Unique features of pediatric spinal cord injury.
METHODS
Systematic review.


OBJECTIVE
The objective of this systematic review was to identify the unique features associated with pediatric spinal cord injury (SCI) with the intention of determining the most effective spinal stabilization methods and identifying the optimum treatment for post-traumatic spinal deformity in pediatric patients with a SCI.


BACKGROUND
Spinal injuries occur in 1.99/100,000 children, 10% are under 15 years, 60% to 80% occur in the cervical spine, and 5.4% to 34% in the thoracolumbar spine. The most frequent incident of spinal injury (50%-56%) occurs during motor vehicle accidents.


METHODS
A systematic review of the English language literature explored articles published between 1950 and 2009. Electronic databases (Medline and Embase) and reference lists of key articles were searched to identify unique features of pediatric SCI based on 2 questions: (1) "What is the most effective means to achieve spinal stabilization in pediatric patients with a SCI?" and (2) "What is the most effective treatment of post-traumatic spinal deformities in pediatric patients with a SCI?" Three Spinal Trauma Study Group faculty members assessed the level of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria and disagreements were resolved by a modified Delphi consensus.


RESULTS
No Level 1 or 2 evidence articles were discovered. Question 1 was addressed by 417 abstracts; from those 15 were selected for inclusion. This literature proved to be controversial, mostly focused on the adult population, pediatric series were retrospective, and most treatments were based on adult experience. The evidence supporting stabilization of the spine in the pediatric SCI population is very low for both the cervical and thoracic spinal regions. Question 2 was discussed in 517 abstracts; 8 relevant articles were selected. The principal key points, regarding the most effective treatment of post-traumatic spinal deformity in the pediatric SCI patients, suggest that the deformity should be prevented before the age of 10 to 12 years, younger SCI patients are unfavorable, nearly 100% of patients with SCI will develop a deformity, and brace treatment is generally recommended. Current evidence in support of brace use is very low.


CONCLUSIONS
Despite the lack of well-designed prospective studies to establish the efficacy of instrumentation in these cases, there remains very low evidence that supports the use of instrumentation in unstable pediatric spines to prevent neurologic injury and maintain spinal alignment. The very low evidence of benefits from early bracing clearly outweighs the risks and complications associated with its use. Close monitoring should be initiated early so as to delay surgical correction as late as possible. There is very low evidence to support the use of surgery for the treatment of deformity triggered by a SCI. There may be evidence suggesting that the correction techniques used for neuromuscular deformities are useful for SCI patients. In conclusion, there is a strong recommendation for the use of instrumentation in the unstable pediatric spinal injured population, and there is a strong recommendation for traditional neuromuscular spinal deformity treatment techniques to be adopted as a treatment of progressive spinal deformities after a neurologic injury.
Parent
Stefan
S
Research Center, Sainte-Justine University Hospital Center, Côte Sainte-Catherine, Montréal, Quebec, Canada. stefan.parent@umontreal.ca
Dimar
John
J
Dekutoski
Mark
M
Roy-Beaudry
Marjolaine
M
D000293:Adolescent; D001915:Braces; D002648:Child; D002675:Child, Preschool; D003697:Delphi Technique; D019317:Evidence-Based Medicine; D005260:Female; D005593:Fracture Fixation, Internal; D006801:Humans; D007223:Infant; D016268:Internal Fixators; D007593:Joint Instability / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D019637:Orthopedic Procedures / Q000009:adverse effects / Q000295:instrumentation; D020127:Recovery of Function; D012600:Scoliosis / Q000209:etiology / Q000628:therapy; D013119:Spinal Cord Injuries / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D016103:Spinal Fractures / Q000150:complications / Q000601:surgery; D013123:Spinal Fusion; D013124:Spinal Injuries / Q000150:complications / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome