Acute evaluation and management of pediatric spinal cord injury

Background/Objective: Of new spinal cord injuries (SCIs) throughout North America, up to 14% occur in children younger than 15 years of age. The purpose of this paper is to present several aspects unique to the evaluation and treatment of a child with SCI. Evaluation: Vital signs may be absent along with minimal blood loss, indicating upper cervical spine injury that is common in children. Lap belt injuries are more prevalent in children, especially since 1984, when seat belt laws were enacted, and more children began using a lap belt but no shoulder harness. Of children with lap belt injuries, 4% to 39% have significant neurologic injuries, and 30% to 50% have associated retroperitoneal injuries. Radiographic evaluation is more challenging in children because of the presence of normal variants such as C2-C3 pseudosubluxation, which occurs in 9% of children younger than 7 years. SCI without radiographic abnormality (SCIWORA) is common in children under 10 years of age and is associated with more complete neurologic injuries than in cases where the injuries can be seen on radiograph. Management: For transportation of children and infants younger than 6 years of age, the cervical spine needs to be in a neutral position, and spine boards need to be modified to allow for the larger head-to-torso ratio that is present in children. Cervical traction with Crutchfield tongs in children <12 years of age is associated with dural leaks, and therefore, the use of halo traction with modified pin placements is recommended. Indications for surgery are generally the same as those for adults in regard to decompression and alignment. The length of a spinal fusion for stabilization should be minimized in the thoracolumbar spine because of the potential for premature arrest of spinal growth. Summary: The differences between children and adults with acute SCI are significant enough that caregivers cannot evaluate and treat a child with SCI as they would a small adult.