paralyzed, thus limiting the examination Therefore, initial treatment should always maintain spinal immobilization until a more detailed neurologic examination becomes possible Injury mechanisms most commonly associated with spinal injury include motor vehicle collisions (across all age groups), falls (toddlers and school age children), sports-related trauma, and gunshot wounds (adolescents) CLINICAL PEARLS AND PITFALLS Because of the overall high elasticity of the pediatric spine, significant spinal cord injury can occur in the absence of radiographic signs of bony injury The risk of posttraumatic scoliosis after a complete spinal cord injury in children is high Pediatric sacral injuries are rare and seldom associated with neurologic injury Patients with fracture and dislocation have a higher incidence of associated neurologic injury than patients with simple fractures Patients improperly restrained by a lap belt in a motor vehicle collision should be carefully evaluated for “seatbelt syndrome” with abdominal bruising (“seatbelt sign”), an associated hyperflexion-induced lumbar fracture (often a Chance fracture), and intra-abdominal injury Current Evidence Structurally, the child’s spine differs from the adult spine as there is increased ligamentous laxity resulting in greater mobility, more shallow angulations at the facet joints, and incomplete ossification of the vertebrae By adolescence, the spine has mechanical qualities more like those of the adult, and the fracture patterns are similar Injuries to the spine are rare in pediatrics; however, they contribute to a significant morbidity and mortality in children and frequently occur in association with multisystem trauma Injuries of the lower thoracic region to upper lumbar region (T11-L1), for example, have been noted to be associated with significantly increased risk of associated gastrointestinal injury Injuries to the lumbar and sacral regions (L2-sacral) are noted to be associated not only with abdominal injuries, but appendicular orthopedic trauma as well Studies have indicated that high-risk mechanisms include motor vehicle crashes, falls,