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Spinal Cord Injury in Children

By James E. Wilberger, MD, Professor of Neurosurgery; Jannetta Endowed Chair, Department of Neurosurgery; DIO, Chairman Graduate Medical Education Committee; Vice-President, Graduate Medical Education, Drexel University College of Medicine; Allegheny General Hospital; Allegheny Health Network Medical Education Consortium; Allegheny Health Network ; Gordon Mao, MD, PGY 5 Neorosurgery Resident, Allegheny Health Network

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(See also Spinal Trauma.)

Although children < 10 yr have the lowest rate of spinal cord injuries, such injuries are not rare. Most spinal injuries in children occur in the neck.

In children < 8 yr, cervical spine injuries occur most commonly above C4 and are most commonly caused by motor vehicle crashes, falls, and child abuse. In children > 8 yr, injuries at C5 to C8 are more common and are due to motor vehicle crashes and sports injuries, particularly gymnastics, diving, horseback riding, American football, and wrestling. Compared with adults, children have distinct anatomic features (eg, larger head size-to-body, elasticity of spinal ligaments capsules) that predispose them to hypermobility of the spinal column without apparent bony injury.

Children with spinal cord injury may have transient symptoms such as paresthesias and weakness. Children may also have lancinating pains down the spine or extremities. In about 25% of affected children, onset of neurologic signs (such as partial neurologic deficits, complete paralysis) is delayed from 30 min to 4 days after injury, making immediate diagnosis difficult.

Spinal cord injury without evidence of radiologic abnormality (SCIWORA) is related to direct spinal cord traction, spinal cord impingement, spinal cord concussion, and vascular injury. This type of injury occurs almost exclusively in children and often occurs in the cervical spine. In spinal cord injury without evidence of radiologic abnormality, the patient has neurologic findings suggestive of spinal cord injury (eg, paresthesias, weakness) but normal anatomic alignment, and no bone abnormalities are seen on imaging studies (plain x-rays, CT and/or MRI).

Children immobilized by SCIWORA or other spinal cord injuries are at risk for complications due to immobility, including decubitus ulcers, thromboembolic complications, atelectasis and pneumonia, hypertensive autonomic dysreflexia, and complications due to neurogenic bladder, including lower or upper urinary traction infection (secondary to a chronic indwelling catheter), ureteral calculi, vesicourethral reflux, and ultimately chronic kidney disease.

Diagnosis

  • X-rays (cross-table lateral view, anteroposterior view, and open-mouth odontoid view)

  • Usually CT, particularly for bony or ligamentous injury

  • MRI to confirm injury to the spinal cord

Spinal cord injury should be suspected in any child who has been in a motor vehicle crash, has fallen from a height 3 m, or has had a submersion injury.

SCIWORA is suspected even in children who have transient symptoms of neurologic dysfunction or lancinating pains down the spine or extremities and a mechanism of injury compatible with spinal cord injury.

Imaging usually begins with x-rays, including cross-table lateral, anteroposterior, and open-mouth odontoid views. If fracture, dislocation, or subluxation is suspected based on x-ray findings or a very high-risk mechanism of injury, CT is usually done. MRI is usually done with any of the following:

  • Spinal cord injury is suspected or confirmed by x-ray or CT

  • Spinal cord injury is suggested by neurologic deficits on examination

  • Spinal cord injury is suggested by a history of even transient neurologic deficits

Treatment

  • Immobilization

  • Maintenance of oxygenation and spinal cord perfusion

  • Supportive care

  • Surgical stabilization when appropriate

  • Long-term symptomatic care and rehabilitation

Children with a spinal injury should be transferred to a pediatric trauma center.

Treatment acutely is similar to that in adults, with immobilization and attention to the adequacy of oxygenation, ventilation, and circulation. Surgical stabilization is less frequently indicated in children than adults with spinal cord injury; because spinal ligaments tend to be more lax in SCIWORA and bone fractures and complete ligamentous avulsion are absent, there may be no suitable target structure for stabilization. Another advantage of bracing is preservation of spinal mobility by avoidance of fusion surgery; fusion surgery increases risk of long term spondylosis. Historically, high-dose corticosteroids have been used at various dosing schedules and regimens, but multiple clinical trials in adults have failed to demonstrate any added clinical benefit but have shown increased risk of wound infection, pulmonary embolism, sepsis, and death.

Long-term treatments for pediatric SCIWORA are similar to treatments adult spinal cord injury, with focus on both intensive physical rehabilitation of neurologically affected extremities and medical support for various common medical complications that occur with prolonged immobilization or weakness. Rehabilitation is multidisciplinary with involvement of physical therapists for gait training and lower extremity strengthening, occupational therapists for cervical cord injuries affected upper extremity motor function that can result in contractures, and even speech therapists to assist with swallowing and secretions clearance issues that affect high cervical injuries. Regular medical care and visits are necessary for severe SCI who are nonambulatory due to high risks of developing complications resulting from immobility.

Prognosis is directly related to initial neurologic function after injury. Children achieve better neurologic outcomes than adult patients with spinal cord injury (1, 2).

Treatment references

  • 1. Pang D, Pollack IF: Spinal cord injury without radiographic abnormality in children—the SCIWORA syndrome. J Trauma 29: 654–664, 1989.

  • 2. Wang MY, Hoh DJ, Leary SP, et al: High rates of neurological improvement following severe traumatic pediatric spinal cord injury. Spine 29:1493–1497, 2004.