The rehabilitation of children with spinal cord injury

Pediatric spinal cord injury with radiographic abnormality: the Beijing experience

BACKGROUND CONTEXT

Spinal cord injury (SCI) without radiographic abnormality (SCIWORA) is a syndrome that usually occurs in children primarily because of the unique biomechanics of the pediatric spine. We recently found that the histopathological and behavioral effects of SCI with radiographic abnormality (SCIWRA) and SCIWORA are very different from each other in animal models. Although numerous studies were conducted to understand the epidemiological and clinical characteristics of the overall pediatric SCI population and the pediatric SCIWORA population, the characteristics of the pediatric SCIWRA population and their differences from those of the SCIWORA population are poorly understood.

PURPOSE

To describe the epidemiology and clinical outcomes of pediatric patients with SCIWRA and their differences from those with SCIWORA.

STUDY DESIGN/SETTING

Retrospective study.

PATIENT SAMPLE

A total of 47 pediatric SCIWRA patients.

OUTCOME MEASURES

Epidemiological characteristics, injury severities, functional deficits, and management and recovery outcomes.

METHODS

Review of all cases with SCIWRA at Beijing Children's Hospital between July 2007 and December 2019 and comparison between the present data and our previous SCIWORA data.

RESULTS

Of the 187 pediatric SCI patients, 47 had SCIWRA (age: 7.06 ± 3.75 years, male-to-female ratio: 3:2). Main causes of SCIWRA were fall (38%) and traffic accidents (38%). Lesions were often located at multiple levels (62%). Incubation period was 3 ± 18 hours. According to the American Spinal Injury Association impairment scale (AIS), many SCIWRA patients had incomplete impairment (AIS B, 9%; AIS C, 9%; AIS D, 32%). Specifically, many of them had abnormal upper and lower limb muscle powers (55% and 60%), upper and lower limb muscle tones (34% and 49%), sensation (38%), and knee, ankle, and abdominal reflexes (47%, 34%, and 36%). 72% of SCIWRA patients were treated with methylprednisolone, dexamethasone, or both. 81% of them showed neurological improvement before discharge. There was no association between corticosteroid therapy and neurological improvement. Moreover, functional outcomes of their upper and lower limb muscle powers were significantly associated with functional outcomes of their upper and lower limb muscle tones (p < 0.01), respectively. In comparison to the SCIWRA population, the SCIWORA population had a higher ratio of younger and female patients of sports-related thoracic injuries with long incubation period leading to lower-body deficits and complete impairment (p<0.05 or p<0.01). Despite all the differences, their neurological improvement was similar (p>0.05).

CONCLUSIONS

Demographic differences exist in the SCIWRA population. Corticosteroids do not appear to be effective in the different types of pediatric SCI. Limb muscle tone may be used to evaluate the functional status of limb muscle power. The epidemiological and clinical characteristics of SCIWRA and SCIWORA are very different from each other. It is important to formulate tailor-made prevention, evaluation, and management strategies for the pediatric population to optimize the SCI outcomes.

Fourteen-year change in activities of daily living of a quadriplegic, ventilator-managed patient injured by high cervical spinal cord injury during infancy: a case report

Background

Rehabilitation of patients with high cervical spinal cord injury (CSCI) to improve activities of daily living (ADL) is challenging due to severe paralysis. In addition, pediatric patients with CSCI are rare, and literature describing ADL changes as the patient grows are limited. In this case report, we present the long-term change in ADL over time in a girl with severe high CSCI from an injury during infancy.

Case presentation

A 2 years and 6 months old girl, who was injured in a traffic accident, was diagnosed with C3 CSCI, resulting in complete quadriplegia and respiratory paralysis below C3. Thus, she was managed with a ventilator. Rehabilitation for quadriplegia, respiratory dysfunction, and autonomic neuropathy was started on the fifth day after the injury while she was in the intensive care unit. Six months after the injury, the patient was transferred to a hospital. Thereafter, she was discharged with nursing and care guidance provided to her family and environmental changes at home. Afterwards, she continued to acquire skills through writing training using a mouse stick, computer operation training, and electric wheelchair operation training, which enabled her to improve her ADL despite her severe disability. In terms of education, she was able to go through a regular elementary school, a regular junior high school, and then to a senior high school of a support school.

Conclusions

We believe that training that utilizes current technology and changes in the environment that are appropriate for daily life are important for improving the ADL of children with severe CSCI.

Health and LifeDomain ResearchPriorities in Children, Adolescents and Young Adults With Pediatric-Onset Spinal Cord Injury: A National Cross-Sectional Survey in England

Background

Although feedback from people with adult-onset spinal cord injury (SCI) has been considered in developing research programs, little is known about pediatric-onset SCI priorities.

Objectives

To describe the health and life (H&L) domain research priorities of youth with pediatric-onset SCI living in England.

Methods

Youth with pediatric-onset SCI (≥6 months) were recruited from five English rehabilitation centers and invited with their parents/caregivers to complete the age-appropriate surveys designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) collaboration.

Results

A total of 73 surveys were received (32 from participants with SCI and 41 from their parents/caregivers), providing information on 47 individuals with SCI: 2- to 7-year-olds (29.8%), 8- to 12-year-olds (19.2%), 13- to 17-year-olds (17.0%), and 18 to 25-year-olds (34.0%). The top three research priorities reported by parents/caregivers of 2- to 12-year-old and 13- to 25-year-olds were pain (81%/89%), physical function (91%/83%) and health care access (78%/78%). Eighty-nine percent of 8- to 12-year-olds emphasized schooling, peer relationships, and general mood as their research priorities. The top three research priorities for Health or Life domains reported by 13- to 25-year-olds included spasms (95%), pain (91%), pressure injuries (91%), health care access (83%), physical function (78%), and daily personal needs (74%).

Conclusion

Although there should be an emphasis on addressing important life domain issues for 8- to 12-year-olds with SCI, adolescents and young adults mostly prioritized health domain research priorities in addition to health care access. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive SCI research strategy in England for the pediatric population.

Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000

PURPOSE

The purpose of this study is to report the current incidence rates of pediatric spinal cord injury (SCI) in the United States and identify specific high-risk populations as a knowledge basis for improving the prevention and treatment of this traumatic injury.

METHODS

The Kids' Inpatient Database (KID) and the National Trauma Data Bank (NTDB) were used to investigate the etiology of pediatric SCI.

RESULTS

Significant differences in the annual incidence rate of pediatric SCI were found to exist between patient populations stratified by race and sex. African Americans (1.53 cases/100,000 children) exhibit a significantly higher rate of pediatric SCI than native Americans (1.00), Hispanics (0.87), and Asians (0.36), whereas Asians show a significantly lower incidence than all other races. Also, boys (2.79) are more than twice as likely to experience SCI as girls (1.15). The overall incidence of pediatric SCI in the United States is 1.99 cases per 100,000 children. From these data, it is estimated that 1455 children are admitted to US hospitals each year for treatment of SCI. The etiology of pediatric SCI was also investigated, and the major causative factors were identified: motor vehicle accident (56%), accidental fall (14%), firearm injury (9%), and sports injury (7%). Of those children injured in a motor vehicle accident, 67.7% (n = 107) were reported as not wearing a seatbelt. The role of alcohol and drugs was also investigated and found to be involved in 30% (n = 82) of all pediatric SCI cases.

CONCLUSIONS

Using discharge records from a public database, it is possible to identify high-risk demographic groups and activities that predispose a child to SCI. With a more thorough understanding of the etiology of pediatric SCI, clinicians and parents are better equipped to devise measures for prevention and treatment of this injury.

Psychosocial aspects of traumatic spinal cord injury with onset during adolescence: a qualitative study

BACKGROUND/OBJECTIVE

Spinal cord injury (SCI) occurring during adolescence poses additional challenges because of the concurrent age-specific bio-psychosocial development. Full understanding of the psychosocial dimensions of rehabilitation requires exploration of the patient perspective. The objective of this study was to focus on psychosocial factors from the patient perspective in persons who had previously sustained a SCI during early and mid-adolescence (11-15 years of age).

METHODS

Twenty-four of the 28 persons who had sustained a SCI in Sweden from 1985 to 1996 participated in the study. Semistructured interviews were made an average of 10 years after injury. Narratives were analyzed qualitatively according to content analysis.

RESULTS

Parents and peers were found to have formed a crucial network. Parents frequently acted as advocates in interactions with health care providers, as supporters, and as containers of sorrow, frustration, and anger. Peers acted as promoters of activity and identity development. However, health care providers were perceived as not making sufficient use of this network.

CONCLUSIONS

Rehabilitation professionals might be encouraged to increase their knowledge of adolescence medicine to better meet the specific needs and demands of persons in this age group. It is further suggested that parents and peers be considered important partners in the joint rehabilitation effort.

Pediatric spinal cord injury in a subset of European countries

STUDY DESIGN

Postal survey.

SETTING

A total of 19 countries in Europe.

OBJECTIVES

Firstly, to collect information about incidence and systems of care for pediatric spinal cord injury (pedSCI); including prevention, initial care and follow-up in a subset of European countries. Secondly, to initiate a network of involved professionals for exchange of information and development of research and care programs.

METHODS

A short semi-structured questionnaire was sent to respondents working with spinal cord injury (SCI) in 19 countries in Europe.

RESULTS

Only in Portugal and Sweden, is the incidence of pedSCI (fatal injuries included) established, that is 27 children/million children/year and 4.6 children/million children/year, respectively. For the other countries, the estimated incidence of pedSCI (nonfatal injuries) varied from 0.9 to 21.2 children/million children/year in the age group of 0-14 years. Although the incidence varies considerably, pedSCI is rare throughout Europe. The management differs between the countries depending on the age of the child and the local organization of health care.

CONCLUSIONS

The survey confirms that pedSCI is rare. In order to establish high-quality standardized care, further integration of knowledge in this area is needed throughout Europe. The contacts initiated by this survey may be used to create an international network serving as a reference for health professionals, researchers and families, thereby possibly alleviating some of the unwanted variations of care identified in this study.

Pediatric spinal cord injury in Sweden: incidence, etiology and outcome

STUDY DESIGN

Retrospective descriptive study.

OBJECTIVES

To assess incidence, causes and early outcome of traumatic spinal cord injury (SCI) among children in Sweden, thereby identifying high-risk groups and situations as a basis for preventative measures and improved care.

METHODS

Data from population registers, County Habilitation Centers as well as from informal sources were used to estimate the incidence of SCI in Sweden during the years 1985-1996 among children aged 0-15 years. Contacts with the treating hospitals, reviews of medical records and/or personal interviews were used to verify primary data. In total, 92 children were thus identified.

RESULTS

The incidence was found to be 4.6/million children/year (95% CI 3.6-5.5). When excluding prehospital fatalities, the incidence was 2.4 (95% CI 1.8-3.1). The main cause of injury among fatalities was traffic accidents. Associated injuries occurred in 41% of the children. Among survivors (10-15 years), sports-related injuries (43%) were as common a cause as traffic accidents (39%). The survivors were treated in 18 different hospitals.

CONCLUSION

Pediatric SCI in Sweden is rare, presumably because of effective primary prevention. Preventative measures should be further differentiated for each age group of children in accordance with their differing risk profiles. In contrast to the effective preventative measures that have been implemented in Sweden, care of these patients is still too fractionated and decentralized for sufficient specialization to emerge.

Functional improvement after pediatric spinal cord injury

OBJECTIVE

To describe the functional gain (FGain) with pediatric spinal cord injury inpatient rehabilitation and to identify the relationship of various factors to FGain in pediatric spinal cord injury inpatient rehabilitation.

DESIGN

Retrospective chart review of a series of 91 children with spinal cord injury admitted from 1993 to 1998 in a freestanding rehabilitation hospital. Admission and discharge functional status were assessed with the Pediatric Functional Independence Measure (WeeFIM) instrument for children <or=7 yr and the Adult Functional Independence Measure (FIM) instrument for children >7 yr. The outcome measure is the FGain (difference between the discharge and admission functional status).

RESULTS

Significant gains in functional status were observed in all patients. FGain was not significantly related to age, sex, length of inpatient rehabilitation, pathogenesis, or completeness or neurologic level of injury. However, there was a trend for higher FGain for patients with incomplete spinal cord injury and traumatic spinal cord injury.

CONCLUSIONS

Functional improvement occurs with pediatric spinal cord injury inpatient rehabilitation. There is a trend for higher FGain in patients with less severe injury and traumatic injury. The lack of relationship between FGain and length of inpatient rehabilitation suggests that a variety of other factors influence the relationship between FGain and length of inpatient rehabilitation.

Spinal cord injury rehabilitation. 2. Medical complications

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.