Delayed treatment of cervical fracture. Dislocation in a 4-year-old.

rauma to the vertebral column is relatively uncommon in the pediatric patient population. It accounts for approximately 5% of all spinal cord and vertebral column injuries.1 In the patient with an immature spine (0-9 years) the majority of spinal injuries occur at the cervical (C) spine, especially between the occiput and C2.2,3 When diagnosed and managed properly, most of these injuries can be treated non-operatively. We present a case of inadequately treated injury of the immature cervical spine and review the available literature regarding these injuries. A 4-year-old girl presented to our hospital 4 months after an injury to her neck. She had a history of an isolated trauma to the neck after falling from a height of 6 meters. At the time of initial trauma, there was no history of loss of consciousness and no other injuries. She had no neurological deficit. Radiographs of the cervical spine on the day of trauma were interpreted as normal and the patient was discharged home on simple painkillers. Repeat radiographs were carried out 3 days latter due to persistent complaints of neck pain. The new set of radiographs revealed a compression fracture of C6 vertebral body as well as bilateral facet dislocation at the C5-C6 level with 50% forward shift of C5 on C6. Magnetic resonance images (MRI) of the cervical spine carried out at that time revealed the same findings as the plain radiographs. There was no significant compression to the cord at the level of injury. The patient was admitted to a local hospital at that time and skull traction was applied for one day after which she was discharged in a rigid cervical collar. When she presented to our hospital 4 months after the initial trauma, she was wearing the cervical collar continually. Her neurological examination was within normal limits. Upon removal of the collar, examination of her neck showed a mildly tender range of motion. She did not have any neurological deficit. All radiographic investigations were repeated, including plain radiographs, computerized axial tomogram (CAT) and MRI. They revealed the fracture of C6 vertebral body with dislocation at the C5-C6 level. The vertebral body of C6 is severely wedged and compressed with anterolisthesis of C5 on C6 of approximately 50%. There were bilateral locked facets at C5-C6 and because the fracture was 4 months old and had united, there was no joint seen between the inferior facet of C5 and the superior facet of C6. The cord was displaced posteriorly at the fracture site but without any evidence of compression (Figure 1). When she presented to us, the posterior elements were fused while the anterior part of the injured vertebra was compromised and unable to support the spine. Progressive deformity and mechanical instability are likely to occur as this patient grows. To reconstruct the anterior part of the injured vertebra, an anterior approach to the cervical spine was used in this patient. Somatosensory evoked potential monitoring was utilized Clinical Notes