Paediatric Spinal Cord Injury

Original Editor - Rucha Gadgil

Top Contributors - Rucha Gadgil, Naomi O'Reilly, Admin, Kim Jackson and Shaimaa Eldib  

Introduction[edit | edit source]

A spinal cord injury is when the spinal cord is damaged from an accident or other situation. Paediatric traumatic spinal cord injury is an uncommon presentation accounting for a mere 5%. The mechanism of injury, the male: female ratio, and the level of injury all differ from adult spinal cord injury. The rate of recovery following spinal cord injury in the paediatric population is also thought to be faster mainly because of the anatomical differences with adults along with the inherent elasticity of the paediatric spine.[1] The typical injuries occurring in children include occipito-atlantal or atlanto-axial dissociation, atlanto-axial rotary subluxation, spinal cord injury without radiological abnormality, and multiple thoracic compression fracture[2].

Congenital and acquired paediatric spinal cord injuries pose unique management challenges because of the dynamic nature of cognitive and physical development in the growing child and the impact of the SCI on this complex process[3].

Spina bifida image 2.jpg

Epidemiology/Etiology[edit | edit source]

Epidemiology[edit | edit source]

In paediatric patients, Traumatic spinal cord injury is relatively rare, with:

  1. Only about 2% to 5% being spine injuries [4]
  2. >80% of injuries occurring in the cervical spine, while the percentage of cervical regions in adults is only around 30% to 40% [5].
  3. Thoracic and lumbar spine injuries representing 6% to 9% of all pediatric spine trauma[6]
  4. Decreased cervical injuries incidence after age 14 with a resemblance adult patient pattern[7]


With respect to the mechanism of injury:

  1. Motor vehicle accidents cause spinal cord injury in smaller children
  2. Sports were responsible for adolescent spinal cord injuries[8].

Etiology[edit | edit source]

  1. Motor Vehicle Accidents
  2. Violence and Sports
  3. Trauma resulting from lap belt injuries, child abuse, and birth injuries
  4. Non-traumatic causes, such as instability of the upper cervical spine seen in Down syndrome, spinal stenosis seen in skeletal dysplasias, and inflammatory conditions, such as juvenile rheumatoid arthritis
  5. Phenomenon of spinal cord injury without radiographic abnormality (SCIWORA).[3]

Pathophysiology[edit | edit source]

The pathophysiology of injury varies markedly in children compared to adults. The spinal anatomy in children differs from adults on the following points:

  1. Children have a different fulcrum due to a large head
  2. Children's vertebra is incompletely ossified
  3. Their ligaments are firmly attached to articular bone surfaces that are more horizontal.


Thus, the younger the age, the more flexible the spine is. The neural damage in children occurs much earlier. The incidence of cervical cord injury decreases with up to 75% of injuries occurring in infancy up to 8 years old because the fulcrum of cervical mobility moves progressively downward with the child’s increasing age.

The mode of injury occurrence can be classified as:

  1. Primary: Primary injury results from mechanical forces directly due to traumatic impact.
  2. Secondary: Secondary injury occurs due to various vascular and chemical processes resulting from a primary injury.[9]

Clinical Presentation[edit | edit source]

The clinical presentation of a paediatric spinal cord injury will depend on the degree of severity and particular location of their injury.[3]

Some of them may be:

  1. Spinal Shock - Pronounced loss of sensation, muscle movement, and reflexes below the level of her injury.
  2. Muscle Weakness
  3. Altered Tone
  4. Altered Sensation
  5. Respiratory Difficulty
  6. Loss of Bowel and Bladder Function


In general, the higher in the back or neck the injury is located, the more extensive the symptoms will be. For example, if the injury is in the lower portion of the spinal column, there may be reduced or absent feeling in and impaired control of the legs, bladder, and bowel. If the spinal cord injury is in the upper neck region, they may be unable to move arms or legs or breathe on their own.

Spinal cord injuries can be severe and potentially life-threatening injuries and as a rule of thumb, in all children admitted with head injury or unconsciousness, spinal injury has to be ruled out[2].

Differential Diagnosis[edit | edit source]

  • Acute Torticollis
  • Cauda Equina and Conus Medullaris Syndromes
  • Cervical Strain
  • Hanging Injuries
  • Strangulation
  • Neck Trauma
  • Septic Shock
  • Spinal Cord Infections
  • Spinal Cord Neoplasms
  • Thoracic outlet syndrome [9]

Imaging and Outcome Measures[edit | edit source]

Imaging[edit | edit source]

  • Blood Tests
  • X-rays
  • CT Scans
  • MRI: helpful to reveal ligamentous or disk injury and of course show the neural elements in great details and useful information in cases of spinal cord injury, especially with regards to prognosis depending on the extent of signal intensity changes of the cord. [2][10]

Outcome Measures[edit | edit source]

The outcome measures that can be used in assessing the Paediatric SCI are:

  1. Paediatric Glasgow Coma Scale
  2. Pediatric Neuromuscular Recovery Scale
    • A capacity-based measure for use in the context of assessing change relative to neurotherapeutic interventions[11]
  3. The American Spinal Injury Association (ASIA) scoring system and the ASIA Impairment Scale (AIS) [12]
  4. Functional Independence Measure (FIM) [13]

Other outcome measures can be found here.

Assessment[edit | edit source]

It is the severity of spinal cord injury which determines the prognosis for recovery of function. The American Spinal Injury Association classifies spinal cord injury into complete spinal cord injury which includes the complete absence of sensory and motor function below the level of injury, and incomplete spinal cord injury in which a patient has partial sensory function, motor function, or both below the neurologic level of the injury. However, this distinction may be possible to make only after the spinal shock has resolved. The following history and physical exam findings are pertinent to explore.[8][9]

History:

  1. The presence of midline pain
  2. A distracting injury that may take attention from the spinal area, for example, a rapidly bleeding open fracture
  3. Paresthesias, the older the child, the more likely the child will report these symptoms
  4. Loss of consciousness may indicate head trauma, but one must not be distracted in ruling out concomitant spinal cord injury
  5. Urinary or fecal incontinence indicate lower spinal level injury


Physical Examination

  1. Mental status using the Glasgow coma scale
  2. Attempt to delineate the level of the spinal cord injury or level of sensory loss
  3. Test for proprioception or vibratory function to examine posterior column function
  4. The anogenital reflexes should be tested. an incomplete spinal cord injury is suspected despite complete sensory and motor loss are suspected if they are present. This evaluation should include bulbocavernosus reflex, anal wink reflex, cremasteric reflex, and rectal tone
  5. A careful evaluation of the entire spine should be performed even if a cervical injury is detected early.
  6. Eerial neurologic examination to document neurologic improvement or deterioration in patients with suspected or diagnosed spinal injuries
  7. Respiratory and circulatory system should also be assessed[9].

Physical Therapy Assessment[edit | edit source]

  1. Mental Status
  2. Higher Functions including memory
  3. Sensations and Reflexes
  4. Strength, Tightness
  5. Cardiorespiratory functions
  6. Posture and Gait
  7. Other Motor Skills


Read more about assessment here.

Medical Management[edit | edit source]

Steps in the management of patients with acute traumatic SCI are divided into pre-hospital and in-hospital management.[10]

  • Pre-hospital Management:
  1. Proper immobilization
  2. Paediatric respiration and airway: Airway control is more important in pediatrics than adults as the major cause of cardiac arrest in them is due to hypoxia secondary to respiratory failure compared to cardiac troubles in adults
  3. Paediatric metabolism
  4. Paediatric cardiovascular system: Controlling blood pressure and maintenance of blood volume by the administration of IV fluid are lifesaving steps.
  • Hospital Management:
  1. Initial hospital evaluation: ABC stability, with a rapid neurologic evaluation.
  2. further diagnosis and radiographic evaluation of the spine is needed.
  3. Respiratory management
  4. Positioning
  5. Ventilation and Breathing
  6. Laryngoscope Blades
  7. Cardiovascular system management
  8. Autonomic nervous system management
  9. pharmacological treatments for SCI

Physiotherapy Management[edit | edit source]

The main goal is to decrease the dependency and to improve the quality of life of the patient. It usually includes inpatient measurements such as wheelchair skills and bed mobility and outpatient measurements, which are also called post-discharge measurements.

Physiotherapy management includes:

  1. Careful assessment of the child for impairments.
  2. Maintaining Muscle integrity: managing spasticity by techniques such as stretching, Rood's approach can be done.
  3. Strengthening: Strengthening of the muscles
  4. Functional Training
  5. Gait training
  6. Improving cardiorespiratory functions


Read more here.

Complications[edit | edit source]

  1. Spinal Coed Deformities
  2. Scoliosis
  3. Syringomyelia[2]

Resources[edit | edit source]

  1. Pediatric Spinal Cord Injury: Recognition of Injury and Initial Resuscitation, in Hospital Management, and Coordination of Care
  2. Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries
  3. Management of spinal cord injury and impairment in an infant, child, or young person

References[edit | edit source]

  1. Parent S, Mac-Thiong JM, Roy-Beaudry M, Sosa JF, Labelle H. Spinal cord injury in the pediatric population: a systematic review of the literature. J Neurotrauma. 2011 Aug;28(8):1515-24. doi: 10.1089/neu.2009.1153. Epub 2011 Jun 9. PMID: 21501096; PMCID: PMC3143390.
  2. 2.0 2.1 2.2 2.3 Basu S (2012) Spinal injuries in children. Front. Neur. 3:96. doi: 10.3389/fneur.2012.00096
  3. 3.0 3.1 3.2 Powell A, Davidson L. Pediatric Spinal Cord Injury. A Review By Organ System. Phy. Med. and Rehab Clinics, 2015; 26(1); 109-132. DOI:https://doi.org/10.1016/j.pmr.2014.09.002
  4. Cirak B, Ziegfeld S, Knight VM, Chang D, Avellino AM, Paidas CN. Spinal injuries in children. J Pediatr Surg. 2004;39(4):607–12.
  5. Eubanks JD, Gilmore A, Bess S, Cooperman DR. Clearing the pediatric cervical spine following injury. J Am Acad Orthop Surg. 2006;14(9):552–64.
  6. Garg H, Pahys J, Cahill PJ. Thoracic and Lumbar Spine Injuries. InPediatric Orthopedic Surgical Emergencies 2012 (pp. 67–86). Springer, New York, NY.
  7. Hall DE, Boydston W. Pediatric neck injuries. Pediatr Rev. 1999;20(1):13–9.
  8. Brown R.L. Brunn M.A. Garcia V.F. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J. Pediatr. Surg. 2001;36:1107–1114.
  9. 9.0 9.1 9.2 Mandadi AR, Koutsogiannis P, Waseem M. Pediatric Spine Trauma. [Updated 2021 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK442027/
  10. 10.0 10.1 Benmelouka A, Shamseldin LS, Nourelden AZ, Negida A. A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries. Adv J Emerg Med. 2019 Oct 10;4(2):e28. doi: 10.22114/ajem.v0i0.256. PMID: 32322796; PMCID: PMC7163256.
  11. Behrman AL, Trimble SA, Argetsinger LC, Roberts MT, Mulcahey MJ, Clayton L, Gregg ME, Lorenz D, Ardolino EM. Interrater Reliability of the Pediatric Neuromuscular Recovery Scale for Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2019 Spring;25(2):121-131. doi: 10.1310/sci2502-121. PMID: 31068744; PMCID: PMC6496963.
  12. Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, et al. Clinical assessment following acute cervical spinal cord injury. Neurosurgery. 2013;72(suppl_3):40–53.
  13. Allen DD, Mulcahey MJ, Haley SM, Devivo MJ, Vogel LC, McDonald C, Duffy T, Betz RR. Motor scores on the functional independence measure after pediatric spinal cord injury. Spinal Cord. 2009 Mar;47(3):213-7. doi: 10.1038/sc.2008.94. Epub 2008 Aug 5. PMID: 18679405; PMCID: PMC2718680.