mylks

population treated over 14 years. The large size of this general pediatric population, which is believed to be representative of a large area, provides a unique opportunity to comment on previous observations regarding the injury profile and outcome of the pediatric spine-injured patients. We have also reviewed an additional group of 55 pediatric patients who died after sustaining spinal injury. 11 The total of 61 deaths represents a 28% mortality rate for this pediatric population compared to an 11 % mortality rate noted for adults during this period: a pediatric

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Mark G. Hamilton and S. Terence Myles

hours of trauma. This mortality rate is significantly higher than in the adult population. Unfortunately, Kewalramani, et al. , did not characterize this important subpopulation and, until now, there have been no other reports that have substantiated their mortality figures. Highlighted in our review is a large group of 61 pediatric deaths associated with spinal injury, representing 28% of the total pediatric spine-injured population composed of patients with vertebral column injuries both with and without spinal cord damage. This compares poorly with an 11

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Paul D. Chumas, Derek C. Armstrong, James M. Drake, Abhaya V. Kulkarni, Harold J. Hoffman, Robin P. Humphreys, James T. Rutka and E. Bruce Hendrick

Neurosurg 76 : 173 – 174 , 1992 (Letter) Aoki N: Thecoperitoneal shunting. J Neurosurg 76: 173–174, 1992 (Letter) 3. Armstrong DC , Harwood-Nash DC : Pediatric spine , in Stark DD , Bradley WG Jr (eds): Magnetic Resonance Imaging. St Louis : CV Mosby , 1992 , Vol 2 , pp 1370 – 1373 Armstrong DC, Harwood-Nash DC: Pediatric spine, in Stark DD, Bradley WG Jr (eds): Magnetic Resonance Imaging. St Louis: CV Mosby, 1992, Vol 2, pp 1370–1373 4. Barkovich AJ , Wippold FJ

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Charles P. Bondurant and John J. Oró

subsequent event predisposed to more severe injury by the previous event, 6, 16, 20, 22 the gradual course followed by most of the children fails to support this notion as the sole answer. Once a slowly expanding mass has been excluded, humoral and ischemic forces are suspect as guiding a gradual course. 3, 6, 17, 22 Indeed, an initial injury may set in motion a gradual deterioration punctuated by, sometimes accelerated by, and perhaps even facilitating subsequent injury. The infrequency of pediatric spine trauma and more importantly the occasional delayed symptom