Prevalence and etiology of autonomic dysreflexia in children with spinal cord injuries

Safety and Feasibility of Cervical and Thoracic Transcutaneous Spinal Cord Stimulation to Improve Hand Motor Function in Children With Chronic Spinal Cord Injury

OBJECTIVE

In adults with cervical spinal cord injury (SCI), transcutaneous spinal stimulation (scTS) has improved upper extremity strength and control. This novel noninvasive neurotherapeutic approach combined with training may modulate the inherent developmental plasticity of children with SCI, providing even greater improvements than training or stimulation alone. Because children with SCI represent a vulnerable population, we first must establish the safety and feasibility of any potential novel therapeutic approach. The objectives of this pilot study were to determine the safety, feasibility, and proof of principle of cervical and thoracic scTS for short-term effect on upper extremity strength in children with SCI.

MATERIALS AND METHODS

In this nonrandomized, within-subject repeated measure design, seven participants with chronic cervical SCI performed upper extremity motor tasks without and with cervical (C3-C4 and C6-C7) and thoracic (T10-T11) site scTS. Safety and feasibility of using cervical and thoracic sites scTS were determined by the frequency count of anticipated and unanticipated risks (eg, pain, numbness). Proof-of-principle concept was tested via change in force production during hand motor tasks.

RESULTS

All seven participants tolerated cervical and thoracic scTS across the three days, with a wide range of stimulation intensities (cervical sites = 20-70 mA and thoracic site = 25-190 mA). Skin redness at the stimulation sites was observed in four of 21 assessments (19%) and dissipated in a few hours. No episode of autonomic dysreflexia was observed or reported. Hemodynamic parameters (systolic blood pressure and heart rate) remained within stable limits (p > 0.05) throughout the assessment time points at baseline, with scTS, and after the experiment. Hand-grip and wrist-extension strength increased (p < 0.05) with scTS.

CONCLUSIONS

We indicated that short-term application of scTS via two cervical and one thoracic site is safe and feasible in children with SCI and resulted in immediate improvements in hand-grip and wrist-extension strength in the presence of scTS.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT04032990.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

Clinical characteristics and treatment of spinal cord injury in children and adolescents

Pediatric and adult spinal cord injuries (SCI) are distinct entities. Children and adolescents with SCI must suffer from lifelong disabilities, which is a heavy burden on patients, their families and the society. There are differences in Chinese and foreign literature reports on the incidence, injury mechanism and prognosis of SCI in children and adolescents. In addition to traumatic injuries such as car accidents and falls, the proportion of sports injuries is increasing. The most common sports injury is the backbend during dance practice. Compared with adults, children and adolescents are considered to have a greater potential for neurological improvement. The pathogenesis and treatment of pediatric SCI remains unclear. The mainstream view is that the mechanism of nerve damage in pediatric SCI include flexion, hyperextension, longitudinal distraction and ischemia. We also discuss the advantages and disadvantages of drugs such as methylprednisolone in the treatment of pediatric SCI and the indications and timing of surgery. In addition, the complications of pediatric SCI are also worthy of attention. New imaging techniques such as diffusion tensor imaging and diffusion tensor tractography may be used for diagnosis and assessment of prognosis. This article reviews the epidemiology, pathogenesis, imaging, clinical characteristics, treatment and complications of SCI in children and adolescents. Although current treatment cannot completely restore neurological function, patient quality of life can be enhanced. Continued developments and advances in the research of SCI may eventually provide a cure for children and adolescents with this kind of injury.

Characterization of heart rate changes associated with autonomic dysreflexia during penile vibrostimulation and urodynamics

STUDY DESIGN

Secondary data analysis.

OBJECTIVES

To characterize autonomic dysreflexia (AD) associated heart rate (HR) changes during penile vibrostimulation (PVS) and urodynamic studies (UDS).

SETTING

University-based laboratory.

METHODS

We analyzed blood pressure (BP) and HR data, recorded continuously, from 21 individuals (4 females; median age 41 years [lower and upper quartile, 37; 47]; median time post-injury 18 years [7; 27]; all motor-complete spinal cord injury (SCI) except one; cervical SCI = 15, thoracic [T1-T6] SCI = 6), who underwent PVS (11/21) or UDS (10/21).

RESULTS

Overall, 47 AD episodes were recorded (i.e. PVS = 37, UDS = 10), with at least one AD episode in each participant. At AD threshold, bradycardia was observed during PVS and UDS in 43% and 30%, respectively. At AD peak (i.e., maximum increase in systolic BP from baseline), bradycardia was observed during PVS and UDS in 65% and 50%, respectively. Tachycardia was detected at AD peak only once during UDS. Our study was limited by a small cohort of participants and the distribution of sex and injury characteristics.

CONCLUSIONS

Our findings reveal that AD-associated HR changes during PVS and UDS appear to be related to the magnitude of systolic BP increases. Highly elevated systolic BP associated with bradycardia suggests the presence of severe AD. Therefore, we recommend cardiovascular monitoring (preferably with continuous beat-to-beat recordings) during PVS and UDS to detect AD early. Stopping assessments before systolic BP reaches dangerously elevated levels, could reduce the risk of life-threatening complications in this cohort.

Pediatric Spina Bifida and Spinal Cord Injury

Pediatric spina bifida (SB) and spinal cord injury (SCI) are unfortunately common in our society, and their unique findings and comorbidities warrant special consideration. This manuscript will discuss the epidemiology, pathophysiology, prevention, and management strategies for children growing and developing with these unique neuromuscular disorders. Growth and development of the maturing child places them at high risk of spinal cord tethering, syringomyelia, ascending paralysis, pressure injuries, and orthopedic abnormalities that must be addressed frequently and judiciously. Similarly, proper neurogenic bladder and neurogenic bowel management is essential not just for medical safety, but also for optimal psychosocial integration into the child’s expanding social circle.

Autonomic Dysreflexia following Spinal Cord Injury

Autonomic dysreflexia (AD) is a potentially life-threatening condition of the autonomic nervous system following spinal cord injury at or above T6. One of the most common symptoms is a sudden increase in blood pressure induced by afferent sensory stimulation owing to unmodulated reflex sympathetic hyperactivity. Such episodes of high blood pressure might be associated with a high risk of cerebral or retinal hemorrhage, seizures, heart failure, or pulmonary edema. In-depth knowledge is, therefore, crucial for the proper management of the AD, especially for spine surgeons, who encounter these patients quite often in their clinical practice. Systematical review of the literature dealing with strategies to prevent and manage this challenging condition was done by two independent reviewers. Studies that failed to assess primary (prevention, treatment strategies and management) and secondary outcomes (clinical symptomatology, presentation) were excluded. A bibliographical search revealed 85 eligible studies that provide a variety of preventive and treatment measures for the subjects affected by AD. As these measures are predominantly based on noncontrolled trials, long-term prospectively controlled multicenter studies are warranted to validate these preventive and therapeutic proposals.

A Systematic Review of the Scientific Literature for Rehabilitation/Habilitation Among Individuals With Pediatric-Onset Spinal Cord Injury

Objectives

To conduct a systematic review to examine the scientific literature for rehabilitation/habilitation among individuals with pediatric-onset spinal cord injury (SCI).

Methods

A literature search of multiple databases (i.e., PubMed/MEDLINE, CINAHL, EMBASE, PsychINFO) was conducted and was filtered to include studies involving humans, published as full-length articles up to December 2020, and in English. Included studies met the following inclusion criteria: (1) ≥50% of the study sample had experienced a traumatic, acquired, nonprogressive spinal cord injury (SCI) or a nontraumatic, acquired, noncongenital SCI; (2) SCI onset occurred at ≤21 years of age; and (3) sample was assessed for a rehabilitation/habilitation-related topic. Studies were assigned a level of evidence using an adapted Sackett scale modified down to five levels. Data extracted from each study included author(s), year of publication, country of origin, study design, subject characteristics, rehabilitation/habilitation topic area, intervention (if applicable), and outcome measures.

Results

One hundred seventy-six studies were included for review (1974-2020) with the majority originating from the United States (81.3%). Most studies were noninterventional observational studies (n = 100; 56.8%) or noninterventional case report studies (n = 5; 2.8%). Sample sizes ranged from 1 to 3172 with a median of 26 (interquartile range [IQR], 116.5). Rehabilitation/habilitation topics were categorized by the International Classification of Functioning, Disability and Health (ICF); most studies evaluated ICF Body Function. There were 69 unique clinical health outcome measures reported.

Conclusion

The evidence for rehabilitation/habilitation of pediatric-onset SCI is extremely limited; nearly all studies (98%) are level 4-5 evidence. Future studies across several domains should be conducted with novel approaches to research design to alleviate issues related to sample sizes and heterogeneity.

Noninvasive spinal stimulation safely enables upright posture in children with spinal cord injury

In children with spinal cord injury (SCI), scoliosis due to trunk muscle paralysis frequently requires surgical treatment. Transcutaneous spinal stimulation enables trunk stability in adults with SCI and may pose a non-invasive preventative therapeutic alternative. This non-randomized, non-blinded pilot clinical trial (NCT03975634) determined the safety and efficacy of transcutaneous spinal stimulation to enable upright sitting posture in 8 children with trunk control impairment due to acquired SCI using within-subject repeated measures study design. Primary safety and efficacy outcomes (pain, hemodynamics stability, skin irritation, trunk kinematics) and secondary outcomes (center of pressure displacement, compliance rate) were assessed within the pre-specified endpoints. One participant did not complete the study due to pain with stimulation on the first day. One episode of autonomic dysreflexia during stimulation was recorded. Following hemodynamic normalization, the participant completed the study. Overall, spinal stimulation was well-tolerated and enabled upright sitting posture in 7 out of the 8 participants.

Scoliosis due to trunk muscle paralysis frequently requires surgical treatment in children with spinal cord injury. The authors demonstrate the safety and efficacy of transcutaneous spinal stimulation to enable upright sitting posture in 7/8 children with trunk control impairment in a within-subjects, repeated measures pilot clinical trial.

Seizures: A Rare Presentation of Autonomic Dysreflexia in a Young Adult with Complete Spinal Cord Injury

BACKGROUND

Autonomic dysreflexia (AD) is a common complication for individuals with cervical or upper-mid thoracic spinal cord injury (SCI). It is a life-threatening emergency; however, it is rarely encountered by many emergency physicians, thus, ongoing awareness of the topic is necessary.

CASE REPORT

An 18-year-old man with cervical spinal cord injury presented to the Emergency Department with headache, nausea, elevated blood pressure, and seizures. He was treated with antiepileptics and transferred to the pediatric intensive care unit (PICU). The PICU care team recognized AD as the cause of the seizure, secondary to a clogged suprapubic catheter causing overdistension of his bladder. Once replaced, over 1 liter of urine drained from his bladder and his autonomic symptoms resolved. He became hypotensive and required fluid resuscitation, but no further seizures occurred. Why Should an Emergency Physician Be Aware of This? Although rare, AD can result in seizures, intracerebral hemorrhage, or even death if not recognized or treated appropriately. Emergency physicians should recognize headaches, facial flushing, and sweating as early symptoms of AD, along with acute elevation in blood pressure (noting that baseline blood pressure may be lower in individuals with SCI). Management involves evaluating and treating noxious stimuli below the level of neurologic injury. Symptom management alone, without resolution of the underlying issue, can add to morbidity and mortality.

What do physiotherapists and physiotherapy students know about autonomic dysreflexia?

CONTEXT/OBJECTIVE

Autonomic dysreflexia (AD) is an emergency condition typical for individuals with spinal cord injury (SCI). Adequate health professionals' knowledge of AD is important for the effective and safe rehabilitation of persons with SCI. The purpose of the study is to assess the knowledge of AD in undergraduate and postgraduate physiotherapists. The data gained will be useful for better addressing of AD in clinical practice.

DESIGN

An observational study.

SETTING

Rehabilitation College in Warsaw, Medical University of Warsaw, Poland.

PARTICIPANTS

52 undergraduate and 68 postgraduate physiotherapists.

INTERVENTION

AD knowledge testing.

OUTCOME MEASURES

A test assessing knowledge of causality and consequences of AD created at the Medical University of Warsaw.

RESULTS

No significant differences in test scores between under- and postgraduates were found (P = 0.09). Higher scores were noted in physiotherapy masters as compared to bachelors (P = 0.01), in participants who have an in-patient practice (P = 0.04), a practice longer than 5 years (P = 0.02) and those who see patients with SCI more frequently (P = 0.01). A self-assessed knowledge of AD was admitted as poor or none by 96.2% of undergraduates and 86.8% of postgraduates.

CONCLUSION

In the studied population the knowledge of causality and consequences of AD presented by undergraduate and postgraduate physiotherapists was low. Lower test scores were associated with a lower level of professional education achieved, having an outpatient practice only and having fewer patients with spinal cord injury. Efforts should be made to improve undergraduate and postgraduate education on AD of physiotherapists.

Effect of Exercise on Cardiovascular Function Following Spinal Cord Injury: A REVIEW

Spinal cord injury (SCI) is associated with a reduced level of physical activity, deterioration of patient body composition, metabolic profile, quality of life, and psychological functioning. As a result, risk of cardiovascular disease (CVD) increases and CVD-related death occurs at an earlier age than in individuals without SCI. Regular participation in exercise has been shown to exert beneficial effects also in patients with SCI. In this review, we analyze and discuss the effects of regular exercise training in SCI on cardiovascular function, autonomic function of the cardiovascular system, arterial stiffness, metabolism, inflammation, and gene expression.

Neurogenic bowel dysfunction

The symptoms of neurogenic bowel dysfunction (NBD) comprise constipation and fecal incontinence. These have a major impact on quality of life and dignity. Bowel symptoms occur in the majority of patients with chronic neurological diseases like multiple sclerosis, spinal cord injury, and Parkinson’s disease. Management relies on obtaining a careful bowel history, including assessment of bowel function prior to the onset of neurological symptoms. Objective measures of NBD are available and important in terms of monitoring response for what are often intensely personal and difficult-to-elicit symptoms. Conservative management begins by establishing an effective and regular bowel regime by optimizing diet and laxative use. If this is insufficient, as seen in about half of patients, transanal irrigation has been shown to reduce NBD symptoms and improve quality of life. Failing that, there are more invasive surgical options available. This review aims to provide practical guidance for the clinician who encounters these patients, focusing on a stepwise approach to assessment, interventions, and monitoring.

Autonomic Dysreflexia in Patients With Spinal Cord Injury: What the Radiologist Needs to Know

OBJECTIVE. Autonomic dysreflexia (AD) is a potentially life-threatening condition that occurs in patients with cervical and high thoracic spinal cord injury (SCI). AD is not completely understood and has a high incidence that increases proportional to the level and severity of the SCI. The signs and symptoms can vary, but severe hypertension is a dominant feature and may be fatal. This condition can be precipitated by a wide range of triggers occurring below the level of the injury, several of which are common to both diagnostic and interventional radiology, such as manipulation or distention of the genitourinary or gastrointestinal tract, patient positioning, or the use of certain anesthetic techniques. There is little guidance in the radiology literature specific to risk stratification or the use of premedication in this population. The incidence and pathophysiology of AD are discussed, along with pragmatic tips to aid the radiologist in selecting patients who may require a higher level of care or anesthesiologist involvement, with instructions for the conservative and medical management of acute episodes of AD. CONCLUSION. Awareness of AD is essential for all health care practitioners involved in the care of patients with SCI. A variety of procedures in the radiology department, both diagnostic and interventional, may precipitate AD. Planning, monitoring procedures, knowledge of the relevant pathophysiology and pharmacology, and communication with clinical colleagues are essential to ensure safe practice. Clinicians ordering procedures and radiologists selecting protocols for those procedures should identify at-risk patients before booking a procedure to ensure appropriate supervision and anesthesiology support. Education of radiologists, interventional nursing staff, and technical staff can assist in prevention, early recognition, and successful management of AD.

Experts' opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta

Background

The 2013 International Classification of Headache Disorders-3 was published in a beta version to allow clinicians to confirm the validity of the criteria or suggest improvements based on field studies. The aim of this work was to review the Secondary Headache Disorders and Cranial Neuralgias and Other Headache Disorders sections of ICHD-3 beta data on children and adolescents (age 0–18 years) and to suggest changes, additions, and amendments.

Methods

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the available literature on pediatric headache, they made observations and proposed suggestions for the mentioned headache disorders on children and adolescents.

Results

Some headache disorders in children have specific features, which are different from adults that should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psychosocial basis in children and adolescents making primary headache disorders in children distinct from those in adults.

Conclusions

Several recommendations are presented in order to make ICHD-3 more appropriate for use in children.

Autonomic dysreflexia after spinal cord injury: Systemic pathophysiology and methods of management

Traumatic spinal cord injury (SCI) has widespread physiological effects beyond the disruption of sensory and motor function, notably the loss of normal autonomic and cardiovascular control. Injury at or above the sixth thoracic spinal cord segment segregates critical spinal sympathetic neurons from supraspinal modulation which can result in a syndrome known as autonomic dysreflexia (AD). AD is defined as episodic hypertension and concomitant baroreflex-mediated bradycardia initiated by unmodulated sympathetic reflexes in the decentralized cord. This condition is often triggered by noxious yet unperceived visceral or somatic stimuli below the injury level and if severe enough can require immediate medical attention. Herein, we review the pathophysiological mechanisms germane to the development of AD, including maladaptive plasticity of neural circuits mediating abnormal sympathetic reflexes and hypersensitization of peripheral vasculature that collectively contribute to abnormal hemodynamics after SCI. Further, we discuss the systemic effects of recurrent AD and pharmacological treatments used to manage such episodes. Contemporary research avenues are then presented to better understand the relative contributions of underlying mechanisms and to elucidate the effects of recurring AD on cardiovascular and immune functions for developing more targeted and effective treatments to attenuate the development of this insidious syndrome following high-level SCI.

International spinal cord injury bowel function basic data set (Version 2.0)

STUDY DESIGN

International expert working group.

OBJECTIVES

To revise the International Spinal Cord Injury (SCI) Bowel Function Basic Data Set as a standardized format for the collecting and reporting of a minimal amount of information on bowel function in clinical practice and research.

SETTING

Working group appointed by the American Spinal injury association (ASIA) and the International Spinal Cord Society (ISCoS).

METHODS

The draft prepared by the working group was reviewed by the International SCI Data Set Committee and later by members of the ISCoS Executive and Scientific Committees and the ASIA board. The revised data set was posted on the ASIA and ISCoS websites for 1 month to allow further comments and suggestions. Changes resulting from a Delphi process among experts in children with SCI were included. Members of ISCoS Executive and Scientific Committees and the ASIA board made a final review and approved the data set.

RESULTS

The International SCI Bowel Function Basic Data Set (Version 2.0) consists of the following 16 items: date of data collection, gastrointestinal and anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, defecation method and bowel-care procedures, average time required for defecation, frequency of defecation, uneasiness, headache or perspiration during defecation, digital stimulation or evacuation of the anorectum, frequency of fecal incontinence, flatus incontinence, need to wear pad or plug, oral laxatives and prokinetics, anti-diarrheal agents, perianal problems, abdominal pain and discomfort and the neurogenic bowel dysfunction score.

CONCLUSION

The International SCI Bowel Function Basic Data Set (Version 2.0) has been developed.

Autonomic dysreflexia during urodynamics in children and adolescents with spinal cord injury or severe neurologic disease

INTRODUCTION

Autonomic dysreflexia (AD) is a well-established association of high spinal cord injury (SCI), particularly in those occurring above T6. When a noxious stimulus is encountered, the body responds by stimulating an increase in blood pressure, which is then countered by vasodilation. In patients with autonomic dysreflexia, the patient is unable to vasodilate below the level of spinal injury due to interruption of the autonomic innervation below the injury. This then leads to persistently elevated blood pressure causing uncoordinated autonomic responses such as headache, flushing, sweating, and even hypertensive crisis. The noxious stimulus most commonly reported is bladder or bowel distention [1]. This potential trigger is especially important since many patients with SCI require catheterization and repeated urodynamic testing, both of which predispose them to bladder distention. In response to an incident during which a patient developed severe hypertension during UDS, institutional concern was raised about the potential risk of AD in other patients with SCI ≥ T8 and other severe neurological disease undergoing urodynamic testing, and a protocol was initiated in 2007 for monitoring for AD during UDS. Although no long-term complication was encountered in this incident, the need for improvement in our understanding of the detection and treatment of AD during urodynamic testing was highlighted. However, due to the potential of UDS to trigger AD and possible subsequent severe cardiovascular crisis, a protocol was established at our institution. Because of reports documenting episodes of AD for patients with severe, non-SCI neurologic disease and the unknown risk, these patients also were historically monitored at our institution as well.

OBJECTIVE

Autonomic dysreflexia (AD) is an uncoordinated autonomic response seen in patients with spinal cord injury (SCI). AD is often triggered by bladder distention, which may occur during urodynamic studies (UDS), and has potentially life-threatening consequences. Our purpose is to determine the prevalence and associated factors of AD in children undergoing UDS with either SCI or other neurological disease.

METHODS

We identified 13 pediatric patients with SCI at the eighth thoracic vertebrae or above (SCI ≥ T8) or other severe neurological disorder with urodynamic evaluations between 2007 and 2011 at our institution. We retrospectively reviewed these patients for age, gender, bladder volume, bladder compliance, detrusor instability, symptoms of AD, blood pressure, and urinary infection.

RESULTS

There were a total of 13 patients with SCI ≥ T8 (9), transverse myelitis (2), and encephalomyelitis (2). There were a total of 41 urodynamic studies with an average of 3.2 studies per patient. One adolescent with C1/2 injury and a prepubertal child with T2/3 injury developed AD. AD was not observed in non-SCI patients. The patients who developed AD had multiple subsequent episodes with follow up UDS. No statistical associations were found for the variables evaluated. No major complications occurred, and AD was successfully managed conservatively.

CONCLUSIONS

With appropriate monitoring and education, AD is easily recognized and managed conservatively. We found an increased risk of patients developing subsequent AD episodes after an initial episode. Patients who did not have autonomic dysreflexia during initial UDS did not experience autonomic dysreflexia on subsequent UDS. We did not observe autonomic dysreflexia occurring in children with transverse myelitis or encephalomyelitis.

Hypertensive encephalopathy as a late complication of autonomic dysreflexia in a 12-year-old boy with a previous spinal cord injury

The scope of paediatric autonomic disorders is not well recognised, and paediatricians seem to be generally unaware of the complexity and diversity of their clinical manifestations. We report a 12-year-old boy presenting with hypertensive encephalopathy caused by autonomic dysreflexia.

CONCLUSION

This observation emphasises the importance of the recognition of this rare autonomic disorder, which can have potentially life-threatening neurological complications.

Normative blood pressure and heart rate in pediatric spinal cord injury

BACKGROUND

Cardiovascular measures in children with spinal cord injury (SCI) may vary depending on the child's age and physical development in addition to injury-related factors. Developmental changes should be considered when addressing cardiovascular complications in this population.

OBJECTIVES

To determine baseline blood pressure (BP) and heart rate (HR) measurements in youth with SCI, and to investigate differences in BP and HR in relation to age, gender, body mass index (BMI), and injury-related factors.

METHODS

Retrospective chart review was conducted for youth under 19 years who had been admitted for rehabilitation at 1 of 2 pediatric SCI programs. Systolic (SBP) and diastolic (DBP) blood pressures and HR were collected in the morning and afternoon on 3 consecutive days. Mean SBP, DBP, and HR were compared among 4 age groups (0-5 years, 6-12 years, 13-15 years, and 16-18 years) and by gender. Diurnal variations were determined according to level and severity of injury. Associations with BMI and injury-related factors were examined. Charts of 315 youths were reviewed: mean age was 12.3 years, 59% were male, 75% were Caucasian, 62% had complete injury, and 66% had paraplegia.

RESULTS

With increasing age, SBP and DBP increased and HR decreased. SBP and DBP were positively correlated with BMI. SBP was higher in males, those with incomplete injury, and those with paraplegia. HR was higher in females. There was no association between cardiovascular measures and injury duration.

CONCLUSION

BP and HR are a function of age, BMI, and completeness and level of injury in youth with SCI. Awareness of baseline measures will allow for more effective management of cardiovascular complications, especially in youth presenting with atypical symptoms.

Spinal cord injuries in young children: a review of children injured at 5 years of age and younger

AIM

To determine the epidemiology and complications of spinal cord injuries (SCIs) in children injured at 5 years of age and younger who were seen between 1981 and 2008 at a children's hospital in the USA.

METHOD

Complications studied were scoliosis, hip dysplasia, latex allergies, autonomic dysreflexia, pressure ulcers, spasticity, deep venous thrombosis, and kidney stones. Demographic and injury-related factors included age at injury, etiology, level of injury, American Spinal Injury Association Impairment Scale (AIS), and SCIs without radiological abnormalities (SCIWORA).

RESULTS

Of the 159 individuals seen (92 males, 67 females) median age at injury was 2 years (range 0 y-5 y 11 mo). Forty-nine percent were injured in vehicular accidents, 60% had complete injuries, 66% had paraplegia, and 72% had SCIWORA. Ninety-six percent developed scoliosis, 57% had hip dysplasia, and 7% had latex allergy. Thirty-four percent with injuries at or above T6 experienced autonomic dysreflexia, 41% developed pressure ulcers, and 61% experienced spasticity. Of those without bowel or bladder control, 82% were on intermittent catheterization and 69% were on a bowel program. Median age of initiating wheelchair use was 3 years 4 months (range 1 y 2 mo-12 y 5 mo). Twenty-four were community ambulators, and they were more likely to have AIS D lesions (half the key muscle functions below the level of injury have a muscle grade 3 or greater) and less likely to have skeletal complications.

INTERPRETATION

The epidemiology, complications, and manifestations of SCIs in children injured at a young age are unique and differ distinctively from adolescent and adult-onset SCIs.

[Cardiac arrest in a 10-month-old boy with spinal cord injury]

A 10-month-old boy with a previous upper spinal cord injury was admitted to hospital with acute respiratory and circulatory distress. Shortly after admission the boy had severe bradycardia leading to asystolia and pulseless electrical activity. He was successfully resuscitated, and the investigation that followed excluded infection, congenital heart defect, arrhythmia and cerebral haemorrhage. Over the following days the patient had several episodes of isolated bradycardia and combined bradycardia and hypotension. It was concluded that the patient suffered from autonomic dysreflexia, triggered by a distended urinary bladder. He was treated with intermittent catheterization and a permanent pacemaker, and after 12 months there have not been any symptomatic episodes or registered arrhythmias. Autonomic dysreflexia is a common and well known complication of spinal cord injury above Th6, but the literature on paediatric patients is scarce. Our case report presents an infant with an atypical and severe episode of autonomic dysreflexia. Patients with spinal cord injury, their caregivers and health-care personal should be aware of this complication of spinal cord injury, in order to prevent and treat autonomic dysreflexia properly and avoid potentially fatal episodes.

Spinal cord injuries in children and adolescents

This chapter provides an overview of spinal cord injuries (SCI) in children and adolescents, including epidemiology, medical and musculoskeletal complications, rehabilitation and psychosocial aspects. Males are more commonly affected than females during adolescence; however, as the age at injury decreases, the preponderance of males becomes less marked, and by 3 years of age the number of females with SCIs equals that of males. The neurologic level and degree of completeness varies with age; among children injured prior to 12 years of age approximately two-thirds are paraplegic and approximately two-thirds have complete lesions. Among adolescents, approximately 50% have paraplegia and 55% have complete lesions. Management of pediatric-onset SCI should be family centered and developmentally based, responsive to the dynamic changes that occur during growth and development. Distinctive anatomical and physiological features of children and adolescents, along with growth and development, are responsible for unique manifestations and complications of pediatric SCI. SCI without radiological abnormalities (SCIWORA), birth injuries, lap-belt injuries, upper cervical injuries, and the delayed onset of neurological deficits are relatively unique to pediatric SCI. Children who sustain their SCI before puberty experience a higher incidence of musculoskeletal complications, such as scoliosis and hip dislocation.

Patient and caregiver knowledge of autonomic dysreflexia among youth with spinal cord injury

OBJECTIVES

To describe the prevalence and knowledge of autonomic dysreflexia (AD) from patient and caregiver perspectives, and its relationship to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification, level of injury, severity of injury, injury etiology, gender and race.

METHODS

Participants were between 1 and 21 years old. Demographic information was collected from the medical records, and patients and caregivers were interviewed with the following questions: (1) Does the patient experience AD? (2) Does the patient/caregiver know what AD is? (3) Can the patient/caregiver name three signs/symptoms of an AD episode? (4) Does the patient/caregiver know how to treat AD?

RESULTS

Overall, 40% of patients and 44% of caregivers said that the patient was symptomatic for AD. AD was more common in those with traumatic etiologies, in patients with injuries at or above T6 and those with greater injury severity as measured by the AIS. For patients and caregivers, AD was less common in the youngest age group (0-5 years old). Patients with greater knowledge of AD were more likely to have traumatic etiologies, have T6 or higher injuries, be in the oldest age at injury group, be older at time of examination and have had a shorter duration of injury.

CONCLUSIONS

AD seems to be more common in patients with traumatic injuries, older ages at injury, greater injury severity on the AIS and level of injury at or above T6.

The flushing patient: Differential diagnosis, workup, and treatment

Cutaneous flushing-a common presenting complaint to dermatologists, allergists, internists, and family practitioners-results from changes in cutaneous blood flow triggered by multiple conditions. Most cases are caused by very common, benign diseases, such as rosacea or climacterum, that are readily apparent after a thorough taking of history and physical examination. However, in some cases, accurate diagnosis requires further laboratory, radiologic, or histopathologic studies to differentiate several important clinicopathologic entities. In particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma, mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid, pancreatic cell tumor, renal carcinoma, and others, should be considered.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the mechanisms of flushing, its clinical differential diagnosis, the approach to establish a definitive diagnosis, and management of various conditions that produce flushing.