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Journal of Neurotrauma
J Neurotrauma. Aug 2011; 28(8): 1515–1524.
PMCID: PMC3143390

Spinal Cord Injury in the Pediatric Population: A Systematic Review of the Literature

Abstract

Spinal Cord Injury (SCI) in the pediatric population is relatively rare but carries significant psychological and physiological consequences. An interdisciplinary group of experts composed of medical and surgical specialists treating patients with SCI formulated the following questions: 1) What is the epidemiology of pediatric spinal cord injury and fractures?; 2) Are there unique features of pediatric SCI which distinguish the pediatric SCI population from adult SCI?; 3) Is there evidence to support the use of neuroprotective approaches, including hypothermia and steroids, in the treatment of pediatric SCI?

A systematic review of the literature using multiple databases was undertaken to evaluate these three specific questions. A search strategy composed of specific search terms (Spinal Cord Injury, Paraplegia, Quadriplegia, tetraplegia, lapbelt injuries, seatbelt injuries, cervical spine injuries and Pediatrics) returned over 220 abstracts that were evaluated and by two observers. Relevant abstracts were then evaluated and papers were graded using the Downs and Black method. A table of evidence was then presented to a panel of experts using a modified Delphi approach and the following recommendation was then formulated using a consensus approach: Pediatric patients with traumatic SCI have different mechanisms of injury and have a better neurological recovery potential when compared to adults. Patients with SCI before their adolescent growth spurt have a high likelihood of developing scoliosis. Because of these differences, traumatic SCI should be highly suspected in the presence of abnormal neck or neurological exam, a high-risk mechanism of injury or a distracting injury even in the absence of radiological anomaly.

Key words: adolescents, children, spinal cord injury, systematic review

Introduction

Spinal cord injury (SCI) before the age of 15 years is a relatively rare occurrence, but it can have important psychological and physiological consequences. Although the exact frequency is unknown, it represents <4% of the overall incidence of SCI annually (National Spinal Cord Injury Statistical Center, 2004). The mechanism of injury, the male:female ratio, and the level of injury are different than in the adult population. The incidence increases rapidly with age, with >30% of injuries occurring between the ages of 17 and 23, and 53% occurring between the ages of 16 and 30. The rate of recovery following SCI in the pediatric population is also thought to be faster.

This systematic review of the literature was undertaken to evaluate three specific questions: 1) What is the epidemiology of pediatric SCI and fractures; 2) Are there unique features of pediatric SCI that distinguish the pediatric SCI population from the adult SCI population; and 3) Is there evidence to support the use of neuroprotective approaches, including hypothermia and steroids, in the treatment of pediatric SCI. The systematic review approach was chosen to review the evidence surrounding these aspects of pediatric SCI because of the paucity (or nonexistence) of good randomized controlled trials for this particular problem.

Methods

A systematic review of the literature of three online databases (EMBASE, Medline, and the Cochrane database) was performed for articles matching the search criteria through June 2009. The search strategy was: (“Spinal Cord Injury” OR “Paraplegia” OR “Quadriplegia” OR “tetraplegia” OR “lapbelt injuries” OR “seatbelt injuries” OR “cervical spine injuries”) AND “Pediatrics” (All mapped to subject heading, including all subheadings, and searched as keywords). This returned a total of 220 abstracts. The search was then limited to English language abstracts and human-subject studies. Case reports of <10 patients were excluded. The abstracts were then read by title and relevant abstracts were reviewed. Full-length articles of interest were then obtained. All articles were then reviewed according to the method of Downs and Black (1998) by two independent reviewers. A total of 48 articles were kept at the end of this process and reviewed, and an evidentiary table was prepared (Table 1). A modified Delphi approach was used in which the questions were submitted to a panel of experts. After careful review of the resulting evidence in the form of evidentiary tables, a recommendation was submitted to a panel of experts and agreement among the panel members was noted. The members of the panel could modify the recommendations until a consensus was obtained.

Table 1.
Evidentiary table

The recommendation that emerged from this process is as follows:

Pediatric patients with traumatic SCI have different mechanisms of injury and have a better neurological recovery potential than adults. Patients with SCI before their adolescent growth spurt have a high likelihood of developing scoliosis. Because of these differences, traumatic SCI should be highly suspected in the presence of abnormal neck or neurological examination, a high-risk mechanism of injury, or a distracting injury, even in the absence of anomaly on plain radiographs.

Data Compilation

The following data were compiled in an evidentiary table: study design, population, treatment or therapeutic measure, outcome measure, study purpose, and key results. The evidentiary table was then used to answer the three study questions.

Results

What is the epidemiology of pediatric spinal cord injury fractures?

A total of five retrospective studies were used to answer this question. Pediatric SCI is relatively rare. In a large retrospective study of the National Pediatric Trauma Registry over a 10-year period, the overall incidence of cervical spine injuries was 1.5% (Patel et al., 2001) In another study, 88 pediatric patients were identified based on the analysis of a database of 1,770 traumatic SCI patients (5%) (Apple et al., 1995). The level of injury differed based on the age category, with C2 lesions occurring in the pre-teen groups, C4 lesions occurring in the teen group, and C4–C5 lesions occurring in the adult group (Apple et al., 1995). In this series, violent etiologies (especially gunshots) accounted for a significant proportion of the pre-teen injuries (19%) compared to adults (12%).

Regarding the mechanism of injury, there appeared to be two distinct mechanisms that affected younger children and adolescents. Motor vehicle accidents (MVA) usually affected younger children whereas adolescents were commonly injured during sporting activities (Brown et al., 2001). In a retrospective study of 103 consecutive cervical spine injuries treated in a single level 1 pediatric trauma center, MVA accounted for 52% of injuries followed by sports injuries (27%) of which 29% were associated with football (Brown et al., 2001) The level of injury was C1 to C4 for 68% of patients, C5 to C7 for 25%, and both in 7%. The mortality rate in this series was 18.5%, occurred in younger children (mean age 5 years), was commonly the result of an MVA (95%) and was most often associated with an upper cervical spine injury (74%). Spinal cord injury without radiological anomaly (SCIWORA) accounted for 43% of injuries. In another study using the National Pediatric Trauma Registry, (Patel et al., 2001) 17% of patients with cervical spine trauma did not show any radiological anomaly, although 50% of patients with SCI show no radiological anomaly.

Most studies report a large predominance of males compared to females (Apple et al., 1995; Bosch et al., 2002; Brown et al., 2001; Carreon et al., 2004; Cirak et al., 2004; Dickman et al., 1991; Wang et al., 2004). All-terrain vehicles (ATVs) are also responsible for a higher injury rate in children than in adults. In a retrospective study of 268 children involved in ATVs accidents, the injury rate per 100 registered ATVs was significantly higher for children (3.41) compared to adults (1.71)(Cvijanovich et al., 2001).

Are there unique features of pediatric SCI, which distinguish the pediatric SCI population from the adult SCI population?

Neurological recovery

Neurological recovery in children with SCI is thought to be better than in the adult population. Several studies have shown good neurological recovery following SCI, with incomplete lesions having the best prognosis (Dickman et al.,1991), although severe complete injuries can also improve over time. In a retrospective review of 30 patients with SCI, Wang and associates (2004) evaluated the neurological injury based on the level of neurological involvement at time of injury. Of the 20 patients with complete injury, 7 died, 7 had no neurological recovery, and 6 improved. Five of these patients eventually gained enough function to become ambulatory. In the subgroup of patients with incomplete lesions (10 patients), 8 patients had neurological improvement. Cervical dislocation had a poor prognosis for neurological recovery (Wang et al., 2004) There are no studies comparing adults and children in terms of recovery and it is therefore difficult to clearly establish if neurological recovery is significantly better in children. The evidence is therefore very slight that neurological recovery is better in the pediatric population.

Scoliosis development

Scoliosis following SCI in children is a common entity especially when the neurological insult occurs at a young age. Apple and associates (1995) showed that scoliosis developed more frequently (23%) in pre-teens (<12 years of age) than in adults (5%). In a retrospective study of 130 children who had sustained SCI between birth and the age of 21 years, Dearolf and associates (1990) showed that 97% of patients injured before the growth spurt developed scoliosis compared to 52% when the injury occurred after the growth spurt.

SCIWORA

SCIWORA remains a recognized entity in the pediatric population although the SCI is usually diagnosed with the use of MRI. In a retrospective study of all children with traumatic spinal injury in a level 1 pediatric center, the incidence of SCIWORA was 6%.(Cirak et al., 2004) In a study by Dare and associates (2002), MRI performed in 17 patients with partial injuries failed to show any neural abnormalities even when performed >72 hours after injury in patients with motor involvement. A high index of suspicion for SCIWORA is important when evaluating patients with sports injuries or or who have been abused, as evidenced by a study by Brown and associates (2001). In this series, 75% of pediatric SCI patients with sports injuries and all patients suffering from child abuse had SCIWORA. The physical examination remains an important component of the diagnostic process, as midline cervical tenderness is the most common physical finding in children with cervical spine injury even in the absence of radiological abnormality (Baker et al., 1999).

Is there evidence to support the use of neuroprotective approaches, including hypothermia and steroids, in the treatment of pediatric SCI?

After a careful review of the available literature, there is no evidence regarding the use of neuroprotective approaches for the treatment of SCI in children.

Discussion

The epidemiological features of pediatric SCI show that these injuries are relatively uncommon and that the mechanism of injury is different depending upon the age at time of injury and compared to the adult population. Neurological recovery appears to be better than in adults (Wang et al., 2004), although large series of cases are rare and no comparative studies between adults and children have so far been undertaken. The evidence is therefore very slight that neurological recovery is better in the pediatric population.

The modified Delphi approach used in this review was done in a stepwise fashion. First, three questions were formulated by a panel of experts. These questions were used to guide the literature review and orient the selection of papers. After careful review of the evidence in the form of evidentiary tables, a recommendation was submitted to a second panel of experts and agreement among the panel members was noted. The recommendation is:

Pediatric patients with traumatic SCI have different mechanisms of injury and have a better neurological recovery potential than adults. Patients with SCI before their adolescent growth spurt have a high likelihood of developing scoliosis. Because of these differences, traumatic SCI should be highly suspected in the presence of abnormal neck or neurological examination, a high-risk mechanism of injury, or a distracting injury, even in the absence of radiological anomaly.

Complete agreement was reached among the expert panel and this recommendation was deemed strong although the evidence available was weak. SCI in the pediatric population remains a catastrophic event and every attempt should be made at decreasing the extent and severity of the injury as well as the complications following the injury. Imaging techniques have improved greatly over the past years making it possible to identify lesions that were not easily distinguishable on plain radiographs a few decades ago. The absence of radiological anomaly does not preclude significant injury.

There was no evidence in the current literature review to support the use of neuroprotective approaches including steroids and hypothermia. The current evidence for steroid use in adults is very weak. A systematic review of the animal literature on the use of corticosteroids showed a positive benefit in only 59% of the studies (Akhtar et al., 2009).

Summary

Pediatric patients with SCI have very different characteristics from their adult counterparts. Neurological recovery seems to be better than in adults. However, patients with SCI before their adolescent growth spurt are at higher risk of developing scoliosis. This systematic review provides the elements to support the proposed guidelines through a modified Delphi approach. The proposed guidelines are meant to help diminish the impact of SCI in the pediatric population.

Author Disclosure Statement

No funds were received for the preparation of this article. Dr. Parent is chair holder of the academic chair for pediatric spinal deformities of CHU Ste-Justine (endowed chair). Dr. Parent has a consulting agreement with Deputy Spine for Education.

References

  • The 2004 Annual Statistical Report for the Model Spinal Cord Injury Care Systems. National Spinal Cord Injury Statistical Center. University of Alabama at Birmingham. 2004.
  • Akhtar A.Z. Pippin J.J. Sandusky C.B. Animal studies in spinal cord injury: a systematic review of methylprednisolone. Alternatives to laboratory animals. ATLA. 2009;37:43–62. [PubMed]
  • Apple D.F. Anson C.A. Hunter J.D. Bell R.B. Spinal cord injury in youth. Clinical Pediatrics. 1995;34:90–95. [PubMed]
  • Baker C. Kadish H. Schunk J.E. Evaluation of pediatric cervical spine injuries. Am. J. Emerg. Med. 1999;17:230–234. [PubMed]
  • Bosch P.P. Vogt M.T. Ward W.T. Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing. Spine. 2002;27:2788–2800. [PubMed]
  • Brown R.L. Brunn M.A. Garcia V.F. Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J. Pediatr. Surg. 2001;36:1107–1114. [PubMed]
  • Carr A.M. Bailes J.E. Helmkamp J.C. Rosen C.L. Miele V.J. Neurological injury and death in all-terrain vehicle crashes in West Virginia: a 10-year retrospective review. Neurosurg. 2004;54:861–867. [PubMed]
  • Carreon L.Y. Glassman S.D. Campbell M.J. Pediatric spine fractures: a review of 137 hospital admissions. J. Spinal Dis. & Tech. 2004;17:477–482. [PubMed]
  • Cirak B. Ziegfeld S. Knight V.M. Chang D. Avellino A.M. Paidas C.N. Spinal injuries in children. J. Pediatr. Surg. 2004;39:607–612. [PubMed]
  • Cvijanovich N.Z. Cook L.J. Mann N.C. Dean J.M. A population-based assessment of pediatric all-terrain vehicle injuries. Pediatrics. 2001;108:631–635. [PubMed]
  • Dare A.O. Dias M.S. Li V. Magnetic resonance imaging correlation in pediatric spinal cord injury without radiographic abnormality. J. Neurosurg. 2002;97:33–39. [PubMed]
  • Davis P.C. Reisner A. Hudgins P.A. Davis W.E. O'Brien M.S. Spinal injuries in children: role of MR. AJNR. 1993;14:607–617. [PubMed]
  • Dearolf W.W. Betz R.R. Vogel L.C. Levin J. Clancy M. Steel H.H. Scoliosis in pediatric spinal cord-injured patients. J. Ped. Orth. 1990;10:214–218. [PubMed]
  • DeVivo M.J. Vogel L.C. Epidemiology of spinal cord injury in children and adolescents. J. Spinal Cord Med. 2004;27:S4–10. [PubMed]
  • Dickman C.A. Zabramski J.M. Hadley M.N. Rekate H.L. Sonntag V.K. Pediatric spinal cord injury without radiographic abnormalities: report of 26 cases and review of the literature. J. Spinal Dis. 1991;4:296–305. [PubMed]
  • Downs S.H. Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J. Epid. Comm. Health. 1998;52:377–384. [PMC free article] [PubMed]
  • Frank J.B. Lim C.K. Flynn J.M. Dormans J.P. The efficacy of magnetic resonance imaging in pediatric cervical spine clearance. Spine. 2002;27:1176–1179. [PubMed]
  • Garland D.E. Shimoyama S.T. Lugo C. Barras D. Gilgoff I. Spinal cord insults and heterotopic ossification in the pediatric population. Clin. Ortho. Rel. Res. 1989:303–310. [PubMed]
  • Garton H.J.L. Hammer M.R. Detection of pediatric cervical spine injury. Neurosurg. 2008;62:700–708. [PubMed]
  • Hamilton M.G. Myles S.T. Pediatric spinal injury: review of 61 deaths. J. Neurosurg. 1992a;77:705–708. [PubMed]
  • Hamilton M.G. Myles S.T. Pediatric spinal injury: review of 174 hospital admissions. J. Neurosurg. 1992b;77:700–704. [PubMed]
  • Kannisto M. Merikanto J. Alaranta H. Hokkanen H. Sintonen H. Comparison of health-related quality of life in three subgroups of spinal cord injury patients. Spinal Cord. 1998;36:193–199. [PubMed]
  • Kewalramani L.S. Kraus J.F. Sterling H.M. Acute spinal-cord lesions in a pediatric population: epidemiological and clinical features. Paraplegia. 1980;18:206–219. [PubMed]
  • Mangano F.T. Menendez J.A. Smyth M.D. Leonard J.R. Narayan P. Park T.S. Pediatric neurosurgical injuries associated with all-terrain vehicle accidents: a 10-year experience at St. Louis Children's Hospital. J. Neurosurg. 2006;105:2–5. [PubMed]
  • Marshall K.W. Koch B.L. Egelhoff J.C. Air bag-related deaths and serious injuries in children: injury patterns and imaging findings. AJNR. 1998;19:1599–1607. [PubMed]
  • Osenbach R.K. Menezes A.H. Pediatric spinal cord and vertebral column injury. Neurosurg. 1992;30:385–390. [PubMed]
  • Patel J.C. Tepas J.J. Mollitt D.L. Pieper P. Pediatric cervical spine injuries: defining the disease. J. Pediatr. Surg. 2001;36:373–376. [PubMed]
  • Pollack I.F. Pang D. Sclabassi R. Recurrent spinal cord injury without radiographic abnormalities in children. J. Neurosurg. 1988;69:177–182. [PubMed]
  • Ruge J.R. Sinson G.P. McLone D.G. Cerullo L.J. Pediatric spinal injury: the very young. J. Neurosurg. 1988;68:25–30. [PubMed]
  • Scarrow A.M. Levy E.I. Resnick D.K. Adelson P.D. Sclabassi R.J. Cervical spine evaluation in obtunded or comatose pediatric trauma patients: A pilot study. Ped. Neurosurg. 1999;30:169–175. [PubMed]
  • Schwartz G.R. Wright S.W. Fein J.A. Sugarman J. Pasternack J. Salhanick S. Pediatric cervical spine injury sustained in falls from low heights. Ann. Emerg. Med. 1997;30:249–252. [PubMed]
  • Sledge J.B. Allred D. Hyman J. Use of magnetic resonance imaging in evaluating injuries to the pediatric thoracolumbar spine. J. Ped. Ortho. 2001;21:288–293. [PubMed]
  • Sun P.P. Poffenbarger G.J. Durham S. Zimmerman R.A. Spectrum of occipitoatlantoaxial injury in young children. J Neurosurg. 2000;93:28–39. [PubMed]
  • Turgut M. Akpinar G. Akalan N. Ozcan O.E. Spinal injuries in the pediatric age group: a review of 82 cases of spinal cord and vertebral column injuries. Euro. Spine J. 1996;5:148–152. [PubMed]
  • Wang M.Y. Hoh D.J. Leary S.P. Griffith P. McComb J.G. High rates of neurological improvement following severe traumatic pediatric spinal cord injury. Spine. 2004;29:1493–1497. [PubMed]

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