Well, thank you very much to the organizers for the very kind invitation. Thank you also for swapping me around. Much appreciated. I have a clash with another session. And thank you for including me. I'm a pediatric neurosurgeon, primarily a spine surgeon, so I feel a little bit out of place. So again, I see you're already in children, and the first thing to recognize when you're looking at the spine of children is that they're very different to adult spines. Once children get to the age of eight or nine, then you start anatomically as well as functionally in terms of the injury patterns. You start seeing an adult pattern developing. But a one-month-old child and a nine-month-old child, they're very, very different. Important things you need to know is the anatomy, the various ossification centers, so you interpret the x-rays correctly, various lines and measurements, and also normal variants that are not pathological. So there are many things that are different. Primarily the spine is much more malleable, and therefore less protection to the cord. The ligaments are much more elastic. The discs are more expansile. You have physiological growth zones and vertebral body end plates, so you have to interpret that on the x-ray, and also those are areas of vulnerability. Some of the normal aspects of it, you see anterior wedging of the vertebral bodies, more prone for deformation because of the shallow facet joints and absence of unsnapped processes, very weak paraspinal muscles, and in particular, with a very large head perched onto a weak spine, and as I said earlier, the biomechanical maturation only occurs around about age eight to nine years old. So ossification centers, you need to know about the various normal variants. One of the important ones is pseudosubluxation. It looks like subluxation, particularly C2, C3. It's completely normal. Retropharyngeal soft tissue swelling, especially when children are crying, may be completely normal. Anterior body wedging, this is in the fracture. It's just normal until about age seven or eight. And then all the normal relationships and measurements are very important to know, and those parameters given the age. So especially around the craniosacral junction, because C0, C1 dislocations are reasonably common, and the various measurements you need to know. Spine trauma is generally uncommon in children. The type of spine trauma really does depend on the age and, therefore, so the mechanism of injury. Birth trauma, of course, in very young children. In children under the age of eight, they have a particular pattern of injury, most commonly road traffic accidents and falls from height. And then as children get older, again, road traffic accidents and sports injuries. And the history, and particularly the mechanism of injury and the severity of it, alerts one to the pattern of injury or the likelihood of spinal cord injury. Age dependent, very broadly, you can classify patients in two groups. Either they are under the age of eight or over the age of nine, or in nine, nine or older. The fulcrum of movement descends with age, so in very young children, it's very high up around between C0 and C3, so that's where the injuries predominate. And then progressively, as children get older, the fulcrum descends with age. So over the age of nine, you have the more typical pattern of adult injuries developing. The various injury patterns, we're only going to be talking about sclera for the moment. Imaging, the plane forms, we don't really bother terribly much at our institution with AP. It's really the lateral reflection extension views. And then, of course, CT scans, we try to avoid CT scans where possible, of course, because of the radiation dose in children and anxiety. But, of course, if there is any anxiety from the X-rays, then it's mandatory. Then, of course, we have a very low threshold for moving on to MRI. Many of these children have concomitant head injuries, so the assessment of spinal cord pathology can be very, very difficult. These are the various sequences that we use. Timing is important because sometimes the features, certainly the edema and sometimes the hemorrhage doesn't show up on the initial MRI, and one has to have a high index of suspicion and a low threshold for repeating the scan after about four to five days, if needed. These are the various types of injuries. I'm not going to speak about all of them. I did want to mention atlanto-occipital dissociation and then sclera very quickly. Atlanto-occipital dissociation, largely it's not a skewer, of course, but you need to know a little bit about it because it's a devastating injury, potentially, and certainly devastating if you miss it. Very common in young children, although it's rare in general, it's much more likely in children and particularly young children because the fulcrum of movement is so high in the spine. But high in autopsy series, which just reflects the fact that this is potentially a devastating injury and many of these kids don't make it to us. High mortality rates and the outcomes can be very variable from patients who are completely normal, patients who are quadriplegic, patients who are dead. These are just a couple of examples of what it looks like, and that's what it looks like on CT scan. And this is, again, a patient with a very high spinal cord injury, quadriplegic, also with a head injury. And these are the patients when, especially this, one really doesn't want that because the prognosis of recovery, the quadriplegic patient, they might have a head injury, but they're waking up and these are all sorts of ethical dilemmas about how to treat these patients. Sciorra, initially described by Dacling-Pang and Wahlberg, if you chat to Dacling-Pang, he was a resident at the time and he's chief of pediatric neurosurgery. I told him that look out for these kids. We don't really understand what they, what the mechanism is. This is just pre the MRI era and they come in, but their plane forms are normal, but they have neurological deficits and we don't really know what's going on. And then as Dacling tells the story, that his very first weekend when he was on call as a resident, one of these kids came in and he said he'd committed himself to doing a prospective study and they started collecting all the cases and eventually doing MRIs on them and then described the syndrome. The nomenclature is very important and we'll get onto that in a moment. So, strictly speaking, these are patients with, that they may have abnormalities on flexion and extension views, but technically they don't have Sciorra because those are radiographic changes. But you may see ligamentous hyperintensity, particularly on STIR images that do not preclude the diagnosis. But the idea is that it's an absence of radiographic abnormalities. But then a whole bunch of other terms have been coined, and Sciorra, the absence of any radio imaging abnormality. Adult Sciorra is a little bit tricky because it's not technically Sciorra. It's, it probably should be better referred as, as patients without evidence of trauma or without CT evidence of trauma. MRI findings are abnormal in between 15 and 65 percent and Dachleng-Pang originally divided it into three classes, major hemorrhage, minor hemorrhage, and edema. Typically see cord signal change. Sometimes you see epidural hematomas. You may see ligamentous injury, particularly on STIR images. Very, very rarely one sees disc herniation or cord compression. And as I said earlier, occasionally a delayed MRI is warranted if patients have normal neurological, at least with abnormal neurological findings, normal MRI. Probably want to repeat that in a few days. Flexion extension views one always does to rule out instability, and there are very minimal concerns about developing pathological inter-segmental motion following extension views. That just hasn't been reported, so it's reasonably safe to do. This is typically what it looks like. Again, there, tends to predominant, again, high in the cervical cord in young children. One of the things that we're progressively becoming very aware of in patients who don't necessarily have a neurological deficit but have come in with a head injury on a CT scan, there's a telltale sign of blood anterior to the brainstem of the cervical cord. So whenever you're looking at the CT scan in children, always make sure that you look at the very lowest cuts. And if there's a little bit of blood there, it's a retroclival hematoma. It's a disruption of the ligaments at the CCJ. This is typically what it looks like. Sometimes it's very large. Sometimes it can be a little bit more subtle, generally a stable injury. Sometimes there's compression, but very, very rarely would that need to be evacuated. These are, again, examples of the same thing. Retroclival hematomas, always look at the lowest, lowest cuts on the CT scan, and if you look for it, they're surprisingly common. Management of patients need to keep in mind that younger children, they have relatively large head. It flexes easily when they supine. Collars are generally poorly sized. You have to look after pressure care and venous return, et cetera. So all the normal aspects of managing a patient with spinal cord injury but adapted to the fact that it's a younger patient. Surgically, most patients do not need treatment, very, very occasionally for compressive lesion or instability. Most centers treat patients with external immobilization for eight to 12 weeks and recommend avoiding high-risk activities for six months. You can discontinue external immobilization early if patients become asymptomatic. But there are some variations in care and in the literature. So Lornet et al. suggested that if you treat, if you immobilize patients for 12 weeks, you reduce the chance that they will develop delayed neurological symptoms versus a study by Bosch et al. suggesting that actually you could get by with immobilization in far fewer patients, prolonged immobilization in far fewer patients and might need to immobilize them for two weeks and their symptoms resolved and their scan is fine and inflection extension views are fine. They don't need to have ongoing immobilization. Pang is really the only one who pressed on hard with somatosensory potentials, the possible roles to evaluating subtle dysfunction that one might not be able to detect clinically, obviously evaluating the spinal cord function in patients with head injury or comatose for other reasons, distinguishing between cranial, spinal, and peripheral nerve injuries, and then establishing a baseline with which to follow up. And of course it is predictive of outcome, but very few people use it. Prognosis corresponds with the initial neurological examination at outset and obviously corresponds with imaging. Patients have a normal MRI with no cord signal, most fully recovered, but not necessarily universally. The incidence of complete cord injuries is particularly high in young children. If inflection extension views are normal, that rules out important instability and probably, as I said earlier, you can get by with reduced immobilization. There have been a few cases of recurrent sclerosis, lots of debate about what those are due to, particularly inflection extension views are normal and therefore whether a shorter or longer period of immobilization is necessary. And then keeping in mind that even some patients, because of the neurological abnormality, will develop delayed deformity of the spine over time. And then just a couple of quick things about children in particular. Non-accidental head injury by definition is a shaken injury, so keep in mind that they can have high spinal cord injuries. These are, again, unique to children. There may be underlying conditions such as achondroplasia. They have narrow cranial cervical junction. This was one of our patients with a narrow CCJ, scheduled for surgery, and then literally the week before surgery, head dropped forward, developed acute quadriplegia with a massive signal in the CCJ. Keep in mind also if they have underlying brain injury, it might not be the spine, even though the CT scan may at first glance look normal. Particularly look for hemorrhages in the midbrain that may be very subtle in the CT scan, but if you MRI them, sometimes what looks very subtle on the MRI scan can look absolutely devastating on MRI. And that might be the reason that the patient's either not waking up or have a neurological deficit, not explained by the CT scan. And with that, I'll thank you and end. Be inclined, rather, to go the full course of immobilization for 12 weeks rather than a shorter course. But essentially, if deflection extension views are normal, then one anticipates a good prognosis with no long-term instability. I don't know if anybody's reported that or a natural history study of that. I'm not aware. I'm not aware. Thank you.

pediatric neurosurgeon

spine injuries

x-rays interpretation

spinal cord injuries

immobilization