the Program Director at LSU Health Sciences Center in Shreveport. As part of our breakfast seminar today on return to play after spine injury, I'm going to be speaking on a pediatric perspective and things to consider with pediatric patients and returning to play. Injury can occur at any level of participation from your recreational athlete to your professional sports player. Obviously it can occur in a variety of different sports not just limited to high impact or high velocity sports and about 10 percent of our spinal cord injuries in the United States are from sport participation. Luckily though when we think about spinal cord injury the really catastrophic neurological injury that we all that always comes to mind is actually quite quite rare and we've seen this in football mostly here in the United States and the reason that some of this has changed over time has been the development of more protective equipment for our players as well as rule changes within the games themselves especially football through the NFL to protect our players from these severe injuries. I'm going to touch briefly on cervical spine injury but I know one of my other speakers will be talking about this in much more detail but when we think about cervical spine injury you think about three things. One is being a transient neuropraxia which is related to a cord injury it's bilateral, a stinger or a burner which is a peripheral nerve injury and then the catastrophic neurological injury which is usually a result of spear tackling in football that's the one that we really kind of draws the most notoriety. When we talk about pediatric spine injury luckily the overall incidence of it is quite rare. It's reported in the literature between one and eleven percent. It's usually affecting older children and African Americans seem to be at a higher risk of having a spine injury and males are more likely than females especially active adolescent males that's probably because they're playing in higher velocity more contact sports than females the majority of the time. However when you think about pediatric spine injury you really have to consider the etiology because it will change as you think about the age of the child so obviously younger patients are going to be having spine injuries from falls or getting hit by a car running out into the street to catch the ball whereas older children are going to have spine injuries related more to sports contact motor vehicle collisions or motorcycle injuries. In reality when we think about pediatric spine injury we really don't know the true incidence and severity and that is because there's a very large variation in referral patterns for pediatric spine injury. The injury and grading itself of the of pediatric spine injuries and the treatments that are carried out vary widely across our specialty as well as incorporating other specialties such as orthopedics and so it's not well reported in the literature and the elasticity of the pediatric spinal column allows it some protection which is good so we see a very low instance of spinal column injuries so when spinal cord injuries or spine injuries are reported out oftentimes we're thinking about them in traumatic events in terms of fracture dislocations and stuff like that with adults however we see in pediatric spine as you would expect we see a much higher instance of sora meaning that the cord is stretching but not breaking and the spinal column itself is stretching but not breaking and when you think about the developmental considerations of a pediatric spine injury you really need to think about the fulcrum of the cervical spine and the development of the spine as the child ages so under eight years of age the maximum ability for a cervical spine is right at the top right at c1 to c3 and that is that descends as the child ages and they reach skeletal maturity so around 8 to 12 years of age it descends to around c3 to 5 and then beyond 12 years of age they've usually reached some skeletal maturity here and it's at the fulcrum of c5 6 which is also the fulcrum level considered for an adult in addition you need to think about the age of the patient and the spine development and growth and so just quickly I'm going to review the three levels of the cervical spine in terms of their development so the atlas has three primary ossification centers the anterior arch and the neural arches and these are usually fused by seven years of age you so moving down when you move down to c2 and look at its ossification centers there are four of them and the apex leodontoid will not completely fuse but until almost 12 years of age the remainder of the cervical of c2 will fuse somewhere around around three to six years of age but this is something to consider as you're looking at your CT scans in these patients sub-axial spine has three ossification centers the vertebral body and the two neural arches which are typically fused by about six years of age when you're talking about biomechanical considerations and pediatric spine you've got to consider the age of the patient and so the infant spine has extremely weak neck neck muscles or support and and in addition has a very large head size in relation to the body and this is why the fulcrum of their injury is so high mainly between the occiput and c2 and this can increase their likelihood of a cervical spine injury under eight still have a significant amount of mobility and elasticity to their spine their neck muscles remain underdeveloped they still have incompletely calcified and more wedge wedge shaped vertebrae and more horizontally oriented facets which allow for increased mobility of the sub-axial spine final maturation of the spine usually starts to occur between eight to ten years of age this is when we really see the muscles and ligaments strengthen the bones grow and reach a mature shape and size that we're used to seeing in our adult patients and the cartilage and soft bone that you're seeing in younger children has been replaced with more normal and calcified bone in addition this is about the time that the torso has grown significantly so that the body habitus changes and the head is much more proportional to the size of the body and this is how the fulcrum of injury can shift down from that occiput c2 level down to c5 6 which is typically considered the adult fulcrum level so again by about 12 years of age the pediatric spine is located the same level of the adult spine fulcrum and when we start to talk about our guidelines for pediatric patients and returning to play there are no specific guidelines to pediatric patients and so what happens is the majority of the time we end up following the adult guidelines to some degree to give us guidance about a few topics particularly important to pediatric patients and returning to play the first of them being sora again is spinal cord injury without a radiographic abnormality the term is pretty pretty dated by now because it was coined over 25 years ago and that's really before we had MRI so it is an acute traumatic myelopathy where there sensory motor deficits and normal radiographs and a CAT scan the incident is widely reported through literature between 4 and 67 percent there is a very wide range in terms of diagnostic procedures and studies that are done in terms of and then also inclusion criteria when you look at the reporting through literature it's a accounts for about 25 percent of spinal cord injury in children and again this predates MRI so there's a lot more information we were probably missing out on 30 30 to 35 years ago Because this is outdated terminology, most patients now, if they have a spinal cord injury or signs of a neurological deficit, and they have a normal CAT scan, they're going to go ahead and get an MRI. And so most patients now have MRIs and a positive MRI findings doesn't alter the diagnosis as we was defined classically. So probably be better to report it as SWONA, which is spinal cord injury without neuroimaging abnormality, to indicate that we have actually imaged the spinal cord itself and not just the bony structures. In younger children, the majority, over two-thirds, have been in children under eight years of age, and they are more likely, the younger children, to have a complete spinal cord injury. We don't see it as often in adolescents, and when we do, it's usually an incomplete and it's usually an incomplete injury, and it's rare in adults. Most of the time in young children, when we're seeing this happen, it's going to be in this context of a motor vehicle collision, and in older children, it's usually in a context of sports or some kind of contact injury. Most often, it's reported in the cervical spine, but typically it can occur in the cervical and thoracic to almost equal degrees. Well, as we just talked about, there's tremendous ligamentous flexibility and elasticity of the immature spine. In that, the vertebral column can actually elongate in children without evidence of any kind of deformity or disruption for up to two inches. However, the spinal cord itself will rupture with about a quarter of an inch of stretch, and so you tear the spinal cord, but the spinal column itself does not appear disrupted on any imaging studies. Just as an example, this is a patient of mine. She was a 21-month-old backseat restrained passenger who was involved in a high-speed MVC. There was extensive body damage to the car. She was reported to be moving all extremities. She came in in a seacollar, and she was obviously, you know, just about two years old, extremely scared, and they obtained this CAT scan, which appears completely normal. She was reported in the trauma bay to be moving all of her extremities, although it's really not well documented, and the trauma team got this CAT scan, said everything looked fine, and took off her collar. She was admitted to the hospital the first time. She really was not moving a lot, and that they really never got her up and walked, although we don't know because we did not see her at that time. The trauma team actually discharged her, and he went back to another hospital the next day because he said that his daughter was not moving her legs, and they were able to obtain this MRI about five days after her injury, and you can see that she's had a complete disruption of her spinal cord in the cervical spine. When you think about it and you suspect it, obviously get an MRI because this may reveal to you some compressible lesions or like a hematoma or some ligamentous injury. It even might show you just a core contusion to give you some clue to explain why a child or an adult is experiencing a neurological deficit. And in addition, if you get an MRI and it's normal, the studies have shown that they're more likely to have a complete recovery and they have better long-term outcomes when compared obviously to those who have an abnormal MRI. And so it's a good way to be able to counsel family and counsel your patient and say hey look I don't see anything here, hopefully this is going to get better and it should get better over time. The treatment guidelines are varied and somewhat controversial. There are no strict guidelines for treating SWORA. Most of them are conservative, meaning rigid immobilization for one to two months or maybe longer. There is an increased risk for repeat injury and usually that injury can be more severe and it can be permanent. So I think most neurosurgeons will kind of err on the side of caution, immobilize these children for a couple of months and then keep them out of play. Talk about return to play in SWORA, there is absolutely no published literature on this. Younger children is going to occur usually in the context of falls or motor vehicle collisions and not sports. So if you think about that that's a different mechanism than maybe an older child sustaining this kind of type of injury. And it's really attributed to the biomechanical properties of the spine itself. So does that child outgrow the risk when skeletal maturity is reached? No one really knows the answer to this question, there's nothing published out there, but we could assume that most likely their ligaments are stronger, their bones are better calcified, and the spinal column is stronger. Perhaps they will outgrow that risk of an additional SWORA injury. Level three evidence that's out there and so the question is should you wait till they reach skeletal maturity? I think that's a reasonable thing to take into consideration when you're talking about a younger child with a sclera. Obviously they need to have complete recovery and be symptom-free, no neck pain, and they have to have normal imaging including an MRI. So this is really going to vary on a case-by-case basis with your patients. There's not going to be a general consensus for every single patient out there. If their MRI shows gliosis, I'd probably not clear them to go back to play at that point even if they had a complete recovery. And if they hadn't reached skeletal maturity but had made a complete recovery, I'd still have restricted my patients at this point to wait until they reach skeletal maturity, which is usually again around 12 years of age, before they return to play. And older children who suffer this, again if they've already reached skeletal maturity and they've made a complete recovery and they have normal imaging, I think it's probably reasonable to consider that, but I think it's going to be returning to play. But it's going to be a case-by-case basis for every neurosurgeon. I'm going to talk a little bit about tethered spine. There's usually some lumbosacral stigmata. This is usually something that's going to be identified in early infancy or early childhood, but sometimes there's delayed diagnosis. And so older children and teens can present to you with complaints of back pain, new onset incontinence, a limb asymmetry, or even scoliosis, even some patchy neurological dysfunctions such as sensory losses that's kind of patchy. And you may end up finding some kind of cutaneous stigmata that leads you to the diagnosis of a tethered spinal cord. The good news is there's no contraindication to sports participation in tethered spinal cords. These patients rarely present with any kind of rapid or catastrophic deterioration. Now they may become more symptomatic with sports and if they had not been previously diagnosed, may be diagnosed with a tethered cord. But an asymptomatic athlete who has a tethered cord, I think periodic clinical follow-up until they've reached their full skeletal maturity, full axial growth, is perfectly reasonable in these children with good counseling between them and their parents. The symptomatic athlete, there's absolutely no contraindication to return to play after detethering. These are usually pretty straightforward surgeries. And once the child has recovered from that and gotten over surgery, it's very safe for them to return to play. Probably the most controversial one is going to be a Chiari malformation. Talking about Chiari malformations, these are a much more common incidental finding now and I'm sure we have all had at least one patient who's been referred to us after being involved in a car accident, having a CAT scan, showed low lying tonsils, someone followed up with an MRI and said, hey you have a Chiari. About 1% of all patients who undergo an MRI are going to have a Chiari. And the symptoms of Chiari, again, because of the crowding the cerebellum and brainstem, they get those occipital tests of headaches that are worse with valsalva maneuvers, sometimes some neck pain, very rare will have cranial nerve findings, snoring, sleep apnea, double vision, sometimes they'll have some sensory patchy sensory loss if they've got associated searings. When you look at return to play in Chiari malformations, it's often listed as an absolute contraindication for return to play. And the thought behind this is that the Chiari is altering the normal CSF capacity to kind of buffer our brain in high-velocity impacts. However, there's actually nothing out there that actually supports this theory. And in addition to that, one of the other reasons why it's listed as an absolute contraindication is that when patients sustain a concussion and they get a scan, sometimes it reveals a Chiari. And so people are unclear whether that the Chiari is incidental or has it contributed in some way to this person getting a concussion or traumatic head injury. And then there are these very rare case reports of injuries that exist out in our literature right now of a catastrophic CNS injury after a trauma with a related Chiari. So the thought being that there's already spinal cord or brainstem compression from the Chiari and then they have a very high impact or traumatic event and because they have the Chiari that made this into a much more catastrophic event for them. However, the true incidence is very low or are really unknown. It's very rare case reports that are reported out there. However, if when you talk to neurosurgeons, up to 36% will say that they recommend avoiding contact sports and patients who come in with a Chiari malformation. But there's nothing that shows any support to this that just because you have a Chiari malformation, you're at a much higher risk of having a catastrophic event. For those out there on Chiari malformations and neurological injury, this study here was a database study. So they looked at over a thousand SOARA cases and the thought being that if a patient had a SOARA and a Chiari, they've already got tight brainstem or tight compression back there, that those patients would probably be more likely when they had a SOARA and a Chiari to have a concussion. When they had a SOARA to have a higher cervical spine injury because they've already got some compression back there to see if that Chiari is a contributor. And what they found was there was really no difference in patients who had a Chiari malformation and SOARA, whether they had a high cervical injury or a low cervical injury. And so the authors concluded that it did not appear to contribute to a higher incidence of a high cervical spine injury. So perhaps the Chiari is just an incidental finding and not the additional factor in this case. Dr. Proctor and Dr. Scott also looked at several different spinal cord abnormalities in sports and found that they do not believe that Chiari is an absolute contraindication for return to play. Again, they're basing this on there are very rare reports of a severe injury with a Chiari and there are several prospective studies that have failed to show any significant incidence with brainstem or spinal cord injury because the patient has a Chiari. They followed up with this study here, which was a 10-item questionnaire sent out to a large cohort of athletes. And in addition, they looked at the MRIs of every single patient, recording tonsil protrusion, morphology, crowding, brainstem compression, whether the patient had a syrinx or not. Ended up with about 147 patients for full participation in the study. 72 had decompressive surgery and 73 had no intervention. They were just strictly observed. And their mean tonsil herniation was about the same for both cohorts. And there was no significant difference when they looked at the surveys in terms of sports participation prior to surgery. So they asked them how many seasons have you played? What positions are you playing? What sports are you playing? And they didn't see any significant difference before surgery. So the patients all with Chiaris were all participating about the same amount of sports. And when they compared them pre- and post-surgery, they found that there was zero catastrophic events out of a total of over 1600 athletic seasons when they talked to these patients. And they found that the risk of a catastrophic injury just in collision sports, just looking at things like football or rugby, per 191 athletic seasons, again, was zero. So there does not seem to be any real significant risk for a patient who has an unoperated on Chiari for any significant catastrophic injury. When you think about an athlete who has a symptomatic Chiari, those are pretty straightforward, right? They were including those who maybe are asymptomatic with a syrinx, who get referred to you. Those you're going to operate on. They're symptomatic. You're going to treat that. And the majority of pediatric neurosurgeons feel that they can return to play after a decompression if they're neurologically intact and their imaging is normal, meaning that they have a follow-up MRI that shows their syrinx is resolved. And they're going to They've got a good decompression. They have no evidence of gliosis in their spinal cord or any other significant notable injury that can be seen on MRI. One of my first patients, actually, he was a 16-year-old football player. He'd been playing his whole life. He came in with low back pain and right arm pain for three to four months. He was hyperreflexic. He had decreased sensation to light touch and pinprick. And he had this Chiari malformation that actually had a syrinx that extended almost, it's a little bit hard to see from here, but from C2 all the way down to like maybe T10. And so, obviously, he's symptomatic from this. He's got a very large syrinx. So we went ahead and operate on his Chiari. And there's his post-op scan. And so, about three months after his surgery, we obtained this MRI. His syrinx has completely resolved. He's completely asymptomatic. He feels good. And he went back to play. And he's So this is a good example of something that you can put out to your patients. If they're symptomatic, then operate on them. If they're asymptomatic, it becomes a little bit more challenging. So, again, let's talk about asymptomatic or incidental. This was a study done a couple years ago. And this was a prospective study given to over 300 patients. And they were asymptomatic Chiari patients. And they tracked, again, their sports participation, imaging findings, and any type of injury related to sports. Almost 200 or over 200 of them participated in contact sports. And, again, no reported catastrophic or permanent injuries. And these are asymptomatic, unoperated on Chiari. And so, this is a good example of something that you can put out to your patients. If they're asymptomatic, And these are asymptomatic, unoperated on Chiari. You think about what's the ethical implications of this. And this was an interesting just commentary that I found. It was a 17-year-old male who had one concussion in two years. He was completely neurologically intact. When he had the concussion, he had a CT scan that showed low-lying tonsils. And he had an MRI, which showed seven millimeters of herniation. So just a small Chiari, no syrinx, and completely normal exam. Do you clear him to play? What do you tell this patient? There are rare events out there reported in the literature of a catastrophic event happening with a Chiari patient. It's really rare. And I think we have to do our best ethically to involve our patients and engage our patients, their families, and the players, I mean the coaches or trainers, to let them understand that, you know, yes, they do have this finding. They're completely asymptomatic. But here are some symptoms we can look for if something happens. And have an open communication so that everyone's on the same page. Some of these kids, like if they're really into, you know, being an athlete and trying to get a college scholarship, they're going to doctor shop until they find someone. But there's really doesn't seem to be any real reason to restrict these patients from playing when they have an asymptomatic, incidental finding of a Chiari malformation. I think it involves a good dialogue, a good understanding between you and the family, and involving the coach or the trainer to understand as well, you know, what you could potentially look for. But there's no reason to restrict these patients. There's no data out there to support that, to restrict an asymptomatic Chiari patient from playing sports. For a symptomatic, or sorry, an asymptomatic Chiari, you're going to observe them. There is absolutely nothing out there to advocate a prophylactic decompression in these patients. And they can return to play. So if they don't have a severe Chiari, which would be severe tonsil herniation, medullary kinking, any type of gliosis or chord edema, that would that would indicate that they're sporadic. So if they don't have severe tonsil herniation, that would indicate that there's potentially something more sinister going on. And I think having an open conversation with the athlete and the parents to understand the risk of, or the potential risk of becoming symptomatic and the very rare risk of a neurological injury. Talking about return to play for pediatric patients, you need to determine You've got to consider the anatomical and developmental findings of the pediatric cervical spine. And you've got to consider the age of the patient and that their spine is not usually completely fused. And think about the mechanism of the injury. Of course, of sure spinal stability and absence of neurological compromise. And in general, you're probably going to follow adult guidelines for for adolescent children. Really no return to play until they reach skeletal maturity. They have completely recovered from their symptoms and your own clinical judgment. This really comes into play here. Chiari malformations, again, asymptomatic, simple, may resume sports. Symptomatic and severe, not recommended to return to play. These are the ones with severe medullary kinking or chord edema or something like that. And then symptomatic and severe, not recommended to return to play. Symptomatic, I think it's very safe for them to return after decompression, provided that they have a normal neurological exam and they have a normal MRI, meaning no residual syrinx or spinal cord gliosis or something like that. And a lot of these times when you're talking about pediatric patients, it's going to be individual and case by case. And so that really involves an open conversation with you as the neurosurgeon, the player themselves, and getting them involved in parents and coaches. And most of the time, some of our other things that happen like transient neuropraxias or stingers are going to fall under adult guidelines when you're talking about adolescent patients. Thank you for your attention.

return to play

spine injury

pediatric perspective

spinal cord injuries

protective equipment

cervical spine injuries