Thoracolumbar Spine Fractures

One of the most important aspects of treating
thoracolumbar spinal fractures is understanding the mechanism of
injury. In general, the mechanism of injury correlates with the age of
the patient.¹³ Spine trauma, just like appendicular trauma, should generate concern for nonaccidental injury in infants and young children.⁹,¹⁵,³⁵ Levin et al.⁴¹ reported on seven unstable thoracolumbar spinal fractures in abused children.

Motor vehicle accidents may be the most common cause of spinal column injury in all age groups.⁴
The type of seatbelt restraint has clear implications in the mechanism
of forced transfer to the spine, with the lap belt a common cause of
both intra-abdominal and spinal injury.²⁷,⁴⁰,⁵⁵,⁵⁹,⁶⁵
The lap belt has been long known to create hyperflexion of the trunk
over the belt with the spine pinching the intra-abdominal organs
anteriorly. The point of flexion is anterior to the spine leading to
anterior compression combined with posterior column distraction (Fig. 19-1).
Addition of a shoulder strap or child seat with a full frontal harness
limits flexion with frontal impact accidents and protects the spine
(and other parts of the body) from injury.

Falls from a height generally result in axial loading of
the spine, which may result in a “burst” fracture or wedge compression
fracture, depending on the degree of flexion of the trunk at the time
of impact. These fracture patterns are possible with any mechanism
associated with axial compression and can occur with motor vehicle
accidents and sporting injuries.¹³
Compression of the vertebra with the trunk flexed creates the greatest
forces in the anterior aspect of the vertebra, leading more commonly to
anterior column wedging. This is in contrast

to
the trunk in an extended position, which loads the vertebral body more
symmetrically. Fractures in this case often collapse with radial
expansion or “bursting.” Displacement of the posterior vertebral body
fragments into the spinal canal may cause injury or compression of the
neurologic elements (spinal cord or cauda equina).³⁰

If the magnitude of injury sustained seems out of
proportion to the force applied, the possibility of an insufficiency
fracture due to weak bone should be considered. Osteoporotic
insufficiency fractures, common in the elderly, are rare in children;
however, several disease states may predispose children to these
fractures. Steroid use frequent in the management of many pediatric
diseases often leads to osteoporosis when taken chronically.⁶⁸ In addition, primary lesions of the bone, such as Langerhans histiocytosis, often affects thoracic vertebrae.³,²² Other tumors and infections warrant consideration when nontraumatic compression fractures are identified.⁴⁷,⁵⁶

Careful evaluation of a patient with a potential
traumatic spinal injury begins as with any serious trauma victim. The
ABCs of resuscitation are performed while maintaining cervical and
thoracolumbar spinal precautions. The frequency of spinal injuries in
the setting of major trauma (motor vehicle accident, fall, etc.) is
particularly high. After stabilizing the cardiorespiratory systems,
symptoms of pain, numbness, and tingling should be sought if the
patient is old enough and alert enough to cooperate. Pain in the back
is often not appreciated when other distracting injuries exist and the
patient is immobilized on a backboard. Examination of the back must not
be forgotten and is performed by logrolling the patient. Visual
inspection, along with palpation, should seek areas of swelling,
deformity, ecchymosis, and/or tenderness that may provide a clue to the
presence of an injury. In trauma patients, thoracolumbar fractures are
more common in older children and adolescents, and there is a low
mortality rate and infrequent need for operative stabilization.⁶⁰

Neurologic examination provides information on the
integrity of the spinal cord. The age of the patient may limit the
thoroughness of this assessment, but some indication of sensory and
motor function should be sought. In cases of spinal cord deficit, a
detailed examination of the strength of each muscle group, sensory
levels, and rectal tone will need to be serially compared over time and
the quality of the documentation cannot be over emphasized. The
prognosis for recovery is significantly better if the spinal cord
injury (SCI) is incomplete.¹⁰,²⁸,⁷¹
The status of the neurologic function over time may lead to important
treatment decisions regarding the necessity and timing of surgical
intervention. A progressive neurologic deficit warrants immediate
surgical attention, while an improving status may suggest a less urgent
approach. Overall, the physical examination has a sensitivity of 87% in
identifying thoracolumbar fractures.⁶⁰

Just as the mechanism of injury should raise suspicion
of a particular injury (e.g., lap belt injury and flexion-distraction
lumbar fracture pattern), so should the presence of one injury raise
suspicion of a concomitant associated injury. First, any spinal
fracture should be considered a significant risk factor for a spinal
fracture at another level. The traumatic force required to create one
fracture is often enough to result in one or more additional fractures
at other locations. Similarly, a cervical injury is frequently
associated with closed head injury and vice versa.

The lap belt mechanism of injury is well known to create
flexion-distraction injuries of the spine, but also is associated with
intra-abdominal injury.⁵⁵ Compressed
between the seatbelt and the spinal column, the aorta, intestinal
viscera, and abdominal wall musculature are at risk for laceration.
Abdominal injuries are present in almost 50% of pediatric patients with
Chance fractures.⁴⁹ Ecchymosis on
the anterior abdomen is suggestive of intra-abdominal injury that
warrants further evaluation with laparoscopy, laparotomy, or additional
imaging by computed tomography (CT).⁴,⁶⁵ A high index of suspicion is required, because missed injuries may be life threatening.⁴⁰

Associated injury to the spinal cord has obvious
significance and may be present with many fracture patterns. Disruption
of the stability of the spinal column or bony intrusion into the spinal
canal may result in compromise of neurologic function. All patients
with a known spinal column fracture or dislocation warrant a careful
neurologic examination. Overall, most pediatric patients with
thoracolumbar fractures are neurologically intact (85%), and less
commonly present with SCIs (incomplete in 5% and complete in 10%).¹⁷
Similarly, patients with a traumatic neurologic deficit require a
careful evaluation of the spinal column integrity. There are, however,
a subset of patients who present with SCI without radiographic
abnormality.⁵⁰,⁵¹
This scenario has been termed SCIWORA, a phenomenon much more common in
children than adults. It is thought that the flexibility of the
immature spine allows spinal column segmental displacements great
enough to lead to SCI without mechanically disrupting the bony and/or
ligamentous elements.⁵⁰ Although
these injuries may not be visible on plain radiographs, nearly all will
have some evidence of soft tissue injury of the spine on

more sensitive magnetic resonance imaging (MRI) studies.²⁵
The term SCIWORA is less relevant in the era of routine MRI, which is
now routinely obtained in all patients with possible spinal cord injury.³³

The goals of treatment for all spinal injuries is to
maximize the potential for recovery of spinal cord function if an SCI
was present and/or to provide skeletal stability to the spinal column
to protect against future SCI. These two goals may be analyzed
separately when both instability and SCI exist. Optimizing return of
any lost spinal cord function is paramount, and the potential for
recovery of spinal cord function in general is greater in children than
in adults.²¹,⁷¹

SCIs in children have remarkable potential for recovery.
In a study from a major metropolitan trauma center, complete SCIs were
associated with fatal injuries in one third and no neurologic recovery
in another third, while most of the remaining onethird of patients made
improvements that ultimately allowed functional ambulation. Less
surprisingly, nearly all patients with incomplete SCI made some
improvement over time as well.⁷¹
This ability to recover, even from complete injuries, has led some to
suggest more aggressive attempts at spinal cord decompression in the
early course of treatment,²⁰,⁵² while others have suggested a period of “spinal cord rest” with observation.⁴²
There is certainly no controlled series of patients treated by both
approaches to support either hypothesis. The data do, however, suggest
a more optimistic view regarding the potential recovery of traumatic
SCIs in children compared with adults.

Spinal column structural integrity should be assessed in
all cases of injury because the functional capacity of the vertebral
elements to protect the spinal cord will continue to be required. This
evaluation may be performed with functional radiographs, such as
flexion-extension views (much more common in the cervical spine) or
with an MRI evaluation of associated soft tissue injuries that may
coexist with more obvious bony fractures. Several methods of estimating
spinal column stability have been proposed including the three-column
concept of Denis.¹⁴ Based on
division into anterior, middle, and posterior columns, injuries to two
and certainly three of these sagittal columns may be associated with an
unstable injury pattern. Plain radiography with a CT scan is
appropriate for evaluating the bony elements. An MRI is often required
to elucidate the nature of the disc and ligamentous injuries.²⁶,³³,⁶⁷
MRI is extremely sensitive and, given the brightness of edema fluid on
T2 images, may be overinterpreted. A study correlating MRI and
intraoperative surgical findings, however, demonstrated high levels of
both sensitivity and specificity in the MRI evaluation of posterior
soft-tissue injuries (Fig. 19-2).³⁹

The final treatment goal is a stable spinal column. This
often requires surgical treatment in unstable fracture patterns. In
contrast, most stable injuries can be managed nonoperatively. There are
particular exceptions to these generalizations, of course. At times the
associated SCI or a substantial associated deformity may alter the
treatment approach to an otherwise mechanically stable injury. The
presence of a complete SCI in a child younger than 10 years is also a
determinant that may affect treatment strategies. The incidence of
paralytic spinal deformity (scoliosis) is nearly 100% in such cases,³⁸,⁵³
and a long instrumented fusion will likely be required at some point.
Depending on the fracture pattern and age of the patient, it may be
prudent to include much of the thoracic and lumbar spine in the initial
instrumented fusion.⁴⁵

There are several methods of classifying thoracolumbar fractures (Holdsworth—two column, Denis—three column,¹⁴ McCormack —load sharing,⁴⁶ Gertzbein—comprehensive²⁴),
each with purported advantages. Designed primarily with the adult spine
fracture patterns in mind, the Denis classification translates well for
the categorization of most pediatric thoracolumbar injuries.³⁷
Based on theories of stability related to the three-column
biomechanical concept of the spine (anterior, middle, posterior
columns), the Denis classification in its simplest form includes
compression, burst, flexion-distraction, and fracture-dislocations (Fig. 19-3).

Compression fractures are the most common thoracolumbar spine fracture pattern.⁸,³¹
The vertebral body loses height anteriorly compared to the posterior
wall. Axial load with flexion is the common mechanism. Depending on the
degree and direction of flexion, the wedging may vary between the
coronal and sagittal planes (Fig 19-4). The
percentage of lost height defines the severity of compression
fractures, which rarely have an associated neurologic deficit. However,
the fractures are often associated with similar or occasionally more
severe fractures at adjacent or distant levels. Contiguous compression
fractures, each of a modest degree, together may result in a
substantial kyphotic deformity. Because the cause of these injuries,
such as a fall, are fairly common, it is at times necessary to
determine if a

wedged
vertebra seen radiographically represents an acute compression
fracture, sequelae of Scheuermann kyphosis, or a remote injury.
Clinical examination can localize pain to the site of the fracture in
acute injuries; however, MRI or bone scanning can confirm acute
fracture based on signal changes and increased isotope uptake.

Burst fractures likely represent a more severe form of
compression fracture that extends posteriorly in the vertebral body to
include the posterior wall (middle column). Axial compression is the
primary mechanism, although posterior ligamentous injury and/or
posterior element fractures may also occur. Laminar fractures have been
known to entrap the dural contents. The fractures are most common in
the lower thoracic and upper lumbar levels. Associated neurologic
injury is related

to the severity of injury (greater injury index scores correlate with greater frequency of spinal cord injury⁴²) and the degree of spinal canal encroachment by retropulsed bony fragments.³⁰
SCI at the thoracolumbar junction may result in conus medullaris
syndrome or cauda equina syndrome. Careful examination of the perineal
area is required to identify these spinal lesions.

Flexion-distraction injuries are especially relevant to
the pediatric population because this classic lap belt injury is more
frequent in back seat passengers, particularly when a shoulder strap is
lacking. Motor vehicle accidents are the primary cause of this injury.
The lap belt, which restrains the pelvis in adults, may ride up onto
the abdomen in children. Chance, and later Smith, described how with a
frontal impact, the weight of the torso is driven forward, flexing over
the restraining belt. With the axis of rotation in front of the spine,
distractive forces are placed on the posterior elements, with variable
degrees of anterior vertebral compression. This three-column injury is
generally unstable. The disruption of the posterior elements may occur
entirely through the bony (Chance) or ligamentous (Smith) elements,
although many times the fracture propagates through both soft and hard
tissues.

The injury is most obvious on lateral radiographs;
however, if no fracture exists, widening of the intraspinous distance
may be the only finding on an anteroposterior (AP) radiograph. Standard
transverse plain CT imaging may also miss this injury because the plane
of injury lies within the plane of imaging. One classic finding in
ligamentous flexion-distraction injuries is the “empty facet” sign.
When the inferior articular process of the superior vertebra is no
longer in contact with the superior articular process of the inferior
vertebra, the facet appears empty in the transverse CT image.²³
Sagittal reconstructions are most revealing and MRI will provide
information about the integrity of the posterior ligamentous complex.
Identification of a purely intravertebral flexion-distraction fracture
is important, because this may alter the treatment in patients with
these injuries compared to those with severe ligamentous injury.

Fracture dislocations of the spinal column result from
complex severe loading mechanisms. These are by definition unstable
injuries with a component of shearing and/or rotational displacement. A
special note in the pediatric population is the documentation of this
injury pattern in young patients exposed to nonaccidental trauma.¹⁵,³⁵

Injury patterns specific to the pediatric population
that do not fit the Denis classification include apophyseal avulsion
fractures and SCIWORA. Apophyseal injuries, typically of the lumbar
spine, occur in adolescents as a result of trauma. The mechanism is
thought to be related to flexion with a portion of the posterior corner
of the vertebral body (ring apophysis) fracturing and displacing
posteriorly into the spinal canal. Symptoms may mimic disc herniation,
although the offending structure is bone and cartilage rather than disc
material (Fig. 19-5).¹⁶,¹⁸

The concept of SCIWORA was popularized by Pang and Wilberger⁵¹
who described their experience at the University of Pittsburgh. They
noted a series of patients presenting with traumatic SCIs that were not
evident on plain radiographs or tomograms. Several mechanisms to
explain these findings have been proposed, including spinal cord
stretch and vascular disruption/infarction. MRI studies have confirmed
patterns of both cord edema and hemorrhage in such cases.²⁵ Important additional facts about SCIWORA include the finding that some

patients had a delayed onset of their neurologic deficits. Transient
neurologic symptoms were persistent in many who later developed a
lasting deficit. Additionally, the younger patients (less than 8 years
old) had more severe neurologic involvement.⁵,⁵⁰,⁵¹

Following a careful clinical examination of all patients
with a suspected spinal injury, plain radiographs are usually valuable.
An alert, cooperative patient without pain or tenderness in the back
can be cleared without radiographs. However, any patient with a
significant mechanism or associated injury (motor vehicle accident,
fall from greater than 10 feet, major long bone fracture, cervical or
head injury) requires thoracolumbar spine radiographs if they have
spinal tenderness, are obtunded, or have a distracting injury. Initial
films should include supine AP and lateral views of the thoracic and
lumbar spine. In addition, due to the strong association between
cervical spine fractures and thoracolumbar spine fractures after blunt
vehicular trauma, routine imaging of the complete spine when a cervical
fracture is identified is indicated.⁷⁵

Plain radiographs often show with relatively subtle
findings that should be sought in all cases. On AP radiographs, soft
tissue shadows may be widened by paravertebral hematoma. The bony
anatomy is viewed to evaluate for loss of height of the vertebral body
as compared to adjacent levels. Similar comparisons can be made with
regard to pedicle width and interspinous spacing. The lateral
radiographs give important information about the sagittal plane:
anterior vertebral wedging or collapse or posterior element distraction
or fracture. Careful scrutiny of the plain radiographs is always
prudent; however, the CT scan will nearly always be used to clarify any
suspected fractures. Antevil et al.¹
reported the sensitivity of plain radiographs to be 70% (14 of 20
patients) for spine trauma, while the sensitivity was 100% for CT
scanning (34 of 34 patients).

CT is now a standard component of the evaluation of many
trauma patients. Multidetector scanners allow rapid assessment with
axial, coronal, and sagittal images for patients with plain x-ray
abnormalities. The axial images are best for evaluating the integrity
of the spinal canal in cases of a burst fracture, while the sagittal
views will demonstrate vertebral body compression as well as posterior
element distraction or fracture. In addition, major dislocations easily
seen on plain radiographs will be better understood with regard to the
space left in the spinal canal for the neurologic elements. The amount
of spinal canal compromise has been correlated with the probability of
neurological deficit.⁴⁸

MRI is the modality of choice for evaluating the discs, spinal cord, and posterior ligamentous structures.³³,³⁹,⁶⁶
Although more difficult to obtain in a multiply injured patient, this
study is mandatory in patients with a neurologic deficit in order to
assess the potential cause of cord dysfunction. The MRI is able to
distinguish areas of spinal cord hemorrhage and edema. Assessment of
the posterior ligamentous complex it critical in differentiating stable
and unstable burst fractures, as well as compression fractures and
flexion-distraction injuries. Although

subject
to overinterpretation, MRI has been shown to correlate very well with
intraoperative findings of the structural integrity of the posterior
soft tissues.³⁹

Anterior vertebral body compression fractures are the
most likely fractures to occur in the thoracic spine secondary to axial
compression and flexion loading. The anterior aspect of the vertebral
body is involved, but the posterior wall of the vertebral body is by
definition intact. The degree of wedging is variable, as is the loss of
anterior height. These are nearly always stable injuries, although
examination of the posterior soft tissues is required to rule out any
more severe flexion-distraction injury, and a CT scan is required to
rule out a burst fracture (Fig. 19-7).

An isolated fracture without neurologic involvement is
the most common thoracolumbar fracture pattern and can nearly always be
treated with immobilization with a brace that limits flexion, provides
pain relief, and reduces further loading of the fracture. Most
fractures heal in 4 to 6 weeks without significant additional collapse;
however, radiographs in the first several weeks should be obtained to
follow the sagittal alignment. Long-term studies have suggested modest
remodeling capacity of compression fractures occurring in childhood.⁴³,⁵⁴
Asymmetric growth at the endplates seems to allow some correction in
the wedged alignment over time in the skeletally immature patient.
Long-term results of compression fractures have been generally
favorable, although fractures of the endplates are associated with
later disc degeneration.³⁴

If the kyphosis associated with a fracture is initially
more than 40 degrees or markedly alters the local sagittal alignment,
surgical treatment may be considered. This is most frequent in multiple
adjacent compression fractures that together create unacceptable
kyphosis. The preferred surgical treatment of such fractures is
generally a posterior compression instrumentation construct that spans
one or two levels above and below the affected vertebrae. Anterior
surgical treatment is rarely required. The intact posterior vertebral
wall provides a fulcrum to achieve kyphosis correction. The method of
posterior fixation may be either hooks or pedicle screws. A posterior
fusion over the instrumented segments ensures a lasting stable
correction. Cadaver studies and clinical studies on the use of balloon
vertebroplasty with calcium phosphate cement in adult patients are
encouraging, as this technique may be a potentially viable option to
treat compression fractures with significant angulation.³⁶,⁶⁹,⁷⁰

Osteoporosis of a variety of etiologies may affect
children and adolescents to a degree that predisposes them to
insufficiency fractures that are most often compression fractures (Fig. 19-8).
Multiple-level fractures are more frequent in this setting, and
problematic kyphosis may develop. Differentiating new from old
fractures can be difficult if serial radiographs are not available. A
thoracolumbosacral orthosis (TLSO) for a period of time longer than
typically used for simple compression fracture healing may be necessary
to prevent progressive kyphosis, though treating the primary cause of
the osteopenia is critical to maintaining normal alignment in such
cases. An endocrinologic evaluation and assessment of bone density by
dual energy x-ray absorptiometry are advised.

Axial compression injuries that are more severe and
extend into the posterior wall of the vertebral body are labeled as
burst fractures. The treatment and classification of this fracture
pattern are controversial areas of spinal trauma management. There are
clearly some burst fractures that can be easily managed nonoperatively
in a brace and others that collapse further, resulting in increased
deformity unless surgically stabilized. Defining the characteristics of
stable and unstable burst fractures has been attempted by several
authors.¹⁴,²⁴,⁴⁶
An additional compounding variable in the treatment algorithm is SCI,
which is more frequent with burst fractures than with compression
fractures.

Assuming an intact neurologic system, defining stable
and unstable burst fractures has been attempted based on the degree of
comminution, loss of vertebral height, kyphotic wedging, and integrity
of the posterior ligamentous complex. A load-sharing classification
system assigns points based on comminution, fragment apposition, and
kyphosis.⁴⁶ Although the Denis
classification suggests that all burst fractures are unstable because
of the involvement of at least two columns, it is clear that in many
cases the addition of a third-column injury (posterior ligamentous
complex) is required to result in a truly unstable condition. Some
advocate differentiating stable and unstable burst fractures solely on
the integrity of the posterior ligamentous complex.⁶³,⁷⁶
When a burst fracture is deemed stable, it must be done so on a
presumptive basis. Treatment is then based on an extension molded cast
or TLSO with the goal of allowing an upright position and ambulation.⁶⁴
Frequent radiographic and neurologic follow-up is necessary to identify
early failures. Depending on the age of the patient and severity of the
fracture, immobilization is suggested for a duration of 2 to 4 months.

Studies of immature patients treated for burst fractures are uncommon,³⁷
yet much of the adult literature provides valuable information about
the outcomes to expect following nonoperative treatment. Most of these
fractures in adults heal with little change in kyphosis and function
and minimal, if any, residual pain.⁷³ It is reasonable to expect adolescent patients to heal at least as well and probably even faster. Wood et al.⁷⁶
compared operative and nonoperative treatment in a prospective
randomized study of patients with burst fractures who were
neurologically intact with a normal posterior ligamentous complex. The

radiologic
and functional outcomes were not substantially different, and these
authors concluded that nonoperative treatment should be considered when
the posterior ligamentous complex and neurologic function are intact.⁷⁶
Functional outcome does not appear to correlate with the degree of
spinal kyphosis, although long-term studies of scoliosis treatment do
suggest that an alteration of sagittal alignment may be detrimental
(flat back syndrome) in the long term.

Even some fractures with posterior ligamentous complex disruption have been successfully treated nonoperatively¹²;
however, these three-column injuries are often operatively stabilized.
When surgical treatment is selected, either an anterior or posterior
approach can be used, although this also remains controversial.
Anterior stabilization generally involves discectomy and strut grafting
that spans the fractured vertebra. Stabilization with a plate or
dual-rod system is appropriate. Posterior

options
include pedicle screw fixation one or two levels above and below the
fractured vertebra. Advances in the application of posterior
instrumentation for thoracolumbar fractures has demonstrated
encouraging, early outcomes with fracture stabilization without fusion
and in minimally invasive surgical techniques.⁷²,⁷⁴

The decision to proceed anteriorly or posteriorly for
the surgical treatment of a burst fracture is largely dictated by
surgeon preference and, to some degree, the features of the fracture.
Posterior approaches are familiar to all surgeons and can easily be
extended over many levels. Decompression of the spinal cord can be
achieved by indirect or direct methods. Restoration of the sagittal
alignment frequently leads to spontaneous repositioning of the
posteriorly displaced vertebral body fracture fragments. If additional
reduction of posterior wall fragments is required, direct fracture
reduction can be accomplished with a posterolateral or transpedicular
decompression.²⁰ This also allows additional anterior column bone grafting that may add structural integrity and speed fracture healing.

The anterior approach allows direct canal decompression

through a corpectomy of the fractured vertebra. Structural strut
grafting restores the integrity of the anterior column. With this
graft, a load-sharing anterior plate or rod system completes the
reconstruction. This approach deals most directly with the pathology,
which in a burst fractures lies within the anterior and middle
vertebral columns (Fig. 19-9).
Proponents of the anterior approach cite better biomechanical
stabilization of the unstable spine, better correction of segmental
kyphosis, and less loss of correction postoperatively.⁶¹,⁶²,⁷⁷

The treatment of flexion-distraction injuries is
dictated by the particular injury pattern and the associated abdominal
injuries. In general, these fractures are reduced by an extension
moment that can be maintained with either a cast or internal fixation.
A hyperextension cast is idea for younger patients (less than
approximately 10 years) with a primary bony injury pattern and no
significant intra-abdominal injuries. As described above, the posterior
disruption may pass through ligaments or joint

capsules
in a purely soft tissue plane of injury or traverse an entirely bony
path. The distinction is important, because bony fractures have the
potential for primary bony union, while the severe ligamentous injuries
are less likely to heal with lasting stability without surgical
intervention. As such, the greater the degree of ligamentous/facet
disruption, the more likely the need for stabilization with an
arthrodesis of the injured motion segment. Options for internal
fixation include posterior wiring in young children (supplemented with
a cast) and segmental fixation in a primarily compressive mode (Fig. 19-10).

These highly unstable injuries nearly always require
surgical stabilization. When the spinal cord function remains intact,
instrumented fusion gives the greatest chance for maintaining cord
function. On the other hand, if a complete SCI has occurred, internal
fixation will aid in the rehabilitation process, allowing early
transfers and upright sitting. At least two levels above and below the
level of injury should be instrumented to ensure restoration of
stability. In cases of SCI below the age of 10 years, a longer fusion
may be considered to reduce the incidence and severity of subsequent
paralytic scoliosis. Those injured after the adolescent growth spurt
are at low risk for late deformity if the fracture is well aligned at
the time of initial fixation (Fig. 19-11).