Introduction to Pediatric Spinal Cord Injury
Epidemiology and Unique Features
- Age Distribution:
- 0-4 years: Predominantly upper cervical injuries
- 5-12 years: Mixed patterns
- 13-17 years: Adult-like patterns
- Common Mechanisms:
- Motor vehicle accidents (45%)
- Sports injuries (15%)
- Falls (14%)
- Birth trauma (10%)
- Non-accidental trauma (8%)
Anatomical Considerations
- SCIWORA (Spinal Cord Injury Without Radiographic Abnormality):
- More common in children <8 years
- Results from increased elasticity of pediatric spine
- May have delayed onset of symptoms
- Growth and Development Factors:
- Large head-to-body ratio in young children
- Incomplete ossification of vertebrae
- Horizontal facet joints
- Ligamentous laxity
- Weak neck muscles
Initial Assessment
Primary Survey
- Airway and Cervical Spine:
- Maintain manual in-line stabilization
- Consider early intubation if respiratory compromise
- Age-appropriate equipment selection
- Breathing:
- Assess for diaphragmatic breathing
- Monitor for respiratory fatigue
- Check for associated chest injuries
- Circulation:
- Assess for neurogenic shock
- Monitor for bradycardia
- Evaluate peripheral perfusion
Neurological Examination
| Component |
Key Elements |
Special Considerations |
| Mental Status |
AVPU, GCS |
Age-appropriate assessment |
| Motor Function |
Strength, Tone, Reflexes |
Compare sides, document changes |
| Sensory Level |
Light touch, Pin prick |
May be difficult in young children |
| Autonomic Function |
HR, BP, Temperature |
Monitor for dysautonomia |
Classification and Imaging
ASIA Impairment Scale
- Grade A: Complete - No sensory or motor function preserved
- Grade B: Incomplete - Sensory but not motor function preserved
- Grade C: Incomplete - Motor function preserved below level, majority of key muscles grade <3
- Grade D: Incomplete - Motor function preserved below level, majority of key muscles grade ≥3
- Grade E: Normal - Sensory and motor function normal
Imaging Protocol
- Initial Imaging:
- Plain radiographs: AP, lateral, odontoid views
- CT scan for bony detail
- MRI for ligamentous and cord injury
- Special Considerations:
- Flexion-extension views when indicated
- Follow-up imaging at 48-72 hours in SCIWORA
- Consider whole spine imaging
Common Injury Patterns
- Upper Cervical (C1-C3):
- Atlanto-occipital dissociation
- Atlas fractures
- Odontoid injuries
- Lower Cervical (C4-C7):
- Compression fractures
- Facet dislocations
- Burst fractures
Acute Management
Initial Stabilization
- Immobilization:
- Age-appropriate collar sizing
- Log-roll technique
- Pressure point padding
- Hemodynamic Support:
- Mean arterial pressure goals
- Fluid resuscitation
- Vasopressor selection
Medical Management
- Methylprednisolone Protocol:
| Timing |
Dosing |
Duration |
| <3 hours post-injury |
30 mg/kg bolus |
24 hours |
| 3-8 hours post-injury |
30 mg/kg bolus |
48 hours |
| Maintenance |
5.4 mg/kg/hr |
As per protocol |
- Neuroprotection:
- Temperature management
- Blood pressure optimization
- Oxygenation goals
Surgical Considerations
- Indications:
- Progressive neurological deficit
- Unstable fractures
- Significant cord compression
- Failed conservative management
- Timing:
- Emergency: Progressive deficit
- Urgent: Within 24 hours
- Early: Within 72 hours
Complications
Early Complications
- Respiratory:
- Atelectasis
- Pneumonia
- Respiratory failure
- Cardiovascular:
- Neurogenic shock
- Bradyarrhythmias
- Autonomic dysreflexia
- Other Systems:
- Pressure injuries
- Deep vein thrombosis
- Neurogenic bowel/bladder
Late Complications
- Musculoskeletal:
- Spasticity
- Contractures
- Heterotopic ossification
- Scoliosis
- Psychological:
- Depression
- Anxiety
- Post-traumatic stress
Rehabilitation
Early Rehabilitation
- Physical Therapy:
- Range of motion exercises
- Positioning protocols
- Respiratory therapy
- Occupational Therapy:
- Activities of daily living
- Adaptive equipment
- Environmental modifications
Long-term Management
- Educational Support:
- School reintegration
- Vocational training
- Social skills development
- Family Support:
- Caregiver training
- Psychological support
- Resource coordination
Prognosis and Outcomes
Prognostic Factors
- Better Prognosis:
- Incomplete injuries
- Preservation of sacral function
- Early recovery of motor function
- Young age at injury
- Poor Prognosis:
- Complete injuries at 72 hours
- High cervical injuries
- Associated traumatic brain injury
- Delayed presentation
Long-term Outcomes
- Functional Outcomes:
- Level-dependent independence
- Adaptive equipment needs
- Educational achievement
- Quality of Life:
- Social integration
- Emotional adjustment
- Family dynamics
