What are the guidelines for managing pediatric patients with spine compression fractures?

Management of Pediatric Spine Compression Fractures

Initial Assessment and Imaging

Most pediatric thoracolumbar compression fractures should be managed conservatively with early mobilization, avoiding prolonged bed rest, and using bracing only for more severe injuries. 1, 2

Imaging Protocol by Fracture Severity

• F0 fractures (minimal compression): Two orthogonal X-rays are sufficient; MRI is not routinely indicated 1
• F1 fractures (mild compression): X-ray is mandatory, with MRI considered based on patient age and injury extent 1
• F2 fractures (moderate compression): X-ray followed by MRI confirmation 1
• F3 fractures (severe compression/burst): X-ray, MRI, and CT scan to evaluate posterior column integrity and canal compromise 1

Special Imaging Considerations

• In children under 6 years requiring general anesthesia for MRI, routine MRI is not performed unless neurological deficits are present 1
• MRI without contrast is the modality of choice for detecting SCIWORA (spinal cord injury without radiographic abnormality), which occurs in up to 38% of pediatric patients with myelopathy 3
• Adequate radiographs miss 22% of thoracolumbar fractures and 35% of sacral fractures compared to MRI 3

Conservative Management Protocol

Mobilization Strategy

Prolonged bed rest is contraindicated in pediatric compression fractures. 1

• F0 fractures: No crutches or bracing required; early mobilization as tolerated 1
• F1 fractures: Consider verticalization with crutches or bracing based on age and injury extent; spinal load reduction for 3-6 weeks (minimum 3 weeks, increasing with age) 1
• F2 fractures: Verticalization with crutches or bracing indicated; spinal load reduction for 6-12 weeks (minimum 6 weeks, increasing with age) 1

Pain Management

• NSAIDs as first-line analgesics 4
• Limit narcotic use to avoid sedation, falls, and deconditioning 4
• Encourage limited activity within pain tolerance 4

Surgical Indications

Early surgical treatment with instrumentation and fusion is mandatory for unstable fractures and any injury associated with spinal cord lesion. 2

Absolute Indications for Surgery

• Neurological deficits: Immediate surgical consultation with corticosteroid initiation and surgery performed as soon as possible to prevent further deterioration 5, 6
• Spinal cord compression: Particularly from osseous compression, where surgery allows better neurological recovery than radiation alone 4
• Frank spinal instability: Based on anatomic and clinical factors 4
• F3 fractures with posterior column involvement: Surgical treatment should be considered 1

Surgical Approach

• Combined anterior and posterior approach may be needed for complete decompression in complex injuries 5, 6
• Instrumentation techniques include pedicle screw fixation and wiring techniques, particularly beneficial in younger children with smaller anatomy 7

Critical Outcomes Data

Conservative Treatment Success

• Conservative treatment is successful in all stable fractures without neurologic lesion 2
• All patients in one series treated conservatively showed no complications, no deterioration of vertebral kyphosis, and no instability requiring surgical intervention 1

Surgical Treatment Necessity

• Conservative treatment fails in unstable injuries 2
• In children with spinal cord injuries treated conservatively, 4 of 11 developed severely progressive paralytic scoliosis 2
• Only 3 of 7 surgically treated patients with cord injuries were stabilized without deformity at long-term follow-up 2
• Children with traumatic spinal cord lesions develop deformity (scoliotic, kyphotic, or lordotic) in >90% of cases 2

Critical Pitfalls to Avoid

• Do not prolong bed rest: This dramatically increases risk of deconditioning, bone loss, thromboembolism, and mortality 4, 1
• Do not delay surgery in unstable fractures or neurological deficits: Conservative management of unstable injuries and cord lesions leads to progressive deformity and worse outcomes 2
• Do not miss SCIWORA: This is more common in children <8 years and requires MRI for diagnosis, as radiographs and CT will be normal 3, 7
• Do not perform inadequate neurological examination: Complete assessment is essential to identify any deficits mandating urgent surgical intervention 4
• Do not misinterpret normal pediatric spine features: Ossification centers, pseudosubluxation, and physiological vertebral wedging can be mistaken for injuries 7

Follow-up Duration

• Spinal load reduction (restriction of sports activities) should be tailored to fracture severity and patient age, with duration increasing with age 1
• Long-term follow-up is imperative given the potential for late deformity, particularly in patients with cord injuries 2, 8