Upper cervical spinal cord injury in neonates: the use of magnetic resonance imaging

Spinal Cord Injury at Birth, Expected Medical and Health Complexity in Chronic Injury Guided Anew by Activity-Based Restorative Therapy: Case Report

As infancy is characterized by rapid physical growth and critical periods of development, disruptions due to illness or disease reveal vulnerability associated with this period. Spinal cord injury (SCI) has devastating consequences at any age, but its onset neonatally, at birth, or within the first year of life multiplies its impact. The immediate physical and physiological consequences are obvious and immense, but the effects on the typical trajectory of development are profound. Activity-based restorative therapies (ABRT) capitalize on activity-dependent plasticity of the neuromuscular system below the lesion and when provided to children with SCI aim to improve the child's neuromuscular capacity, health and quality of life. This is a report of an infant with a cervical SCI at birth resulting in paralysis of leg and trunk muscles and paresis of arm and hands who was enrolled in an ABRT program at 3 years of age. After 59 sessions of ABRT, the child demonstrated significant improvements in trunk control and arm function, as well as social and emotional development. Despite the chronicity of injury and low expectations for improvement with therapeutic interventions, ABRT had a positive impact on the child's physical capacity and provided benefits across multiple developmental domains.

Normal anterior-posterior diameters of the spinal cord and spinal canal in healthy term newborns on sonography

BACKGROUND

There are no published normal values for spinal cord and canal diameters in newborns. Spinal cord and spinal canal diameters are assessed subjectively by radiologists without any objective values for the upper limit of normal.

OBJECTIVE

To determine normal values for anteroposterior (AP) diameters of the spinal cord and spinal canal on sonography in healthy term newborns.

MATERIALS AND METHODS

We performed ultrasound of the entire spine on 37 healthy newborns (23 male, 14 female). The AP diameters of the spinal canal and spinal cord were measured at representative levels of the cervical (C4, C5, C6), thoracic (T5, T6, T7, T8) and lumbar spine (lumbar enlargement and above and below the lumbar enlargement level). Statistical analysis was performed to determine the mean and standard deviation of the spinal canal and spinal cord AP diameter at each aforementioned vertebral level, and their correlations with birth weight, length and head circumference.

RESULTS

The mean AP spinal cord diameter was 4.1±0.5 mm at the cervical level, 3.3±0.3 mm at the thoracic level and 4.4±0.6 mm at the lumbar level. The mean AP spinal canal diameter was 7.7±0.7 mm at the cervical level, 6.2±0.8 mm at the thoracic level, and 8.4±0.7 mm at the lumbar level.

CONCLUSION

In this prospective study, we have determined normal values for AP diameters of the spinal cord and spinal canal on sonography in healthy newborns at representative cervical, thoracic and lumbar levels. This data may assist in evaluating the neonatal spine in clinical situations such as suspected spinal cord injury.

Interdisciplinary, Intensive, Activity-Based Treatment for Intrauterine Spinal Cord Infarct: A Case Report

Intrauterine spinal cord infarcts (IUSCI) with resulting tetraplegia are extremely rare, and there is minimal evidence describing outcomes in this population. This case describes the functional progress of a 3-year-old girl born with IUSCI who participated in activity-based therapies (ABT). Children have developing nervous systems and are particularly suited to benefit from ABT. Over the course of treatment, the child in this case has demonstrated improvements in developmental milestone achievement including fine and gross motor skills and social/cognitive development. Intense, interdisciplinary ABT should be considered for the treatment of children with IUSCI.

Neonatal spinal cord injury after an uncomplicated vaginal delivery

Neonatal spinal cord injury has been reported after traumatic births and as a consequence of underlying lesions in the spinal cord. This report describes an infant who was born with bilateral flaccid paralysis of the upper extremities after an atraumatic, noninstrumented vaginal delivery. The infant was otherwise neurologically intact. The infant was initially thought to exhibit bilateral brachial plexus injury. However, magnetic resonance imaging demonstrated an upper cervical spinal cord hemorrhage, with no underlying lesions of the spinal cord or surrounding vasculature. This case highlights the importance of thoroughly evaluating any neurologic deficit in the newborn, and suggests that normal mechanical forces of labor and delivery may be sufficient to cause damage to the newborn spinal cord.

MRI of the neonatal and paediatric spine and spinal canal

Today several modalities for imaging the spine, the spinal canal and the spinal cord are available. Since children represent one of the most vulnerable patient groups, care has to be taken and imaging assessment should start always with less invasive procedures. Thus, in neonates and infants ultrasound should be used as first line imaging procedure due to their unique features of more cartilaginous parts of the yet non-ossified bones. Beyond this age group Magnetic Resonance Imaging (MRI) represents the modality of choice for radiological assessment of the spine, the spinal canal and the spinal cord. The purpose of this review is to present MRI and common MRI findings of typical diseases in children-ranging from congenital to acquired conditions. In addition, general imaging details will be given as well as a brief embryological description of the spine and spinal canal.

Syringomyelia and chronic respiratory failure in a term infant delivered by Caesarean section

The case of a term, male neonate (birthweight 3785g) with cephalic presentation, Caesarean-section (C-section) delivery, and failure to thrive is reported. The infant presented with generalized hypotonia and respiratory failure immediately following birth. An initial diagnosis of hypoxic-ischemic encephalopathy was made. However, ventilator dependency and slow recovery of generalized tonus over the following weeks could not be explained. Late cervical magnetic resonance imaging showed extensive syringomyelia from C2 to C7. To the authors' knowledge, this is the first report of syringomyelia after a C-section delivery following cephalic presentation without any associated abnormalities. Follow-up at 2 years of age revealed no improvement on neurological examination: poor head control, difficulty swallowing, flaccid paralysis of upper limbs, and spasticity of lower limbs with exacerbated deep reflexes and spontaneous clonus. Difficulties in establishing the diagnosis and managing the case are discussed.

[Can we still perform instrumental rotations using Thierry's spatula? Preliminary study among primiparous]

OBJECTIVES

To study immediate perineal and neonatal outcomes after instrumental rotational performed with Thierry's spatula among primiparous, and compare subsequent perineal tear with occiput posterior position delivery.

MATERIALS AND METHODS

The study was performed from December 2005 to June 2006 at Paule-de-Viguier hospital (Toulouse university hospital) including all persistent occiput posterior vaginal deliveries among primiparous (49 patients). Mode of delivery was: 1) seven patients with spontaneous occiput anterior vaginal delivery (14.3%); 2) seven patients with rotational extraction using spatula with occiput anterior delivery (30.6%); 3) twenty-seven patients with instrumental extraction and occiput posterior delivery (55.1%). Maternal and fetal parameters were studied prospectively.

RESULTS

Spatula was performed for failure of progress in 71.4% of cases (n=30) and for no reassuring fetal status in 28.6% of cases (n=12). In "rotational group", only one perineal tear was observed (Third degree) (6.6%) versus seven in "occiput posterior extraction group" (26%) with three severe perineal lacerations. Neonatal superficial lesions are frequent (26,6% after rotation versus 11.6% after occiput posterior extraction). None severe traumatic tears were observed.

CONCLUSION

Instrumental rotation using Thierry's spatula seems to be less deleterious for maternal perineum than occiput posterior extraction, without increasing neonatal complications. Theses preliminary results have to be confirmed by more important prospective works.

Neonatal trauma

A variety of traumatic lesions can occur during the neonatal period. Some of those lesions are clearly birth injuries due to delivery and others are caused by necessary procedures during intensive care in critically ill neonates. As usual patient history must be known and knowledge about the typical complications is necessary in order to select the appropriate imaging modality and thus enabling correct interpretation of those investigations by the radiologist. The purpose of this article is to present typical neonatal injuries, describe the underlying pathomechanisms and aetiology as well as the imaging findings.

Cervical spine fracture-dislocation birth injury: prevention, recognition, and implications for the orthopaedic surgeon

Spinal cord birth injury is rare, and orthopaedic surgeons infrequently encounter it. The injury is associated with hyperextension of the fetal head in utero and during delivery and with forceps-assisted breech vaginal deliveries. These cervical spinal cord injures may be complete or partial. They most commonly occur in the absence of bony injury, which can lead to diagnostic difficulties. Ultrasound and MRI studies are valuable diagnostic tools for identifying spinal cord injury in cases of hypotonic newborns with difficult deliveries. The authors report an unusual case of spinal cord birth injury with frank cervical fracture-dislocation following a difficult footling breech vaginal delivery. Early recognition of hyperextension of the fetal head in utero and planned cesarean section are important prevention methods. While this type of injury is rare, the pediatric orthopedic surgeon must understand its nature and severity to facilitate timely treatment.

Dislocation traumatique cervicale périnatale

We report on a case of cervical dislocation in which the severity of the lesion contrasts with the paucity of the symptoms. An eight-month-old girl presented with weakness of the left upper limb. She had a normal cephalic delivery. On the following days, increased weakness of the limb showed a spontaneous, partial regression. Clinical examination at eight months showed a normal physical and psychical development, a falling neck and an impossibility to maintain the sitting position, but a normal mobility of the lower limbs. Cervical radiography performed showed a complete dislocation. CT confirmed the diagnosis and eliminated congenital vertebral anomalies. Magnetic resonance imaging showed an important stretching and compression of the spinal cord. Cervical spine damage in the newborn are scarce and serious. The here reported case is characterized by a complete vertebral dislocation associated with medullar stretching and compression, but few initial symptoms.

Management of birth injuries

Birth injuries are a significant cause of neonatal morbidity and mortality. Although often associated with traumatic delivery, birth injuries often occur in normal spontaneous deliveries in the absence of any risk factors. This article discusses the diagnosis and management of the most common birth injuries that are encountered by health care providers who care for newborns.

Management of birth injuries

Birth injuries are a significant cause of neonatal morbidity and mortality. Although they are frequently associated with traumatic delivery, birth injuries often occur in normal spontaneous deliveries in the absence of any risk factors. This article discusses the diagnosis and management of the most common birth injuries encountered by health care providers caring for newborns.

In utero spontaneous cervical thoracic epidural hematoma imitating spinal cord birth injury

A neonate male born cesarian due to a breech presentation was noted to have no spontaneous movements of the limbs after delivery. Radiographs were not demonstrative of pathology. However, MRI revealed a large intraspinal mass with significant distortion of the cervicothoracic spinal cord. At operation, a brown, fibro-gelatinous, moderately adherent mass was evident extradurally dorsal to the spinal cord. It was noted to extend anterolaterally to the left such that the cord was deviated anteriorly and to the right. There was no indication of the mass being under pressure but the cord was not pulsatile. There was sufficient mass to the anterolateral component of the cord that it appeared rotated to the right within the canal. The right cervical roots exited dorsally, with a markedly lengthened course through the spinal canal before exiting above their respective pedicles. Histology was that of blood clot. The patient clinically demonstrated no neurologic improvement post-operatively. Now, six months after surgery, the patient has still had no significant change in clinical function. To our review, this is the first reported case of a spontaneous spinal epidural hematoma mimicking a birth-related spinal injury.