Injuries of the cervical spine in high school wrestling

Severe injuries to the cervical spine and spinal cord have been widely reported from many causes: automobile accidents, diving mishaps, falls, and contact sports. This paper concerns three young men who sustained severe trauma to the cervical spine and spinal cord during high school wrestling. Certain head-holds are prone to cause such injuries. Their tetraparesis and tetraplegia were reversed by reducing the fracture-dislocation and internal stabilization, in one case by decompressive laminectomy when no bony disruption was encountered. Their recoveries were satisfactory, but prevention of these cervical injuries may be accomplished by elimination of the more dangerous holds in wrestling.     

Development of the spine after traumatic spinal cord injury in children and adolescents

In the 1970s, there was growing concern about the risk of secondary deformations of the spine as these seemed to endanger the otherwise improving prognosis for the life of paraplegic subjects, especially of paralyzed children and adolescents. According to the literature, the level and extent of the spinal cord injury and the age at the time of injury are determinants of the development of scoliosis, hyperlordosis or global kyphosis. Correction of the deformity by brace orthosis is not indicated except for children. The indications for surgical intervention in terms of the extent of the scoliosis and technical performance corresponds to the well known situation for idiopathic scoliosis except for the length of fusion. A special form of scoliosis, the so called "collapsing spine", allows good surgical correction because it is usually not rigid. Early, substantial degenerative processes such as segmental intervertebral instability at the level of the paraplegia, as well as distinct uncarthrosis proximally distant from the innervated zones with secondary radicular damage, are observed. By means of modern surgical procedures, the appearance of the patient's body, as well as the quality of life, can be favorably influenced.     

Injuries of the cervical spine in children

Summary Injuries of the spine in children rarely occur. They amount to about 0.2 % of all fractures and dislocation and to 1.5 to 3 % of all lesions of the spine. The younger an injured child is, the more likely it has sustained a lesion of the upper cervical spine. This spinal segment in comparison to adults is concerned more often and accounts for 50 % of all C-spine injuries. Important differences between the adult spine and the spine in the child disappear with the age of 10 years. Later diagnostics, classification and treatment correspond widely with the principles valid in adults. The knowledge of the normal shape and development of the spine are crucial in avoiding misinterpretations of X-ray films. Typical examples include the confusion of synchondrosis with fractures or of subluxations of the atlas and the C2/C3 segment with “true” instabilities. Relevant lesions always are accompanied by clear clinical symptoms. Specific injuries of the growing axial skeleton are lesions of the cartilaginous endplates and “fractures” of the synchondrosis. Atlantooccipital dislocations (AOD) occur typically in children. According to our experiences with 16 AOD we propose – dependent on the direction of dislocation of the occipital condyles – a simplified classification in anterior, posterior and completely unstable AOD. In one boy in our series we treated the lesion successfully by temporary interal fixation. He presented a massive improvement of initially subtotal neurologic symptoms. Injuries to the synchondrosis of the dens represent another typical lesion in childhood. Four out of 5 children treated in our clinic were involved as back seat passengers in head-on motor vehicle accidents. Three of them were restrained by 4 point children's seat harnesses. For conservative treatment we prefer a halo and plaster-vest for 12 weeks after closed reduction. We recommend operative treatment in cases of major dislocation with greater instability where it may be impossible to maintain alignment with halo fxation. Surgical equipment and techniques correspond in detail to those used in adults. Three of the five children mentioned have been stabilized successfully by anterior screw fixation. Atlantoaxial dislocations (AAD) are devided into translatory and rotatory instabilities. Sagittal dislocations of the atlas in children also need to be fixed by a fusion between C1 and C2. Rotatory instabilities in the acute phase are easy to reduce and are treated with a halo-fixator. According to our experiences in two delayed cases anatomical reduction is also possible after months partly by open, partly by closed means. For the lower C-spine lesion with encroachment of the spinal canal and above all ligamentous injuries represent a clear indication for operative treatment because, similar to the adult spine, they do not become stable after close management.      

Cervical spine injuries in children

Cervical spine injuries in children and adolescents are rare. Common mechanisms include motor vehicle accidents, sports injuries, fall from height, and gunshot injuries. Cervical spine injuries are classified by Allen and Ferguson according to the period they occur, as infantile, early juvenile, and late juvenile. Anatomically, two main types are defined as occipitoatlantal (upper cervical) and subaxial injuries. The purpose of this paper is to review cervical spine injuries in children and adolescents with respect to epidemiology, injury mechanisms, diagnosis, clinical and radiologic aspects, and treatment in the light of the current literature.     

Cervical spine injuries in children

Cardiorespiratory arrest occurring immediately after multiple injuries is usually assumed to be due to severe cerebral injury, acute hemorrhage, or airway obstruction. We have identified a group of 19 children (mean age, 6.3 years) who presented with absent vital signs (VSA) or severe hypotension, unexplained by blood loss, where these findings were caused by injury to the high cervical spine and cord, demonstrated either by X-ray or postmortem examination. Fourteen had radiologic evidence of injury to the spine between C1 and C3. In two patients the bony injury was at the C6-7 level, while in two patients the cervical spine X-ray was normal. Eighteen of the 19 children were initially resuscitated but died from a combination of hypoxic/ischemic encephalopathy and cerebral injury. Sixteen patients underwent postmortem examination and in 13 there was evidence of cord laceration, up to and including cord transection. These findings demonstrate a distinct pattern of "juvenile" cervical spine injury involving the high spine and cord which results in either apnea and cardiorespiratory arrest, or severe hypotension. This previously unrecognized cause of cardiorespiratory arrest should be considered in all children presenting with VSA after multiple trauma, even when there is no apparent radiologic abnormality of the cervical spine.     

Tibial spine fractures in children

Fractures of the intercondylar eminence of the tibia are not uncommon in the pediatric age group. This eminence consists of two projecting tibial spines: the anterior cruciate ligament being attached to the medial one. In spite of an avulsion of this bony fragment and its attached ligament, cruciate laxity does not appear to be a significant clinical finding on follow-up examination, regardless of the type of fracture, method of treatment, or mode of injury. Computed instrumental testing of these knees, however, revealed measurable degrees of residual cruciate laxity in spite of the absence of patient symptoms. In the pediatric age group, treatment by closed or open methods is directed toward reattachment of the loose fragment and achievement of some degree of joint congruity rather than restoration of cruciate integrity.     

Cervical spine injuries in children

Review of 24 consecutive cases of cervical spine injuries in children were reviewed showed that this uncommon injury occurred at a rate of 1.2 cases per year. Associated injuries occurred in 38%, and neurologic injury occurred in 29%, including two deaths. Results showed that 43% of children with neurologic injuries recovered. Nonoperative treatment was successful in 95%; however, 14% later developed kyphotic deformities. Surgical stabilization is recommended for flexion injuries associated with late sequelae and for compression (burst) fractures associated with neurologic injuries.     

Fracture of the anterior tibial spine in children

Considerable differences of opinion exist concerning the best treatment of anterior tibial spine fractures in children. In this retrospective study of 32 cases, residual symptoms and/or clinical instabilities were found in 16 instances. Open surgery is suggested for displaced fractures in patients 10 years and older.     

Lower cervical spine facet cartilage thickness mapping

OBJECTIVE: Finite element (FE) models of the cervical spine have been used with increasing geometric fidelity to predict load transfer and range of motion (ROM) for normal, injured, and treated spines. However, FE modelers frequently treat the facet cartilage as a simple slab of constant thickness, impeding the accuracy of FE analyzes of spine kinematics and kinetics. Accurate prediction of facet joint contact forces and stresses, ROM, load transfer, and the effects of facet arthrosis require accurate representation of the geometry of the articular cartilage of the posterior facets. Previous research has described the orientations of the facet surfaces, their size and aspect ratio, and mean and maximum thickness. However, the perimeter shape of the cartilaginous region and the three-dimensional distribution of cartilage thickness remain ill-defined. As such, it was the intent of this research to further quantify these parameters. METHOD: Vertebrae from seven fresh-frozen unembalmed human cadavers were serially sectioned and the osteochondral interface and the articulating surface of each facet on each slice were identified. The cartilage thickness was recorded at nine equidistant points along the length of each facet. It was observed that facets tended to have elliptic or ovoid shapes, and best-fit ovoid perimeter shapes were calculated for each facet. The thickness distribution data were used to represent the entire three-dimensional cartilage distribution as a function of one variable, and a thickness distribution function was optimized to fit the thickness distribution. The antero-posterior and medial/lateral shifts of the thickness center relative to the geometric were calculated and reported. RESULTS: High correlation was observed between the ovoid perimeter shapes and the measured facet shapes in radial coordinates, indicating that the ovoid approximation is able to accurately represent the range of facet geometries observed. High correlation between the measured and fitted thickness distributions indicates that the fitting function used is able to accurately represent the range of cartilage thickness distributions observed. CONCLUSION: Utilization of a more physiologic cartilage thickness distribution in FE models will result in improved representation of cervical spine kinematics and increased predictive power. The consistency observed in the thickness distribution function in this study indicates that such a representation can be generated relatively easily.