Anatomic and biomechanical features unique to the immature spine account for differences in injury patterns between pediatric and adult patients. The pediatric spine has increased phyisologic mobility because of several factors. Laxity of the interspinous ligaments and joint capsules, the horizontal orientation of facet joints, incompletely ossified wedge-shaped vertebrae, and the underdeveloped neck and paraspinous musculature all contribute to increased flexibility, particularly of the cervical spine. This elasticity affords children some protection against spinal trauma. When spinal injury occurs in the pediatric population, however, it is generally secondary to mechanisms involving considerable force. The resulting injuries are associated with a high degree of neurologic compromise at presentation. In addition, there is an increased occurrence of spinal cord injury without radiographic evidence of abnormality (SCIWORA) in patients younger than 10 years. 28 Growth plate fractures are most common, but these are difficult to detect on plain radiographs. If spinal cord injury is suspected, based on history or results of the neurologic examination, normal spine radiographs cannot be used to exclude injury. Immobilization must be maintained. Neurologic deficits should be aggressively evaluated with CT scan and MRI.

An additional concern in the pediatric population is child abuse. Vigorous shaking of infants, termed "shaken baby syndrome," may result in avulsion or compression fractures of the spine. A history that is inconsistent with the nature and extent of the injuries should raise the suspicion of child abuse. A thorough search for associated injuries should be undertaken, and appropriate governmental agencies notified.

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