Ignasi Barber MD PhD

Hospital Sant Joan de Déu

Barcelona

Sport injuries in the Spine

No disclosure

Sports injuries Spine

1. Anatomy and biomechanics (pediatric spine)

2. Type of injuries (acute vs chronic)

3. Imaging evaluation

4. Specific sports injuries

5. Treatment and follow up

6. Prevention

Sports injuries Spine

Pediatric Spine:

1. Anatomy and biomechanics

Passive elements: Bones and ligaments

Active elements: Muscles

Sports injuries Spine

1. Anatomy and biomechanics

Development of the pediatric spine 8 Years old

Younger children have a large head-to-body ratio and a hypermobile spine: ligamentous laxity, horizontal facet joints, underdeveloped spinous processes, and relatively weak musculature.

These factors can lead to high-level cervical spine injuries and to spinal cord injury without radiographic abnormality (SCIWORA).

Egloff AM et al. Pediatric cervical spine trauma imaging: a practical approach. Ped Radiol (2009) 39:447-456.

Normal Variants

*Images from Lustrin ES et al. Pediatric cervical spine: normal anatomy, variants and trauma. Radiographics (2003) 23:539-560

Familiarity with normal anatomy can helpavoid misinterpretation of normal epiphyses as pathologic conditions.

C1Pseudoluxation C2-C3: physiological anterior displacement of C2 on C3 in children. It is common in children <7 years. It is more pronounced in flexion and should not be considered a traumatic cervical injury. (Swischuk’s line)

1. Ghanem I, El Hage S, Rachkidi R et-al. Pediatric cervical spine instability. J Child Orthop. 2008;2 (2): 71-84.2. Swischuk LE. Anterior displacement of C2 in children: physiologic or pathologic.

Radiology. 1977;122 (3): 759-63.

Sports injuries Spine

EpidemiologyEach year in the United States, more than 44 million children participate in organized sports and recreational activitiesMore than 9000 emergency department visits each day37 to 80% of pediatric spine injuries following trauma involve the cervical spine.

Sports injuries to the cervical spine: higher incidence of subaxial injuries and increased odds of sustaining SCIWORA.

Babcock L, Olsen CS, Jaffe DM, Leonard JC, Cervical Spine Study Group for the Pediatric Emergency Care Applied Research Network (PECARN). Cervical Spine Injuries in Children Associated With Sports and Recreational Activities. Pediatr Emerg Care. 2018 Oct;34(10):677–86.

Sports injuries Spine

Pediatric Spine:

1. Anatomy and biomechanics

2. Type of injuries: acute

3. Clinical and Imaging evaluation

4. Treatment and follow up

5. Prevention

Acute Injuries in pediatric spine

1. Occiput-C1 dislocation

2. Jefferson fracture (ring of C1 fracture)

3. Atlantoaxial injuries: Rotatory subluxation and ligamentous disruption

4. C2 fractures: Odontoid and Hangman fractures

5. Subaxial cervical spine injuries: Body compression fractures, facet fracture/dislocation

6. Thoracic and lumbar spine fractures: compression, burst and Chance fractures

Imaging techniques• Plain films

Lateral view, AP and Odontoid

• CT

Helical and multiplanar reconstruction

• MR

Evaluation of spinal cord

Evaluation of ligamentous injuries

AP and Lateral plain films in a 5 yo girl

AP transoral“odontoyd” view in a 4 yo girl : Unnecesary in younger than 5-9 years.

Forced flexion and extension lateral views in a 4 yo girl. Not usefull in the acute setting.

Plain films

Vertebral bodyLateral MassFacet jointLaminaSpinous process

C1

C2

C3

C4

C5

C6

C7

Imaging techniques

• CT

Screening tool in adults

When should we do it in children?

High risk of spine injury

Severe head trauma (Glasgow score under 8)

Inadequate plain films or suspected fracture

It should not be used as a screening tool in children!!!

Adelgais KM, Grossman DC, Langer SG et al (2004) Use of helical computed tomography for imaging the pediatric cervical spine. Acad Emerg Med 11:228–236

3 yo boy with neck pain after playground accidentA friend fell on top of him from 2 m high!!!

Imaging techniques• MR

Evaluation of spinal cord

Evaluation of soft-tissue injuries

Neurologic symptoms with or without radiographic findings

A 13-year-old boy with SCIWORA.Image from AH Karantanas. Sports injuries in children and adolescents.© Springer-Verlag Berlin Heidelberg 2011

Case courtesy of Dr I. Delgado Hospital Vall d’Hebrón . Barcelona.

T1 STIR T2 T2*

5 year old boy who suffered a motor vehicle accident who presents with an acute tetraparesia

16 year old boy with head and neck trauma and neck pain. Plain films (OSH) normal.

Subaxial cervical spine injuries: Lateral facet fracture. No dislocation

Subaxial cervical spine injuries:Hyperflexion fractureUsually related to sports-related injuries or MVA in older children and adolescentsFlexion and axial loading

Skeletal trauma: spinal column

Acute thoracic-lumbar spine injuriesOlder children are subject to similar fractures as adults.

Vertebral body compression fractures are most common.

The presence of injury at multiple noncontiguous levels in children is associated with an increased probability of neurologic injury.

Rebecca Stein-Wexler, Sandra L. Wootton-Gorges and M.B. Ozonoff. “Pediatric Orthopedic Imaging”. Firth GB. Pediatric noncontiguous spinal injuries: the 15-year experience at a level 1 trauma center. Spine. 2012;37(10):E599–608.

Spinous Process Fracture (Clay-shoveler's fracture)

L2 Chance fracture in a 17 yo girl.Unstable flexion-distraction transverse disruption involving vertebral body and posterior elementsUsually at T12-L2 level (thoracolumbar junction)In adolescent fracture line through the physeal plate (never through disc)

Sports injuries Spine

Pediatric Spine:

1. Anatomy and biomechanics

2. Type of injuries: chronic

3. Clinical and Imaging evaluation

4. Treatment and follow up

5. Prevention

Nonspecific uncomplicated thoraco lumbar spine pain8-16 years old, girls>boys, family history

Stress injury/Spondylolysis/SpondylolisthesisDisc pathology (hernia, Scheuermann)

Repetitive trauma associated with athletics may be responsible for clinical or subclinical injuries that lead to chronic back pain

A detailed history and physical examination and plain PA / lateral plain films of the spine are the initial steps…

"…the value of a lumbar spine radiograph is to establish the presence of a spine” Michael Modic MD

Variant 1: Child. Back pain with no clinical red flags

Clincal red flags1. Constant pain2. Night pain3. Radicular pain4. Pain lasting >4 weeks5. Abnormal neurologic examination

Imaging is usually not appropriate

Variant 2: Child. Back pain with 1 or more clinical red flags

X-ray spine area of interestMRI complete spine

Variant 3: Child. Back pain with 1 or more clinical red flags and negative radiographs

MRI complete spine

Variant 4: Child. Back pain with 1 or more clinical red flags and positive radiographs

MRI complete spine

ACR Appropriateness Criteria for Low Back Pain

All low back pain imaging variants

and clinical scenarios:

https://acsearch.acr.org/docs/6948

3/Narrative/

Feldman DS1, Straight JJ, Badra MI, MohaideenA, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop. 2006 May-Jun;26(3):353-7.

Systematic approach provided a definitive diagnosis in 34%

The authors found that disk pathology (17%) was the most common finding followed by spondylolysis/spondylolisthesis and Scheuermann disease

Ramirez N1, Flynn JM, Hill BW, Serrano JA, Calvo CE, Bredy R, Macchiavelli RE. Evaluation of a systematic approach to pediatric back pain: the utility of magnetic resonance imaging. J Pediatr Orthop. 2015 Jan;35(1):28-32

SPONDYLOLYSIS

• Defect in the pars interarticularis of the neural arch • Mechanical stress between articular apophysis• Axial and hyperextension repetitive load• Present in ~5% of the population and higher in the

adolescent athletic population• Common cause of low back pain• L5 (90%), bilateral (80-90%)• 43-74% of patients with spondylolysis will progress

to spondylolisthesis

https://orthoinfo.aaos.org

Imaging Spondylolysis

▪ Plain films (oblique views, La Chapelle)

Courtesy of Dr Lopez PinoHospital Niño Jesús. Madrid

CT

High specificity, excelentanatomic detailComplete vs incompletefractureSclerosis/consolidation

Radiation burden, unsensitive to otherpathologies, uneable todepict bone edema

Collar around theneck of a Scottie dog

MR Imaging ▪ High sensibility for early changes(edema)

▪ Limited in the evaluation of the cortical bone

▪ Can be missed by MRI!!

Courtesy of Dr Lopez PinoHospital Niño Jesús. Madrid

▪ grade 0: normal pars

▪ grade 1: stress injury▪ grade 3: incomplete fracture▪ grade 3: Acute complete fracture ▪ grade 4: Chronic fracture

Grading Spondylolysis

Hollenberg GM, (2002) Stress reactions of the lumbar pars interarticularis:the development of a new MRI classification system. Spine 27:181–186

NM Imaging

Bone scintigraphy

SPECTTrout AT. Spondylolysis and Beyond: Value of SPECT/CT in Evaluation of Low Back Pain in Children and Young Adults RadioGraphics 2015; 35:819–834

14 yo boy, soccer player, lumbar pain

There is association of spondylolysis withtransitional lumbar vertebra and spinabifida occulta

13 yo boyLumbar pain

9 years old boy. Lumbar pain

Spondylolisthesis (chronic condition)Graded based on Meyerding system (% of anterior displacement of the

proximal vertebra relative to the lower): Grade 1: 1–25%, Grade 2: 26–50%, Grade 3: 51–75%, Grade 4: 76–100% and Grade 5: >100% slippage

Courtesy of Dr Lopez PinoHospital Niño Jesús. Madrid

14yoBasketball playerNormal Plain films

Feldman DS1, Straight JJ, Badra MI, MohaideenA, Madan SS. Evaluation of an algorithmic approach to pediatric back pain. J Pediatr Orthop. 2006 May-Jun;26(3):353-7.

Consider CT

Localized CTLow dose (as low as you can go!!!)

Journal of Digital ImagingAutomatic Lumbar MRI Detection and Identification Based on Deep Learning. October 2018AI detects lumbar vertebrae in MRI images with 98.6% accuracy

Comparison of natural language processing rules-based and machine-learning systems to identify lumbar spine imaging findings related to low back pain. Katherine et al. Academic Radiology 2018, Volume 25 , 1422 - 1432

Disc herniation• Repetitive trauma causes weakening of annular fibers which predisposes to

herniation of nucleus pulposus.• Pain, reduced range of motion and radicular symptoms• Can be associated with ring apohysis fracture• Associated with a haematoma in the epidural space (evident on MRI).

Singhal A . Ring apophysis fracture in pediatric lumbar disc herniation: a common entity. PediatrNeurosurg 2013;49:16–20

Limbus vertebrae

Often included as ‘normal variants’Intraosseous disc herniationOveruse injury / symptomatic.

Athletic adolescents or those with a history of increased axial stress to the spine

13 yo boy

Lumbar Scheuermann’s disease

15 yo boy with thoracic spine pain Scheuermann´s disease

Challenging case and differential diagnosis

13 yo girl with lumbar pain for 2 weeks. Now a palpable mass. MR!

T1

T2

STIR

Gado

Myositis OssificansHeterotopic ossification 6-8 weeks after injury (sports)Avoid biopsy (may mimic malignancy on histology)

2 months FU

6 months FU

1 year FU

Myositis Ossificans

Paediatric Interverterbaldisc calcification (IVDC)Spinal pain /asymptomaticSelf-limited

14 yo girl with lower back painOppenheimer Ossicle

Conclusions• Acute sport spine injuries involve cervcial spine and have a

higher risk of spinal cord injury (SCIWORA)

• Chronic injuries: thoraco-lumbar spine

• Clinical red flags

• In Spondylolysis: plain films, MR and localized low dose CT

Ignasi Barber MD PhD

ibarber@sjdhospitalbarcelona.org

Hospital Sant Joan de Déu

Barcelona Children’s Hospital

Thank you for your attention