Introduction
Spinal injury is uncommon in the pediatric population, representing only 1% to 10% of all reported spinal injuries. There are certain anatomic and biomechanical differences between the immature spine of pediatric patients and in adults.
These include a greater mobility of the spine owing to ligamentous laxity, shallow angulations of facet joints, immature development of neck musculature, and incomplete ossification of the vertebrae. MVAs account for most injuries affecting adults and children in Saudi Arabia. They tend to be more common in males, mostly affect the cervical area, and can be associated with significant morbidity and mortality .
The paraspinal musculature and ligamentous structures in pediatrics, are immature. As the child rises, this covering strengthens. These allow the spine to lengthen more than the spinal cord, letting cord injuries to occur without vertebral column injury. The biomechanical characters of the immature spine result in more injuries above C4 in children who are younger than eight years. These features also allow for a relatively high incidence of spinal cord injury without vertebral column injury in children.
Spinal cord injury without radiographic abnormality (SCIWORA) was defined by Pang and Wilberger in 1982. This may account for up to a third of cord injuries. It is most common in the cervical spine. Magnetic resonance imaging may result in normal finding while the patient have complete cord injuries, including cord transections.
The epidemiological and radiological characteristics of spinal injuries in children of Saudi Arabia have not been described. Several reports have commented on the frequency of camel accidents in causing significant spinal injuries in adults.
The main goal of the current study is to address the frequency and etiology of traumatic injuries of the spine among children in Saudi Arabia aged 18 years and younger as well as hospital course, radiological investigations and clinical outcomes.
Materials and Methods
Study Design
This is a retrospective case series study, included all trauma cases in the trauma database at King Abdulaziz Medical City Trauma Registry (KAMC-TR), who are 18 years old and below, included in the study. Inclusion criteria were all consecutive cases with spine injury as the first, second or third diagnosis and are 18 years old and below between 2001 and 2009. Exclusion criteria were those Patients who sustained pathologic fractures or sacral fractures or those with injuries associated with congenital vertebral column anomalies or birth injuries were excluded. We conducted this study in the city of Riyadh, which is home to 5.8 million residents comprising 24.1% of the country’s population [13]. The median age of Saudi population is 21 years and children under the age of 19 comprise 41.7% of the total population [13]. Major traumas get transferred to a trauma center based on the location of the accident. King Abdulaziz Medical city (KAMC), where the study was conducted, is regarded as the country’s première trauma center for clinical care and research.
Study Variables and Outcome
Hospital and clinic records for each patient were reviewed, noting demographic data, mechanism of injury, seat- belt use, level(s) involved, type of bony injury, presence of spinal cord injury, Glasgow coma scale, Injury Severity Score at the time of presentation to Emergency, treatment received, neurological outcome, surgical intervention, length of hospital stay, discharge status, any associated injuries, and any complications during the hospital stay. We stratified patients according to their age at the time of head injury into three age groups: 0-8, 8-15, 16-18 years.
Statistical Analysis
Statistical analysis was performed using Statistical package for Social Science software (SPSS Pc+ version 17.0, IBM Corporation, USA). Descriptive statistics (mean, standard deviation, proportion, median and Inter quartile range) were used to describe the quantitative and categorical variables. A p-value of <0.05 was considered as statistically significant.
Results
Patient Demographics
In 8 years, KAMC-TR identified Eight thousand, nine hundred and forty one patients; all patients above 18 years were excluded to be 3796, of which 120 (3.2% of all pediatric trauma cases) patients were identified in 141 spinal injuries. The mean age was 13.5 (8.8 -18.2), of them 49.2% were at the age 16-18. (Table.1). we found that 100 (83.3%) patients are males and 20 (16.7%) were females.
Injury Characteristics
Motor vehicle crash (MVC) was found to be the leading cause of pediatric spine injury accounting 73 patients (60.8%). Followed by 25 patients (20.8%) were injured as pedestrians.
And mechanism of injury is significantly different among different age groups (P<0.002), in which causes in children less than 12 years old predominates pedestrian injury, while MVC predominates in patients from 12-18 years (figure. 2). There is also a significant difference between males and females regarding mechanism of injury (P0.013) with 40% of female injuries was caused by fall as well as 40% was caused by MVC, while male injuries accounted 65% were caused by MVC and 22% causes by pedestrian injury.
Regarding the time and date of injury, 2005 accounted the highest year in spine injuries (21.7%). 9.2% of injuries was delivered to the ER at 10 a.m., and 7.5% at 8 p.m.
Focusing on the use of safety devices, there were 32 cases (43.8%) were known that they used safety devices, of them 29 (90.6%) did not use it, while only 3 (9.3%) used seatbelts.
The road accounted for 82.5% of places, with 18 cases (15%) were unknown.
Cervical spine is the most common level affected 55.8, multiple level of spine affected accounted for 23.2%. (table. 2)
Injury Severity
The mean ISS was 15.02 (SD=13.2) and the mean GCS was 12 (SD=4), and the mean length of stay was 29.3 days (SD=60), and the maximum length of stay was 444 days, there is significant negative correlation between GCS and ISS (P<0.000), as well as hospital length of stay (P<0.000), But there is a positive correlation between ISS and hospital length of stay (P<0.001), ISS (p0.246), Hospital Length of stay(p0.264), GCS (p0.174) were not significantly different among different age groups. (figure. 4). There is significant difference between males and females in regards of GCS (p<0.000) and ISS (p0.036), but there is no significant difference regarding hospital length of stay (p0.539). And Pedestrian injury was the worse among mechanisms of injuries, with mean ISS= 20.16, and mean GCS= 10.08
Outcome
In the series, there were 10 (8.3%) deaths, 25 (20.8%) patients discharged with neurological deficit, and 85 (70.8%) fully recovered.
Analysis of Mortality
The registry accounted 10 (8.3%) deaths as a result of spine injury (might be associated with head or body injury), 9 of them died in the hospital and one died after disposition home. They were all male, 7 of them had GCS of 3, 2 had GCS of 15, and one had GCS of 4, the cause of spine injury was distributed as: five cases were pedestrian (20% of all pedestrians with spinal cord injury), three cases as result of motor vehicle crash (4.11% of all MVC patients), one motor cycle accident, and died as after fall. Two of them had fracture to one or more vertebra, three had dislocation injury and six cases had an unknown type of injury. Interestingly, four of these cases transported to Hospital via private vehicle, one stayed pending, and five transported via BLS ambulance. Two of them underwent spinal surgery and two underwent non-spinal surgery.
Type of Intervention
Out of 120 cases, 55(45.8%) underwent surgery, of these 22(40.7%) underwent spine surgery, 10 cases developed neurological deficit after spine surgery, and 12 recovered neurologically. The rest of cases treated conservatively by casts or collars.
Transportation
Only four (3.3%) cases transported from the scene of accident to the hospital by ALS ambulance, their initial GCS were 8, 9, and two of them had 15 GCS, most of them had head, body and spine injuries. Three of them had vertebral fracture and one had dislocation.
44 (36.7%) came with private vehicle, 32 (72%) had cervical spine injury!! 16 had thoracic spine injury, and 8 had lumbosacral injury. 5 (12.4%) there ISS were more than 30. Three (6.8%) of cases, the initial GCS was 3, two (4.5%) GCS was 9, and the remaining GCS was more than 10. In outcome point of view, three cases (6.8%) died, five (11.4) had neurological deficit, and 35 (79.5%) recovered completely.
