Study Design: Prospective cohort study.

Objective: To study the relationship between scoliosis and Chiari I malformation, with reference to the possible role of cranio-vertebral decompression in preventing the need for scoliosis correction.

Methods: Prospective data collection on all Chiari I patients referred to a single paediatric neurosurgeon with an interest in Chiari malformation.

Subjects: From a total of 35 patients with symptomatic Chiari I who underwent primary cranio-vertebral decompression, 13 had clinically detected scoliosis. Of these 13, 10 (7 males) had no other structural spine abnormality, which could influence the natural history of scoliosis and were included in this study. Mean age at diagnosis was 11.5 years (range 8.8– 15.9 years).

Results: Of the 10 patients, 8 had left-sided curves and two had right sided curves. Six patients did not require corrective scoliosis surgery following cranio-vertebral decompression. The mean Cobb angle for those not requiring scoliosis correction was 29 degrees compared to 76 degrees for those requiring correction (p=0.001, one way ANOVA). The mean age of patients requiring corrective surgery was 12.75 years versus 10.33 years for those not requiring correction (p=0.084, one way ANOVA). These findings were confirmed by multivariate analysis, which also confirmed that symptom duration, syrinx length and site were not significant in predicting the need for corrective surgery following cranio-vertebral decompression.

Conclusion: Cranio-vertebral decompression for Chiari I may prevent the need for corrective scoliosis surgery when performed before the age of ten and below a Cobb angle of 30 degrees.

Objective: To investigate the incidence, treatment and outcome of spinal injuries in paediatric patients with head injuries admitted ventilated to the paediatric ICU.

Design: Retrospective review of all head injury patients admitted ventilated to Birmingham Children’s Hospital from September 1995 to March 2001.

Outcome Measures: Severe head injury is defined as an initial GCS of 8 or less; moderate head injury as GCS between 9 – 12 and minor head injury – GCS above 12. Spine injuries detected on plain trauma radiographs and/or CT. Outcome is described by Glasgow Outcome Scale and Frankel grade.

Subjects: Two hundred and two consecutive patients were admitted during period: 141 (70%) patients had severe head injury; 44 (22%) patients had moderate head injury; 17 (8%) had minor head injuries. There were 131 males (65%) and 49 females (35%). Age ranged from nine months to sixteen years (mean eight years). The head injuries were: 35 extradural haematoma, 47 acute subdural haematoma, 41 contusions and 79 diffuse axonal injury (DAI).

Results: All 202 patients had cervical radiographs done. Forty-eight patients (24%) had further cervical spine CT mainly for inadequate cervical radiographs. Seven patients (3.5%) had CT of the thoracic or lumbar spine. Nineteen patients (9.5%) had MRI of the spine performed. In total, eight of the 202 (4%) patients had spinal injuries (aged two to ten years): 6/8 (75%) were cervical and 2/8 (25%) thoracic and lumbar spine. They were: C3 lamina fracture, C2/3 subluxation, C1/2 sub-luxation, C2 fracture with C6/7 dislocation and cord transection, C6/7 dislocation with cord transection, distraction of atlanto-axial junction, T12 crush fracture and L3/4 fracture dislocation. The cause was road traffic accidents (n=5) and falls from windows (n=3). All had the spinal injury diagnosed on radiographs with no false negative radiographs. All were treated conservatively: one halo vest, one thoracolumbar corset and five hard collars. There were three deaths due to the head injury (C6/7 dislocation with cord transection, L3/4 fracture dislocation and distraction of atlanto-axial junction) at day one, day five and day ten of injury respectively, one patient (C2 fracture) remained quadraplegic (Frankel A), four patients (C3 lamina fracture, C2/3 subluxation, C1/2 subluxation, T12 crush fracture) had good outcomes (Frankel D). Four patients had a GOS of 5 and one patient had GOS of 3 at six months.

Conclusion: The incidence of spinal injuries especially cervical injuries was higher than expected, probably reflecting the severity of the injury in this group of patients. Plain cervical and thoracolumbar radiographs detected all patients with spinal injuries suggesting that this investigation alone is sensitive enough for this purpose. Non-operative treatment resulted in good outcome for most of the patients.