Pediatric Spinal Trauma at a Single Level 1 Trauma Center: Review of 62 Cases

The study was reviewed and approved by the Ethics Committee of the Ajou University Hospital (No. AJOUIRBDB-2023-125), and patient consent was waived.

Traumatic spinal injury is uncommon in children and is estimated to account for only 1%–10% of all spinal injuries.1, 2) However, spinal trauma in children brings significant morbidity and mortality to affected children, which is also socioeconomically fatal.3, 4, 11) The anatomy and biomechanics of children’s vertebrae are different from those of adults and are characterized by immature neck muscles, anterior wedging of vertebral bodies, shallow and horizontal facets, and elastic and lax interspinous ligaments.12, 13) These characteristics gradually change similar to adults as they age, and thus show various injury patterns for trauma through age groups.10) The purpose of this study was to investigate epidemiology of pediatric spinal trauma in a single Korean level 1 trauma center and to see differences according to age groups.

The most common age group in this study population was group III (15–17 years old). In previous studies, most of the traumatic spinal injuries were frequent at adolescent ages.8, 14) Children in this age group are more likely to be exposed to dangerous situation because they act more independently without adult supervision and tend to illegally participate in driving motorcycles. In our study, fall (74.2%) was the most common mechanism of injury followed by RTC (21.0%). This is a significantly different result from previous studies. Many papers reported that nearly 50% of pediatric spinal injuries were caused by traffic accidents.11, 15, 16, 17) This result is probably due to the difference in inclusion criteria. Since our study excluded minor injuries such as fractures of spinous and transverse process, it is possible that the injuries caused by minor traffic accidents was excluded from the analysis. In terms of intentionality of injury, 29 of a total of 62 patients attempted suicide through falls. Of these, 20 (69.0%) had mental health problems such as depression, schizophrenia, and anorexia. This result is similar to Kano et al.18) reporting that 77% of suicidal jumpers with spinal injuries had psychiatric conditions. In addition, there were differences in the proportion of intentional injuries depending on the age group, with more than 50% of suicide attempts were found in group III, and the proportion of unintentional accidents in group I and group II was higher. In other words, children in adolescence are more vulnerable to fall due to mental health problems, and this highlights the importance of social and family interest in adolescent children to prevent traumatic spinal injury in children.

The injuries seen in our study population predominantly occurred in the thoracolumbar junction. Some previous studies have reported that cervical vertebrae are the most frequent region;9, 19) in our study, cervical spine injuries were only 4.3%. However, we believe that these results are due to the age distribution. In studies with similar age distribution to ours, thoracic and lumbar injuries were the most common.2, 11) In addition, young children seem to sustain more cervical spine injuries, whereas adolescents tend to sustain more thoracic and lumbar injuries.20, 21)

Like other studies of pediatric spinal trauma, we found that multilevel contiguous injury was more common than single-level or multilevel non-contiguous injury.22, 23) In our series, we found multilevel injuries in 75.8% of patient—58.1% contiguous and 17.7% noncontiguous injuries. Eleraky et al.24) have described this problem as hyperflexibility of the young spinal column, but it does not fully explain why there are many multilevel injuries even in relatively less flexible adolescent age groups. This is probably the effect of trauma passing through a small body, so the imaging studies evaluating traumatic spinal injuries in children should include the entire spine. The incidence of neurological deficits associated with spinal injury is 19%, similar to previous series.9) As in other studies, most patients with neurological deficits improved, which is thought due to the plasticity and ability for recovery of the immature spinal cord.25)

In this study, 83.9% of the patients had associated injuries accompanied by spinal injuries. Compared to patients with isolated spinal injuries, polytrauma patients had significantly higher ISS, which seems reasonable for ISS to add up the Abbreviated Injury Scale squares for different regions of the body.26) There were only 2 deaths, accounting for about 3% of all included patients, similar to other published studies.10, 11)

The limitation of the study is that it is a small sample-sized retrospective analysis from a single trauma center. Minor pediatric spinal injuries managed by local general hospitals were not reflected and the results will be difficult to generalize due to the small sample size. However, since our hospital’s trauma center is the largest in South Korea, we believe that the epidemiology of pediatric spinal trauma will not be much different from our study. As the follow-up period after discharge was short, spinal deformity that may occur after growth was not included in the analysis. Finally, sex distribution analysis according to injury mechanism or injury intention was not conducted. Additional multicenter and long-term follow-up studies are warranted.

Our study identified fall from height as the most common mechanism of pediatric spinal injury. All intentional injuries were suicide attempts through falls, and many cases had already mental health problems. Thoracolumbar junction injuries were predominant, and the rate of multilevel contiguous injuries was high. The support and interest of the society and families for adolescent children are important in preventing spinal trauma, and image testing of the entire spine is essential when evaluating pediatric spinal injuries.