Injury of the spine in children: causes, symptoms, diagnosis, treatment

Injury of the spine in children is relatively rare.

In relation to all fractures occurring in childhood, they are 0.7-1.3%.

[1], [2], [3]

What causes spinal trauma in children?

The main type of violence is flexion as a result of falling from a height or falling of gravity from above to the shoulders of the victim. The most common clinical form of spinal injury is compression wedge fractures of vertebral bodies. Much less frequent are fractures of spinous and transverse processes and very rarely isolated fractures of the arches. According to the research, for 51 injured children with spine injuries, isolated fracture of the arch was observed in only one, while compression fractures of the vertebral bodies were present in 43 children. Most often, fractures are localized in the mid-thoracic region. More common are not single, but multiple fractures. The above-mentioned features find an explanation in the anatomical and functional features of the children's spine and in the features of the child's relationship with the external environment.

Spine in children: anatomical and functional features

The skeleton of the child is more rich in organic substances, which gives it considerable flexibility and elasticity. The bodies of his vertebrae contain a large amount of cartilaginous tissue, grouped in the area of growth zones. The smaller the child, the less in the body of his vertebra is the spongy bone. Well pronounced, high, elastic intervertebral discs with a high turgor are excellent shock absorbers, protecting the body of the vertebrae from the effects of external violence. The least relative height is the mid-thoracic intervertebral discs. According to AI Strukov, in the bodies of the upper and middle thoracic vertebrae, the bony beams are located mainly vertically and have short horizontal anastomoses, while in the bodies of the lower thoracic vertebrae the network of vertical beams is closely intertwined with an equally well-defined network of horizontal beams that and gives the bodies of the lower thoracic vertebrae greater strength. Finally, the bodies of the middle thoracic vertebrae are located on top of the physiological thoracic kyphosis. These three anatomical premises - the lower height of the intervertebral discs, the architectonics of the vertebral bodies, the location at the height of the kyphosis - and are the cause of the most frequent fractures in the bodies of the middle thoracic vertebrae.

The anatomical features of the vertebral bodies of the child find their reflection on spondylograms. According to the data of VA Dyachenko (1954), the bodies of the infant's vertebrae have an ovoid shape and are separated from each other by wide intervertebral spaces, which in the lumbar region are equal to the height of the bodies, while in the thoracic and cervical regions it is somewhat smaller than the height of the bodies of the corresponding vertebrae.

On the profile spondylogram of children of this age, strictly in the middle of their dorsal and ventral surfaces, there are characteristic slit-like recesses reminiscent of the lips of the closed mouth (GI Turner). These depressions are the place where inter-segmental vessels enter, mostly vv. Basivertebrales. In later life periods of the child, these gaps are determined only on the ventral surface of the body. In the lower thoracic and upper lumbar vertebrae, these cracks can be traced to 14-16 years.

In a child aged l, 5-2 years in the profile spondylogram, the vertebral bodies are represented by regular quadrilaterals with rounded corners. Subsequently, the rounded edges of the vertebral bodies undergo changes and acquire a stepped shape, which is caused by the formation of a cartilaginous roller. Such "stepped" vertebrae are observed in girls up to 6-8 years, in boys - up to 7-9 years. By this age, additional points of ossification appear in the cartilaginous rolls, radiographically, according to SA Reinberg, become visible at the age of 10-12 years.

They are most well expressed in the anterior parts. Their appearance is very variable both in terms of time and location. Solid ossification of these cartilaginous ridges is revealed by 12-15 years, partial merging with vertebral bodies - by 15-17 years, and full fusion with vertebral bodies - by 22-24 years. At this age on spondylograms, the bodies of the vertebrae are represented in the form of a rectangular quadrilateral, and on the posterior spondylogram the surfaces of this rectangle are somewhat impressed.

Symptoms of spine trauma in children

Clinical diagnosis of vertebral fractures in children is difficult due to the entrenched idea that spinal fractures in childhood are almost never met.

Carefully collected history and detailed elucidation of the circumstances of the trauma will allow to suspect the presence of a fracture. To draw attention of the doctor should such information from the anamnesis, as falling from height, excessive bending at somersaults, falling on a back. With the fall on the back, the flexural compression fracture of the vertebral bodies is apparently explained by instant reflex bending of the upper segment of the trunk, which leads to compression of the bodies. This moment of the forced bending in the anamnesis is revealed with difficulty, since it passes unnoticed for the victim and usually does not appear in his story.

As a rule, children have uncomplicated, lighter forms of spine trauma.

The most characteristic complaint of the injured are pains in the area of spine trauma. The intensity of this unprovoked pain in the first hours after the injury can be significant and pronounced. Pain increases with movement.

During examination, abrasions and bruising of various localizations can be noted. Usually the general condition of the victims is quite satisfactory. In some, very rare cases, the pallor of the skin, the rapidity of the pulse is noted. If the lumbar spine is damaged, there may be abdominal pain, anterior abdominal wall tension. Local tenderness is the most constant of local symptoms. Which is enhanced by movement and palpation of spinous processes, as well as varying degrees of mobility of the spine. Axial load on the spine causes pain only in the first hours and days after injury. On the 2-3rd day this symptom, as a rule, is not detected.

There can be a rapid passing radicular pain and symptoms of concussion of the spinal cord. In a significant part of cases, all these symptoms disappear by the 4th-6th day, and the condition of the affected child is so improved that the doctor does not have a thought about spinal trauma.

Fractures of the transverse processes are characterized by restriction and pain when moving with legs and pains when trying to change the position in bed. Fractures of spinous processes differ in the presence of abrasions and bruising at the fracture level, local soreness, sometimes the mobility of the broken process is determined.

Diagnosis of spine trauma in children

When diagnosing compression fractures of vertebral bodies in children, spondylography becomes particularly important, since it is often the only way to timely diagnose correctly. The most reliable radiologic symptom of a compression fracture of the vertebral body is a decrease in the height of the fractured vertebra. This decrease can be very unconvincing and controversial, barely noticeable, but can be significant up to a decrease in body height by half its normal height. Decrease in height can be uniform, covering the entire length of the body or limited to its ventral divisions. Decrease in height can be observed by the type of canting of the closure plate with some apparent compaction due to the collapse of the subchondral layer of the bone. Densification of the bone trabeculae of the vertebral body can be observed. Slipping of the closure plate anteriorly, more often cranial, with the formation of a protrusion is observed. A.V. Raspopina described the symptom of the asymmetric location of the vascular gash or its disappearance on the fractured vertebra. All these symptoms are revealed on the profile spondylogram. The anterior spondylogram represents a significantly lower diagnostic value.

In the differential diagnosis should be remembered about congenital wedge-shaped vertebrae, apophysitis and other certain anomalies in the development of vertebrae, which can be mistaken for fractures.

When X-ray diagnosis of fractures of the transverse and spinous processes should be remembered for additional points of ossification, which can be mistaken for fractures.

[4], [5], [6], [7], [8], [9]

Treatment of spinal trauma in children

Treatment should ensure the unloading of the broken vertebral bodies and prevent their further deformation. With proper and timely treatment, the shape of the broken vertebra is restored. The smaller the child, the more pronounced the growth potential, the faster and more fully the restoration of the anatomical shape of the broken vertebra occurs. Usually, there is no need to carry out anesthesia of the body of a broken vertebra, because in children this procedure is much more painful than the pains experienced by them.

Treatment is carried out by laying the injured child on a hard bed in a position on the back with a light unloading pulling along the inclined plane by pulling under the axillae. Under the fracture area, dense sacs for reclining are put. Children require constant attention from the staff, as they quickly feel that they are healthy and do not follow the treatment regimen for the disappearance of pain. They can also be laid on a soft bed in the position on the stomach. It is better to combine these two positions. A change of position makes a difference in a child's life, but he can more easily reconcile with forced staying in bed. Since the first days of the therapeutic gymnastics on the above described complexes.

The length of the child's stay in bed depends on the degree of compression of the broken body, the number of damaged vertebrae and the age of the victim. This period varies from 3 to 6 weeks. In the vertical position the child is transferred in a special reclining lightweight corset. It should be as long as possible to keep the children from sitting in position. The terms of wearing a recliner and practicing physical therapy are on average 3-4 months. They should be individualized in each individual case and dictated by the child's well-being and control spondylography. With fractures of the processes, the treatment is carried out on a hard bed for 2 weeks.

In these cases, according to the relevant indications, the entire complex of necessary treatment should be carried out. With complicated fracture-dislocations, it may be necessary to close the displaced vertebrae, to revise the contents of the spinal canal, and to operatively stabilize the spine. Stabilization, and depending on the level and nature of the displacement, as well as the return of patients, is carried out either with a wire seam or metal plates with bolts or bolted plates in combination with a posterior spondylosis. In each case, all these issues are resolved strictly individually, taking into account the characteristics of a particular patient.

Consequently, spine fractures in childhood have a number of characteristics that are determined by the anatomical and physiological features of the structure of the children's spine. However, children can also have "normal" trauma of the spine, typical for adults, which should be treated by appropriate methods and methods, taking into account the features and differences of the child's organism.