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Treatment for Children with Spinal Cord Injuries

Posted on: 11/10/2010
Fifty years have gone by since the first study published on spinal cord injuries in children. Although this injury doesn't happen very often, when it does occur, surgeons must be ready to provide the best treatment possible.

Systematic reviews like this one are important because they summarize evidence to support best practice. Researching all studies published on a subject like pediatric spinal cord injuries gives everyone a better idea of who suffers these injuries and how they should be treated.

What do we know about who is spinal cord injured at an early age? Most of the children are in their teens. Only 10 per cent of all pediatric spinal cord injuries affect children younger than 15 years.

Their injuries come from car accidents, falls, sports, diving, gunshot wounds, and pedestrian injuries. Boys (males) are injured more often than girls (females).

Car accidents rank as the number one cause of spinal injuries. Just slightly more than half of all spinal cord traumas are the result of car accidents for all ages. And two thirds of these injuries occur when the child was not wearing a seat belt.

What's the best way to treat these injuries? The first problem surgeons face is the stabilization of the spine. Broken vertebral bones must be put back together and held in place so that they don't do further damage to the spinal cord.

Taking pressure off the spinal cord is referred to as a decompression procedure. Using wires, screws, metal plates, or rods to hold the spine in place is referred to as internal fixation or instrumentation.

The timing of the surgery (how soon after the accident) and the methods used (fixation or not? type of instrumentation?) are two of the biggest debates. Most of the research done so far has been on adults. As you can imagine (especially with young children), the small size of the bones and immature skeletal structures presents unique challenges.

Applying treatment techniques designed for spinal cord injured adults on children often yields better results than when using them on adults. Results are measured in terms of fusion rates and complications.

That discovery raises the question, Are there even better ways to treat pediatric cases of spinal cord injury? Improved spinal cord monitoring techniques and Stereotactic and CT guidance systems used during surgery are now available.

Are there improved results because of them? Hopefully future studies of children will bring about some answers to these questions. For now, the evidence suggests that unstable spinal fractures should be surgically corrected. Realigning the bones protects the nerve tissues.

What about spinal deformities that develop later? What's the best way to treat scoliosis (curvature of the spine) in children who are still growing? Is more surgery needed? What about the use of back braces?

Studies show that almost all children who have not completed growth at the time of the spinal cord injury will develop a spinal curvature. Trunk deformity is most common in girls during a growth spurt. This occurs most often before the age of 12 when trunk growth slows to a stop. The same is true for boys but growth slows to a stop at a slightly older age (12 to 14).

Everyone on the team (parents or family, physicians, physical therapists, nurses) monitors the child closely for the first sign of spinal deformity. Bracing right away is strongly encouraged to keep the curve from getting worse and perhaps prevent the need for spinal fusion.

When bracing doesn't prevent worsening of the deformity, then surgery may be needed to fuse the spine and hold it in place. There is very low evidence to support this recommendation. It is how treatment is carried out right now. This approach will likely continue as such until studies are done to show whether there is a better way to approach this problem.

In summary, use of instrumentation is strongly recommended for unstable spinal fractures in children. Protecting the spinal cord is a high priority. Traditional treatment with bracing and physical therapy remains the approach to spinal deformities (scoliosis).

Future studies are needed to further examine both of these issues. High-quality evidence is needed to support continued treatment as it is now provided or to offer guidance in a different direction -- one that will yield better results.

References:
Stefan Parent, MD, PhD, et al. Unique Features of Pediatric Spinal Cord Injury. In Spine. October 1, 2010. Vol. 35. No. 21S. Pp.S202-S208.

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