Spinal cord infarction due to minor trauma in children

Anterior Spinal Artery Syndrome in a Patient With Multilevel Cervical Disc Disease: A Case Report

Anterior spinal artery syndrome (ASAS) is a rare form of spinal cord infarction, making its incidence and prevalence difficult to determine. We present the case of a 60-year-old woman with multiple vascular risk factors who experienced a sudden onset of severe lower limb weakness, raising immediate concerns about spinal cord ischemia. Diagnostic evaluations confirmed ASAS, although the exact cause and mechanism of her spinal cord infarction remained undetermined. The potential presence of significant cervical disc disease suggests fibrocartilaginous embolism (FCE) as a possible underlying mechanism, despite the lack of direct evidence. This case underscores the importance of clinical awareness and timely intervention in patients with similar symptoms and vascular risk factors. Early recognition, cause identification, and appropriate management are crucial for improving outcomes in spinal cord ischemia, guiding specific treatment strategies, and potentially preventing recurrence.

Pediatric spinal injuries- current concepts

Spinal injuries in children contribute to the highest mortality and morbidity among all pediatric injuries. Fortunately, these injuries are a rare clinical entity but pose a difficulty in diagnosis due to challenges in neurological evaluation of a child and varied radiological presentation. Anatomical and biomechanical aspects of developing musculoskeletal system, relative plasticity of the pediatric spine make children vulnerable to spine injuries. Though motor vehicle collisions are common, children also suffer non-accidental trauma, falls and sports injuries. More chances of cervical spine involvement, higher susceptibility of spinal cord to tensile forces and associated multisystem injuries result in devastating consequences in children compared to adults. Injuries like SCIWORA, vertebral apophyseal injuries, birth-related spinal cord injuries are more specific injuries in pediatric age group. A vigilant clinical, neurological and radiological evaluation is mandatory in all children with suspected spinal injuries. Normal radiological features like ossification centers, pseudosubluxation and physiological vertebral wedging should be carefully noted as they could be misinterpreted as injuries. While CT scans help in better understanding of the fracture pattern, Magnetic Resonance Imaging in children is beneficial especially in detecting SCIWORA and other soft tissue injuries. Management principles of these pediatric spinal injuries are similar to adults. Literature evidences support conservative management in injuries like SCIWORA, unless there is an ongoing spinal cord compression. As in adults, the role of high dose methylprednisolone is still controversial in pediatric spinal cord injuries. Stable spinal injuries can be managed conservatively using orthosis or halo. Instrumentation by both anterior and posterior techniques has been described, but it is challenging due to smaller anatomy and poor implant purchase. In addition to pedicle screw instrumentation, wiring techniques are very beneficial especially in younger children.

Ischemic damage may play an important role in spinal cord injury during dancing

STUDY DESIGN

Retrospective analysis.

SETTING

China Rehabilitation Research Center, Beijing, China.

OBJECTIVE

To explore possible mechanisms underlying spinal cord injury (SCI) in children caused by hyperextension of the spine while dancing.

METHODS

The clinical records of 88 children with SCI (mean age, 5.97 years; age range, 4-10 years) admitted to our hospital from January 1989 to October 2019 were retrospectively reviewed. Computed tomography and magnetic resonance imaging were performed on the day of injury. The time from injury to development of paralysis, as well as post-injury activities were surveyed, while abnormal patterns on images, the range of the involved vertebrae, and the extents of edema and atrophy were assessed.

RESULTS

Among the 88 patients, 6 (6.8%) were unable to move immediately after SCI, while paralysis occurred in 42, 23, and 17 patients at <30, 30-60, and >60 min after SCI, respectively. The neurological level of injury of 84 patients was between T4 and T12. On sagittal T2-weighted images (T2WIs), the longitudinal range of spinal cord edema was more than one vertebral body in 65 patients, while spinal cord atrophy below T8 was found in 40 patients. On axial T2WIs, although three patients had none, long T2 signals were found in the central gray matter of seven patients. Meanwhile, necrosis of the central area combined with the peripheral white matter was observed in 57 patients, while three patients had total involvement on a cross section.

CONCLUSION

Ischemia-related damage, rather than direct trauma to the spinal cord, may play an important role in SCI due to spinal hyperextension during dancing.

Spinal cord infarction in a sick neonate from predominant haemorrhagic aetiology: a case report

INTRODUCTION

Spinal cord injuries in new born infants following a traumatic delivery or umbilical cord catheterisation due to thromboembolism are well known. Cases with atraumatic acute onset of neonatal paraplegia have also been described in preterm babies or babies born small for gestational age with a stormy postnatal course related to ischaemic aetiology. We describe a rare case of infarction of the spinal cord from a predominant haemorrhagic aetiology.

CASE PRESENTATION

A term female baby, first child of unrelated parents, was born by normal vaginal delivery. She had meconium aspiration at birth, leading to severe respiratory distress, requiring neonatal intensive care admission. At 2 weeks, she developed new flaccid paraplegia. MRI scan of the spine showed haemorrhagic infarction of the spinal cord from the level of thoracic inlet, vertebral level C7-T1. A follow-up MRI scan at 11 months revealed severe atrophy of the cord distal to C6. At 3 years of age, she had good upper-limb function, diaphragmatic breathing and flaccid paralysis of lower limbs.

DISCUSSION

In an acutely unwell term infant with symptoms of paralysis or spinal cord damage, haemorrhagic infarction needs to be considered in the differential diagnosis. To our knowledge, this is the first reported case of spinal cord injury in a term infant with a haemorrhagic lesion, and it helps to understand the pathogenesis of nontraumatic insult.

Craniovertebral junction injuries in children. A Review

The craniovertebral junction (CVJ) is the most complex and dynamic region of the cervical spine. The wide range of movements possible at this region makes it vulnerable to injury and instability. The special anatomical features make children more prone to injuries of CVJ than adults where lower cervical spine is involved more frequently. The classical clinical manifestation in CVJ injury patients are pyramidal signs including weakness and spasticity, stigmata of CVJ anomalies (short neck, low hair line, facial or hand asymmetry, high arched palate, ), torticolis and neck movement restriction. The history of transient loss of consciousness or sudden neurological deterioration following minor trauma may be elicited. Most authors advocate conservative management (in form of immobilization) of CVJ injuries in children as is true in adults. Halo vest provides superior immobilization in upper cervical and CVJ injuries and can be used in a child as young as 1 year of age with minimal difficulty. Early surgical intervention, i.e. within 2 weeks of injury include is indicated in injuries that cannot be reduced and stabilized by external means, partial spinal cord injury with progressive neurological deficit and in children with extradural hematoma.

Longitudinally extensive myelopathy in children

When children present with acute myelopathy manifested by sensory, motor, or bowel and bladder symptoms, MRI of the neuraxis with contrast agent is the most important imaging study to obtain. Although occasionally normal, MRI often demonstrates signal abnormality within the spinal cord. Classically, longitudinally extensive transverse myelitis (≥3 vertebral bodies in length) has been described with neuromyelitis optica (NMO), but alternative diagnoses should be considered. This pictorial essay reviews the differential diagnoses that may present with longitudinally extensive spinal cord signal abnormalities. Multiple inflammatory, infectious, vascular, metabolic and neurodegenerative etiologies can present with a myelopathy. Thus, radiologists can assist in the diagnosis by familiarizing themselves with the spectrum of diseases in childhood that result in longitudinally extensive signal abnormalities in the absence of trauma.

Spinal Cord Injury without Radiographic Abnormality (SCIWORA) - Clinical and Radiological Aspects

The acronym SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) was first developed and introduced by Pang and Wilberger who used it to define "clinical symptoms of traumatic myelopathy with no radiographic or computed tomographic features of spinal fracture or instability". SCIWORA is a clinical-radiological condition that mostly affects children. SCIWORA lesions are found mainly in the cervical spine but can also be seen, although much less frequently, in the thoracic or lumbar spine. Based on reports from different authors, SCIWORA is responsible for 6 to 19% and 9% to 14% of spinal injuries in children and adults, respectively. Underlying degenerative changes, including spondylosis or spinal canal stenosis, are typically present in adult patients. The level of spinal cord injury corresponds to the location of these changes. With recent advances in neuroimaging techniques, especially in magnetic resonance imaging, and with increasing availability of MRI as a diagnostic tool, the overall detection rate of SCIWORA has significantly improved.

Central cord syndrome in a 7-year-old boy secondary to standing high jump

Acute traumatic central cord syndrome is commonly associated with major trauma such as falling and motor vehicle crash, but minor or nontraumatic causes are very rare in children. As a consequence, most physicians frequently overlook children presenting with complaints of arm weakness when history of any definite major trauma does not exist, especially in the emergency department. We present the case of a 7-year-old boy who was experiencing weakness in both arms after a standing high jump with tilting his head back in school. He had no history of any definite trauma and no evidence of bone abnormalities on plain radiography and computed tomography of the cervical spine. Magnetic resonance imaging of the cervical spine revealed observable swelling with increased signal intensity at C1 to 4 levels. This case showed a spinal cord injury caused by standing high jump with neck extension alone. Therefore, the physicians have to consider the possibility of spinal cord injury even without any history of major trauma.

Vascular diseases of the spinal cord

Vascular disease affecting the spinal can cause substantial neurologic morbidity. Several vascular spinal cord ailments present as neurologic emergencies, and should thus be recognizable to the practicing neurologist. We review the epidemiology, presentation, management strategies, and prognosis of various pathologies, including infarction, dural arteriovenous fistula, arteriovenous malformation, cavernous malformation, compressive epidural hematoma, vasculitis, and genetic abnormalities.

Spinal cord infarction following minor trauma in children: fibrocartilaginous embolism as a putative cause

Spinal cord infarctions following seemingly innocuous trauma in children are rare, devastating events. In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma. An analysis of the clinical, radiographic, and laboratory features of these cases suggests that thromboembolism of the nucleus pulposus into the spinal cord microcirculation is the likely mechanism. A review of the human and veterinary literature supports this notion. To the authors' knowledge, this is the largest pediatric series of myelopathy due to thromboembolism of the nucleus pulposus reported to date, and it is the first report of this condition occurring in an infant.

Non-traumatic spinal cord ischaemia in childhood - clinical manifestation, neuroimaging and outcome

BACKGROUND

Spinal cord ischaemia is rare in childhood and information on clinical presentation and outcome is scarce.

METHODS

This is a retrospective analysis of eight patients and 75 additional cases from the literature. Data search included: patient's age, primary manifestation, risk factors, neuroimaging and outcome.

RESULTS

Five female and three male patients gave consent to participate. Mean age was 12.5 years (10-15 years). Six patients presented with paraplegia; this was preceded by pain in four. Brown Sequard syndrome and quadriparesis were the two others' presenting condition. Sensation levels were thoracolumbar in seven cases. Bladder dysfunction only or bladder and bowel dysfunction were reported in eight and five patients respectively. Time to maximal symptom manifestation was <12 h in 7/8. Risk factors included surgery, minor trauma, recent infection, and thrombophilia. Mean follow-up was 3.3 years (0.25-6.3 years). Three patients remained wheelchair-dependent and three patients were ambulatory without aid. Bladder function recovered fully in five children. Most affected aspects of quality of life were physical and mental well-being and self-perception. T2-weighted-MR images showed pencil-like hyperintensity (8/8) in sagittal and H-shaped or snake-eyes-like lesion (6/8) in axial views. Analyses of all 83 patients were in congruence with the above results of the study group.

CONCLUSION

Spinal cord ischaemia in childhood presenting with pain, paraplegia, and bladder dysfunction has high morbidity concerning motor problems and quality of life. Acute arterial ischaemic event in children seems similar to adult events with respect to clinical presentation and, surprisingly, also in outcome.

Delayed post-traumatic spinal cord infarction in an adult after minor head and neck trauma: a case report

INTRODUCTION

Delayed post-traumatic spinal cord infarction is a devastating complication described in children. In adults, spinal cord ischemia after cardiovascular interventions, scoliosis correction, or profound hypotension has been reported in the literature. However, delayed spinal cord infarction after minor head trauma has not been described yet.

CASE PRESENTATION

We report the case of a 45-year-old Hispanic man who had a minor head trauma. He was admitted to our hospital because of paresthesias in his hands and neck pain. A radiological workup showed cervical spinal canal stenosis and chronic cervical spondylotic myelopathy. Twelve hours after admission, our patient became unresponsive and, despite full resuscitation efforts, died. The autopsy revealed spinal cord necrosis involving the entire cervical spinal cord and upper thoracic region.

CONCLUSIONS

This case illustrates the extreme fragility of spinal cord hemodynamics in patients with chronic cervical spinal canal stenosis, in which any further perturbations, such as cervical hyperflexion related to a minor head injury, can have catastrophic consequences. Furthermore, the delayed onset of spinal cord infarction in this case shows that meticulous maintenance of blood pressure in the acute post-traumatic period is of paramount importance, even in patients with minimal post-traumatic symptoms.

Anterior spinal artery syndrome in a girl with Down syndrome: case report and literature review

BACKGROUND/OBJECTIVE

Anterior spinal artery syndrome is an extremely rare cause of acute ischemic cord infarction in children. It is caused by hypoperfusion of the anterior spinal artery, leading to ischemia in the anterior two thirds of the spinal cord. The presentation is usually with an acute and painful myelopathy with impaired bladder and bowel control. Pain and temperature sensation below the lesion are lost, whereas vibration and position sense is intact because of the preservation of the posterior columns.

METHODS

Case report.

RESULTS

A 16-year-old girl with Down syndrome presented with urinary retention and acute complete flaccid paralysis of the legs with absent deep tendon and abdominal reflexes. Magnetic resonance imaging showed a signal abnormality in the anterior half of the thoracic cord from T5 to T12, consistent with anterior spinal artery infarction.

CONCLUSIONS

Pediatricians should consider anterior spinal artery syndrome in the child who presents with acute, painful myelopathy. We summarize the etiology, neurological findings and outcomes of 19 children found in the literature with anterior spinal artery syndrome.

Traumatic spinal cord injury: accidental versus nonaccidental injury

A 21-month-old boy with steroid-dependent asthma presented to the emergency room with Glascow Coma Score (GCS) 3 and retinal hemorrhages. He was found to have subdural and subarachnoid hemorrhage on computed tomography plus findings of hypoxic-ischemic encephalopathy (HIE). The caretaker history was thought to be inconsistent with the clinical and imaging features, and the patient was diagnosed with nonaccidental injury (NAI) and "shaken baby syndrome." The autopsy revealed a cranial impact site and fatal injury to the cervicomedullary junction. Biomechanical analysis provided further objective support that, although NAI could not be ruled out, the injuries could result from an accidental fall as consistently described by the caretaker.

Ischemic spinal cord infarction in children without vertebral fracture

Spinal cord infarction in children is a rare condition that is becoming more widely recognized. There are few reports in the pediatric literature characterizing etiology, diagnosis, treatment, and prognosis. The risk factors for pediatric ischemic spinal cord infarction include obstruction of blood flow associated with cardiovascular compromise or malformation, iatrogenic or traumatic vascular injury, cerebellar herniation, thrombotic or embolic disease, infection, and vasculitis. In many children, the cause of spinal cord ischemia in the absence of vertebral fracture is unknown. Imaging diagnosis of spinal cord ischemia is often difficult, due to the small transverse area of the cord, cerebrospinal fluid artifact, and inadequate resolution of magnetic resonance imaging. Physical therapy is the most important treatment option. The prognosis is dependent on the level of spinal cord damage, early identification and reversal of ischemia, and follow-up with intensive physical therapy and medical support. In addition to summarizing the literature regarding spinal cord infarction in children without vertebral fracture, this review article adds two cases to the literature that highlight the difficulties and controversies in the management of this condition.

Cervical spine trauma in children: a review

Injuries of the cervical spine are relatively rare in children but are a distinct clinical entity compared with those found in adults. The unique biomechanics of the pediatric cervical spine lead to a different distribution of injuries and distinct radiographic features. Children younger than 9 years of age usually have upper cervical injuries, whereas older children, whose biomechanics more closely resemble those of adults, are prone to lower cervical injuries. Pediatric cervical injuries are more frequently ligamentous in nature, and children are also more prone to spinal cord injury without radiographic abnormality than adults are. Physical injuries are specific only to children. Radiographically benign findings, such as pseudosubluxation and synchondrosis, can be mistaken for traumatic injuries. External immobilization with a halo brace can be difficult and is associated with a high complication rate because of the thin calvaria in children. Surgical options have improved with the development of instrumentation specifically for children, but special considerations exist, such as the small size and growth potential of the pediatric spine.

Acute arm paresis with cervical spondylosis: three case reports

BACKGROUND

The mild type of anterior spinal artery syndrome (ASAS) is characterized by motor loss with an absent or insignificant sensory deficit due to a disturbance in the blood supply to the anterior horn of the spinal cord. The clinical symptoms of cervical spondylotic amyotrophy (CSA) are motor loss or atrophy with an absent or insignificant sensory deficit or a long tract sign; however, the pathophysiology has not been clarified.

METHODS

Three patients who suffered from palsy of the deltoid and biceps brachii are presented. Magnetic resonance imaging confirmed the intrinsic cord disease as the cause of the paresis. We measured the central motor conduction time (CMCT) and the latencies of the tendon reflex (T waves) of the biceps and triceps and those of the F waves of the abductor pollicis brevis and abductor digiti minimi before, 2 weeks after, and 3 months after starting intravenous injections of prostaglandin E(1) (PGE(1)).

RESULTS

In these 3 cases, restoration of muscle strength began after starting injection of PGE(1). The electrophysiologic diagnosis revealed a disturbance of the motor conduction, in the CMCT and the latencies of the T waves, in the paretic muscle, which is more severe than that in other muscles. The radiological diagnosis suggested damage in the spinal cord. Improvements in the disturbance of the motor conduction and those of symptoms were parallel.

CONCLUSION

From symptomatologic or radiological viewpoints, it is difficult to differentiate CSA from ASAS with cervical spondylosis. This suggests that there have been patients with ASAS whom we have diagnosed as CSA, and we may add administration of PGE(1) to the treatment for the patients with CSA. The present 3 patients showed improvement of muscle strength after starting injections of PGE(1). Although this improvement was measured by an electrophysiologic method, the mechanisms of PGE(1) require further study.

Spinal Cord Injury without Radiographic Abnormality in Children, 2 Decades Later

OBJECTIVE:

Much new research has emerged since1982, when the original description of spinal cord injury without radiographic abnormality (SCIWORA) as a self-contained syndrome was reported. This article reviews new and old data on SCIWORA, from the past 2 decades.

METHODS:

This article reviews what we have learned since 1982 about the unique biomechanical properties of the juvenile spine, the mechanisms of injuries, the profound influence of age on injury pattern and outcome, the magnetic resonance imaging (MRI) features, and management algorithms of SCIWORA.

RESULTS:

The increasing use of MRI in SCIWORA has yielded ample evidence of damage in virtually all nonbony supporting tissues of the juvenile vertebral column, including rupture of the anterior and posterior longitudinal ligaments, intervertebral disc disruption, muscular and interspinal ligament tears, tectorial membrane rupture, and shearing of the subepiphyseal growth zone of the vertebral endplates. These findings provide the structural basis for the postulated “occult instability” in the spine of a patient after SCIWORA. MRI also demonstrated five classes of post-SCIWORA cord findings: complete transection, major hemorrhage, minor hemorrhage, edema only, and normal. These “neural” findings are highly predictive of outcome: patients with transection and major hemorrhage had profoundly poor outcome, but 40% with minor hemorrhage improved to mild grades, whereas 75% with “edema only” attained mild grades and 25% became normal. All patients with normal cord signals made complete recovery.

The large pool of clinical data from our own and other centers also lends statistical power to uphold most of our original assertions regarding incidence, causes of injury, pathophysiology, age-related changes in the malleability of the spine, vectors of deformation, and the extreme vulnerability of young children to severe cord injury, particularly high cervical cord injury. Thoracic SCIWORA has been identified as an important subset, comprising three subtypes involving high-speed direct impact, distraction from lap belts, and crush injury by slow moving vehicles. Computation of the sensitivities of MRI and somatosensory evoked potentials in detecting SCIWORA shows that both tests were normal in 12 to 15% of children with definite, persistent myelopathy; all of these children were nevertheless braced for 3 months because of their clinical syndrome. Children with transient deficits but abnormal MRI and/or somatosensory evoked potentials were also braced, but the 60% with transient deficits and normal MRI and somatosensory evoked potentials were not braced. This is a change from our original policy in 1982 of bracing all children with persistent or transient deficits, brought on by our new MRI and electrophysiology data.

CONCLUSION:

Injury prevention, prompt recognition, use of MRI and electrophysiological verification, and timely bracing of SCIWORA patients remain the chief measures to improve outcome.

Pediatric care report of spinal cord injury without radiographic abnormality (SCIWORA): case report and literature review

STUDY DESIGN

Case report of SCIWORA following trivial trauma in childhood and review of the literature.

OBJECTIVES

To describe a case of 'spinal cord injuries without radiographic abnormality (SCIWORA)', which was diagnosed 2 years after the event, and define its relevance from a differential diagnostic and medico-legal viewpoint.

SETTING

An Austrian neuro-traumatological rehabilitation and workers' insurance appraisal center.

METHODS

A 12-year-old patient is presented who suffered an ischemic spinal lesion of unknown origin on her way home from school. The patient was reinvestigated as part of an insurance appraisal 2 years later. The aim of this investigation was to elucidate the origin of the spinal cord lesion, in particular, whether it was because of accidental trauma or because of a preexisting condition (eg vascular malformation).

RESULTS

SCIWORA due to a trivial trauma was diagnosed during the reinvestigation. This was of importance for the patient because of accident insurance coverage.

CONCLUSION

In children developing a quadroparesis following a minor trauma, spinal cord injury without radiographic abnormality must be considered in the differental diagnosis.

Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing

STUDY DESIGN

A retrospective review of medical records and imaging studies of children diagnosed with spinal cord injury without radiographic abnormality (SCIWORA) or SCIWORA-like symptoms at Children's Hospital of Pittsburgh between 1965 and 1999 was undertaken.

OBJECTIVES

To evaluate the existence of occult segmental spinal instability and a role for bracing as treatment for SCIWORA, we contrasted the Children's Hospital of Pittsburgh experience with literature reports on SCIWORA.

SUMMARY OF BACKGROUND DATA

There is a great deal of confusion and conflicting evidence regarding pediatric SCIWORA in the literature. Previous reports from our institution reported unique findings, including the only description of serious, recurrent SCIWORA in the literature. These findings have frequently been cited as the justification for long-term immobilization in all cases of SCIWORA.

METHODS

All records on patients coded as spinal cord injury without fracture or dislocation (ICD-9 code 952.xx) were reviewed. Children 17 years of age or younger with traumatic spinal cord injury and normal plain radiographic findings were included. Penetrating trauma, infection, or metabolic diseases were excluded.

RESULTS

A total of 189 patients were diagnosed with SCIWORA at our institution over the 35-year review period. These patients differed from those reported in the literature with respect to a higher incidence, older age, less involved neurologic injury, and more low-energy mechanisms, such as sports and falls. There were no cases of a patient with SCIWORA who deteriorated and developed a permanent neurologic deficit after having either recovered or plateaued from an initial SCIWORA. All recurrent SCIWORA recovered to normal neurologic function. Bracing did not demonstrate any benefit in preventing these minor recurrent SCIWORAs.

CONCLUSION

We identified no cases of serious, recurrent SCIWORA at our institution from 1965 to 1999. A case-by-case evaluation is required for the treatment of spinal cord injury without apparent spinal column injury, and bracing is not uniformly indicated.

Upper thoracic spinal cord injury without vertebral bony lesion: a report of two cases

STUDY DESIGN

Case report.

OBJECTIVES

To describe a rarely reported type of upper thoracic spinal cord injury without vertebral bony lesion in two cases with multiple trauma.

SUMMARY OF BACKGROUND DATA

Because it is supported by the stiffness of the rib cage, the upper thoracic spine has greater stability than the cervical and lumbar regions, and thus its fracture or fracture dislocation is less frequent. Nevertheless, when fracture or fracture dislocation of upper thoracic spine occurs, spinal cord involvement and severe concomitant injuries are frequently associated.

METHODS

Two cases who were suspected to have thoracic spinal cord injuries were referred to our emergency center: a 19-year-old girl presented with paraparesis after her motorcycle collided with a truck, and a 63-year-old male involved in an industrial accident presented with paraplegia.

RESULTS

Radiograph and computed tomography scan showed no abnormality or dislocation in the vertebral bodies in these two cases, although the upper thoracic spinal cord injuries were suspected by clinical features. Magnetic resonance images detected abnormal signals, suggesting spinal cord injuries, and these signals each emanated from levels that coincided with the observed clinical features.

CONCLUSIONS

Transient subluxation or displacement might have caused the upper thoracic spinal cord injuries after the support of the rib cages was temporarily lost on application of excessive force, although such findings could not be confirmed by imaging procedures.

Pediatric spine fractures

Children have more elastic soft tissue and more potential for remodeling than adults. Certain injuries are unique to children, including posterior limbus injuries, most cases of spinal cord injury without radiographic abnormalities, and spinal trauma in child abuse. This article discusses the pathomechanics, clinical presentation, treatment, and some of the complications of injuries of the thoracolumbar spine in children.

Prothrombin G20210A mutation in a child with spinal cord infarction

Prothrombin G20210A is a newly described common mutation that is associated with an increased risk of arterial and venous thrombosis. We describe a healthy child heterozygous for this prothrombin mutation who had a spinal cord infarct with no other prothrombotic risk factors.

SCIWORA (spinal cord injury without radiographic abnormality) in infants and children

We review the biomechanics of the pediatric cervical spine and the clinical findings that pertain to SCIWORA (spinal cord injury without radiographic abnormality) in order to provide a more thorough understanding of this pediatric phenomenon of closed spinal trauma with significant neurologic sequelae but without bony injury. The unique hypermobility and ligamentous laxity of the pediatric bony cervical and thoracic spine predispose to a SCIWORA-type injury. In SCIWORA, the unusually elastic biomechanics of the pediatric bony spine allow deformation of the musculoskeletal structures beyond physiologic extremes, permitting direct cord trauma followed by spontaneous reduction of the bony spine. Potential mechanisms of the SCIWORA include hyperextension/flexion, longitudinal distraction, and ischemic injury of the spinal cord.

Delayed central cord syndrome after a handstand in a child: case report

We report a case of a central cord syndrome in a 7 year-old girl. After several handstands, with sudden upper thoracic back pain and weakness of the legs 2 to 3 h later, then rapidly progressive tetraplegia with apnea. Plain X-rays and CT myelography of the cervical spine revealed no abnormalities. Although the initial neurological deficit was severe enough to require the child to be placed on a mechanical ventilator, she recovered to be able to walk on the 24th hospital day. Since the development of a central cord syndrome after handstands is exceptional in a child with a normal cervical spine, we report here briefly.

Spinal cord injury without radiographic abnormality and Chiari malformation

Spinal cord injury without radiographic abnormality and asymptomatic Chiari I malformation have an unusual coincidence. A young boy who had recently fallen from his porch was transferred to the neurosurgery service with a high cervical central cord syndrome. Careful study demonstrated no radiographic abnormality and, although the patient was previously quite well, magnetic resonance imaging revealed Chiari I malformation. Although expectedly uncommon, reports of three other similar cases support a less than independent relationship between these two processes. All four children, each aged 2 years, were premorbidly asymptomatic and were playing when they fell from low elevations; two were on a couch. All were evaluated by primary authorities 12 to 48 hours before definitive admission, and all had normal plain film examinations. Three of the four children suffered injuries in flexion, the fourth in extension. Three realized a 5-minute to 3-hour delay before the onset of symptoms, and three suffered gradual progression of deficit. Magnetic resonance imaging was the most commonly applied and productive diagnostic medium, demonstrating cerebellar ectopia in three of three cases. Two children were surgically treated, and all achieved at least a functional outcome. Similarities among these cases support a common mechanism of injury, and indicate careful counseling in children with asymptomatic Chiari I malformation and consideration of operative decompression in those children with progressive neurological injury and deficit.

Spinal cord infarction associated with primary antiphospholipid syndrome in a young child. Case report

Antiphospholipid antibodies have been reported to occur in ischemic stroke patients, but there have been no previous reports linking these antibodies to spinal cord infarction. A case of spinal cord infarction associated with primary antiphospholipid syndrome in a 6-year-old boy is reported. Magnetic resonance imaging clearly demonstrated marked swelling of the thoracolumbar spinal cord with gadolinium-diethylenetriamine pentaacetic acid enhancement at an acute stage, followed later by cord atrophy. Serological study disclosed positive lupus anticoagulant and immunoglobulin G anticardiolipin antibody. It is suggested that the role of antiphospholipid antibodies as an etiological factor for spinal cord ischemia should be recognized among causes that might have been categorized as either spontaneous spinal cord infarction or myelitis.

Isolated paraplegia from a remote stab wound

A stab wound to the right flank of a 24-year-old man produced immediate paralysis of both legs but spared sensation. Recovery was slow but sufficient to allow walking with a cane. Radicular artery interruption, in combination with systemic hypotension, is presumed to have caused selective watershed infarction of the spinal cord. Strokes of the spinal cord after trauma are rare, and those at a thoracic level usually represent delayed infarctions after pediatric chest or abdominal injuries. Our patient sustained an immediate and highly selective infarction.

Thoracic spinal cord injury without spine fracture in an adult: case report and literature review

The syndrome of traumatic spinal cord injury without spinal column fracture is well known and predominantly involves the cervical spine of children. One case of a thoracic spinal cord injury without bony abnormalities in an adult is reported, and the pertinent literature is reviewed. Although spinal cord injury without radiographic abnormality may exist, such injuries without neuroimaging pathology may not.

Pediatric spinal cord and vertebral column injury

Between January 1, 1970, and December 31, 1988, 179 children (birth to age 16) were treated for spinal cord and/or vertebral column injury by the Neurosurgical Service at the University of Iowa Hospitals and Clinics. Pediatric injuries accounted for 9% of all spinal trauma seen during this period. The mean age was 10.2 years. Sixty-two children were between birth and 8 years of age and 117 were between ages 9 and 16. The cause, distribution, type of injury, and severity of neurological injury varied with age. Neurological outcome was dependent on the severity of the initial neurological injury. Children with complete or severe incomplete myelopathy uniformly remained with severe neurological dysfunction; children with mild to moderate injuries recovered normal or nearly normal neurological function. Surgical versus nonoperative management had no bearing on neurological outcome. Twelve percent of the children with severe spinal cord injuries developed posttraumatic spinal deformity. We conclude that spinal injury patterns differ between preadolescent and older children. Most injuries can be successfully managed with nonoperative therapy. Prognosis is primarily correlated with the severity of the initial neurological insult. Finally, children with severe spinal cord injury must have close, long-term follow-up to monitor the development of posttraumatic spinal deformity.

Quadriplegia after chiropractic manipulation in an infant with congenital torticollis caused by a spinal cord astrocytoma

An infant with congenital torticollis underwent chiropractic manipulation, and within a few hours had respiratory insufficiency, seizures, and quadriplegia. A holocord astrocytoma, with extensive acute necrosis believed to be a result of the neck manipulation, was found and resected. We believe that every child with torticollis, regardless of age, should undergo neurologic and radiologic evaluation before any form of physical treatment is instituted.

[Spinal cord infarction: clinical, electrophysiologic and laboratory diagnosis]

In the international, but more so in the latin-american, medical literature infarction of the spinal cord has been rarely described except in relationship with surgery of the abdominal aorta. The objective of this report is to describe the diagnostic approach including clinical, electrophysiological, imaging and cerebrospinal fluid criteria. With these methods 17 cases were diagnosed between 1982 and 1989, one related to surgery of the abdominal aorta. This series suggests that infarction of the spinal cord is a more common clinical entity than presently considered. Its rarity may be due to a high diagnostic threshold related to the perception that there is no specific therapy.

Spinal injuries in children

We reviewed 47 children with spinal injuries. Three distinct patterns of injury were observed: subluxations and dislocations without a fracture (type 1), spinal cord injury without radiographic abnormality (type 2), and spinal fractures which may be associated with subluxation or dislocation (type 3). The neurological recovery was poor in complete lesions associated with type 2 injuries.

Vascular insufficiency of the cervical cord due to hyperextension of the spine

A patient with acute transverse myelopathy after minor trauma due to hyperextension of the neck is reported. The pattern of neurologic deficit favors the diagnosis of acute central cervical spinal cord syndrome. The proposed causative mechanism is temporary vascular insufficiency of the spinal cord. The architecture of vascular supply of the spinal cord and specific cerebrospinal fluid abnormalities in this patient are compatible with the diagnosis. The differential diagnosis of traumatic vascular spinal cord lesions is discussed.

Acute transverse myelopathy in children

Twenty-three children with acute transverse myelopathy (ATM) are reviewed. Antecedent minor trauma or exercise was reported in 10 patients. Despite a positive history in 7 patients no preceding infection was documented. Two patients had a history of less severe ATM followed by recovery prior to a second more severe episode. The most common initial symptom was back pain and the most prominent clinical signs were weakness, sensory level and sphincter disturbances. Myelography and CT myelography at presentation was performed to exclude a compressive lesion. Spinal cord enlargement was demonstrated in 6 of 21 cases. Magnetic resonance imaging (MRI) of the spinal cord, performed in one patient, showed enlargement of the cord. Poor prognostic features were severity of weakness at the time of maximum deficit and a delayed onset of recovery. Maximum motor recovery occurred at a mean of 6 1/2 months but did not occur in one patient until 1 1/2 years. Normal or good outcome was obtained in 64%.

Recurrent spinal cord injury without radiographic abnormalities in children

Spinal cord injury without radiographic abnormality is a well-known entity in the pediatric age group. Age-related elasticity of the vertebral ligaments as well as immaturity of the osseous structures in the pediatric spine allow momentary subluxation in response to deforming forces. The resultant neurological injuries range from transient dorsal column dysfunction to complete cord transection. Between 1960 and 1985, 42 such injuries were treated at the Children's Hospital of Pittsburgh. Management of these radiographically occult spinal cord injuries consisted of cervical immobilization for 2 months in a hard collar and restriction of contact sports. Recurrent cord injury occurred in eight cases during the 2-month immobilization period. A clearly defined traumatic episode was identified in seven of the eight patients, although in four children the recurrent trauma to the spine was trivial. Five of the children removed their collars briefly before the second injury, and two children incurred reinjury with the hard collar in place. The remaining child was too young for hard-collar immobilization, and recurrent neurological deterioration occurred during sleep. Serial flexion-extension films failed to detect frank instability in any of the eight cases. The children most susceptible to reinjury were those who sustained mild or transient neurological deficits from an initial cord injury and who rapidly resumed normal activities. Radiographically occult spinal instability resulting from the initial injury to the vertebral and paravertebral soft tissues presumably made these children vulnerable to recurrent spinal cord injury, often from otherwise insignificant trauma. During the last 21 months, 12 additional children have been managed with a more stringent protocol combining neck immobilization in a rigid cervical brace for 3 months and restriction of both contact and noncontact sports, together with a major emphasis on patient compliance. With this new protocol, no recurrent cord injuries have been documented.

Pediatric spinal injury: the very young

Maturity of the spine and spine-supporting structures is an important variable distinguishing spinal cord injuries in children from those in adults. Clinical data are presented from 71 children aged 12 years or younger who constituted 2.7% of 2598 spinal cord-injured patients admitted to the authors' institutions from June, 1972, to June, 1986. The 47 children with traumatic spinal cord injury averaged 6.9 years of age and included 20 girls (43%). The etiology of the pediatric injuries differed from that of adult injuries in that falls were the most common causative factor (38%) followed by automobile-related injuries (20%). Ten children (21.3%) had spinal cord injury without radiographic abnormality (SCIWORA), whereas 27 (57%) had evidence of neurological injury. Complete neurological injury was seen in 19% of all traumatic pediatric spinal cord injuries and in 40% of those with SCIWORA. The most frequent level of spinal injury was C-2 (27%, 15 cases) followed by T-10 (13%, seven cases). Upon statistical examination of the data, a subpopulation of children aged 3 years or younger emerged. These very young children had a significant difference in level of injury, requirement for surgical stability, and sex distribution compared to 4- to 12-year-old children.

Traumatic infarction of the spinal cord in children

Infarction of the spinal cord in childhood is rarely due to trauma. During a 15-year period (1971 to 1985), eight children were admitted to The Hospital for Sick Children, Toronto, with a diagnosis of traumatic infarction of the spinal cord. All of these patients had delayed onset of neurological signs varying between 2 hours and 4 days after their initial trauma. No bone abnormalities were seen on plain spine x-ray films. Myelography was carried out in seven of these children and found to be normal in all seven. Six patients who were paraplegic at the time of admission remained permanently paraplegic, but two with incomplete cord signs did show some improvement.

Acute Quadriplegia Following the Use of Progressive Resistance Exercise Machinery

In brief: This case report describes a 26-year-old female fitness instructor in excellent health who suffered the acute onset of permanent quadriplegia only a few minutes after using progressive resistance exercise devices. She began her workday as she usually did-with a light workout of low-resistance exercise that lasted about 20 minutes. The onset of quadriplegia may have been a tragic coincidence or may have been related to her workout in a way that remains unexplained. Several possible causes of her condition, which was diagnosed as spinal apoplexy of an unknown cause, are discussed.