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MULTIPLE FRACTURES OF VERTEBRAL BODIES IN CHILDREN AND ADOLESCENTS Skryabin E.G., Smirnykh A.G., Bukseev A.N., Akselrov M.A., Naumov S.V., Sidorenko A.V., Chuprov A.Yu.

Tyumen State Medical University,

Regional Clinical Hospital No. 2, Tyumen, Russia

 

Various aspects of spinal fractures in children and adolescents are still important and require for further studies, development and improvement [1]. The analysis of the recent scientific publications shows that many authors are not satisfied with the current situation and offer to revise the approaches to treatment of children and adolescents with uncomplicated compression fractures of vertebral bodies [2]. All above-mentioned facts relate to the problem of diagnosis and treatment of children and adolescents with multiple vertebrogenic fractures.

Objective − to study the prevalence, nature and type of multiple fractures of the vertebral bodies in children and adolescents for the choice of management strategy.

 

MATERIALS AND METHODS

We have the experience with dynamic observation and treatment of 1,000 patients at the age of 1.5-17 years with uncomplicated compression fractures of vertebral bodies in cervical, thoracic and lumbar regions within the period from September 1, 2010, to September 18, 2019.

Among 1,000 injured patients, 744 (74.4 %) children had fractures of two and more vertebrae. Their data present the basis for this study. There were 387 male patients (52 %) and 357 female patients (47.99 %). The mean age of patients was 9 years and 2 months.

The clinical diagnosis was made with the techniques which are common for urgent traumatology: complaints and anamnesis data collection, clinical examination with the standard methods, radial diagnosis. Radial diagnosis included plain X-ray imaging of the injured site (n = 744), computer tomography (CT (n = 426)), magnetic resonance imaging (MRI (n = 689)). For some clinical indications, adjacent specialists were attracted to examination.

AO/ASIF was used for determination of a type and a subtype of vertebral fractures [3]. The classification by Andrushko N.S. et al. was used for detailed description of degree of vertebral body compression [4]. The summary severity of injures was determined with ISS [5].

The statistical analysis of clinical materials included calculation of relative values (P), their allowable error (m) in samples, determination of extensive values, estimation of significance of difference in relative values with use of Student's test (t-test) for various confidence coefficient (p).

The study was approved by the ethical committee of Tyumen State Medical University (the protocol No. 59, June 27, 2014). The study complies with the ethical principles of good clinical practice, laws of the Russian Federation and Helsinki Declare of human rights in biomedical studies.

 

RESULTS

All 744 children with multiple vertebral fractures were distributed into five age groups. 56 (7.52 %) patients were at the age < 5 years, 300 (40.32 %) − at the age of 5-9, 238 (31.98 %) − at the age of 9-12, 90 (12.09 %) − at the age of 12-15, 60 (9.09 %) − at the age of 15-17.

Examination of circumstances of spinal injuries is the important stage of diagnosis which allows high probability of fact of vertebral fractures. The table 1 shows the proportion of various mechanisms of spinal injuries which were identified during questioning of victims, their relatives, bystanders and employees of emergency teams.

Table 1

Proportion of various mechanisms of spinal injury

Injury mechanism	Proportion
	Abs. number	P ± m (%)
Falling from height of own stature	275	36.96 ± 1.77
Falling from height of 1 meter and more	156	20.96 ± 1.49
Axial load to spine	111	14.91 ± 1.31
Low-energy trauma	104	13.97 ± 1.27
Road traffic accidents	52	6.98 ± 0.93
Other	46	6.22 ± 0.88
Total	744	100.0

As the table 1 shows, the main causes of injuries were falling to the back from height of own stature (275 cases, 36.96 %). One should note that this type of injury relating to vertebral fractures in children causes some skepticism among trauma surgeons. The main pathogenetic links of injuries with above-mentioned mechanisms are described below in the section Results and discussion. The rarest causes were presented by diving in non-deep places, after falling from merry-go-round rotating on the height of 30-40 cm from the ground, and during jumping. The mentioned and some other causes of injuries (46 clinical cases, 6.22 %) were combined in the section others.

The term "multiple" vertebral fractures supposes two and more fractures at the same time [6]. Among 744 children and adolescents of the analyzed cohort, 277 (37.23 %) patients received 2 vertebral fractures, 214 (28.76 %) − 3, 110 (14.78 %) − 4, 143 (19.23 %) − 5 and more vertebral fractures.

Separately, the cervical spine was injured in 5 (0.67 %) patients, isolated thoracic spine injury − in 534 (71.79 %), isolated lumbar spine injury − in 58 (7.79 %) patients. Traumatic injuries in two regions of the spine were diagnosed in 147 (19.75 %) of clinical cases. Concomitant injuries to the cervical and thoracic spine were identified in 8 (5.44 %) of cases, thoracic and lumbar spine − in 139 (94.56%) (t = 16.48; p = 0.001). Combination of injuries to the cervical and thoracic spine was not found in any case, as well as injuries to three spinal regions at the same time.

The table 2 presents the data on proportion of fractures of each vertebra, and the rank place in structure of all vertebral fractures. Totally, 744 children had fractures of 2,547 vertebrae. Therefore, on average, one patient received compression of 3.42 vertebrae.

Table 2

Proportion of fractures of each vertebra and ordinal position

Number of vertebra	Proportion		Ordinal position
	Abs. number	P ± m (%)
CI	-	-	-
CII	2	0.07 ± 0.05	XXII
CIII	-	-	-
CIV	4	0.15 ± 0.08	XXI
CV	6	0.24 ± 0.09	XX
CVI	9	0.35 ± 0.12	XVIII-XIX
CVII	9	0,35±0,12	XVIII-XIX
ThI	31	1.20 ± 0.21	XVI
ThII	75	2.94 ± 0.33	XIII
ThIII	167	6.55 ± 0.49	VII
ThIV	257	10.09 ± 0.20	III
ThV	297	11.66 ± 0.63	I
ThVI	270	10.60 ± 0.60	II
ThVII	218	8.55 ± 0.55	IV
ThVIII	186	7.30 ± 0.52	V
ThIX	146	5.73 ± 0.46	X
ThX	125	4.90 ± 0.42	XII
ThXI	152	5.96 ± 0.47	IX
ThXII	159	6.24 ± 0.50	VIII
LI	176	6.91 ± 0.50	VI
LII	128	5.02 ± 0.43	XI
LIII	70	2.74 ± 0.32	XIV
LIV	41	1.60 ± 0.25	XV
LV	19	0.85 ± 0.18	XVII
Total	2 547	100.0

Totally, the fractures of 30 (1.17 %) cervical, 2,083 (81.78 %) thoracic and 434 (17.05 %) lumbar vertebrae were diagnosed in the analyzed cohort. According to the incidence, the first three places were taken by Th5, Th6 and Th7 vertebrae − 297 (11.66 %), 270 (10.6 %) and 257 (10.09 %) cases correspondingly. The rarest cases were fractures of C2 (22nd place) − 2 (0.07 %) cases. C1 and C3 vertebrae injuries were not identified.

The analysis of clinical materials from the perspective of severity of injuries showed that the vertebral fractures corresponded to types A (2,535 (99.52 %) cases) and B (12 (0.48 %) cases) according to AO-ASIF [3]. The use of the classification by Andrushko N.S. et al. [4] allowed describing the severity of vertebral fractures. In concordance with criteria of this classification, the degree 1 of compression was registered for 1,178 (46.25 %) vertebrae, degree 2 − for 967 (37.96 %), degree 3 − for 327 (12.83 %) vertebrae, degree 4 − for 75 (2.96 %).

Among 744 children and adolescents with multiple vertebral fractures, 42 (5.64 %) patients had concurrent fractures of bones and injuries to internal organs and skull. So, among these 42 patients, the multiple pattern of injuries was found in 29 (69.04 %) clinical cases, concomitant pattern − in 12 (28.57 %), combined one − in 1 (2.39 %). Totally, 42 patients with polytrauma had fractures of 198 vertebrae, i.e. 4.71 fractures per one patient. The mean value of polytrauma severity was 16.14 points according to ISS [5].

Radial diagnosis confirmed the fact of an injury, as well as allowed estimating the number of injured vertebrae, their location, compression severity, identification of dysplasia and abnormalities of spinal motional segments. Like most modern researchers who study issues of diagnosis and of vertebral fractures in children, we think that MRI is one of the most informative techniques of radial diagnosis of this type of injuries. MRI reduces the percentage of hyperdiagnosis of vertebral fractures. It is very important since diagnosis vertebral fracture is made very rare in case of vertebral bone bruise [7]. The main diagnostic criterion of the bruise is bone marrow edema without other osseous changes [8]. These changes are usually presented by disorder of the vertebra shape at whole and by deformation of its upper end plate which indicate the presence of a fracture [2, 6].

Among 744 patients with multiple vertebral fractures, 525 (70.56 %) children and adolescents had adjacent vertebral fractures, i.e. in one by one manner. The table 3 shows the proportion of the amount of injured adjacent vertebrae.

Table 3

Proportion of number of adjacent injured vertebrae in patients of the studied cohort

Number of adjacent injured vertebrae	Proportion
	Abs. number	P ± m, %
2	219	41.71 ± 2.15
3	151	28.76 ± 1.97
4	67	12.76 ± 1.46
5	43	8.19 ± 1.20
6	21	4.02 ± 0.86
7	6	1.14 ± 0.46
8	5	0.95 ± 0.42
9	5	0.95 ± 0.42
10	4	0.76 ± 0.37
11	2	0.38 ± 0.27
13	2	0.38 ± 0.27
Total	525	100.0

As one can see in the table, fractures of 2 and 3 adjacent vertebrae were diagnosed more often: 219 (41.71 %) and 151 (28.7 %) cases correspondingly (t = 9.39; p < 0.001).

Moreover, 219 children and adolescents had fractures of two adjacent vertebrae. 58 (7.79 %) clinical cases were presented by fractures of two vertebrae, but with intervals between vertebrae, not in one by one manner. These intervals were presented by a single non-injured vertebra (43 cases), 2 (8 cases), 3 (3 cases) and 5 (4 cases) intact vertebrae.

Along with above-mentioned common clinical cases of location of compressed vertebrae, 39 various combinations of location of injured vertebrae with various number of clinical cases were identified. The most common variant (20 clinical cases) included cases of diagnosis of 2 fractured adjacent vertebrae, with the next uninjured vertebra and the following injured one. 14 cases included one fractured vertebra, one intact vertebra and 2 compressed vertebrae. 12 children had an injury to 2 adjacent vertebrae, followed by 2 intact vertebrae and one injured vertebra. Other 36 combinations of location of compressed and intact vertebrae were not common.

During the study, we considered the opinion by some authors: to exclude diagnostic errors, one should examine the whole organ along its extension, but not only a region of the patient's complaints [9]. Saul K. et al. [10] recommend to exclude presence of other vertebrogenic fractures if a fracture of one vertebra is identified. It is associated with the fact that diagnostic errors can cause incorrect management strategy.

A clinical case. We describe the following case of diagnosis and treatment of multiple vertebral fractures in a child. A patient, female, age of 5, was admitted to the admission unit of a big multi-profile hospital. She was transferred by the ambulance team. Her mother were with her. The child's complaints after admission: pain in the thoracic and lumbar spine. She was injured as result of a falling from the second floor. Immediately after admission, the child was examined by the team of on-duty physicians at the pediatric inpatient unit: anesthesiologist-intensivist, traumatologist-orthopedist, surgeon, neurosurgeon. The examination with "polytrauma" mode included CT, abdominal ultrasonic examination,  (no pathology), electrocardiography (age norm), clinical minimum (age norm), biochemical study of the blood (age norm). On the basis of the results of a conducted study, acute surgical and neurosurgical abnormalities were excluded. Diagnosed left-sided pneumothorax was minimal according to volume, and it did not require for active medical procedures.

The local status of the spine: the child was positioned in prone position in the wheel-chair. Visually, the spine axis was correct. There were not any disorders of skin surface, edema and blood stains on the posterior part of the body. Spine palpation showed pain in the region of spinous processes, interspinous intervals, along thoracic and lumbar regions in paravertebral manner. Chest palpation showed pain at the level of ribs 5-7 to the left along the middle scapular line. The axial load to the spine was moderately painful. There were not any vascular and neurological disorders in the upper and lower extremities. The axial load to iliac wings was painful. Spinal CT showed compression fractures of Th7, Th8, Th9, Th10, Th11, Th12,  L1 and L2 vertebrae (Fig. 1a).

Figure 1a

Picture of results of radial diagnosis of the spine of the patient (age of 5): CT-image 

The preliminary diagnosis was made on the basis of complaints, anamnesis and results of clinical and radial examination: "A concomitant injury. Compression non-complicated fractures of Th7-12 and L-1-2 vertebrae. The contusion of left lateral surface of the chest. Left-sided pneumothorax". The girl with her mother was admitted to the traumatology and orthopedics unit of the pediatric inpatient department. She was placed onto the functional bed with pelvic traction along incline plane. Analgetics with dosages for adults were prescribed. Her mother was recommended to control the adherence of the orthopedic mode (not to sit, not to stand up). Physiotherapeutic treatment was initiated on the second day of treatment: ultrahigh frequency therapy No. 8 for the thoracolumbar spine, remedial gymnastics with physician. Spinal pain did not disturb the patient by that moment. There were not any complaints relating to the chest. Spinal MRI was conducted on the third day after trauma. It identified the following abnormalities: decreasing height of bodies of Th5-12 and L1-3 by 10-15 %, foci of alternation of MR signal from bone marrow of cranial parts of the above-mentioned vertebral bodies with edema (Fig. 1b).

Figure 1b

Picture of results of radial diagnosis of the spine of the patient (age of 5): MRI-image

As compared to CT, MRI study identified compression of Th5, Th6, L3, and allowed making the main clinical diagnosis: "The concomitant injury. Compression uncomplicated fractures of Th5, Th6, Th7, Th8, Th9, Th10, Th11, Th12, L1, L2 and L3 vertebrae of severity degree 1-2 (types A, subtypes A1 according to AO/ASIF; ICD-10 code: S22.1). Contusion of left lateral surface of the chest. Left-sided pneumothorax (ICD-10 code: S27.0)".   

The child adhered to strict orthopedic mode with physiotherapy and remedial gymnastics. The surgeon and neurosurgeon conducted periodical examinations. On the 9th day after trauma, the spine was fixed with the plaster jacket in position of overextension of the thoracic spine. Two days later, after completion of the course of physiotherapeutic procedures, the girl was discharged for outpatient treatment with traumatologist-orthopedist. The inhospital period was 11 bed-days. The spine was immobilized in the plaster jacket during 8 weeks. After removal of the jacket, immobilization was continued with dismountable posture device for 16 weeks. All this time, the child performed remedial gymnastics. After completion of immobilization, another course of physiotherapeutic procedures (electrophoresis with 2.4 % euphylline) for the thoracolumbar spine was conducted.

The examination of the short term results of treatment showed the absence of any complaints. The spinal axis was correct. There were not any structural vertebrogenic deformations and muscular tension on the posterior part of the body. Spinal pain was not registered during palpation. The function was sufficient according to the volume in all planes. The axial load to the spine was painless. The short term results of treatment were estimated as good. The child received the recommendations for continuation of remedial gymnastics, swimming in the pool, appropriate nutrition and courses of general tonic massage for posterior part of the body.

 

DISCUSSION

The recent medical literature describes the various data of incidence of multiple fractures of vertebrae in children and adolescents. So, the minimal percentage of this type of injuries was 19.62 % in a study by Kanna R.M. et al. [11], the highest one − 81.1 % in a study by Franklin D.B. et al [12]. Our results of incidence of fractures in 74.4 % of cases are similar to the data from Baindurashvili et al [13]. They studied a big sample of patients (1,230) and identified this category of injuries in 67.3 % of children. Similar findings were related to distribution of patients according to gender. There were 52.01 % of female and 47.99 % of male patients in our study. Baindurashvili A.G. et al. [13] showed the gender differences as men/women ratio 53 % / 47 %.

Predominance of multiple injuries in the middle thoracic spine in patients of young age groups is primarily associated with anatomic and physiological features of the child's spine. It is known the spine of children at the age of 5-12 presents the flexible structure. Moreover, in the middle thoracic vertebrae, the bone rods are located vertically and have short horizontal connections, and these rods are connected in various planes in the vertebrae of inferior thoracic and lumbar spine. These features of thoracolumbar and lumbar vertebrae give them high density and, as result, strength as compared to thoracic ones [6]. The vertebrae on the top of physiological kyphosis are more exposed to compression after traumatic impact as compared to upper or lower ones [4]. Diagnostics showed 1,228 (48.21 %) vertebrogenic fractures in the middle thoracic spine (Th4-7) among 2,547 compressed vertebrae.

The high incidence of multiple fractures with low injury severity (for example, after falling to the back from the height of own stature) is mainly associated with so called arch-key mechanism [14]. Belenkiy V.E. et al. (1984) conducted an experimental study with biological dummies, with simulation of an impact to spinous process in the thoracolumbar spine that often occurs after falling from the height of own stature. The researchers documented the fact that the traumatic force, which influenced on the top of the spinous process, resulted in compression of the upper vertebrae and in extension of lower intervertebral disks. So, in two cases, the impact to Th10-11 spinous processes caused fractures of 2 (Th2-3) and one (Th3) vertebrae [14].

According to Hsu J.M. et al. [15], about a half of all vertebral fractures in children occur after falling to the back. In our study, this injury mechanism was identified in 275 (36.96 %) patients. It was the most common cause of vertebral fractures.

The concurrent injuries to the bones, brain and visceral organs burdened the general condition of the patients. The clinical picture of vertebral fractures was usual. Pain syndrome, posttraumatic apnoea, limited spine function and its palpation tenderness, paravertebral muscular tension and painful axial load were the main clinical symptoms of multiple injuries. Their presence is mentioned by all authors dealing with the problem of pediatric vertebrogenic fractures [6]. Estimation of pain intensity in trauma children showed a relationship: the younger age was associated with faster regression of algia, even in cases with injuries to five vertebrae and more. There were some cases when children at the age < 12 did not complain of pain in several compressed vertebrae already on the second day of hospital stay. At the same time, late childhood (especially, adolescents at the age of 15-17) had persistent complaints of pain in injured vertebrae even in case of minimal compression within several days and sometimes more than a week.

As compared to the general population of patients with multiple vertebral fractures, the children with polytrauma had higher rate of spinal surgery despite of uncomplicated vertebral fractures. So, 15 (35.71 %) patients with polytrauma were operated among 42 ones. The indication for surgery was high probability of formation of mechanic and/or neurological instability at the level of injured spinal motional segments. There were more male patients (66.66 %) among operated ones, the mean age of which was 16.5 years. In most cases, surgery was conducted for fractures of L2 (4 cases), Th12 (3 cases) and L1 (3 cases).

Most patients with multiple vertebral fractures (729 patients, 97.98 %) were treated with conservative techniques. The treatment of the patients included spinal axis traction from the pelvis along the incline plane on the retractor-roller, remedial gymnastics, physiotherapy, spinal immobilization with extension plaster jacket or with enhanced posture device. The mean amount of bed-days for conservative management was 9.3, for surgical management − 15.5.

The important and unsolved problem of urgent vertebrology of childhood is absence of uniform approaches to estimation of results of treatment of vertebral fractures in children and adolescents. Oswestry questionnaire and the score by S.T. Vetrile et al. (2004) cannot be efficiently used in pediatric practice. Considering this fact, "The Individual Card for Estimation of Conservative Management Results in Children with Vertebral Fractures", which included the results of clinical and radiologic examinations of the spine after 6 and 1 months from the injury, was used. Totally, the long term results were examined in 65 (8.73 %) of 744 children in the study group. In concordance with the developed criteria, "good" results of therapy were in 58 (89.24 %) children, "satisfactory" results − in 7 (10.76 %). There were no registered symptoms of "poor" results.

 

CONCLUSION

The problem of multiple uncomplicated compression fractures of vertebral bodies in children and adolescents is multi-sided and important according to various reasons including high incidence of this type of injuries in children, difficulties of diagnosing, absence of uniform approaches to management and estimation of long term results of therapy. So, among children and adolescents with uncomplicated compression fractures of vertebral bodies, the proportion of patients with multiple injuries is 74.4 % of clinical cases. More often, children have fractures of two (37.23 %) vertebrae, including 41.71 % with fractures of adjacent vertebrae. Totally, the studied cohort included 45 various combinations of location of injured vertebrae. The severity of the fractures corresponded to the types A (99.52 %) and B (0.48 %) in compliance with AO/ASIF. According to severity of injuries, most patients (99.52 %) received conservative management. Surgical management was conducted for 2.02 % of cases. The worrying high percentage of multiple vertebral fractures in children and adolescents requires for further investigation of this problem.

 

Information on financing and conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.