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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 ; Derrick A. Dupre, MD, Department of Neurosurgery;, Allegheny General Hospital;Drexel University College of Medicine

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Although children < 10 yr have the lowest rate of spinal cord injuries (SCI), such injuries are not rare. 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 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.

Of increasing importance has been the recognition of spinal cord injury without evidence of radiologic abnormality (SCIWORA), which often occurs in the cervical spine. SCIWORA occurs in children with neurologic findings suggestive of spinal cord injury (eg, paresthesias, weakness) with normal anatomic alignment and no bony abnormalities seen on imaging studies (plain X-rays, CT, and/or MRI). This type of injury occurs almost exclusively in children and is related to direct spinal cord traction, spinal cord impingement, spinal cord concussion, and vascular injury.


  • 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 that has been in a motor vehicle crash, has fallen from a height 3 m, or has had a submersion injury.

SCIWORA is suspected in children who have even transient symptoms of neurologic dysfunction or lancinating pains down the spine or extremities and a mechanism of injury compatible with spinal cord injury. In about 25 % of 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.

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


  • 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. Treatment may also include high-dose corticosteroids (same weight-based dose as for adults).