Evaluation and Management of Thoracolumbar Spine Trauma in Pediatric Patients: A Critical Analysis Review.

¼ Pediatric thoracolumbar trauma, though rare, is an important cause of morbidity and mortality and necessitates early, accurate diagnosis and management.¼ Obtaining a detailed history and physical examination in the pediatric population can be difficult. Therefore, the threshold for advanced imaging, such as magnetic resonance imaging, is low and should be performed in patients with head injuries, altered mental status, inability to cooperate with examination, and fractures involving more than 1 column of the spine.¼ The classification of pediatric thoracolumbar trauma is based primarily on adult studies and there is little high-level evidence examining validity and accuracy in pediatric populations.¼ Injury pattern and neurologic status of the patient are the most important factors when determining whether to proceed with operative management.

PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.

BACKGROUND: Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. METHODS: In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. FINDINGS: Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. INTERPRETATION: Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. FUNDING: The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.

Value of MRI in the cervical spine imaging series of trauma patients: A state-of-the-art review.

INTRODUCTION: Clinical decision protocols for evaluation and assessment of traumatic cervical spine injuries (TCSI) lean more towards the use of CT imaging. Investigation with MRI is therefore considered unnecessary following negative CT findings according to some local protocols. This review aims to explore what benefits MRI may offer in the clinical management of TCSI patients. METHODS: A systematic search of the literature was conducted in the following databases: AMED, CINAHL, EMBASE and MEDLINE using defined key terms and synonyms optimised for each database. The eligible articles were subjected to data extraction and thematic synthesis. RESULTS: The initial electronic search yielded 2527 articles. Of these, 15 articles remained following the application of a pre-defined inclusion criteria and full-text assessment. Four themes (mechanism of injury, type of patient, injuries detected on MRI, significance of injuries detected on MRI) were developed relating to the usage and value of MRI in the management of CSI. DISCUSSION: Our findings indicate that MRI may be very valuable in some situations for the evaluation of TCSI, however, its usage must be cautiously considered on a case-by-case basis in light of additional clinical benefit, patient safety and resource availability following a normal CT scan or in conjunction with CT or projection radiography where appropriate. IMPLICATIONS FOR PRACTICE: MRI may serve as a confirmatory test in the management pathway of TCSI based on individual clinical needs. Consideration for key limitations (e.g., patients' cooperation) and accessibility challenges (e.g., cost) against the clinical benefit to the patient must be noted. Development of centre-specific policies from standard trauma imaging protocols may be essential for the timely management of TCSI.

Comparison of iCT-based navigation and fluoroscopic-guidance for atlantoaxial screw placement in 78 patients with traumatic cervical spine injuries.

BACKGROUND CONTEXT: Studies have shown biomechanical superiority of cervical pedicle screw placement over other techniques. However, accurate placement is challenging due to the inherent risk of neurovascular complications. Navigation technology based on intraoperative 3D imaging allows highly accurate screw placement, yet studies specifically investigating screw placement in patients with traumatic atlantoaxial injuries are scarce. The aim of this study was to compare atlantoaxial screw placement as treatment of traumatic instabilities using iCT-based navigation or fluoroscopic-guidance with intraoperative 3D control scans. METHODS: This was a retrospective review of patients with traumatic atlantoaxial injuries treated operatively with dorsal stabilization of C1 and C2. Patients were either assigned to the intraoperative navigation or fluoroscopic-guidance group. Screw accuracy, procedure time, and revisions were compared. RESULTS: Seventy-eight patients were included in this study with 51 patients in the navigation group and 27 patients in the fluoroscopic-guidance group. In total, 312 screws were placed in C1 and C2. Screw accuracy was high in both groups; however, pedicle perforations > 1 mm occurred significantly more often in the fluoroscopic-guidance group (P = 0.02). Procedure time was on average 23 min shorter in the navigation group (P = 0.02). CONCLUSIONS: This study contributes to the available data showing that navigated atlantoaxial screw placement proves to be feasible as well as highly accurate compared to the fluoroscopic-guidance technique without prolonging the time needed for surgery. When comparing these data with other studies, the application of different classification systems for assessment of screw accuracy should be considered.

Injuries in Fatalities of Dismounted Blast: Identification of Four Mechanisms of Head and Spine Injury.

Blast is the most common injury mechanism in conflicts of this century due to the widespread use of explosives, confirmed by recent conflicts such as in Ukraine. Data from conflicts in the last century such as Northern Ireland, the Falklands, and Vietnam up to the present day show that between 16% and 21% of personnel suffered a traumatic brain injury. Typical features of fatal brain injury to those outside of a vehicle (hereafter referred to as dismounted) due to blast include the presence of hemorrhagic brain injury alongside skull fractures rather than isolated penetrating injuries more typical of traditional ballistic head injuries. The heterogeneity of dismounted blast has meant that analysis from databases is limited and therefore a detailed look at the radiological aspects of injury is needed to understand the mechanism and pathology of dismounted blast brain injury. The aim of this study was to identify the head and spinal injuries in fatalities due to dismounted blast. All UK military fatalities from dismounted blast who suffered a head injury from 2007-2013 in the Iraq and Afghanistan conflicts were identified retrospectively. Postmortem computerized tomography images (CTPMs) were interrogated for injuries to the head, neck, and spine. All injuries were documented and classified using a radiology brain injury classification (BIC) tool. Chi-squared (χ2) and Fisher's exact tests were used to investigate correlations between injuries, along with odds ratios for determining the direction of correlation. The correlations were clustered. There were 71 fatalities from dismounted blast with an associated head injury with a CTPM or initial CT available for analysis. The results showed the heterogeneity of injury from dismounted blast but also some potential identifiable injury constellations. These were: intracranial haemorrhage, intracranial deep haemorrhage, spinal injury, and facial injury. These identified injury patterns can now be investigated to consider injury mechanisms and so develop mitigation strategies or clinical treatments. Level of Evidence: Observational. Study type: cohort observational.

Triage tools for detecting cervical spine injury in paediatric trauma patients.

BACKGROUND: Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES: To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS: For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA: We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

Clinical characteristics of upper cervical spine injuries in children: a retrospective case series.

OBJECTIVE: Pediatric cervical spine injuries (CSI) can be devastating, and children < 8 years are particularly at risk for upper CSI given unique anatomical differences. Diagnosis of these injuries can be delayed due to variable clinical presentations and a paucity of existing literature. The authors aimed to characterize the spectrum of pediatric upper CSI. METHODS: This was a retrospective, single-center case series of trauma patients aged < 16 years who were assessed at a level I pediatric trauma center and diagnosed with upper CSI between 2000 and 2020. Patients were included if they had evidence of bony or ligamentous injury from the occiput to C2 on imaging or autopsy. Data were obtained from manual chart review and analyzed using descriptive statistics. RESULTS: In total, 502 patients were screened and 202 met inclusion criteria. Of these, 31 (15%) had atlanto-occipital (AO) joint distractions, 10 (5%) had atlanto-axial (AA) joint distractions, 31 (15%) had fractures of C1-2, and 130 (64%) had ligamentous injury without joint distraction. Of the patients with AO injury, 15 patients had complete dislocation. They presented as hemodynamically unstable with signs of herniation and 14 died (93%). In contrast, 16 had incomplete dislocation (subluxation). They usually had stable presentations and survived with good outcomes. Of the patients with AA injury, 2 had complete dislocation, presented with arrest and signs of herniation, and died. In contrast, 8 patients with subluxation mostly presented as clinically stable and all survived with little residual disability. The most common fractures of C1 were linear fractures of the lateral masses and of the anterior and posterior arches. The most common fractures of C2 were synchondrosis, hangman, and odontoid fractures. Overall, these patients had excellent outcomes. Ligamentous injuries frequently accompanied other brain or spine injuries. When these injuries were isolated, patients recovered well. CONCLUSIONS: Among upper CSI, AO and AA joint injuries emerged as particularly severe with high mortality rates. Both could be divided into complete dislocations or incomplete subluxations, with clear clinical differences and the former presenting with much more severe injuries. Lateral cervical spine radiography should be considered during resuscitation of unstable trauma patients to assess for these CSI subtypes. Fractures and ligamentous injuries were clinically heterogeneous, with presentations and outcomes depending on severity and associated injuries.

Supplementary value and diagnostic performance of computed tomography scout view in the detection of thoracolumbar spine injuries.

PURPOSE: Assessing the diagnostic performance and supplementary value of whole-body computed tomography scout view (SV) images in the detection of thoracolumbar spine injuries in early resuscitation phase and identifying frequent image quality confounders. METHODS: In this retrospective database analysis at a tertiary emergency center, three blinded senior experts independently assessed SV to detect thoracolumbar spine injuries. The findings were categorized according to the AO Spine classification system. Confounders impacting SV image quality were identified. The suspected injury level and severity, along with the confidence level, were indicated. Diagnostic performance was estimated using the caret package in R programming language. RESULTS: We assessed images of 199 patients, encompassing 1592 vertebrae (T10-L5), and identified 56 spinal injuries (3.5%). Among the 199 cases, 39 (19.6%) exhibited at least one injury in the thoracolumbar spine, with 12 (6.0%) of them displaying multiple spinal injuries. The pooled sensitivity, specificity, and accuracy were 47%, 99%, and 97%, respectively. All experts correctly identified the most severe injury of AO type C. The most common image confounders were medical equipment (44.6%), hand position (37.6%), and bowel gas (37.5%). CONCLUSION: SV examination holds potential as a valuable supplementary tool for thoracolumbar spinal injury detection when CT reconstructions are not yet available. Our data show high specificity and accuracy but moderate sensitivity. While not sufficient for standalone screening, reviewing SV images expedites spinal screening in mass casualty incidents. Addressing modifiable factors like medical equipment or hand positioning can enhance SV image quality and assessment.

Rethinking cervical spine clearance in obtunded trauma patients: An updated systematic review and meta-analysis.

BACKGROUND: Cervical spine injuries (CSI) are often challenging to diagnose in obtunded adult patients with blunt trauma and the optimal imaging modality remains uncertain. This study systematically synthesized the last decade of evidence to determine the type of imaging required to clear the c-spine in obtunded patients with blunt trauma. METHODS: A systematic review with meta-analysis was conducted and reported using PRISMA 2020 guidelines. The protocol was registered on June 22, 2022 (PROSPERO CRD42022341386). MEDLINE (Ovid), EMBASE, and Cochrane Library were searched for studies published between January 1, 2012, and October 17, 2023. Studies comparing CT alone to CT combined with MRI for c-spine clearance were included. Two independent reviewers screened articles for eligibility in duplicate. Meta-analysis was conducted using a random-effect model. Risk of bias and quality assessment were performed using the ROBINS-I and QUADAS-2. The certainty of evidence was assessed using the GRADE methodology. RESULTS: 744 obtunded trauma patients from six included studies were included. Among the 584 that had a negative CT scan, the pooled missed rate of clinically significant CSI using CT scans alone was 6 % (95 % CI: 0.02 to 0.17), and the pooled missed rate of CSI requiring treatment was 7 % (95 % CI: 0.02 to 0.18). High heterogeneity was observed among included studies (I² > 84 %). The overall risk of bias was moderate, and the quality of evidence was low due to the retrospective nature of the included studies and high heterogeneity. CONCLUSIONS: Limited evidence published in the last decade found that CT scans alone may not be sufficient for detecting clinically significant CSI and injuries requiring treatment in obtunded adult patients with blunt trauma. IMPLICATIONS OF KEY FINDINGS: Clinicians should be aware of the limitations of CT scans and consider using MRI when appropriate. Future research should focus on prospective studies with standardized outcome measures and uniform reporting.

Outcomes of Follow-up Imaging After Pediatric Spinal Trauma Confirmed With Magnetic Resonance Imaging.

BACKGROUND: Imaging plays a crucial role in the diagnostic workup of pediatric spinal trauma. Computed tomography and conventional radiographs are widely used as the primary imaging methods. Magnetic resonance imaging (MRI) is a radiation-free alternative with high sensitivity for bony and soft tissue injuries. There is no consensus on the optimal use of follow-up imaging in pediatric spinal trauma without immediate surgical treatment, especially if the injury is primarily confirmed with MRI. This study aimed to assess the diagnostic value of follow-up imaging after MRI-confirmed spinal trauma in children. METHODS: The medical records and the imaging data of children and adolescents with emergency spinal MRI and follow-up imaging over 8 years were retrospectively reviewed. The primary study outcome was the outcome of follow-up imaging and its effect on management. RESULTS: The study population consisted of 127 patients. The follow-up imaging did not alter the management in any patient with presumably stable injury in emergency MRI. Short-term follow-up imaging showed no clinically significant progression in thoracolumbar compression fractures. Flexion-extension radiographs had no additional value in cases with stable cervical spinal injury on emergency MRI. CONCLUSIONS: The clinical utility of short-term follow-up imaging is low in children with stable spinal injury on emergency MRI. LEVEL OF EVIDENCE: Level III-retrospective observational study.

Paediatric spine injuries in the thoracic and lumbar spine-results of the German multicentre CHILDSPINE study.

BACKGROUND: Paediatric thoracolumbar spine injuries are rare, and meaningful epidemiological data are lacking. OBJECTIVES: The aim of this study was to provide epidemiological data for paediatric patients with thoracolumbar spinal trauma in Germany with a view to enhancing future decision-making in relation to the diagnostics and treatment of these patients. MATERIALS AND METHODS: A retrospective multicentre study includes patients up to 16 years of age who were suffering from thoracolumbar spine injuries who had been treated in six German spine centres between 01/2010 and 12/2016. The clinical database was analysed for patient-specific data, trauma mechanisms, level of injury, and any accompanying injuries. Diagnostic imaging and subsequent treatment were investigated. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years) and age group III (10-16 years). RESULTS: A total of 153 children with 345 thoracolumbar spine injuries met the inclusion criteria. The mean age at the time of hospitalization due to the injury was 12.9 (± 3.1) years. Boys were likelier to be affected (1:1.3). In all age groups, falls and traffic accidents were the most common causes of thoracolumbar spine injuries. A total of 95 patients (62.1%) were treated conservatively, while 58 (37.9%) of the children underwent surgical treatment. Minimally invasive procedures were the most chosen procedures. Older children and adolescents were likelier to suffer from higher-grade injuries according to the AOSpine classification. The thoracolumbar junction (T11 to L2) was the most affected level along the thoracolumbar spine (n = 90). Neurological deficits were rarely seen in all age groups. Besides extremity injuries (n = 52, 30.2%), head injuries represented the most common accompanying injuries (n = 53, 30.8%). Regarding spinal injuries, most of the patients showed no evidence of complications during their hospital stay (96.7%). CONCLUSIONS: The thoracolumbar junction was more frequently affected in older children and adolescents. The majority of thoracolumbar spinal column injuries were treated conservatively. Nevertheless, 37.9% of hospitalized children had to be treated surgically, and there was an acceptable complication rate for the surgeries that were performed.

Pediatric trauma population spine immobilization during resuscitation: A call for improved guidelines.

INTRODUCTION: This review aims to evaluate current practices regarding spine immobilization in pediatric trauma patients to evaluate their efficacy, reliability, and impact on clinical outcomes to guide future research and improved evidence-based practice guidelines. METHODS: PubMed, ProQuest, Embase, Google Scholar, and Cochrane were queried for studies pertaining to spinal immobilization practices in pediatric trauma patients. Articles were separated into studies that explored both the efficacy and clinical outcomes of spine immobilization. Outcomes evaluated included frequency of spinal imaging, self-reported pain level, emergency department length of stay (ED-LOS), and ED disposition. RESULTS: Six articles were included, with two studies examining clinical outcomes and 4 studies evaluating the efficacy and reliability of immobilization techniques. Immobilized children were significantly more likely to undergo cervical spine imaging (OR 8.2, p < 0.001), be admitted to the floor (OR 4.0, p < 0.001), be taken to the ICU or OR (OR 5.3, p < 0.05) and reported a higher median pain score. Older children were significantly more likely to be immobilized. No immobilization techniques consistently achieved neutral positioning, and patients most often presented in a flexed position. Lapses in immobilization occurred in 71.4% of patients. CONCLUSION: Immobilized pediatric patients underwent more cervical radiographs, and had higher hospital and ICU admission rates, and higher mean pain scores than those without immobilization. Immobilization was inconsistent across age groups and often resulted in lapses and improper alignment. Further research is needed to identify the most appropriate immobilization techniques for pediatric patients and when to use them.

The 'nutcracker' spino-laminar fracture: evaluation as a sentinel lesion of a hyperextension mechanism in cervical spine trauma.

OBJECTIVE: We hypothesised that the orientation of the fracture line in the cervical vertebral arch depends on the traumatic mechanism, specifically focusing on frontal oblique spino-laminar fractures to determine if this pattern can serve as an indicator of a hyperextension mechanism of injury of the cervical spine. MATERIALS AND METHODS: We reviewed the imaging records of 114 adult patients admitted to the emergency department of the Strasbourg University Hospital for severe polytrauma between January 2016 and December 2021 and who presented with a fracture of the posterior vertebral arch of the lower cervical spine on the whole-body CT scan. A radiology resident (R1) and a musculoskeletal radiologist (R2) independently read the CT scans to determine the type of vertebral arch fracture; inter- and intra-observer agreements were calculated using Cohen's Kappa test. Two musculoskeletal radiologists (R2 and R3) then reviewed the CT scans and possible MRIs to identify specific hyperextension injuries of the cervical spine. The association between frontal oblique spino-laminar fracture and hyperextension injuries was assessed using chi2 test. RESULTS: Thirty-five patients had frontal oblique spino-laminar fractures of the cervical spine. These fractures were significantly associated (p = 0.001) with hyperextension injuries of the cervical spine. The inter- and intra-observer agreements for the identification of these spino-laminar fractures were very good (0.86 (0.75-0.96) and 0.90 (0.81-0.99)). CONCLUSION: Frontal oblique spino-laminar fractures are easily recognisable on CT scans and significantly associated with other traumatic injuries known as resulting from hyperextension. Their identification should lead to a search for potential associated unstable vertebral disco-ligamentous injuries with MRI.

Are severity and location of facial trauma risk factors for cervical spine injuries? 10-year analysis based on the use of the AO spine injury classification and the comprehensive facial injury (CFI) score.

PURPOSE: This study aims to demonstrate a correlation between cervical spine injury and location and severity of facial trauma. METHODS: We did a 10-year retrospective analysis of prospectively collected patients with at least one facial and/or cervical spine injury. We classified facial injuries using the Comprehensive Facial Injury (CFI) score, and stratified patients into mild (CFI < 4), moderate (4 ≤ CFI < 10) and severe facial trauma (CFI ≥ 10). The primary outcome was to recognize the severity and topography of the facial trauma which predict the probability of associated cervical spine injuries. RESULTS: We included 1197 patients: 78% with facial injuries, 16% with spine injuries and 6% with both. According to the CFI score, 48% of patients sustained a mild facial trauma, 35% a moderate one and 17% a severe one. The midface was involved in 45% of cases, then the upper facial third (13%) and the lower one (10%). The multivariate analysis showed multiple independent risk factors for associated facial and cervical spine injuries, among them an injury of the middle facial third (OR 1.11 p 0.004) and the facial trauma severity, having every increasing point of CFI score a 6% increasing risk (OR 1.06 p 0.004). CONCLUSIONS: Facial trauma is a risk factor for a concomitant cervical spine injury. Among multiple risk factors, severe midfacial trauma is an important red flag. The stratification of facial injuries based on the CFI score through CT-scan images could be a turning point in the management of patients at risk for cervical spine injuries before imaging is available.

Diagnosis and treatment of cervical spine injuries in children.

Cervical spine injuries in children are a common reason for emergency room visits, while bone, ligament or spinal cord cervical lesions are relatively rare (1-1.5% of severe trauma in children) and mainly involve the upper cervical spine. The main causes are sports injuries, accidents at home and traffic accidents. Clinical triage is needed to avoid unnecessary radiation exposure from imaging. We propose a protocol to optimize the diagnosis and treatment. In children, conservative treatment using rigid immobilization (cervical collar or halo-vest) is the preferred option in stable and/or minimally displaced injuries. Frequent clinical and radiological monitoring is required to ensure the patient's condition does not deteriorate due to inappropriate or poorly tolerated treatment. In these cases, surgical treatment can be proposed as second-line treatment. Internal fixation is indicated as the first-line treatment if the injury is unstable or a neurological deficit is present. The fixation methods must be adapted to the pediatric population by taking into account the vertebral volume and residual growth potential. Intraoperative CT scans or neuronavigation can make the surgical procedure safer and easier. Clinical, radiographic and CT scan monitoring should continue until the end of growth in a child who underwent surgical treatment to quickly detect any mechanical complications or sagittal imbalance due to poor craniocervical or cervicothoracic alignment. LEVEL OF EVIDENCE: IV.

Pediatric case of a penetrating lumbar spinal injury.

PURPOSE: Penetrating spinal injuries are generally extremely rare and are seldom encountered in pediatric patients. The non-compliance of pediatric patients with physical examination can sometimes delay diagnosis and treatment. Here, we present a case of a child who had a fall and suffered penetrating spinal trauma due to a small glass fragment. CASE REPORT: A penetrating foreign body was detected in the lumbar spinal region of a 2-year-old patient with complaints of increased restlessness on physical activity followed by difficulty in walking. The patient was operated on and followed up without any complications in the perioperative and late postoperative periods. CONCLUSION: A detailed physical examination is necessitated in the pediatric age group because of insufficient anamnesis. The high number of patients per physician, especially in societies having a low socioeconomic standard, prevents detailed examinations, and unnecessary examinations may cause delays in diagnosis. However, one must note that the skin findings of pediatric patients can be very helpful, especially in pediatric neurosurgery, and examination should not be neglected.

Is it true that treatment in patients with Subaxial Cervical Spine Injury Classification System (SLICS) 4 is the surgeon's choice?

BACKGROUND: The Subaxial Cervical Spine Injury Classification System (SLICS) is a commonly used algorithm for diagnosing and managing subaxial cervical spine trauma. A SLIC score 4 suggests either surgery or non-surgically treatment depending on the surgeon's experience and patient's conditions. OBJECTIVE: Prognosis and treatment results were analyzed in patients with SLIC score 4. METHODS: The patients with SLIC score 4 were retrospectively reviewed from 2012 to 2019. Forty-one patients were included and divided into two groups: non-surgically treated and surgically treated. Demographic data and radiographs were analyzed. Statistical analysis was performed to determine the difference between the two clinical groups. RESULTS: Twenty-two patients were non-surgically treated, and nineteen patients were surgically treated. There was no neurological deterioration in both groups. However, there was no statistically significant difference in the last follow-up AISA and Nurick grade (p> 0.05). There was no significant difference in the number of patients who showed improvement when comparing the initial and the last follow-up neurological status (p> 0.05). CONCLUSION: Regardless of the treatment method, the spinal cord injury patients with SLICS point 4 showed a relatively good prognosis. Patients with SLIC score 4 could be treated non-surgically or surgically based on the surgeon's experience and factors associated with the patient's acute health status and chronic comorbidities.