Review Article Pediatric Spinal Trauma Thierry A.G.M. Huisman, MD, Matthias W. Wagner, MD, Thangamadhan Bosemani, MD, Aylin Tekes, MD, Andrea Poretti, MD From The Russell H. Morgan Department of Radiology and Radiological Science, Division of Pediatric Radiology, Section of Pediatric Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, MD. Keywords: Trauma, spine, children, imaging. Acceptance: Received May 14, 2014, and in revised form July 23, 2014. Ac- cepted for publication August 16, 2014. Correspondence: Address correspon- dence to Thierry A.G.M. Huisman, MD, The Russell H. Morgan Department of Radiology and Radiological Sci- ence, Director of Pediatric Radiology and Pediatric Neuroradiology, The Johns Hopkins School of Medicine, Charlotte R. Bloomberg Children’s Center, Sheikh Zayed Tower, Room 4174, 1800 Orleans Street, Baltimore, MD 21287-0842. E-mail: thuisma1@jhmi.edu. J Neuroimaging 2015;25:337-353. DOI: 10.1111/jon.12201 ABSTRACT Pediatric spinal trauma is unique. The developing pediatric spinal column and spinal cord deal with direct impact and indirect acceleration/deceleration or shear forces very different compared to adult patients. In addition children are exposed to different kind of traumas. Moreover, each age group has its unique patterns of injury. Familiarity with the normal developing spinal anatomy and kind of traumas is essential to correctly diagnose injury. Various imaging modalities can be used. Ultrasound is limited to the neonatal time period; plain radiography and computer tomography are typically used in the acute work- up and give highly detailed information about the osseous lesions. Magnetic resonance imaging is more sensitive for disco-ligamentous and spinal cord injuries. Depending on the clinical presentation and timing of trauma the various imaging modalities will be employed. In the current review article, a summary of the epidemiology and distribution of posttraumatic lesions is discussed in the context of the normal anatomical variations due to progressing development of the child. Introduction Pediatric spinal trauma is unique because of various reasons. 1,2 First of all, the biomechanical properties of the initially pre- dominantly cartilaginous pediatric spine are very different com- pared to the adult spine. 3,4 In the early years of life, the stability of the pediatric spine relies predominantly on the cartilaginous spine and the relatively lax ligaments. The pediatric spine is consequently more mobile and deformable compared to adults. Traumatic forces will be absorbed differently in children and varies for the various age groups. Vertebral fractures are less frequent in young children compared to adults. Dislocations, ligamentous injuries, epiphyseal detachments, and lesions of the ossification centers are more frequent. With progressing age and physical activity of the child the paraspinal musculature will develop and contribute to the dynamic stability of the spinal col- umn. In addition the proportions of the pediatric body changes dramatically in the first years of life. Young children have a relatively large and heavy head compared with the torso. Later in life, the head-to-torso ratio progressively decreases. This is of particular importance for the craniocervical junction. Next to the large head and the “weak” neck musculature, the “young” pediatric spine is also more mobile due to the shallow occipital condyles, the horizontal orientation of the facet joints (30° vs. 60°-70° in adults), small uncinate processes, immature uncover- tebral joints, increased elasticity of the posterior joint capsules, and a cartilaginous junction between the vertebral bodies and their end plates. 5 The transverse (extension/flexion) and rota- tional mobility of the cervical spine is increased compared to adults. This makes the craniocervical junction and upper cervi- cal spine very vulnerable for sudden acceleration and deceler- ation forces and trauma-related injuries. Most pediatric spinal traumas occur consequently in the cervical spine (80%). 3,4,6,7 In children younger than 8 years primarily the first three cervical segments are involved. 8 With progressive age the fulcrum of flexion gradually shifts caudally from C2/3 to C5/6. In older children and young adults, the lower cervical spine is conse- quently more frequently affected. 3,9 At about 10 years of age the more typical adult distribution of injury is noted, affecting predominantly the cervicothoracic junction. Similar to adult patients, also in children the thoracic spine is less frequently affected due to the stabilizing effects of the adjacent rib cage. The lumbar spine is again more mobile. Another feature that increases the risks of spinal trauma in children is that young children typically have less well- developed protective reflexes if exposed to an approaching force. Copyright ◦ C 2014 by the American Society of Neuroimaging 337