{
 "topic": "Spinal Cord Injury",
 "slug": "spinal-cord-injury",
 "category_id": 15606,
 "summary": "Traumatic and nontraumatic spinal cord injury in children, including the pediatric-specific patterns of upper cervical injury, SCIWORA, and birth-related cord injury, and how management and outcome depend on injury level and completeness.",
 "written_by": "claude-sonnet",
 "references": [
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  }
 ],
 "short": [
  {
   "title": "In short",
   "content": "- Spine and spinal cord injuries are rare in children, especially young children, compared with adults, reflecting both anatomic differences and different injury mechanisms; individuals from birth to 21 years account for about 25% of all traumatic spinal cord injuries (SCI).\n- Motor vehicle injuries remain the major cause of morbidity and mortality from SCI across all pediatric ages; other mechanisms include falls, sports, violence, birth trauma, and child abuse.\n- Age determines injury pattern: children under 5 more often sustain fractures/mechanical disruption of the upper cervical spine (occiput to C3), while adolescents show an epidemiology like adults \u2014 male predominance and fracture-dislocations of the lower cervical spine or thoracolumbar region.\n- Children are more susceptible than adults to lap-belt injuries, upper cervical injuries, spinal cord injury without radiologic abnormality (SCIWORA), and delayed-onset neurologic deficits (30 minutes to 4 days after injury).\n- Low-income populations are disproportionately affected by firearm-related pediatric SCI.\n- Nontraumatic causes are relatively more prevalent in pediatric SCI than in adults, and include hematologic and oncologic causes; acute spinal cord compression in children is usually from trauma, infection (epidural abscess, most commonly from hematogenous Staphylococcus aureus), or cancer (ependymoma, astrocytoma, or extrinsic neuroblastoma/lymphoma).\n- If SCI is suspected by mechanism or exam, a normal spine X-ray does not rule it out (SCIWORA) \u2014 watch for local pain or torticollis, and steroids are no longer recommended for acute spinal cord injury.\n- Birth-related SCI is rare (under 0.2 per 10,000 births), occurs almost exclusively with vaginal breech delivery or forceps use, and results from stretching, hyperextension, or torsion of the fetal neck; a higher injury level carries greater risk of respiratory compromise, and severe cases show profound hypotonia with spinal shock (flaccid extremities, diaphragmatic breathing, distended bladder).\n- Neurologic status at presentation is the best predictor of outcome: an intact or incomplete injury predicts a likely good outcome, while complete loss of function at the injury level, or spinal cord hemorrhage, predicts a poor chance of recovery."
  }
 ],
 "long": [
  {
   "title": "Epidemiology",
   "content": "Spine and spinal cord injuries are uncommon in children relative to adults, particularly in young children, reflecting anatomic differences in the pediatric spine and differences in the mechanisms of injury children experience. Individuals from birth to 21 years of age account for about 25% of all cases of traumatic spinal cord injury. Epidemiology varies substantially by age, ethnicity, and payor status in population-based studies, and low-income populations are more likely to sustain SCI from firearms than other populations."
  },
  {
   "title": "Etiology",
   "content": "The main mechanisms of spine injury are motor vehicle crashes, falls, sports, and violence (assaults, stabbings, gunshot wounds), which affect young children less often than older children and adolescents. Motor vehicle injuries remain the major cause of morbidity and mortality from SCI across all pediatric ages. Additional mechanisms specific to children include birth trauma and child abuse. Unlike in adults, nontraumatic causes are relatively more prevalent in pediatric SCI, including hematologic and oncologic etiologies. Acute spinal cord compression in children is usually caused by trauma, infection, or cancer: traumatic causes include cord contusion or concussion (with hemorrhage, edema, and local mass effect) or spinal epidural hematoma, which may develop over several days after the trauma rather than presenting immediately. Epidural abscess is the most common infectious cause of cord compression, usually from hematogenous spread of bacteria, most often Staphylococcus aureus. Neoplastic causes include primary intraspinal tumors (ependymoma, astrocytoma) and extrinsic lesions such as neuroblastoma or lymphoma."
  },
  {
   "title": "Pathophysiology",
   "content": "As with traumatic brain injury, the primary pathophysiology of SCI stems from the physical damage of the initial injury, while secondary injury results from cord neurometabolic pathways of distress, including edema, hypoxia, and ischemia. Mass lesions can damage the cord directly by compression or secondarily by interfering with its tenuous arterial (or, less commonly, venous) blood supply, causing cord infarction. Two concepts are central to pediatric SCI: spinal shock, and spinal cord injury without radiographic abnormality (SCIWORA), in which significant cord injury occurs despite normal imaging \u2014 a phenomenon more common in children because of the pediatric spine's greater elasticity relative to the cord itself."
  },
  {
   "title": "Clinical features",
   "content": "Age strongly influences the pattern of injury: in infants and children under 5, fractures and mechanical disruption of spinal elements more often occur in the upper cervical spine, between the occiput and C3. Adolescents show an injury epidemiology similar to adults, with significant male predominance and a high likelihood of fracture-dislocation of the lower cervical spine or thoracolumbar region. Children are more susceptible than adults to lap-belt injuries, upper cervical injuries, SCIWORA, and delayed onset of neurologic deficits, which can appear from 30 minutes up to 4 days after the injury. Clinical manifestations vary by the neurologic level of injury: lesions above T10 cause symmetric weakness, increased lower extremity deep tendon reflexes, a sensory level deficit, and up-going toes; conus medullaris lesions (T10-L2) cause symmetric weakness, increased knee reflexes but decreased ankle reflexes, saddle sensory loss, and variable toe responses; cauda equina lesions (below L2) cause asymmetric weakness, loss of lower extremity deep tendon reflexes, sensory deficit, and down-going toes. Spinal cord tumors most often present with back pain, sometimes with gait disturbance, weakness, scoliosis, sphincter dysfunction, or, in younger children, motor regression."
  },
  {
   "title": "Diagnostics",
   "content": "The most accurate way to evaluate a child with sustained SCI is a standardized physical examination, as endorsed by the International Standards for Neurological and Functional Classification of SCI, recommended for children 6 years and older. If SCI is suspected based on mechanism or clinical examination, a normal X-ray and initial exam are not sufficient to exclude it, given the possibility of SCIWORA \u2014 clinicians should not be reassured by normal radiographs and should watch for local pain or torticollis. Screening MRI is important whenever there is concern for spinal cord injury, particularly in the newborn."
  },
  {
   "title": "Treatment",
   "content": "Management prioritizes avoiding secondary and iatrogenic injury; corticosteroids are no longer recommended for acute spinal cord injury. Treatment includes support of impaired systemic function, stabilization of the spine (internal or external surgical stabilization, which may limit the ability to reassess with MRI), and emergent decompression of any spinal cord impingement. Injuries require interdisciplinary team management across neurosurgery, critical care, trauma surgery, neurology, physical medicine and rehabilitation, physical therapy, occupational therapy, speech therapy, social work, psychology, and neuropsychology. Most patients require acute inpatient rehabilitation for individualized programs of range of motion, strengthening, and early mobilization, alongside education on gastric/duodenal stress ulcer prevention, pressure ulcer prevention (regular skin checks, rotation schedule), thermoregulation (impaired heat and cold regulation), and anticoagulation for prolonged immobility. In neonatal SCI, treatment is supportive."
  },
  {
   "title": "Complications",
   "content": "Deficits in pediatric SCI range from full tetraplegia requiring respiratory ventilation to slight distal dysesthesias and weakness; function is primarily determined by the level of injury and whether the injury is complete or incomplete. Neurologic status at presentation is the best predictor of outcome: an intact or incomplete injury predicts a likely good outcome, whereas complete loss of function at the level of injury predicts a poor chance of recovery, and spinal cord hemorrhage carries a worse potential for recovery. In birth-related cervical spine injury, a higher level of injury carries greater risk of respiratory problems; severe injury can produce spinal shock, with paralyzed abdominal movements, diaphragmatic breathing, a distended bladder, and flaccid extremities."
  }
 ],
 "clinical": [
  {
   "title": "Bedside evaluation of the child with possible SCI",
   "content": "In any child with a significant mechanism of injury (motor vehicle crash, fall, sports injury, or assault) or clinical findings suggesting SCI, remember that in children under 5 injury more often localizes to the upper cervical spine (occiput to C3), while adolescents pattern more like adults, with lower cervical or thoracolumbar fracture-dislocation. Perform a standardized neurological examination (per the International Standards for Neurological and Functional Classification of SCI, applicable from age 6) rather than relying on imaging alone: a normal X-ray and initial exam do not exclude SCI, since children are prone to SCIWORA and can have neurologic deficits with delayed onset up to 4 days after injury. Watch specifically for local spinal pain or torticollis. Logroll to examine the back, and look under hair, collars, and splints. Do not give corticosteroids for acute spinal cord injury \u2014 this is no longer recommended. Obtain MRI whenever there is real concern for cord injury."
  },
  {
   "title": "Managing the confirmed injury",
   "content": "Once SCI is identified, prioritize avoiding secondary and iatrogenic injury: support impaired systemic function, stabilize the spine (surgically if indicated, recognizing this may limit subsequent MRI assessment), and pursue emergent decompression for any cord impingement. Manage as an interdisciplinary team from the outset \u2014 neurosurgery, critical care/trauma surgery, neurology, physical medicine and rehabilitation, and allied therapies. In a neonate with severe respiratory compromise and profound hypotonia after a breech or forceps delivery, consider birth-related cervical spinal cord injury and watch for spinal shock (flaccid extremities, diaphragmatic breathing, distended bladder, paralyzed abdominal movements); treatment here is supportive. Counsel families early that neurologic status at presentation \u2014 intact/incomplete versus complete injury \u2014 is the strongest predictor of eventual recovery, and plan for acute inpatient rehabilitation addressing mobility, skin and pressure-ulcer prevention, thermoregulation, and stress-ulcer prophylaxis."
  }
 ]
}