Pediatric spinal injuries

Pediatric Nursing,  Nov-Dec, 2005  by Janice S. Hayes,  Trish Arriola

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The incidence of spinal injuries in children is reported to be 2 to 5% of all spine injuries (Reynolds, 2000). Although uncommon, these injuries are more common than anyone would like them to be, and they can be associated with significant morbidity posing challenges to care. Automotive injuries are the most common cause followed by sporting injuries. More than half of pediatric spinal cord injuries occur in the cervical area (Brown, Brunn, & Garcia, 2001; Cirak et al., 2004; Eleraky, Theodore, Adams, Rekate, & Sonntag, 2000).

Signs and Symptoms

Spinal cord injuries can be classified as either complete or incomplete. Complete spinal cord injury results in total loss of sensation and movement below the level of the injury. Incomplete spinal cord injuries often fall into one of the following patterns (Schreiber, 2004):

* Anterior cord syndrome results from injury to the motor and sensory pathways in the anterior cord. These patients can feel some crude sensation, but movement and more detailed sensation is lost.

* Central cord syndrome is injury to nerve cells and pathways in the center of the cervical spinal cord producing weakness or paralysis of arms and some sensory loss in the arms. The legs are less affected.

* Brown-Sequard syndrome results from injury to the right or left half of the cord. Movement and some types of sensation are lost below the level of the injury. Pain and temperature sensation are lost on the opposite side of the body because the pathways cross to the opposite side after they enter the spinal cord.

* Spinal concussion can also occur. This consists of complete or incomplete dysfunction that is transient. It generally resolves within a day or two.

* Cauda equina syndrome results from injury to the lumbosacral nerve roots caused by central lumbar disk herniation. Loss of reflexes to the affected limbs, bowel, and/or bladder result.

Symptoms of spinal cord injury are not easily discerned in young children and are variable depending on the child's age, the injury location, the spinal fracture stability, and other systemic injuries. Generally, signs of spinal cord injury include the following:

* Flaccid extremities.

* Paralysis.

* Numbness or paresthesias (sensations such as tingling or burning).

* Paresis or weakness.

* Priaprism.

* Incontinence of bowel or bladder and loss of rectal tone.

Other necessary assessments include the abdomen (if a lap belt was in place during a motor vehicle crash), rectal tone, and inspection and palpation of the back (Thomas & Bernardo, 2003).

Damage to the vertebrae and ligaments usually causes severe pain and swelling in the area of the injury, and damage to the cord may cause a loss of sensation and/or motor function below the injury. The spinal cord is divided into 31 segments, each with a pair of spinal nerve roots--anterior (motor) and dorsal (sensory). These pairs of anterior and dorsal nerve roots combine to form a spinal nerve as it exits from the vertebral column. The spinal cord is organized into a series of tracts or neuro-pathways that carry motor (descending) and sensory (ascending) information. Spinal shock refers to flaccidity and loss of reflexes that may make the cord appear functionless; the duration is variable, but generally some signs of return to function are seen within the first 72 hours of injury. Neurogenic shock results from impairment of the descending sympathetic pathways resulting in loss of vasomotor tone and sympathetic innervation to the heart. The triad of hypotension, bradycardia, and peripheral vasodilation results (Schreiber, 2004; American College of Surgeons Committee on Trauma, 1997). This is a very important sign in early assessment in the field and the ED.

Differences in Children

The growth and development differences found in children 8 years of age and younger affect injury patterns. These anatomical differences include the following:

* Larger head size relative to body size, which creates greater force on the neck when the head is jerked about. Craniocervical disruption (atlanto axial dislocation) is almost unique to children and difficult to diagnose without a high index of suspicion.

* Greater flexibility of the spine and supporting structures allowing more stretching when force is applied, thus injuring the spine without associated bony damage. This accounts for a condition referred to as Spinal Cord Injury Without Radiographic Abnormality (SCIWORA).

* Growth plates are present so that injury and compression of the bone can cause bone damage.

* Development of the spine varies according to the level of the spine. Growth and development is cephalocaudal, or head to tail, so that development in the upper cervical spine differs from the lower cervical spine.

* Ossification centers are present at birth, and fusion occurs as the child grows. Prior to fusion, children are predisposed to subluxation and distraction resulting in spinal injury.

The spine has attained near adult size by the age of 8 to 10 years, so assessment and care of the child under the age of 8 years with a spinal injury has to be individualized (Cirak et al., 2004; Martin, Dykes, & Lecky, 2004; Reynolds, 2000; Zuckerbraun, Morrison, Gaines, Ford, & Hackam, 2004).