Pediatric Spinal Cord Injury: Recognition of Injury and Initial Resuscitation, in Hospital Management, and Coordination of Care

Abstract

Spinal cord injury is uncommon in the pediatric population with a lifelong impact for the patient and family. Knowledge of spine embryology, mechanisms of injury that lead to specific injuries, appropriate utilization of radiographic imaging based on suspected injury, prehospital and hospital management of various spinal cord injuries is essential for providers attending to traumatically injured patients. In addition to patients who present with soft tissue and bony injuries diagnosed with clinical examination and confirmed with computed tomography or magnetic resonance imaging, it is important to note that the pediatric population is at a higher risk for spinal cord injury without radiographic abnormality than the adult population. Patients who survive the acute phase of injury face long-term rehabilitation and have an increased risk of depression and mortality. Understanding the long-term sequelae of spinal cord injuries is also an essential management component of traumatically injured children. A program that provides long-term rehabilitation, psychosocial and spiritual support, and adaptive environmental supports gives patients and their families the best opportunity for long-term recovery. A review of the current literature on the diagnosis, management, and follow-up of pediatric spinal cord injury is presented.

Keywords

spinal cord injury - spinal cord injury without radiographic abnormality - spinal shock - neurogenic shock

• References

• 1 Parent S, Dimar J, Dekutoski M, Roy-Beaudry M. Unique features of pediatric spinal cord injury. Spine 2010; 35 (21, Suppl): S202-S208
• 2 Mortazavi M, Gore PA, Chang S, Tubbs RS, Theodore N. Pediatric cervical spine injuries: a comprehensive review. Childs Nerv Syst 2011; 27 (5) 705-717
• 3 Chien LC, Wu JC, Chen YC , et al. Age, sex, and socio-economic status affect the incidence of pediatric spinal cord injury: an eleven-year national cohort study. PLoS ONE 2012; 7 (6) e39264
• 4 Bulas DI, Fitz CR, Johnson DL. Traumatic atlanto-occipital dislocation in children. Radiology 1993; 188 (1) 155-158
• 5 Hagen EM, Rekand T, Gilhus NE, Grønning M. Traumatic spinal cord injuries—incidence, mechanisms and course. Tidsskr Nor Laegeforen 2012; 132 (7) 831-837
• 6 The University of Alabama at Birmingham. NSCISC National Spinal Cord Injury Statistical Center 2014. Available at: https://www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202014.pdf . Accessed September 9, 2014
• 7 Keith LM, Persaud TVN, Mark GT. Before We Are Born: Essentials of Embryology and Birth Defects. 8th ed. Philadelphia, PA: Elsevier/Saunders; 2013: 227-230
• 8 Wang JC, Nuccion SL, Feighan JE, Cohen B, Dorey FJ, Scoles PV. Growth and development of the pediatric cervical spine documented radiographically. J Bone Joint Surg Am 2001; 83-A (8) 1212-1218
• 9 Fesmire FM, Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med 1989; 7 (2) 133-142
• 10 Ogden JA. Radiology of postnatal skeletal development. XII. The second cervical vertebra. Skeletal Radiol 1984; 12 (3) 169-177
• 11 Liang CL, Lui CC, Lu K, Lee TC, Chen HJ. Atlantoaxial stability in ossiculum terminale. Case report. J Neurosurg 2001; 95 (1, Suppl): 119-121
• 12 Brown RL, Brunn MA, Garcia VF. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg 2001; 36 (8) 1107-1114
• 13 Cirak B, Ziegfeld S, Knight VM, Chang D, Avellino AM, Paidas CN. Spinal injuries in children. J Pediatr Surg 2004; 39 (4) 607-612
• 14 Ware ML, Gupta N, Sun PP, Brockmeyer DL. Clinical biomechanics of the pediatric craniocervical junction and the subaxial spine. In: Brockmeyer DL, , ed. Advanced Pediatric Craniocervical Surgery. New York, NY: Thieme; 2006: 27-42
• 15 Marshall KW, Koch BL, Egelhoff JC. Air bag-related deaths and serious injuries in children: injury patterns and imaging findings. AJNR Am J Neuroradiol 1998; 19 (9) 1599-1607
• 16 Dickman CA, Papadopoulos SM, Sonntag VK, Spetzler RF, Rekate HL, Drabier J. Traumatic occipitoatlantal dislocations. J Spinal Disord 1993; 6 (4) 300-313
• 17 Sun PP, Poffenbarger GJ, Durham S, Zimmerman RA. Spectrum of occipitoatlantoaxial injury in young children. J Neurosurg 2000; 93 (1, Suppl): 28-39
• 18 Connolly B, Emery D, Armstrong D. The odontoid synchondrotic slip: an injury unique to young children. Pediatr Radiol 1995; 25 (Suppl. 01) S129-S133
• 19 Mandabach M, Ruge JR, Hahn YS, McLone DG. Pediatric axis fractures: early halo immobilization, management and outcome. Pediatr Neurosurg 1993; 19 (5) 225-232
• 20 Odent T, Langlais J, Glorion C, Kassis B, Bataille J, Pouliquen JC. Fractures of the odontoid process: a report of 15 cases in children younger than 6 years. J Pediatr Orthop 1999; 19 (1) 51-54
• 21 Sherk HH, Nicholson JT, Chung SM. Fractures of the odontoid process in young children. J Bone Joint Surg Am 1978; 60 (7) 921-924
• 22 Leonard JC. Cervical spine injury. Pediatr Clin North Am 2013; 60 (5) 1123-1137
• 23 Horn EM, Lekovic GP, Feiz-Erfan I, Sonntag VK, Theodore N. Cervical magnetic resonance imaging abnormalities not predictive of cervical spine instability in traumatically injured patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 2004; 1 (1) 39-42
• 24 Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. (Fixed rotatory subluxation of the atlanto-axial joint). J Bone Joint Surg Am 1977; 59 (1) 37-44
• 25 Pang D, Li V. Atlantoaxial rotatory fixation: part 3-a prospective study of the clinical manifestation, diagnosis, management, and outcome of children with alantoaxial rotatory fixation. Neurosurgery 2005; 57 (5) 954-972 , discussion 954–972
• 26 Torg JS, Corcoran TA, Thibault LE , et al. Cervical cord neurapraxia: classification, pathomechanics, morbidity, and management guidelines. J Neurosurg 1997; 87 (6) 843-850
• 27 Torg JS, Pavlov H, Genuario SE , et al. Neurapraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg Am 1986; 68 (9) 1354-1370
• 28 Nigrovic LE, Rogers AJ, Adelgais KM , et al; Pediatric Emergency Care Applied Research Network (PECARN) Cervical Spine Study Group. Utility of plain radiographs in detecting traumatic injuries of the cervical spine in children. Pediatr Emerg Care 2012; 28 (5) 426-432
• 29 Mower WR, Hoffman JR, Pollack Jr CV, Zucker MI, Browne BJ, Wolfson AB ; NEXUS Group. Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med 2001; 38 (1) 1-7
• 30 Baker C, Kadish H, Schunk JE. Evaluation of pediatric cervical spine injuries. Am J Emerg Med 1999; 17 (3) 230-234
• 31 Pollack Jr CV, Hendey GW, Martin DR, Hoffman JR, Mower WR ; NEXUS Group. Use of flexion-extension radiographs of the cervical spine in blunt trauma. Ann Emerg Med 2001; 38 (1) 8-11
• 32 Schenarts PJ, Diaz J, Kaiser C, Carrillo Y, Eddy V, Morris Jr JA. Prospective comparison of admission computed tomographic scan and plain films of the upper cervical spine in trauma patients with altered mental status. J Trauma 2001; 51 (4) 663-668 , discussion 668–669
• 33 Flynn JM, Closkey RF, Mahboubi S, Dormans JP. Role of magnetic resonance imaging in the assessment of pediatric cervical spine injuries. J Pediatr Orthop 2002; 22 (5) 573-577
• 34 Kaiser ML, Whealon MD, Barrios C, Kong AP, Lekawa ME, Dolich MO. The current role of magnetic resonance imaging for diagnosing cervical spine injury in blunt trauma patients with negative computed tomography scan. Am Surg 2012; 78 (10) 1156-1160
• 35 Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery 2004; 55 (6) 1325-1342 , discussion 1342–1343
• 36 Frankel HL, Hancock DO, Hyslop G , et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969; 7 (3) 179-192
• 37 Kochanek PM, Carney N, Adelson PD , et al; American Academy of Pediatrics-Section on Neurological Surgery; American Association of Neurological Surgeons/Congress of Neurological Surgeons; Child Neurology Society; European Society of Pediatric and Neonatal Intensive Care; Neurocritical Care Society; Pediatric Neurocritical Care Research Group; Society of Critical Care Medicine; Paediatric Intensive Care Society UK; Society for Neuroscience in Anesthesiology and Critical Care; World Federation of Pediatric Intensive and Critical Care Societies. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition. Pediatr Crit Care Med 2012; 13 (Suppl. 01) S1-S82
• 38 Ledsome JR, Sharp JM. Pulmonary function in acute cervical cord injury. Am Rev Respir Dis 1981; 124 (1) 41-44
• 39 Casha S, Christie S. A systematic review of intensive cardiopulmonary management after spinal cord injury. J Neurotrauma 2011; 28 (8) 1479-1495
• 40 Hachen HJ. Idealized care of the acutely injured spinal cord in Switzerland. J Trauma 1977; 17 (12) 931-936
• 41 Aprahamian C, Thompson BM, Finger WA, Darin JC. Experimental cervical spine injury model: evaluation of airway management and splinting techniques. Ann Emerg Med 1984; 13 (8) 584-587
• 42 Hastings RH, Marks JD. Airway management for trauma patients with potential cervical spine injuries. Anesth Analg 1991; 73 (4) 471-482
• 43 Lennarson PJ, Smith D, Todd MM , et al. Segmental cervical spine motion during orotracheal intubation of the intact and injured spine with and without external stabilization. J Neurosurg 2000; 92 (2, Suppl): 201-206
• 44 Rozzelle CJ, Aarabi B, Dhall SS , et al. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 2013; 72 (Suppl. 02) 205-226
• 45 Nypaver M, Treloar D. Neutral cervical spine positioning in children. Ann Emerg Med 1994; 23 (2) 208-211
• 46 Herzenberg JE, Hensinger RN, Dedrick DK, Phillips WA. Emergency transport and positioning of young children who have an injury of the cervical spine. The standard backboard may be hazardous. J Bone Joint Surg Am 1989; 71 (1) 15-22
• 47 Curran C, Dietrich AM, Bowman MJ, Ginn-Pease ME, King DR, Kosnik E. Pediatric cervical-spine immobilization: achieving neutral position?. J Trauma 1995; 39 (4) 729-732
• 48 Huerta C, Griffith R, Joyce SM. Cervical spine stabilization in pediatric patients: evaluation of current techniques. Ann Emerg Med 1987; 16 (10) 1121-1126
• 49 Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkisson A. Respiratory effects of spinal immobilization in children. Ann Emerg Med 1991; 20 (9) 1017-1019
• 50 Mallek JT, Inaba K, Branco BC , et al. The incidence of neurogenic shock after spinal cord injury in patients admitted to a high-volume level I trauma center. Am Surg 2012; 78 (5) 623-626
• 51 Vale FL, Burns J, Jackson AB, Hadley MN. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 1997; 87 (2) 239-246
• 52 Levi L, Wolf A, Belzberg H. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery 1993; 33 (6) 1007-1016 , discussion 1016–1017
• 53 Stratman RC, Wiesner AM, Smith KM, Cook AM. Hemodynamic management after spinal cord injury. Orthopedics 2008; 31 (3) 252-255
• 54 Krassioukov AV, Karlsson AK, Wecht JM, Wuermser LA, Mathias CJ, Marino RJ ; Joint Committee of American Spinal Injury Association and International Spinal Cord Society. Assessment of autonomic dysfunction following spinal cord injury: rationale for additions to International Standards for Neurological Assessment. J Rehabil Res Dev 2007; 44 (1) 103-112
• 55 Ditunno JF, Little JW, Tessler A, Burns AS. Spinal shock revisited: a four-phase model. Spinal Cord 2004; 42 (7) 383-395
• 56 Agrawal SK, Fehlings MG. Mechanisms of secondary injury to spinal cord axons in vitro: role of Na+, Na(+)-K(+)-ATPase, the Na(+)-H+ exchanger, and the Na(+)-Ca2+ exchanger. J Neurosci 1996; 16 (2) 545-552
• 57 Pettiford JN, Bikhchandani J, Ostlie DJ, St Peter SD, Sharp RJ, Juang D. A review: the role of high dose methylprednisolone in spinal cord trauma in children. Pediatr Surg Int 2012; 28 (3) 287-294
• 58 Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev 2002; (3) CD001046
• 59 Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev 2012; 1: CD001046
• 60 Arora B, Suresh S. Spinal cord injuries in older children: is there a role for high-dose methylprednisolone?. Pediatr Emerg Care 2011; 27 (12) 1192-1194
• 61 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; 28 (8) 1515-1524
• 62 Pastrana EA, Saavedra FM, Murray G, Estronza S, Rolston JD, Rodriguez-Vega G. Acute adrenal insufficiency in cervical spinal cord injury. World Neurosurg 2012; 77 (3-4) 561-563
• 63 Lemons VR, Wagner Jr FC. Respiratory complications after cervical spinal cord injury. Spine 1994; 19 (20) 2315-2320
• 64 Mathias CJ. Orthostatic hypotension and paroxysmal hypertension in humans with high spinal cord injury. Prog Brain Res 2006; 152: 231-243
• 65 Claydon VE, Steeves JD, Krassioukov A. Orthostatic hypotension following spinal cord injury: understanding clinical pathophysiology. Spinal Cord 2006; 44 (6) 341-351
• 66 Mathias CJ. Bradycardia and cardiac arrest during tracheal suction—mechanisms in tetraplegic patients. Eur J Intensive Care Med 1976; 2 (4) 147-156
• 67 Lehmann KG, Lane JG, Piepmeier JM, Batsford WP. Cardiovascular abnormalities accompanying acute spinal cord injury in humans: incidence, time course and severity. J Am Coll Cardiol 1987; 10 (1) 46-52
• 68 Prakash M, Raxwal V, Froelicher VF , et al. Electrocardiographic findings in patients with chronic spinal cord injury. Am J Phys Med Rehabil 2002; 81 (8) 601-608
• 69 Mathias CJ, Christensen NJ, Frankel HL, Peart WS. Renin release during head-up tilt occurs independently of sympathetic nervous activity in tetraplegic man. Clin Sci (Lond) 1980; 59 (4) 251-256
• 70 Claydon VE, Krassioukov AV. Orthostatic hypotension and autonomic pathways after spinal cord injury. J Neurotrauma 2006; 23 (12) 1713-1725
• 71 Teasell RW, Arnold JM, Krassioukov A, Delaney GA. Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Arch Phys Med Rehabil 2000; 81 (4) 506-516
• 72 Mathias CJ, Frankel HL. Autonomic disturbances in spinal cord lesions. In: Mathias C, Bannister R, , eds. Autonomic Failure: A Textbook of Clinical Disorders of the Autonomic Nervous System. New York, NY: Oxford University Press; 2002: 494-513
• 73 Karlsson AK, Friberg P, Lönnroth P, Sullivan L, Elam M. Regional sympathetic function in high spinal cord injury during mental stress and autonomic dysreflexia. Brain 1998; 121 (Pt 9): 1711-1719
• 74 Karlsson AK, Elam M, Friberg P, Biering-Sörensen F, Sullivan L, Lönnroth P. Regulation of lipolysis by the sympathetic nervous system: a microdialysis study in normal and spinal cord-injured subjects. Metabolism 1997; 46 (4) 388-394
• 75 Gao SA, Ambring A, Lambert G, Karlsson AK. Autonomic control of the heart and renal vascular bed during autonomic dysreflexia in high spinal cord injury. Clin Auton Res 2002; 12 (6) 457-464
• 76 Corbett JL, Debarge O, Frankel HL, Mathias C. Cardiovascular responses in tetraplegic man to muscle spasm, bladder percussion and head-up tilt. Clin Exp Pharmacol Physiol 1975; (Suppl. 02) 189-193
• 77 Karlsson AK. Autonomic dysreflexia. Spinal Cord 1999; 37 (6) 383-391
• 78 Sugarman B, Brown D, Musher D. Fever and infection in spinal cord injury patients. JAMA 1982; 248 (1) 66-70
• 79 Price MJ, Campbell IG. Effects of spinal cord lesion level upon thermoregulation during exercise in the heat. Med Sci Sports Exerc 2003; 35 (7) 1100-1107
• 80 Kwon OY, Lee JS, Choi HS, Hong HP, Ko YG. Shock bowel caused by neurogenic shock: computed tomography findings. J Emerg Med 2012; 43 (4) e251-e253
• 81 Vogel LC, Hickey KJ, Klaas SJ, Anderson CJ. Unique issues in pediatric spinal cord injury. Orthop Nurs 2004; 23 (5) 300-308 , quiz 309–310
• 82 Thompson AJ, McSwain SD, Webb SA, Stroud MA, Streck CJ. Venous thromboembolism prophylaxis in the pediatric trauma population. J Pediatr Surg 2013; 48 (6) 1413-1421
• 83 Biering-Sørensen F, Bohr H, Schaadt O. Bone mineral content of the lumbar spine and lower extremities years after spinal cord lesion. Paraplegia 1988; 26 (5) 293-301
• 84 Betz RR. Unique management needs of pediatric spinal cord injury patients: orthopedic problems in the child with spinal cord injury. J Spinal Cord Med 1997; 20 (1) 14-16
• 85 Oleson CV, Patel PH, Wuermser LA. Influence of season, ethnicity, and chronicity on vitamin D deficiency in traumatic spinal cord injury. J Spinal Cord Med 2010; 33 (3) 202-213
• 86 Kim CT, Greenberg J, Kim H. Pediatric rehabilitation: trends in length of stay. J Pediatr Rehabil Med 2013; 6 (1) 11-17
• 87 Shavelle RM, Devivo MJ, Paculdo DR, Vogel LC, Strauss DJ. Long-term survival after childhood spinal cord injury. J Spinal Cord Med 2007; 30 (Suppl. 01) S48-S54
• 88 Bryden AM, Ancans J, Mazurkiewicz J, McKnight A, Scholtens M. Technology for spinal cord injury rehabilitation and its application to youth. J Pediatr Rehabil Med 2012; 5 (4) 287-299
• 89 Johnston TE, McDonald CM. Health and fitness in pediatric spinal cord injury: medical issues and the role of exercise. J Pediatr Rehabil Med 2013; 6 (1) 35-44
• 90 Kelly EH, Klaas SJ, Garma S, Russell HF, Vogel LC. Participation and quality of life among youth with spinal cord injury. J Pediatr Rehabil Med 2012; 5 (4) 315-325
• 91 Hwang M, Chlan KM, Vogel LC, Zebracki K. Substance use in young adults with pediatric-onset spinal cord injury. Spinal Cord 2012; 50 (7) 497-501
• 92 January AM, Zebracki K, Chlan KM, Vogel LC. Symptoms of depression over time in adults with pediatric-onset spinal cord injury. Arch Phys Med Rehabil 2014; 95 (3) 447-454
• 93 Chlan KM, Zebracki K, Vogel LC. Spirituality and life satisfaction in adults with pediatric-onset spinal cord injury. Spinal Cord 2011; 49 (3) 371-375
• 94 Akhtar M, Kennedy P, Webster G, Graham A. What about us? Children's experiences of living with a sibling with spinal cord injury. J Pediatr Rehabil Med 2012; 5 (4) 301-313
• 95 Garma SI, Kelly EH, Daharsh EZ, Vogel LC. Health-related quality of life after pediatric spinal cord injury. J Pediatr Psychol 2011; 36 (2) 226-236