Spinal cord injury in the newborn infant

Remarkable recovery in an infant presenting with extensive perinatal cervical cord injury

Cervical-cord damage is a complication of a difficult delivery, and results in spinal shock with flaccidity progressing to spastic paralysis. Conventionally, outlook for such patients is extremely poor and most will recover only slightly from quadriplegia and autonomic dysfunction. Here, we report a case in which the extent of damage considerably contrasted with the outcome and recovery. A full-term baby girl born by difficult vaginal delivery displayed bilateral flaccid paralysis of the lower limbs with absent spontaneous movements, weakness of both upper limbs, hyporeflexia in all limbs and axial hypotonia. MRI of cervicothoracic spine exhibited raised signal intensity in the dorsal aspects of C7 to T1 signifying myelopathy. MRI at 4 months revealed a near-total transection of the cervical cord. However, at 6 months, the child could move all lower limbs independently with a marked increase in power. There was no spasticity, wasting or incontinence. Reflexes had also returned.

Spinal cord injuries at birth: A multicenter review of nine cases

OBJECTIVE

To report a multicenter study of nine cases of children presenting with a birth-related spinal injury.

METHODS

The medical charts of nine patients identified by a questionnaire sent to the members of the French Society of Pediatric Orthopedics (SOFOP) were reviewed.

RESULTS

The pregnancy was uneventful in all cases. The fetal presentation was cephalic in three cases, a breech presentation in four cases, and a face presentation in two cases. The lesion involved the cervical spine in six cases. Three patients presenting upper cervical injuries died before the age of six years. The six remaining patients experienced no neurological improvement.

CONCLUSIONS

These rare conditions occur during difficult deliveries with abnormal presentations, the most common being a breech presentation with entrapment of the fetal head. In a child with hypotonia, flaccid quadriplegia or high thoracic paraplegia after a difficult delivery, a spinal cord injury must be suspected and plain radiographs and MRI must be performed.

Birth-related spinal cord injuries: a multicentric review of nine cases

OBJECTIVE

The objective of this study was to report a multicentric study of nine cases of children presenting with a birth-related spinal injury.

MATERIALS AND METHODS

The medical charts of nine patients identified by a questionnaire sent to the members of the French Society of Paediatric Orthopaedics (SOFOP) were reviewed.

CONCLUSIONS

The pregnancy was uneventful in all cases. The fetal presentation was cephalic in three cases, a breech presentation in four cases, a face presentation in two cases. The lesion involved the cervical spine in six cases. Three patients presenting upper cervical injuries died before the age of 6 years. The six remaining patients experienced no neurological improvement. These rare conditions occur during difficult deliveries with abnormal presentations, the most common being a breech presentation with entrapment of the fetal head. In a child with hypotonia, flaccid quadriplegia or high thoracic paraplegia after a difficult delivery, a spinal cord injury must be suspected and plain radiographs and magnetic resonance imaging (MRI) must be performed.

Part 1: recognizing neonatal spinal cord injury

Neonatal spinal cord injury can occur in utero, as well as after either a difficult delivery or a nontraumatic delivery. Spinal cord injury can also be related to invasive nursery procedures or underlying neonatal pathology. Early clinical signs of spinal cord injury that has occurred in utero or at delivery includes severe respiratory compromise and profound hypotonia. Knowledge of risk factors and awareness of symptoms is required for early recognition and appropriate treatment. This article reviews the embryological development of the spinal column highlighting mechanisms of injury and identifying underlying factors that increase the risk of spinal cord injury in newborns. Signs and symptoms of injury, cervical spine immobilization, and the differential diagnosis are discussed. Nursing implications, general prognosis, and research in spinal cord injury are provided.

Spinal injuries in children

BACKGROUND/PURPOSE

Traumatic spinal injury (TSI) is an uncommon source of morbidity and mortality in children. The aim of this study was to describe childhood TSI in a single level 1 urban pediatric trauma center.

METHODS

The authors retrospectively analyzed all children younger than 14 years with TSI, treated at a level I pediatric trauma center between 1991 and 2002 (n = 406, 4% total registry). All children were stratified according to demographics, mechanisms, type and level of injury, radiologic evaluations, associated injuries, and mortality.

RESULTS

The mean age was 9.48 +/- 3.81 years. The most common overall mechanism of injury was motor vehicle crash (MVC; 29%) and ranked highest for infants. Falls ranked highest for ages 2 to 9 years. Sports ranked highest in the 10 to 14 year age group. Paravertebral soft tissue injuries were 68%. The most common injury level was the high cervical spine (O-C4). The incidence of spinal cord injury without radiologic abnormality (SCIWORA) was 6%. Traumatic brain injury (37%) was the most common associated injury. Overall mortality rate was 4% in this urban catchment.

CONCLUSIONS

TSI in children requires a different preventive and therapeutic logarithm compared with that of adults. The potential devastating nature of TSI warrants that the health care team always maintains a high index of suspicion for injury. Future prospective studies are needed to further elucidate injury patterns.

A case of neonatal spinal cord injury: magnetic resonance imaging and somatosensory evoked potentials

This is the first case report on the diagnosis of spinal cord injury due to hemorrhage during the neonatal period using magnetic resonance imaging (MRI). Somatosensory evoked potentials are also helpful in the functional demonstration of this lesion. When discrepant signs, alert consciousness and intact cranial nerves are observed in newborn babies with flaccid extremities and respiratory disturbance, the immediate carrying out of MRI is mandatory in order to differentiate spinal cord injury from hypoxic-ischemic encephalopathy, cerebral hemorrhage, and neuromuscular disease.

Sonographic evaluation of traumatic spinal cord lesions in the newborn infant

We present a case of spinal cord injury due to birth trauma and assess the value of sonography for diagnosis, lesion characterization, and follow-up. Sonography is a non-invasive and easily reproducible imaging method for examining a ventilated child, and its initial sensitivity is comparable to that of MRI. Sonography is the method of choice for guiding diagnosis in this type of traumatic lesion to the newborn.

Spinal cord birth injury: value of computed tomographic myelography

The value of myelography in the assessment of spinal cord injury in the early neonatal period has not been documented, although this study has been recommended frequently in the literature. Eight neonates are reviewed who presented with the clinical features of spinal cord injury and who had myelography performed. Clinical features included difficult delivery, absent respiration, flaccid paralysis, sensory level, and neurogenic bladder. Myelography revealed that 7 patients had the early changes of swollen cord and 1 patient had the late changes of cord atrophy. None of the neonates had surgical intervention. One neonate died at 3 days of age, while 2 others died after prolonged ventilation. Of the 5 infants who survived, 3 still require ventilation and have spastic quadriparesis, 1 has almost recovered completely and 1 had spontaneous respiration and limb movement but brisk deep tendon reflexes when last examined at 1 month of age. Myelography, which was performed in the early neonatal period in our infants, was abnormal in all patients. Myelography is useful in confirming the diagnosis, outlining the level and extent of the lesion, and excluding extramedullary compression. Myelography may assist in the assessment of prognosis but did not alter management in our patients.

Brachial plexus birth palsy

Eighty cases of obstetrically related brachial plexus palsy were followed over a five-year period. Serial muscle testing was done to establish classification and level of damage. Gentle passive exercises to the shoulder and elbow should be done prior to age 2 years, after which time no further spontaneous improvement is likely. Anticipating joint deformities on the basis of muscle imbalance evident at this age will allow the clinician to plan the proper reconstructive surgery.

Spinal cord lesions after diagnostic and therapeutic procedures

This paper is dealing with spinal cord lesions following diagnostic and therapeutic procedures according to the literature and some personal observations. It becomes quite clear what prices have to be payed using modern methods. There are not only surgical procedures involved. Spinal cord lesions following medical activities cannot be judged as malpractice in any case. Some of these accidents can be avoided by strong indications and sophisticated performance of any procedure.