Spinal cord injury in the pediatric population: a systematic review of the literature

The relationship between the structural changes in the cervical spinal cord and sensorimotor function of children with thoracolumbar spinal cord injury (TLSCI)

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To study the relationship between the structural changes in the cervical spinal cord (C2/3 level) and the sensorimotor function of children with traumatic thoracolumbar spinal cord injury (TLSCI) and to discover objective imaging biomarkers to evaluate its functional status.

SETTING

Xuanwu Hospital, Capital Medical University, China; Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, China.

METHODS

30 children (age range 5-13 years) with TLSCI and 11 typically developing (TD) children (age range 6-12 years) were recruited in this study. Based on whether there is preserved motor function below the neurological level of injury (NLI), the children with TLSCI are divided into the AIS A/B group (motor complete) and the AIS C/D group (motor incomplete). A Siemens Verio 3.0 T MR scanner was used to acquire 3D high-resolution anatomic scans covering the head and upper cervical spinal cord. Morphologic parameters of the spinal cord at the C2/3 level, including cross-sectional area (CSA), anterior-posterior width (APW), and left-right width (LRW) were obtained using the spinal cord toolbox (SCT; https://www.nitrc.org/projects/sct ). Correlation analyses were performed to compare the morphologic spinal cord parameters and clinical scores determined by the International Standard for Neurological Classification of Spinal Cord Injuries (ISNCSCI) examination.

RESULTS

CSA and LRW in the AIS A/B group were significantly lower than those in the TD group and the AIS C/D group. LRW was the most sensitive imaging biomarker to differentiate the AIS A/B group from the AIS C/D group. Both CSA and APW were positively correlated with ISNCSCI sensory scores.

CONCLUSIONS

Quantitative measurement of the morphologic spinal cord parameters of the cervical spinal cord can be used as an objective imaging biomarker to evaluate the neurological function of children with TLSCI. Cervical spinal cord atrophy in children after TLSCI was correlated with clinical grading; CSA and APW can reflect sensory function. Meanwhile, LRW has the potential to be an objective imaging biomarker for evaluating motor function preservation.

The Relationship Between Physical Activity and Mental Health Among Individuals With Spinal Cord Injury: Protocol for a Scoping Review

BACKGROUND

Spinal cord injury (SCI) is a devastating condition that often leads to significant impairments in physical function, leading to disability and mental health disorders. Hence, understanding the prevalence of SCI and the relationship between physical activity and mental health in individuals with SCI is crucial for informing rehabilitation strategies and optimizing outcomes.

OBJECTIVE

This study aims to comprehensively analyze existing research on the link between physical activity and mental health and identify the level of physical activity and mental health status, the barriers to physical activity, and SCI's impacts on psychological well-being in individuals with SCI.

METHODS

An electronic search strategy will be used to identify prevalence studies published since 1993 in health-related databases such as PubMed, MEDLINE, COCHRANE Library, and Wiley Library using the following query: "Spinal Cord Injury" OR "Paraplegia" OR "Tetraplegia" AND "Physical Activity" OR "Exercise" AND "Mental Health" OR "Mental Illness" OR "Mental Disorder." Bibliographies of primary studies and review articles meeting the inclusion criteria will be searched manually to identify further eligible studies. The risk of bias in the included studies will be appraised using the Joanna Briggs Institute checklist for prevalence studies by 2 review authors. Any disagreement will be resolved by reaching a consensus.

RESULTS

Funding was received in October 2023, data collection will commence in July 2024, and the results are expected by 2025. We will summarize the selection of the eligible studies using a flowchart. The data from the studies will be extracted and tabulated. This scoping review will be published in a peer-reviewed journal in accordance with PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines.

CONCLUSIONS

This scoping review underscores the complex relationship between physical activity and mental health among individuals with SCI, highlighting the level of physical activity and mental health status, barriers to physical activity engagement, and psychological implications. Understanding these dynamics is crucial in devising tailored interventions aimed at enhancing mental well-being. This synthesis of evidence emphasizes the need for personalized strategies to promote physical activity, addressing unique challenges faced by this population to foster improved mental health outcomes and overall quality of life.

TRIAL REGISTRATION

Open Science Framework osf.io/ugx7d; https://osf.io/ugx7d/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/56081.

Evaluation of traumatic spinal injuries: a pediatric perspective

PURPOSE

The aim of the present study is to provide information about pediatric patients with spinal trauma.

METHODS

A single-center retrospective chart review was carried out. Children who arrived at the pediatric emergency department due to trauma and those with spinal pathology confirmed by radiological assessment were included. Demographics, mechanisms of trauma, clinical findings, radiological investigations, applied treatments, hospital stay and prognosis were recorded.

RESULTS

A total of 105 patients [59 (56.2%) boys; mean age: 12.9 ± 3.8 years (mean ± SD)] were included. The most common age group was that of 14-18 years (58.1%). The three most common trauma mechanisms were road traffic collisions (RTCs) (60.0%), falls (32.4%), and diving into water (2.9%). A fracture of the spine was detected in 97.1% patients, vertebral dislocation in 10.7%, and spinal cord injury in 16.3%. Of the patients, 36.9% were admitted to the ward and 18.4% to the pediatric intensive care unit; 17.1% were discharged with severe complications and 2.9% cases resulted in death. While 34.3% of the patients had a clinically isolated spine injury, the remaining cases entailed an injury to at least one other body part; the most common associated injuries were to the head (39.8%), abdomen (36.1%), and external areas (28.0%).

CONCLUSION

Spinal trauma was found to have occurred mostly in adolescent males, and the majority of those cases were due to RTCs. Data on the incidence and demographic factors of pediatric spinal trauma are crucial in furthering preventive measures, allowing for the identification of at-risk populations and treatment modalities.

Paediatric Spinal Cord Injury: A Review of Current Management

Spinal cord injury (SCI) in the paediatric population is considered a separate entity from the same injury in adults due to the unique anatomical, physiological, and biomechanical properties of the pediatric spine. No comprehensive, standardized, international guidelines currently exist for physicians to follow regarding the management of paediatric spinal cord injuries. Therefore, a narrative literature review approach was employed to explore the management of paediatric spinal cord injuries. The review adhered to the methodological frameworks that entailed identifying a curated selection of pertinent articles on the topic, rather than an exhaustive comprehensive search that is utilised in systematic reviews, this was followed by a reflective interpretation of their content. Using the electronic databases, PubMed and Google Scholar, a search of peer-reviewed studies conducted only in the English language was included. Only studies in which the full article was available were included. Paediatric populations are defined as individuals aged between 0 and 18 years. In total, 26 studies were included in our review. We conclude that it is necessary to factor in specific paediatric considerations, such as disproportionate head size, increased ligament laxity, increased prevalence of upper cervical injury, and future development of scoliosis, in the prehospital, medical, and surgical management of paediatric spinal cord injuries. Clinicians should be made aware of these considerations, as they can improve the outcomes in the paediatric population who suffer from this devastating injury. There is a lack of high-quality studies and data concerning the paediatric population who have sustained SCIs. This literature review highlights the available data and calls for more studies to be conducted in this field.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

Pediatric non-Hodgkin lymphoma as a rare cause of spinal cord injury: When lymphoma hides in the canal

Key Clinical Message

Spinal cord compression from non-Hodgkin lymphoma (NHL) should be considered as a potential diagnosis in cases of acute signs of myelopathy in pediatric patients.

Abstract

Spinal cord compression in pediatric non-Hodgkin lymphoma (NHL) is a rare presentation with potential diagnostic challenges. We report on two pediatric patients with NHL who exhibited myelopathy signs as initial presentation. Considering NHL as a differential diagnosis in pediatric patients presenting with spinal cord compression is crucial for optimizing the outcome of these patients.

Epidemiological Study of Traumatic Brain and Spinal Injuries in a Pediatric Population: A One-Year Analysis of Prevalence, Causes and Trends

Background Traumatic brain injury (TBI) and spinal cord injury (SCI) are leading causes of morbidity and mortality in pediatric patients. However, the epidemiology of pediatric brain and spine injuries in Bulgaria is poorly documented. This study aims to analyze and identify the prevalence, causes, and trends of traumatic brain and spinal cord injuries in pediatric patients during the period of 1st June 2022 to 30th June 2023. Methods A retrospective study was conducted on the medical records of patients under 18 years of age who visited the emergency department of University Multiprofile Hospital for Active Treatment (UMHAT) Burgas, Bulgaria between 1st June 2022 and 30th June 2023. The incidence and etiology were stratified by age, gender, and anamnesis. Data processing and analysis were performed with the statistical package IBM SPSS v. 26.0 (IBM Corp., Armonk, NY, USA), and graphical analysis with MS Office Excel 2016 (Microsoft, Redmond, WA, USA). Means ± standard deviation and 95% confidence interval were calculated. All p-values less than 0.05 were considered indicative of statistical significance. Results Data for patients aged <18 years, admitted to the emergency department (ED) of UMHAT Burgas, Bulgaria from 1st June 2022 to 30th June 2023 were analyzed (n=38504). Of these patients, 32% were children (n=13857). One hundred thirty-four (0.3%) of the pediatric patients were hospitalized in the neurosurgical ward, and 4653 (10.7%) were hospitalized in other wards. Of the analyzed patients, 89 are boys (66.4%), 45 are girls (33.6%) (male-female ratio 2:1) and the mean age of the patients with a head trauma was 8.07 years old. The average number of patients by diagnosis is 13.4±35.37. The largest percent are patients with brain concussion (85.07%, n=114), followed by contusion of the nerve roots in the lumbar region or late contusion wound of the head (with 2.99% each, n=4); hydrocephalus or skull fracture (with 2.24% each, n=3); contusion of the nerve roots in the thoracic region (1.49%, n=2); and fracture at Th9 vertebrae, fracture at C2 vertebrae, brain trauma or brain tumor (with 0.75% each, n=1). The average number of patients by anamnesis is 13.2±17.99. The largest percent are patients who fall from their own height (44.78%, n=60); followed by falls from height (20.90%, n=28); car accident (7.46%, n=10); injured by fight, fall from a bicycle or incident during a football game (with 5.97% each, n=8); fall from electric scooter (4.48%, n=6); hit in the closet (2.99%, n=4); and finally from bike accident or hit by a rock (with 0.75% each, n=1). From 134 hospitalized patients in neurosurgery, 114 (85.07%) did not require surgical treatment and were treated with conservative treatment and 20 (14.93%) were treated surgically.  Conclusion In conclusion, this study highlights a significant burden of pediatric traumatic brain and spinal injuries in Bulgaria. The majority of cases were managed conservatively, emphasizing the need for preventive measures.

Research Priorities of the Pediatric Spinal Cord Injury Population: An International Insight for Rehabilitation Care

BACKGROUND

Although feedback from people with adult-onset spinal cord injury (SCI) has been considered for new rehabilitation programs, little is known about the priorities of the pediatric-onset SCI population. This study describes and compares health and life (H&L) domain research priorities of youth with pediatric-onset SCI and their parents/caregivers.

METHODS

A cross-sectional survey, designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) Collaboration, was performed at six European countries. Dyad data from 202 participants, youth with pediatric-onset SCI (n = 101) and their parents/caregivers (n = 101), were analyzed with the PEPSCI H&L domain surveys.

RESULTS

The cohort was composed of 8 to 12-year-olds (30.7%), 13 to 17-year-olds (38.6%), and 18 to 25-year-olds (30.7%). The top three H&L domain research priorities reported by parents/caregivers of 8 to 12-year-olds were "walking/ability to move" (91%), "bladder" function (90%), and "general health/feel" (89%), compared with "physical function" (93%), "general health/feel" (90%), and "walking/ability to move" (89%) rated by parents/caregivers of 13 to 25-year-olds. "Bowel" function (85%), "leg/foot movement" (84%), and "bladder" function (84%) were reported as priorities by 13 to 25-year-olds, whereas "physical function" (84%), "experience at school" (83%), and "general mood" were highlighted by 8 to 12-year-olds. The top 10 priorities preferred by 13 to 25-year-olds when compared with the top 10 priorities reported by their parents/caregivers, included problems related to "bowel" and "pain."

CONCLUSIONS

Health domain research priorities were highlighted by 13 to 25-year-olds, compared with their parents/caregivers who equally identified H&L domains. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive research strategy for the pediatric SCI population.

Development of a rocking chair for use by children with spinal cord injuries

PURPOSE

Activity-based locomotor training improves intrinsic trunk control in children with spinal cord injury (SCI). To reinforce these improvements, there is a need to develop community integration activities to allow a patient to apply the retrained nervous system at home. One activity that has been explored is rocking in a rocking chair. This paper describes the design, fabrication, and evaluation of a rocking chair for children with SCI.

MATERIALS AND METHODS

The Quality Function Deployment (QFD) design process was used. Fundamental needs and features for the rocking chair were defined in a focus group with experienced therapists, and needs were then rated for importance. A House of Quality (HOQ) matrix was developed to correlate needs with design features, and a prototype design was generated. Virtual motion studies and finite element analysis (FEA) were utilized to assess the design. The chair was fabricated and physical testing was performed, including tipping and static and dynamic load assessments.

RESULTS AND CONCLUSIONS

The needs identified through the QFD process were categorized into (1) safety, (2) therapeutic, (3) practical and aesthetic, and (4) data to track chair use. Features selected to meet these needs include safety stops, padding, straps, a stable base, armrests, adjustable footrest, and sensors to capture rocking data. FEA showed a factor of safety (FOS) > 5. Physical testing confirmed physical integrity, load-bearing capacity, and stability of the prototype glider rocking chair. The prototype provides a safe tool for further investigation of rocking for promotion of trunk muscle activation in children with SCI.

Pediatric health and life domain priorities: A national survey of people with spinal cord injury and their parents and caregivers

CONTEXT/OBJECTIVE

No information is available regarding priorities for pediatric-onset spinal cord injury (SCI). This study described the Health and Life (H&L) domain priorities of youth with pediatric-onset SCI and their parents/caregivers living in Spain.

DESIGN

A cross-sectional survey.

SETTING

Two SCI rehabilitation centers.

PARTICIPANTS

Sixty participants, youth with pediatric-onset SCI (n = 26) and parents/caregivers (n = 34).

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Median overall priorities calculated on the basis of importance, unhappiness, and research measured with a new survey of pediatric H&L domains and rated using a 5-point Likert Scale.

RESULTS

A total of 60 surveys were received providing information on 35 individuals with SCI: 2-7-year-olds (25.7%), 8-12-year-olds (22.9%), 13-17-year-olds (31.4%), and 18-25-year-olds (20.0%). The top three overall H&L priorities reported by parents/caregivers of 2-12-year-olds were "parenthood expectations" (84%), "leg/foot movement" (83%), and "bladder" function (83%), compared to "dressing/undressing" (78%), "walking/ability to move" (77%) and "bladder" function (77%) rated for 13-25-year-olds. "Sit-to-stand" (79%), "leg/foot movement" (78%) and "arm/hand movement" (77%) were reported as priorities by 13-25-year-olds. The 13-25-year-olds highlighted "sit-to-stand" (100%), "eating/drinking" (54%), and "physical function" (94%) as their top unhappiness, importance, and research priorities, respectively. Significant differences between tetraplegia and paraplegia were found in "mobility in the community" (unhappiness item) for 13-25-years-old.

CONCLUSION

Health domains were considered the top overall H&L priorities by parents/caregivers of 13-25-year-olds, compared to life domains reported for their 2-12-year-olds. This survey will aid rehabilitation professionals to engage stakeholders to implement a comprehensive SCI management program for the pediatric population.

Pediatric Spinal Trauma at a Single Level 1 Trauma Center: Review of 62 Cases

Background

Traumatic spinal injuries in children are uncommon and result in different patterns of injuries due to the anatomical characteristics of children's spines. However, there are only a few epidemiological studies of traumatic spinal injury in children. The purpose of this study was to investigate the characteristics of traumatic spinal injury in children.

Methods

We retrospectively reviewed the cases of pediatric patients (age < 18 years) with traumatic spinal injury who were treated at a level 1 trauma center between January 2017 and December 2021. We divided them into three groups according to age and analyzed demographics, injury mechanism, level of injury, and injury pattern.

Results

A total of 62 patients (255 fractures) were included, and the mean age was 13.8 ± 3.2 years. There were 5 patients (22 fractures) in group I (0-9 years), 24 patients (82 fractures) in group II (10-14 years), and 33 patients (151 fractures) in group III (15-17 years). Both the Injury Severity Score and the Revised Trauma Score were highest in group I, but there was no statistical difference between the age groups. Fall from height was the most common injury mechanism, of which 63% were suicide attempts. The level of spinal injury was different in each age group, T10-L2 injury being the most common. In all age groups, the number of multilevel continuous injury was larger than that of single-level injury or multilevel noncontinuous injury. Surgical intervention was required in 33.9%, and mortality was 3.2%.

Conclusions

In our study, fall from height was the most common mechanism of injury, and there were many suicide attempts associated with mental health issues. Thoracolumbar junction injuries were predominant, and the rate of multilevel contiguous injuries was high. The support and interest of the society and families for adolescent children seem crucial in preventing spinal trauma, and image testing of the entire spine is essential when evaluating pediatric spinal injuries.

A systematic review and meta-analysis of the global epidemiology of pediatric traumatic spinal cord injuries

Despite being relatively rare, pediatric traumatic spinal cord injury (TSCI) is a debilitating event with high morbidity and long-term damage and dependency. This study aims to provide insight on the epidemiological characteristics of pediatric TSCI worldwide. The studies were included if they provided data for the pediatric population with the diagnosis of TSCI. Information sources included PubMed, Embase, Web of Science, and Scopus. All databases were searched from 1990 to April 2023. The quality of included studies was evaluated by Joanna Briggs Institute Critical Appraisal Tools. The results of the meta-analysis were presented as forest plots. PROSPERO Registration code: CRD42020189757. We identified 87 studies from 18 developed and 11 developing countries. Of the 87 studies evaluated, 52 studies were considered medium quality, 27 studies were considered high quality, and 8 studies were considered low quality. In developed countries, the proportion of TSCIs occurring in patients aged 0-15 years was 3% (95% CI: 2.2%; 3.9%), while in developing countries, it was 4.5% (95% CI: 2.8%; 6.4%). In developed countries, the pooled incidence of pediatric TSCI was 4.3/millions of children aged 0-15/year (95% CI: 3.1; 6.0/millions children aged 0-15/year) and boys comprised 67% (95% CI: 63%; 70%) of cases. The most prevalent level of injury was cervical (50% [95% CI: 41%; 58%]). The frequency of SCI Without Obvious Radiological Abnormality (SCIWORA) was 35% (95% CI: 18%; 54%) among children 0-17 years. The most common etiology in developed countries was transport injuries (50% [95% CI: 42%; 57%]), while in developing countries falls were the leading cause (31% [95% CI: 20%; 42%]). The most important limitation of our study was the heterogeneity of studies in reporting age subgroups that hindered us from age-specific analyses.   Conclusion: Our study provided accurate estimates for the epidemiology of pediatric TSCI. We observed a higher proportion of pediatric TSCI cases in developing countries compared to developed countries. Furthermore, we identified distinct epidemiological characteristics of pediatric TSCI when compared to adult cases and variations between developing and developed countries. Recognizing these unique features allows for the implementation of cost-effective preventive strategies aimed at reducing the incidence and burden of TSCI in children. What is Known: • Pediatric Traumatic Spinal Cord Injury (TSCI) can have profound physical and social consequences for affected children, their families, and society as a whole. • Epidemiological insights are vital for they provide the data and understanding needed to the identification of vulnerable populations, aiding in the development of targeted prevention strategies and effective resource allocation. What is New: • The estimated incidence of pediatric TSCI in developed countries is 4.3 cases per million children aged 0-15. The proportion of pediatric TSCI cases in relation to all-age TSCI cases is 3% in developed countries and 4.5% in developing countries. • The etiology of TSCI in pediatric cases differs between developing and developed countries. In developed countries, transport injuries are the most prevalent cause of pediatric TSCI, while falls are the least common cause. Conversely, in developing countries, falls are the leading cause of pediatric TSCI.

Nationwide emergency department visits for pediatric traumatic spinal cord injury in the United States, 2016-2020

Introduction

Traumatic spinal cord injury (tSCI) is a debilitating neurological condition resulting in lifelong disability for many individuals. The primary objectives of our study were to describe national trends in incident emergency department (ED) visits for tSCI among children (less than 21 years) in the United States, and to determine the proportion of visits that resulted in immediate hospitalization each year, including stratified by age and sex. Secondary objectives were to examine associations between select characteristics and hospitalization following tSCI, as well as to assess sports-related tSCIs over time, including by individual sport and geographic region.

Methods

We used the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample to identify ED visits among children between January 2016 and December 2020 for incident tSCI. Diagnosis codes were used to identify tSCI and sports-related injury etiologies. Census Bureau data were used to approximate annual rates of pediatric ED visits for tSCI per 100,000 children. Unconditional logistic regression modeling assessed whether select factors were associated with hospital admission.

Results

We found that the annual ED visit rate for tSCI remained relatively stable between 2016 and 2020, with approximately 2,200 new all-cause pediatric ED visits for tSCI annually. Roughly 70% of ED visits for tSCI resulted in hospitalization; most ED visits for tSCI were by older children (15-20 years) and males, who were also more often admitted to the hospital. Notable secondary findings included: (a) compared with older children (15-20 years), younger children (10-14 years) were less likely to be hospitalized immediately following an ED visit for tSCI; (b) patient sex and race were not associated with hospital admission; and (c) American tackle football was the leading cause of sports-related ED visits for tSCI among children. Our findings also suggest that the proportion of sports-related tSCI ED visits may have increased in recent years.

Discussion

Future research should further examine trends in the underlying etiologies of pediatric tSCI, while assessing the effectiveness of new and existing interventions aimed at tSCI prevention.

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.

Use of Invasive Brain-Computer Interfaces in Pediatric Neurosurgery: Technical and Ethical Considerations

Invasive brain-computer interfaces hold promise to alleviate disabilities in individuals with neurologic injury, with fully implantable brain-computer interface systems expected to reach the clinic in the upcoming decade. Children with severe neurologic disabilities, like quadriplegic cerebral palsy or cervical spine trauma, could benefit from this technology. However, they have been excluded from clinical trials of intracortical brain-computer interface to date. In this manuscript, we discuss the ethical considerations related to the use of invasive brain-computer interface in children with severe neurologic disabilities. We first review the technical hardware and software considerations for the application of intracortical brain-computer interface in children. We then discuss ethical issues related to motor brain-computer interface use in pediatric neurosurgery. Finally, based on the input of a multidisciplinary panel of experts in fields related to brain-computer interface (functional and restorative neurosurgery, pediatric neurosurgery, mathematics and artificial intelligence research, neuroengineering, pediatric ethics, and pragmatic ethics), we then formulate initial recommendations regarding the clinical use of invasive brain-computer interfaces in children.

Pediatric cervical spine injuries-results of the German multicenter CHILDSPINE study

OBJECTIVES

The aim of this study was to provide epidemiological data of pediatric patients suffering from cervical spinal trauma in Germany, in order to integrate these data in future decision-making processes concerning diagnosis and therapy.

MATERIALS AND METHODS

Retrospective multicenter study includes all patients up to 16 years suffering from cervical spine injuries who were treated in six German spine centers between 01/2010 and 12/2016. The clinical databases were screened for specific trauma mechanism, level of injury as well as accompanying injuries. Diagnostic imaging and the chosen therapy were analyzed. Patients were divided into three age groups for further evaluation: age group I (0-6 years), age group II (7-9 years), age group III (10-16 years).

RESULTS

A total of 214 children with 265 cervical spine injuries were included during the mentioned period. The mean age at the time of injury was 11.9 (± 3.9) years. In age group I, 24 (11.2%) patients were included, age group II consisted of 22 patients (10.3%), and 168 patients belonged to age group III (78.5%). Girls and boys were equally affected. In all age groups, falls and traffic accidents were the most common causes of cervical spine injuries. A total of 180 patients (84.1%) were treated conservatively, while 34 (15.9%) children underwent surgery. Distorsion/whiplash injury was the most common entity (n = 165; 68.2%). Children aged 0-9 years had significantly (p < 0.001) more frequent injuries of the upper cervical spine (C0-C2) compared to older age groups. Patients of age group III were more likely to suffer from injuries in subaxial localizations. Neurological deficits were rarely seen in all age groups. Head injuries did represent the most common accompanying injuries (39.8%, n = 92).

CONCLUSIONS

The upper cervical spine was more frequently affected in young children. Older children more often suffered from subaxial pathologies. The majority of cervical spinal column injuries were treated conservatively. Nevertheless, 15% of the hospitalized children had to be treated surgically.

Guidelines for management of pediatric acute hyperextension spinal cord injury

Pediatric acute hyperextension spinal cord injury (SCI) named as PAHSCI by us, is a special type of thoracolumbar SCI without radiographic abnormality and highly related to back-bend in dance training, which has been increasingly reported. At present, it has become the leading cause of SCI in children, and brings a heavy social and economic burden. Both domestic and foreign academic institutions and dance education organizations lack a correct understanding of PAHSCI and relevant standards, specifications or guidelines. In order to provide standardized guidance, the expert team formulated this guideline based on the principles of science and practicability, starting from the diagnosis, differential diagnosis, etiology, admission evaluation, treatment, complications and prevention. This guideline puts forward 23 recommendations for 14 related issues.

Minimally invasive retrieval of a bullet settling into the thoracic spinal canal in a pediatric patient: A case report

A 10-year-old boy presented to neurosurgery department after a gunshot wound to the upper thoracic spine. The bullet entered through the right deltoid muscle and lodged inside the spinal canal at T1 level. The patient arrived conscious and obeying commands; however, he experienced a loss of sensation below T3 level, loss of reflexes below the injured T1 level, loss of anal sphincter tone and paraplegia in the lower limbs (American Spinal Injury Association grade-A). Imaging studies revealed an intra-canalicular metallic bullet at the T1 level. The patient underwent urgent operation using a tubular retractor system and the microscope. Subsequently, the bullet was successfully retrieved. Postoperatively, the patient made a significant recovery and by the end of the 6th month, he was able to walk independently despite some gait instability. A minimally invasive approach for intra-canalicular bullet removal in the thoracic region is a safe and effective technique in pediatric patients.

Transcutaneous Spinal Stimulation From Adults to Children: A Review

Neuromodulation via spinal stimulation is a promising therapy that can augment the neuromuscular capacity for voluntary movements, standing, stepping, and posture in individuals with spinal cord injury (SCI). The spinal locomotor-related neuronal network known as a central pattern generator (CPG) can generate a stepping-like motor output in the absence of movement-related afferent signals from the limbs. Using epidural stimulation (EP) in conjunction with activity-based locomotor training (ABLT), the neural circuits can be neuromodulated to facilitate the recovery of locomotor functions in persons with SCI. Recently, transcutaneous spinal stimulation (scTS) has been developed as a noninvasive alternative to EP. Early studies of scTS at thoracolumbar, coccygeal, and cervical regions have demonstrated its effectiveness in producing voluntary leg movements, posture control, and independent standing and improving upper extremity function in adults with chronic SCI. In pediatric studies, the technology of spinal neuromodulation is not yet widespread. There are a limited number of publications reporting on the use of scTS in children and adolescents with either cerebral palsy, spina bifida, or SCI.

Transitioning between paediatric and adult healthcare services: a qualitative study of the experiences of young people with spinal cord injuries and parents/caregivers

OBJECTIVES

Healthcare transition (HCT) interventions are pivotal to paediatric rehabilitation. However, there has been limited research focusing on HCT in young people with spinal cord injury (SCI). To date, little has been reported on key factors that may contribute to a positive or negative transition experience and what, if any, are the gaps in the transition process. This study explored the experiences of transition from paediatric to adult healthcare for young people with SCI and parents/caregivers in pursuit of co-designing and developing an intervention to support transition.

DESIGN, SETTING AND PARTICIPANTS

This qualitative study forms part of the planning phase of a larger participatory action research project. It supports obtaining a rich understanding of the phenomenon and the issues and actions necessary to achieve change. Semi-structured individual interviews were conducted online between April and June 2021 with young people with SCI and parents/caregivers who had transitioned or were preparing for the transition from paediatric to adult healthcare in NSW, Australia. The interviews were analysed using an inductive reflexive thematic analysis approach.

RESULTS

The study recruited nine participants, five young people with SCI and four parents/caregivers. The interviews provided invaluable insight into young people with SCI and their parents'/caregivers' experiences of HCT. As HCT experiences were often less than optimal and needs were not adequately met, some recommendations were offered. These included a coordinated and streamlined handover from paediatric to adult healthcare providers, and a 'one-stop shop' for young people with SCI and their parents/caregivers to access transition information, such as how it occurs, who to call for ongoing support and advice, and tips on how to transition successfully.

CONCLUSION

Providing a coordinated and streamlined handover process as well as access to more context-related information could improve the transition experiences of young people with SCI and parents/caregivers, resulting in improved health outcomes and greater independence.

TRIAL REGISTRATION

ACTRN12621000500853.

Specific brain gray matter volume changes in pediatric complete spinal cord injury without fracture or dislocation using voxel-based morphometry analysis: Preliminary Results

This study aims to investigate the brain gray matter volume (GMV) alterations of pediatric complete thoracolumbar spinal cord injury without fracture or dislocation (SCIWOFD) using voxel-based morphometry (VBM) analysis and assess the sensitive neuroimaging biomarkers which may be surrogate targets to enhance brain plasticity. A total of 52 pediatric subjects (age range, 6-12 years), including 25 pediatric SCIWOFD patients and 27 typically developing (TD) children were recruited. Independent two-sample t test was performed to assess between-group differences of brain GMV. Partial correlation analyses were performed to explore the correlations between GMV values and ISNCSCI scores, age at the time of injury, time after initial SCI. Receiver operating characteristic (ROC) analysis was performed to compute the sensitivity and specificity of the imaging biomarkers for pediatric SCIWOFD diagnosis. As the results, pediatric SCIWOFD patients showed significantly decreased GMV of bilateral Cerebellum lobule VIII, right middle occipital gyrus (MOG) and putamen (PUT), left pallidum (PAL) and thalamus (THA), and increased GMV of Vermis_III, right Cerebellum lobule VI and SupraMarginal gyrus (SMG). Additionally, GMV of left PAL and right PUT were negatively correlated with the pinprick/light touch sensory scores in pediatric SCIWOFD patients. Finally, when using the GMV values of left PAL and right PUT in combination as the predictor, area under the curve (AUC) reached the highest, of 0.93. These findings provided evidence that the brain undergoes GMV changes following pediatric SCIWOFD, which may suggest important targets for functional remodeling after SCI in children and provide valuable information for the development of novel and effective rehabilitation therapies in the future.

Management and Outcomes of Traumatic Paediatric Spinal Cord Injuries in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

Traumatic spinal cord injury (TSCI) is a subset of neurotrauma, which is a significant contributor to global trauma mortality and morbidity in children. The management and outcomes of paediatric TSCI in low-and-middle income countries (LMICs) is unknown. We conducted a scoping review to characterise the methods of management and outcomes of TSCI in LMICs.

METHODS

MEDLINE, EMBASE, and Global Index Medicus were searched from database inception to February 15, 2021. Studies reporting management or outcomes of paediatric TSCI in LMICs were included. Pooled statistics were calculated using measures of central tendency and spread.

RESULTS

A total of 1171 studies were identified, of which, 5 were included. A total of 212 patients were included in our review with age of participants ranging from 2.5 to 18 years old (mean = 15.4 years). Most patients were male (n=162, 76.4%). The commonest cited cause of injury were falls (n=104/212, 49.1%). The most common level of injury was cervical (n=83, 39.2%). The majority of patients underwent surgery (n=134/212, 63.2%). The extent of injury was quantified and classified using the ASIA chart in only one paper. Long-term management data was not present in any of the included studies.

CONCLUSION

There is a scarcity of published studies reporting the management and outcome of paediatric TSCI in LMICs. The paucity of studies in this domain provides insufficient data to be compared, reducing the ability to draw a strong conclusion. This hinders the development of guidelines to inform best practice.

Spatiotemporal responses of trabecular and cortical bone to complete spinal cord injury in skeletally mature rats

Objective

Methods

Results

Conclusions

•

Skeletally mature spinal cord transected rats display biphasic bone loss

•

The osteoporosis manifests over slower time scales than in skeletally immature rats.

•

Relevancy for testing efficacy of interventions against SCI-induced osteoporosis.

Needs and Research Priorities for Young People with Spinal Cord Lesion or Spina Bifida and Their Caregivers: A National Survey in Switzerland within the PEPSCI Collaboration

The aim of this study was to describe the needs and research priorities of Swiss children/adolescents and young adults (from here, “young people”) with spinal cord injury/disorder (SCI/D) or spina bifida (SB) and their parents in the health and life domains as part of the international Pan-European Pediatric Spinal Cord Injury (PEPSCI) collaboration. Surveys included queries about the satisfaction, importance, research priorities, quality of life (QoL), and characteristics of the young people. Fifty-three surveys with corresponding parent-proxy reports were collected between April and November 2019. The self-report QoL sum scores from young people with SCI/D and SB were 77% and 73%, respectively. Parent-proxy report QoL sum scores were lower, with 70% scores for parents of young people with SCI/D and 64% scores for parents of young people with SB. “Having fun”, “relation to family members”, and “physical functioning” were found to be highly important for all young people. “Physical functioning”, “prevention of pressure injuries”, “general health”, and “bowel management” received the highest scores for research priority in at least one of the subgroups. As parents tend to underestimate the QoL of their children and young people prioritized research topics differently, both young peoples’ and caregivers’ perspectives should be included in the selection of research topics.

Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children

Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.

Time course changes to structural, mechanical and material properties of bone in rats after complete spinal cord injury

OBJECTIVE

Characterise the spatiotemporal trabecular and cortical bone responses to complete spinal cord injury (SCI) in young rats.

METHODS

8-week-old male Wistar rats received T9-transection SCI and were euthanised 2-, 6-, 10- or 16-weeks post-surgery. Outcome measures were assessed using micro-computed tomography, mechanical testing, serum markers and Fourier-transform infrared spectroscopy.

RESULTS

The trabecular and cortical bone responses to SCI are site-specific. Metaphyseal trabecular BV/TV was 59% lower, characterised by fewer and thinner trabeculae at 2-weeks post-SCI, while epiphyseal BV/TV was 23% lower with maintained connectivity. At later-time points, metaphyseal BV/TV remained unchanged, while epiphyseal BV/TV increased. The total area of metaphyseal and mid-diaphyseal cortical bone were lower from 2-weeks and between 6- and 10-weeks post-SCI, respectively. This suggested that SCI-induced bone changes observed in the rat model were not solely attributable to bone loss, but also to suppressed bone growth. No tissue mineral density differences were observed at any time-point, suggesting that decreased whole-bone mechanical properties were primarily the result of changes to the spatial distribution of bone.

CONCLUSION

Young SCI rat trabecular bone changes resemble those observed clinically in adult and paediatric SCI, while cortical bone changes resemble paediatric SCI only.

Pediatric spinal cord injury rehabilitation: A protocol for an international multicenter project (SINpedSCI)

PURPOSE

Children and adolescents (<18 years old) who sustain a spinal cord injury (SCI) should ideally be managed in specialized rehabilitation services. This project aims to describe the organization of pediatric SCI in ten rehabilitation units in seven countries and to qualitatively explore psychosocial aspects of adolescents living with SCI.

METHODS

A multicenter cross-sectional project is planned, using quantitative (web survey) and qualitative (interview) methods in ten rehabilitation units from Norway, Sweden, United States, Israel, PR China, Russia and Palestine. Individual interviews will be conducted with ≥20 adolescents aged 13-17 years at least 6 months' post rehabilitation.

RESULTS

Units involved will be described and compared, according to funding, attachment to an acute SCI unit, catchment area, number of beds, admittance and discharge procedures, availability of services, staff/patient ratio, content and intensity of rehabilitation programs, length of stay, measurement methods, follow-up services, health promotion services, and pediatric SCI prevention acts. The semi-structured interview guide will include experiences from acute care and primary rehabilitation, daily life, school, contact with friends, leisure time activities, peers, physical and psychological health, and the adolescents' plans for the future.

CONCLUSION

Based on the present protocol, this project is likely to provide new insight and knowledge on pediatric SCI rehabilitation and increase the understanding of pediatric SCI in adolescents and their families internationally.

Stiffness of the Masseter Muscle in Children-Establishing the Reference Values in the Pediatric Population Using Shear-Wave Elastography

In children, the quality and muscle function are altered in many pathologic conditions, including temporomandibular disorders. Although several methods have been used to evaluate muscle tonus, none became a golden standard. Moreover, the masseter muscle characteristics in children have not been investigated to date. This study aimed to measure the stiffness of the masseter muscle using shear-wave elastography in healthy children. We enrolled 30 healthy children (mean age 10.87 ± 3.38 years). The stiffness of masseter muscles was measured with shear wave elastography. Stiffness for the total sample was 6.37 ± 0.77 kPa. A comparison of the measurements did not show significant differences between the right and the left masseter muscles (left—6.47 ± 0.78 kPa; right—6.24 ± 0.76 kPa; p = 0.3546). A significant difference was seen between boys and girls (boys—5.94 ± 0.50 kPa; girls—6.63 ± 0.80; p = 0.0006). Shear-wave elastography is a promising diagnostic tool. It may help to detect changes in the stiffness of the masseter muscle and draw attention to pathological processes within the jaw muscles. Directions for further research shall include determining stiffness values in pathological conditions and the impact of biological and functional factors on the stiffness of the masseter muscle.

American football is the youth sporting activity most commonly associated with acute vertebral fractures

OBJECTIVES

Athletics confer cardiovascular fitness and improved cognitive processing in pediatric populations. However, one risk of sports participation is acute vertebral fracture, an injury with significant morbidity. It is currently unknown which sports represent the highest risk of acute vertebral fracture in pediatric populations. This study seeks to identify the youth sporting activities most commonly associated with acute vertebral fractures presenting to United States (U.S.) emergency departments (EDs).

METHODS

This cross-sectional, retrospective study queries the National Electronic Injury Surveillance System database to report national weighted estimates and demographic characteristics of pediatric patients with acute vertebral fractures presenting to U.S. EDs.

RESULTS

The mean annual incidence of estimated acute vertebral fractures over the study period was 1,672 (C.I. 1,217-2,126). From 2000-2001 (N = 4,030; C.I. 2,934-5,125) to 2016-2017 (N = 2,559; C.I. 1,681-3,438), there was no significant change in the estimated rate of sports-related acute vertebral fractures in pediatric patients (p = 0.09). American football was identified as the sport most frequently associated with acute vertebral fractures (23.4%; C.I. 17.6-29.3%). We found no appreciable change in the rate of football-related acute vertebral fractures over time, with 48.2% (C.I. 37.3-59.0%) occurring from 2000 to 2008 and 51.8% (C.I. 41.0-62.7%) from 2009 to 2017.

CONCLUSIONS

While sports-related acute vertebral fractures remain rare injuries in pediatric populations, we identify youth football as the sport associated with the highest risk of such injuries. Despite decreasing football participation rates over our study period, the annual incidence of football-associated acute vertebral fractures has not exhibited a proportional decline. Our findings raise concern that the relative risk of acute vertebral fracture associated with youth football has not significantly decreased over time. Elimination of dangerous tackling technique, improvement in helmet fit and technology, and availability of on-site medical care may contribute to decreased estimates in the future.

Adult sports-related traumatic spinal injuries: do different activities predispose to certain injuries?

OBJECTIVE

Sports injuries are known to present a high risk of spinal trauma. The authors hypothesized that different sports predispose participants to different injuries and injury severities.

METHODS

The authors conducted a retrospective cohort analysis of adult patients who experienced a sports-related traumatic spinal injury (TSI), including spinal fractures and spinal cord injuries (SCIs), encoded within the National Trauma Data Bank from 2011 through 2014. Multiple imputation was used for missing data, and multivariable linear and logistic regression models were estimated.

RESULTS

The authors included 12,031 cases of TSI, which represented 15% of all sports-related trauma. The majority of patients with TSI were male (82%), and the median age was 48 years (interquartile range 32-57 years). The most frequent mechanisms of injury in this database were cycling injuries (81%), skiing and snowboarding accidents (12%), aquatic sports injuries (3%), and contact sports (3%). Spinal surgery was required during initial hospitalization for 9.1% of patients with TSI. Compared to non-TSI sports-related trauma, TSIs were associated with an average 2.3-day increase in length of stay (95% CI 2.1-2.4; p < 0.001) and discharge to or with rehabilitative services (adjusted OR 2.6, 95% CI 2.4-2.7; p < 0.001). Among sports injuries, TSIs were the cause of discharge to or with rehabilitative services in 32% of cases. SCI was present in 15% of cases with TSI. Within sports-related TSIs, the rate of SCI was 13% for cycling injuries compared to 41% and 49% for contact sports and aquatic sports injuries, respectively. Patients experiencing SCI had a longer length of stay (7.0 days longer; 95% CI 6.7-7.3) and a higher likelihood of adverse discharge disposition (adjusted OR 9.69, 95% CI 8.72-10.77) compared to patients with TSI but without SCI.

CONCLUSIONS

Of patients with sports-related trauma discharged to rehabilitation, one-third had TSIs. Cycling injuries were the most common cause, suggesting that policies to make cycling safer may reduce TSI.

The Influence of Sex on Upper Extremity Joint Dynamics in Pediatric Manual Wheelchair Users With Spinal Cord Injury

INTRODUCTION

Manual wheelchair propulsion is a physically demanding task associated with upper extremity pain and pathology. Shoulder pain is reported in over 25% of pediatric manual wheelchairs users, and this number rises over the lifespan. Upper extremity biomechanics in adults has been associated with shoulder pain and pathology; however, few studies have investigated upper extremity joint dynamics in children. Furthermore, sex may be a critical factor that is currently unexplored with regard to pediatric wheelchair mobility.

OBJECTIVES

To investigate differences in upper extremity joint dynamics between pediatric male and female manual wheelchair users with spinal cord injury (SCI) during wheelchair propulsion.

METHODS

Novel instrumented wheelchair hand-rims synchronized with optical motion capture were used to acquire upper extremity joint dynamics of 20 pediatric manual wheelchair users with SCI (11 males, 9 females). Thorax, sternoclavicular, acromioclavicular, glenohumeral, elbow, and wrist joint kinematics and kinetics were calculated during wheelchair propulsion. Linear mixed models were used to assess differences between sexes.

RESULTS

Females exhibited significantly greater peak forearm pronation (p = .007), normalized wrist lateral force (p = .03), and normalized elbow posterior force (p = .04) than males. Males exhibited significantly greater peak sternoclavicular joint retraction (p < .001) than females. No significant differences between males and females were observed for the glenohumeral joint (p > .012).

CONCLUSION

This study found significant differences in upper extremity joint dynamics between sexes during manual wheelchair propulsion. Our results underscore the importance of considering sex when evaluating pediatric wheelchair mobility and developing comprehensive wheelchair training interventions for early detection and prevention of upper extremity pain and pathology.

Protocol for developing a healthcare transition intervention for young people with spinal cord injuries using a participatory action research approach

INTRODUCTION

While healthcare transition (HCT) interventions are recognised as an important area in paediatric rehabilitation, there has been limited research focusing on young people with spinal cord injuries (SCI). In this study, researchers will collaborate with young people with SCI and their parents/caregivers to develop, implement and evaluate the feasibility and acceptability of a HCT intervention aimed at supporting young people with SCI during their transition from paediatric to adult healthcare services.

METHODS AND ANALYSIS

A participatory action research (PAR) approach will be used to co-develop the HCT intervention with young people with SCI aged 14-25 years and their parents/caregivers. Three phases will be conducted to address the five objectives of this study. Phase 1 will use semi-structured interviews to explore young people and parent/caregivers' experiences of HCT. In Phase 2a, both young people and parent/caregivers will be co-researchers. They will be included in the analysis of the interviews and will be asked to participate in co-design workshops to inform the development of a prototype HCT intervention. In Phase 2b, using focus groups, feedback on the prototype HCT intervention will be collected. In Phase 3, the refined prototype HCT intervention will be implemented, and young people with SCI and parent/caregivers will evaluate the feasibility and acceptability of the HCT intervention in semi-structured interviews. A reference group, including stakeholders and end users, will be consulted at different time points.

ETHICS AND DISSEMINATION

The study has received ethics approval from Western Sydney University Human Research and Ethics Committee (H14029). The researcher will use the results of this study as chapters in a thesis to obtain a Doctor of Philosophy degree. The findings will be disseminated via publication in peer-reviewed journals and will be presented at local, national or international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12621000500853.

Traumatic Anterior L4 Fracture Dislocation With Iliac Artery Compression in a 6-Year-Old Patient: A Case Report

CASE

A six-year-old Caucasian boy sustained an L4 anterior fracture dislocation with cauda equina transection at L3/L4 level with L4 vertebral body compression of the left common iliac artery after a single motor vehicle accident. He was treated with emergent open reduction and pedicle screw fixation with return of left common iliac patency. This was followed by multiple bowel resections on postadmission day 3.

CONCLUSION

Anterior spinal fracture dislocations in pediatric patients are rare, caused by high-energy collisions, and are often complicated by multiple traumatic injuries, including vascular and neurological compromise that necessitate emergent intervention.

Trem1 mediates neuronal apoptosis via interaction with SYK after spinal cord ischemia-reperfusion injury

OBJECTIVE

This research aimed to study the impact and regulatory mechanism of Trem1 in spinal cord ischemia-reperfusion injury (SCIRI).

METHOD

Temporary aortic cross clamp followed by reperfusion was used to establish SCIRI mice model. Mice motion function was estimated by Basso, Beattie, Bresnahan (BBB) score. Spinal cord infract zone was analyzed by HE and TUNEL staining. High throughput sequencing was performed to explore potential target for SCIRI. N2a cells were used to simulate the pathophysiological process of SCIRI in vitro with oxygen-glucose-serum deprivation/restoration (OGSD/R). RT-PCR and Western blot were token to determine mRNA and protein expression levels. Knockdown of Trem1 was performed with siRNA transfection in vitro and shRNA adenovirus injection in vivo. The relationship between Trem1 and SYK was analyzed by immunoprecipitation and immunofluorescence.

RESULT

We observed that neuronal apoptosis of spinal cord was aggravated after SCIRI. Trem1 expression was dramatically upregulated as shown by high throughput sequencing, RT-PCR and Western blot results. Furthermore, Trem1 triggered apoptosis of N2a cells induced by OGSD/R, and knockdown of Trem1 by siRNAs blocked apoptosis via PI3K/AKT and NF-κB signaling pathway by interacting with SYK. In addition, we found that intrathecal injection of adenovirus with Trem1 shRNA could downregulate SYK and inhibit neuron apoptosis caused by SCIRI in vivo.

CONCLUSION

Trem1 interacts with SYK and mediates neuronal apoptosis via the PI3K/AKT and NF-κB signaling pathway. Trem1 may be a therapeutic candidate for patients with SCIRI.

Psychiatric Evaluation and Management in Pediatric Spinal Cord Injuries: a Review

PURPOSE OF REVIEW

To summarize current key recommendations in the evaluation and management of mental health disorders associated with spinal cord injuries (SCI) among pediatric patients, based on a review of recent evidence-based literature and clinical experience.

RECENT FINDINGS

Anticipating potential mental health risks among youth with SCI and implementing early multidisciplinary management improves physical and mental health outcomes. When caregivers of youth with SCI model healthy coping strategies, it promotes healthy coping strategies in patients themselves. Peer mentor programs can be instrumental in patient adjustment, improve mental health, and aid in recovery. Pediatric SCI is particularly impactful on a child's development and individuation. Early involvement of a mental health team while in the hospital can help with the initial adjustment period and address psychiatric concerns that might interfere with recovery. The transition from the hospital to home is a period of vulnerability for individuals with SCI.

Management of neurogenic bladder dysfunction in children update and recommendations on medical treatment

INTRODUCTION

Defective closure of the neural tube affects different systems and generates sequelae, such as neurogenic bladder (NB). Myelomeningocele (MMC) represents the most frequent and most severe cause of NB in children. Damage of the renal parenchyma in children with NB acquired in postnatal stages is preventable given adequate evaluation, follow-up and proactive management. The aim of this document is to update issues on medical management of neurogenic bladder in children.

MATERIALS AND METHODS

Five Pediatric Urologists joined a group of experts and reviewed all important issues on "Spina Bifida, Neurogenic Bladder in Children" and elaborated a draft of the document. All the members of the group focused on the same system of classification of the levels of evidence (GRADE system) in order to assess the literature and the recommendations. During the year 2020 the panel of experts has met virtually to review, discuss and write a consensus document.

RESULTS AND DISCUSSION

The panel addressed recommendations on up to date choice of diagnosis evaluation and therapies. Clean intermittent catheterization (CIC) should be implemented during the first days of life, and antimuscarinic drugs should be indicated upon results of urodynamic studies. When the patient becomes refractory to first-line therapy, receptor-selective pharmacotherapy is available nowadays, which leads to a reduction in reconstructive procedures, such as augmentation cystoplasty.

Neonatal Rats Exhibit a Predominantly Anti-Inflammatory Response following Spinal Cord Injury

It has been reported that children may respond better than adults to a spinal cord injury (SCI) of similar severity. There are known biomechanical differences in the developing spinal cord that may contribute to this "infant lesion effect," but the underlying mechanisms are unknown. Using immunohistochemistry, we have previously demonstrated a different injury progression and immune cell response after a mild thoracic contusion SCI in infant rats, as compared to adult rats. Here, we investigated the acute inflammatory responses using flow cytometry and ELISA at 1 h, 24 h, and 1 week after SCI in neonatal (P7) and adult (9 weeks) rats, and locomotor recovery was examined for 6 weeks after injury. Adult rats exhibited a pronounced pro-inflammatory response characterized by neutrophils and M1-like macrophage infiltration and Th1 cytokine secretion. Neonatal rats exhibited a decreased pro-inflammatory response characterized by a higher proportion of M2-like macrophages and reduced Th1 cytokine responses, as compared to adults. These results suggest that the initial inflammatory response to SCI is predominantly anti-inflammatory in very young animals.

Increased cerebral integrity metrics in poliomyelitis survivors: putative adaptation to longstanding lower motor neuron degeneration

BACKGROUND

Post-polio syndrome (PPS) has been traditionally considered a slowly progressive condition that affects poliomyelitis survivors decades after their initial infection. Cerebral changes in poliomyelitis survivors are poorly characterised and the few existing studies are strikingly conflicting.

OBJECTIVE

The overarching aim of this study is the comprehensive characterisation of cerebral grey and white matter alterations in poliomyelitis survivors with reference to healthy- and disease-controls using quantitative imaging metrics.

METHODS

Thirty-six poliomyelitis survivors, 88 patients with ALS and 117 healthy individuals were recruited in a prospective, single-centre neuroimaging study using uniform MRI acquisition parameters. All participants underwent standardised clinical assessments, T1-weighted structural and diffusion tensor imaging. Whole-brain and region-of-interest morphometric analyses were undertaken to evaluate patterns of grey matter changes. Tract-based spatial statistics were performed to evaluate diffusivity alterations in a study-specific whiter matter skeleton.

RESULTS

In contrast to healthy controls, poliomyelitis survivors exhibited increased grey matter partial volumes in the brainstem, cerebellum and occipital lobe, accompanied by increased FA in the corticospinal tracts, cerebellum, bilateral mesial temporal lobes and inferior frontal tracts. Polio survivors exhibited increased integrity metrics in the same anatomical regions where ALS patients showed degenerative changes.

CONCLUSIONS

Our findings indicate considerable cortical and white matter reorganisation in poliomyelitis survivors which may be interpreted as compensatory, adaptive change in response to severe lower motor neuron injury in infancy.

Superiority of thoracolumbar injury classification and severity score (TLICS) over AOSpine thoracolumbar spine injury classification for the surgical management decision of traumatic spine injury in the pediatric population

PURPOSE

Thoracolumbar fractures are the most common kind of spine injury in children. Several types of spine injury can occur, and for this reason, treatment algorithms have been put in place for the management of these patients. At present, the thoracolumbar injury classification and severity score system (TLICS) and the thoracolumbar AOSpine injury score (AOSpine score) aimed at providing treatment recommendations. We aimed to assess the reliability, in children, of the TLICS scoring and AOSpine scoring systems, and to define the superiority of one of the methods of scoring, to spread its use in routine clinical management in the pediatric spine trauma.

METHODS

A retrospective chart review of consecutive children admitted to a Level 1 trauma center for traumatic thoracolumbar fractures, between 2006 and 2019, was performed. We compared the management we performed in clinical practice in children with spine trauma, to the decisional algorithms based on the TLICS and AOSpine scores. According to these scores, surgical treatment should be performed when the TLICS score ≥ 5 and the AOSpine score > 5; and surgical or conservative treatment was considered reasonable when the TLICS score = 4 and the AOSpine score = 4 or 5. Surgical indications were based on the clinical status, the anatomy of the fracture, and the risk of sagittal imbalance of the growing spine.

RESULTS

Fifty-four patients met the inclusion criteria. We demonstrated that both the AOSpine score and the TLICS scores had a significant correlation for surgical management decision of spine trauma (p < 0.0001). We found a high concordance between surgical decision making in the pediatric clinical practice and the TLICS score. In our pediatric cohort, there were significantly more patients with TLICS ≥ 5 (n = 47, 87%) than with AOSpine score > 5 (n = 26, 46%, p < 0.0001). There were significantly more patients with TLICS ≥ 4 (n = 53, 98%), than with AOSpine score ≥ 4 (n = 42, 77%, p = 0.001). ConclusionsThe TLICS score was significantly more appropriate than the AOSpine score, for the surgical treatment decision in children, especially when considering the future risk of sagittal imbalance.

Rehabilitation of a child with a complicated aneurysmal bone cyst

An aneurysmal bone cyst (ABC) is a benign lesion often found in long bones. Almost one third of ABCs are secondary to primary tumors. When found in the spine, ABCs can cause insidious back pain and, in rare cases, neurological deficits. This case will discuss an adolescent female who acquired a non-traumatic spinal cord injury (NTSCI) as a result of complications from an aneurysmal bone cyst. Treatment consisted of surgical removal of the cyst, laminectomy, corpectomy, and fusion of the thoracic spine. Following surgical intervention, the child spent several weeks in an acute inpatient pediatric rehabilitation facility. Goal oriented outpatient services facilitated further recovery and led to near complete resolution of symptoms associated with non-traumatic spinal cord injury. Contemporary and clinically oriented child and family interventions are essential in successful rehabilitation of children with NTSCI as a result of ABCs.

Contribution of Trunk Muscles to Upright Sitting with Segmental Support in Children with Spinal Cord Injury

To investigate and compare trunk control and muscle activation during uncompensated sitting in children with and without spinal cord injury (SCI). Static sitting trunk control in ten typically developing (TD) children (5 females, 5 males, mean (SD) age of 6 (2)y) and 26 children with SCI (9 females, 17 males, 5(2)y) was assessed and compared using the Segmental Assessment of Trunk Control (SATCo) test while recording surface electromyography (EMG) from trunk muscles. The SCI group scored significantly lower on the SATCo compared to the TD group. The SCI group produced significantly higher thoracic-paraspinal activation at the lower-ribs, and, below-ribs support levels, and rectus-abdominus activation at below-ribs, pelvis, and no-support levels than the TD group. The SCI group produced significantly higher lumbar-paraspinal activation at inferior-scapula and no-support levels. Children with SCI demonstrated impaired trunk control with the ability to activate trunk muscles above and below the injury level.

Football (soccer)-related spinal cord injury-reported cases from 1976 to 2020

STUDY DESIGN

An analysis of reported cases.

OBJECTIVES

To analyze the existing data on soccer (international football)-related spinal cord injury (SCI).

SETTING

Cases of soccer (international football)-related SCI that were reported globally.

METHODS

PubMed/MEDLINE, EMBASE, and online news publication databases were searched.

RESULTS

Fourteen cases of football-related SCI that occurred between 1976 and 2020 were found. Average age at the time of injury was 19 and 86% of individuals were males. Eight of 14 individuals had vertebral fracture/dislocation, whereas two individuals had concomitant traumatic brain injury. Neurologically, 54% had tetraplegia, 39% had paraplegia, and 8% each suffered from hemiplegia and sensory deficit. Two cases could regain ability to walk with orthosis and four had full mobility with "Return to Play" (RTP). The mortality was 14%.

CONCLUSIONS

Younger males were most commonly affected. The most common etiology, vertebral level of injury, and neurological manifestation was fall, cervical spine, and tetraplegia respectively. More than 50% of the individuals with football-related SCI were able to walk or RTP after rehabilitation. Further studies are required to establish universal RTP criteria and formulate preventive measures.

Multiple-level cervical spine trauma in children: Case report and literature review

Spinal trauma is rare in children, but when it occurs, trauma of the cervical spine corresponds to 60%–80% of all cases. The most common causes of pediatric cervical spine injuries are automobile accidents, sports activities, and leisure-related accidents. Herein we report a surgically-treated case of cervical spine trauma with fractures of multiple vertebrae. A 12-year-old female victim of a high fall (from a tree) was admitted to the emergency room with neck pain and weakness in all the limbs. On examination, she was conscious, breathing spontaneously, with grade-4 tetraparesis, and preserved sphincter control. Cervical spine computed tomography (CT) revealed a burst fracture of the C4 body with retropulsion into the spinal cord and fractures of the C5 body and posterior elements of C2, C3, and C4. Cervical spine magnetic resonance imaging (MRI) revealed a hypersignal of the spinal cord from C3 to C6 in T2, indicating contusion. Because no signs of posterior spine instability (ligament lesions) were noted on MRI, we decided to perform a C3–C5 anterior arthrodesis with C4 corpectomy and autologous (iliac) graft placement. The patient had a good postoperative evolution. Furthermore, the patient had no motor deficit, but due to the other fractures in the spine, we chose to keep the cervical collar for 3 months and followed-up on an outpatient basis. Although spinal trauma is less frequent in children than in adults, children can have severe cervical spine injuries (multiple fractures with spinal contusion), and then surgery plays a key role in stabilizing the spine and decompressing the spinal cord to avoid sequelae.

Analysis of Human-Exoskeleton System Interaction for Ergonomic Design

OBJECTIVE

Lower-limb exoskeleton systems are defined as gait training or walking-assisting devices for spinal cord injury or hemiplegic patients. Crutches, straps, and baffles are designed to protect subjects from falling. However, skin abrasions occur when the interaction forces are too large. In this study, the interaction forces between the human body and an exoskeleton system named the AIDER were measured to confirm whether the design was ergonomic.

BACKGROUND

The AIDER system is a wearable lower-limb exoskeleton. It secures a subject by binding on the waist, thighs, shanks, and feet.

METHOD

Eight healthy subjects participated in the study. The interaction forces of the waist strap, thigh baffles, shank baffles, and crutch handles were measured by pressure sensors. Ten repetitions were completed in this study. After one repetition, custom comfort questionnaires were completed by the subjects.

RESULTS

Although a few of the peak values of the maximum intensities of pressure between the hands and crutch handles reached the minimum value of the pain-pressure threshold (PPT), the average pressure intensities were much smaller than the PPT value.

CONCLUSIONS

The results indicated that the mechanical structure and control strategy of the AIDER must be improved to be more ergonomic in the future.

Morbidity after traumatic spinal injury in pediatric and adolescent sports-related trauma

OBJECTIVE

Sports injuries present a considerable risk of debilitating spinal injury. Here, the authors sought to profile the epidemiology and clinical risk of traumatic spinal injuries (TSIs) in pediatric sports injuries.

METHODS

The authors conducted a retrospective cohort analysis of pediatric patients who had experienced a sports-related TSI, including spinal fractures and spinal cord injuries, encoded in the National Trauma Data Bank in the period from 2011 to 2014.

RESULTS

Included in the analysis were 1723 cases of pediatric sports-related TSI, which represented 3.7% of all pediatric sports-related trauma. The majority of patients with TSI were male (81%), and the median age was 15 years (IQR 13-16 years). TSIs arose most often from cycling accidents (47%) and contact sports (28%). The most frequently fractured regions were the thoracic (30%) and cervical (27%) spine. Among patients with spinal cord involvement (SCI), the cervical spine was involved in 60% of cases.The average length of stay for TSIs was 2 days (IQR 1-5 days), and 32% of the patients required ICU-level care. Relative to other sports-related trauma, TSIs without SCI were associated with an increased adjusted mean length of stay by 1.8 days (95% CI 1.6-2.0 days), as well as the need for ICU-level care (adjusted odds ratio [aOR] 1.6, 95% CI 1.3-1.9). Also relative to other sports-related trauma, TSIs with SCI had an increased length of stay by 2.1 days (95% CI 1.8-2.6 days) and the need for ICU-level care (aOR 3.6, 95% CI 2.6-4.8).TSIs without SCI were associated with discharge to or with rehabilitative services (aOR 1.7, 95% CI 1.5-2.0), as were TSIs with SCI (aOR 4.0, 95% CI 3.2-4.9), both relative to other sports-related trauma. Among the patients with TSIs, predictors of the need for rehabilitation at discharge were having a laminectomy or fusion, concomitant lower-extremity injury, head injury, and thoracic injury. Although TSIs affected 4% of the study cohort, these injuries were present in 8% of patients discharged to or with rehabilitation services and in 17% of those who died in the hospital.

CONCLUSIONS

Traumatic sports-related spinal injuries cause significant morbidity in the pediatric population, especially if the spinal cord is involved. The majority of TSI cases arose from cycling and contact sports accidents, underscoring the need for improving education and safety in these activities.

Clinical clearance and imaging for possible cervical spine injury in children in the emergency department: A retrospective cohort study

OBJECTIVES

While cervical spine injuries (CSIs) are rare in the paediatric population, presentations to EDs with possible neck injuries are common. Based on a lack of Australian data we set out to determine how many possible injuries are clinically cleared, what imaging is used on the remainder and the incidence and characteristics of confirmed paediatric CSIs.

METHODS

We undertook a retrospective electronic medical record review of children <18 years with potential CSIs at a large tertiary paediatric trauma centre in Victoria, Australia over a 12 month period (annual census 87 000). For possible injuries we extracted key epidemiologic, imaging and short-term outcome data.

RESULTS

During the study period, a total of 617 patients with potential neck injuries were seen in the ED (617/87 000, 0.7%). The median age was 11 years. The most common mechanisms of injury were falls (41%), motor vehicle injuries (28%) and sports-related injuries (24%). Four hundred and fourteen of 617 (67%) underwent neck imaging (345/414, 83% plain radiograph; 100/414, 24% computed tomography; 7/414, 1.6% magnetic resonance imaging). Twenty-three of 617 (4.1%) had radiologically documented CSIs. Two required operative interventions for their neck injuries.

CONCLUSION

While two-thirds of children with potential CSIs undergo radiological evaluation, actual injuries are rare (<4%). These data suggest that there is a potential for improved targeting of cervical spine imaging for trauma. The development of a clinical decision tool may help reduce neck radiography.