What are thoracic, lumbar and sacral spine injuries?

In children older than 9 years, spinal column injuries tend to occur in the thoracic, lumbar and sacral regions (TLS) of the spine, rather than in the cervical spine as with very young children.

Thoracic, lumbar and sacral spine injuries occur at about the same rate as cervical spine fractures — 2-5 percent of blunt trauma injuries. [See C1 atlas injuries, C2 axis injuries and C3-C7 injuries.]

Fractures of the thoracic spine in children occur due to:

• High energy trauma in healthy children
• Milder injury in pediatric patients with osteoporosis

The most common injuries in both situations are compression fractures (a collapse of a vertebra). This can occur as a single vertebral fracture or may involve two or more vertebrae.

Causes

Common spine trauma fractures among children include:

• Compression fractures
• Flexion-distraction fractures (also known as Chance fractures) of the lumbar spine

Chance fractures involve only the bony part of the spine — not the spinal cord — and many times are caused by inappropriate use of a lap seat belt in a motor vehicle.

In children, the Chance fracture is most common in the upper lumbar spine, but it can occur in the mid-lumbar region, which is around the spine at the waistline. It occurs at a lower level in children because of their lower center of gravity.

Injuries in the thoracic spine or upper lumbar areas can be accompanied by loss of function in lower extremities (legs and feet) and bowel and bladder function. Lower down on the spine — in the lumbar region — injuries can show patchy loss of function, as well as some loss of bowel and bladder function.

Some thoracic, lumbar and sacral fractures can lead to a wedged deformity that causes shortened height of the anterior (front) vertebra and normal height in the posterior (back). This results in a spinal deformity. If there are two or more adjacent wedged vertebrae, kyphosis can occur. Kyphosis is a forward curvature of the vertebrae in the upper back, giving a child an abnormally rounded or “humpback” appearance.

Another possible complication of a TLS injury is that significant compression of the spine can lead to a disc protruding into the spinal cord space. This can cause paralysis.

Signs and symptoms

Symptoms of a spine injury in the thoracic, lumbar and sacral regions can include:

• Neck or back pain, especially when moved
• Tenderness
• Numbness
• Tingling or a pricking sensation of the skin
• Paralysis
• Urinary or fecal incontinence
• Urinary retention

Testing and diagnosis

To diagnose TLS spine injuries, physicians at Children's Hospital of Philadelphia (CHOP) perform a comprehensive physical examination and detailed family history of the child.

We also use the following imaging tests to help determine your child’s diagnosis and the potential cause of the traumatic spine injury.

• X-rays, which use invisible electromagnetic energy beams to produce images of internal tissues, bones and organs on film 
• Magnetic resonance imaging (MRI), which uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body
• Computed tomography (CT) scan, which uses a combination of X-rays and computer technology to produce cross-sectional images (“slices”) of the body

A modified version of the Glasgow Coma Scale (GCS) will be used to assess the consciousness level of your child if the injury was traumatic. The GCS is a neurological scale that assesses a patient’s consciousness through three tests that look at eye, verbal and motor responses. Traumatic brain injury in children is classified as mild (GCS score of 13-15), moderate (GCS score of 9-12), or severe (GCS score of 3-8).

Treatments

Physicians treat TLS spine injuries with surgical and nonsurgical approaches. At CHOP, treatment recommendations depend on the type of injury, as well as injury location and severity.

Treatment options include:

• An external brace such as a “halo” device, which consists of a metal ring affixed to the skull and connected to a padded vest by rigid bars
• Surgical fusion, a surgical technique to join two or more vertebrae, with or without using rigid metal devices
• Adjacent wedge fractures may require a brace or surgery to prevent further damage and kyphosis.

If your child needs surgery, we take every precaution to ensure safety in spine surgery. Our multidisciplinary approach helps us to address all aspects of your child’s care and treatment.

While surgery can dramatically improve traumatic spine injuries, it can be a stressful experience for you and your child. Our team can help you prepare your child for surgery and know what to expect during surgery.

Additionally, we recognize your child's pediatrician or referring physician as an important part of your child's care team and provide regular updates about your child's progress.

Follow-up care

It is important to note that at times it is difficult to diagnose a spinal cord injury in very young children through radiologic tests because the spine is not fully calcified. Other issues can also develop during treatment of an injury. That's why follow-up care with an experienced orthopedic physician is essential after any spine injury.  

Your physician will suggest a follow-up schedule geared to your child’s specific needs. Follow-up care is available at CHOP's Main Campus or at a CHOP Care Network location.

Our pediatric clinical professionals will follow your child until young adulthood (between age 18 and 21) and help transition to adult orthopedic care, if needed.

At CHOP, we offer ongoing services and support to your child and family. Your child will have access to clinical services such as physical and occupational therapy, as well as psychosocial support from social workers and psychologists who can help your child deal with any emotional effects of the injury.

Outlook

Recovery from injuries to the thoracic, lumbar and sacral regions of the spine depend on the severity of neurological injuries. However, even pediatric patients with devastating neurological injuries have made good recoveries.