Spinal Cord Injuries in Children

See also Chapter 729 .

Compared with adults, spine and spinal cord injuries are rare in children, particularly young children, because of both anatomic differences and etiologies of injury. The main mechanisms of injury to the spine are motor vehicle crashes, falls, sports, and violence, which affect young children less often (see Chapter 82 ).

Several anatomic differences affect the pediatric spine. The head of a young child is larger relative to body mass than in adults, and the neck muscles are still underdeveloped, which places the fulcrum of movement higher in the spine. Therefore, children <9 yr old have a higher percentage of injuries in the upper cervical spine than older children and adults. The spine of a small child also is very mobile, with pliable bones and ligaments, so fractures of the spine are exceedingly rare. However, this increased mobility is not always a positive feature. Transfer of energy leading to spinal distortion may not affect the structural integrity of the bones and ligaments of the spine but can still lead to significant injuries of the spinal cord. This phenomenon of spinal cord injury without radiographic abnormalities (SCIWORA) is more common in children than adults. The term is relatively outdated, since almost all injuries are detectable by MRI, but is still clinically useful when referring to spinal cord injuries evaluated by plain radiographs or CT. There seem to be 2 distinct forms of SCIWORA. The infantile form involves severe injury of the cervical or thoracic spinal cord; these patients have a poor chance of complete recovery. In older children and adolescents, SCIWORA is more likely to be a less severe injury, with a high likelihood of complete recovery over time. The adolescent form, also called transient neurapraxia , is assumed to be a spinal cord concussion or mild contusion, as opposed to the severe spinal cord injury related to the mobility of the spine in small children.

Although the mechanisms of spinal cord injury in children include birth trauma, falls, and child abuse, the major cause of morbidity and mortality across all ages remains motor vehicle injuries . Adolescents incur spinal cord injuries with epidemiology similar to that of adults, including significant male predominance and a high likelihood of fracture dislocations of the lower cervical spine or thoracolumbar region. In infants and children <5 yr old, fractures and mechanical disruption of spinal elements are more likely to occur in the upper cervical spine between the occiput and C3, for the reasons previously discussed.

Clinical Manifestations

One in 3 patients with significant trauma to the spine and spinal cord will have a concomitant severe head injury, which makes early diagnosis challenging. For these patients, clinical evaluation may be difficult. Patients with a potential spine injury need to be maintained in a protective environment, such as a collar, until the spine can be cleared by clinical and/or radiographic means. A careful neurologic examination is necessary for infants with suspected spinal cord injuries. Complete spinal cord injury will lead to spinal shock with early areflexia (see Chapter 729 ). Severe cervical spinal cord (C-spine) injuries will usually lead to paradoxical respiration in patients who are breathing spontaneously. Paradoxical respiration occurs when the diaphragm, which is innervated by the phrenic nerves with contributions from C3, C4, and C5, is functioning normally, but the intercostal musculature innervated by the thoracic spinal cord is paralyzed. In this situation, inspiration fails to expand of the chest wall but distends the abdomen. Other complications during the acute (2-48 hr) phase include autonomic dysfunction (brady- and tachyarrhythmias, orthostatic hypotension, hypertension), temperature instability, thromboembolism, dysphagia, and bowel/bladder dysfunction.

The mildest injury to the spinal cord is transient quadriparesis evident for seconds or minutes with complete recovery in 24 hr. This injury follows a concussion of the cord and is most frequently seen in adolescent athletes. If their imaging is normal, these children can generally return to normal activities after a period of rest from days to weeks, depending on the initial severity, similar to cerebral concussion management.

Significant spinal cord injury in the cervical region is characterized by: flaccid quadriparesis, loss of sphincter function, and a sensory level corresponding to the level of injury. An injury at the high cervical level (C1-C2) can cause respiratory arrest and death in the absence of ventilatory support. Injuries in the thoracic region are generally the result of fracture dislocations. They may produce paraplegia when at T10 or above, or the conus medullaris syndrome if at the T12-L1 level. This includes a loss of urinary and rectal sphincter control, flaccid weakness, and sensory disturbances of the legs. A central cord lesion may result from contusion and hemorrhage in the center of the spinal cord. It typically involves the upper extremities to a greater degree than the legs, because the motor fibers to the cervical and thoracic region are more centrally located in the spinal cord. There are lower motor neuron signs in the upper extremities and upper motor neuron signs in the legs, bladder dysfunction, and loss of sensation caudal to the lesion. There may be considerable recovery, particularly in the lower extremities, although sequelae are common (see Chapter 729 ).

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here