The Operation for Thoracolumbar Spine Trauma in Children

Patient Positioning

  • Prone for posterior spine procedures: For posterior procedures, the prone position with a head pillow is used. The eyes must be inspected to ensure there is not pressure on them while prone. Great care is taken when turning the patient from the supine to the prone position, and intraoperative electrophysiological interrogation may be necessary before and after turning the patient.
  • Supine or lateral for anterior spine procedures: For anterior procedures, the supine or lateral position is used.

Operative Set-up with Fluoroscopy

  • Optimize positioning with fluoroscope: Once the patient is in the initial position, the intraoperative fluoroscope is brought in.
  • Fluoroscopy: This is also useful in localizing the fracture for accurate spine incision.

Surgical Approach

  • Posterior approaches: For posterior approach, dissection is carried out in a subperiosteal fashion. Fluoroscopy is also useful in localizing the fracture for accurate spine incision.
  • Decompression: Decompression to remove bone fragments or compression is often necessary.
  • Repair of dural tears: Traumatic dural tears might be encountered and should be primarily repaired, if possible (or with muscle or fascia graft, if necessary).

Intervention

Spine surgery for trauma in children uses many of the same techniques as in adults, but because the patients are smaller and still growing, this difference must be considered in planning surgical intervention. Intervention can involve instrumentation, reduction, or fusion.

Instrumentation

  • Pedicle screws: Pedicle screws are placed with or without fluoroscopic guidance based on landmarks.
  • Pilot hole: Generally, a pilot hole is made with the drill and a pedicle finder (“gearshift”) is used to cannulate the pedicle.
  • Inspect for breaches: A probe is then used to inspect the pedicle tract for breaches prior to screw insertion.

Reduction

  • Medial facet joints: Removal of the medial facet joints may be required to allow for reduction of the fracture.

Fusion

  • Autograft: Autograft bone is placed along the facet joints and over the transverse processes for a posterior-lateral arthrodesis.
  • Decortication is necessary: Adequate decortication of the bone must be performed prior to bone graft placement.

Closure

  • Routine closure techniques are used.
  • Drainage: Sterile, closed-suction drains are often placed and removed after a few days (5).