TRAUMATIC SPINAL CORD INJURIES IN CHILDREN

TRAUMATIC SPINAL CORD INJURIES IN CHILDREN

Larkin I.I., Larkin V.I., Preobrazhenskiy A.S., Goreva L.M.

 Omsk State Medical University, City Pediatric Clinical Hospital No.3, Omsk, Russia 

According to the data from various authors, pediatric spinal cord injury consists 1-10 % of all spinal injuries [1, 2, 3]. The anatomical and functional features of the child’s body promote the development of a specific type of injuries – SCIWORA (Spinal cord injury without radiographic abnormality). Such injury is described by D. Pang et al. in 1982 [4]. According to the authors’ opinion, the appearance of this phenomenon in children is associated with higher compliance of the spine as compared to the spinal cord. Currently, there are a lot of publications describing the different aspects of pathogenesis, diagnosis and also surgical treatment of SCIWORA. Wide implementation of MRI extended our understanding of the course of pathologic processes and prediction of outcomes of these injuries. A new term appeared – SCIWONA (spinal cord injury without neuroimaging abnormality) [5]. However the issues of diagnosis, features of clinical manifestations and their estimation are insufficiently described in the Russian literature, explaining the importance of our report [6, 7].
Objective – to study the features of clinical and MRI diagnosis of spinal cord injuries, the main mechanisms of injuries and age-related characteristics of clinical manifestations of spinal cord injuries in children. 

MATERIALS AND METHODS

The retrospective analysis included 112 clinical cases of spinal cord injuries in children (age < 15) who received treatment in City Pediatric Clinical Hospital No.3 in 2007-2017. All patients received the clinical estimation of neurological deficiency and spinal X-ray examination with two views. A degree of neurological deficiency was estimated with Frankel’s score. All patients received the spine and spinal cord MRI. A spinal injury was estimated according to Ignatyev Yu.T. (2000).
There were 2 study groups: the group A (n = 72) with SCIWORA, and the group B (n = 40), the patients with spinal cord injuries in combination with stable spinal injuries. The groups were divided into the subgroups for examination of the clinical features: A1 and B1 – children aged < 7, A2 and B2 – children older 7.
The inclusion criteria to the study: age < 15, absence of concurrent diseases or spinal and CNS injuries, which could influence on the study, absence of spinal injuries or stable spinal injuries.
The exclusion criteria: age > 15, presence of concurrent spinal and CNS abnormality, a possibility of influence on results of the study, unstable spinal injuries.
The results were analyzed with the ratio technique. Statistical significance of odds ratio was assessed with confidence intervals. Chi-square test with Yates’ correction was used. The calculations were made in MS Excel 2007.
The study was approved by the ethical committee of Omsk State Medical Academy (the extract from the protocol No.59, 12 December 2013).

RESULTS

Home injuries dominated in both groups (91.6 % in the group A, 95 % in the group B). There were more boys than girls (58.3 % in the group A, 78 % in the group B). The table 1 shows the main mechanisms of traumatic injuries.

Table 1. Leading mechanisms of spine and spinal cord injuries in children

Leading mechanism

Compression flexion

Distraction flexion

Distraction extension

Torsion flexion

Vertical compression

Unclear

Group A
(n = 72)

39
(54.20 %)

3
(4.20 %)

23
(31.90 %)

5
(6.90 %)

0 (0 %)

2
(2.80 %)

Group B
(n = 40) 

29
(72.50 %)

4
(10 %)

2
(5 %)

1
(2.50 %)

2 (5 %)

2
(5 %)

Total
(n = 112) 

68
(60.70 %)

7
(6.30 %)

25
(22.30 %)

6
(5.40 %)

2
(1.80 %)

4
(3.60 %)

Odds ratio (OR)*

0.448

0.391

8.918

2.91

0.05

0.543

Confidence limits*

1.386-3.476

1.159-3.699

7.413-10.509

1.727-5.216

1.391-8.933

1.457-3.568

χ2

15

1.5

42.6

6.9

5.4

0.9

Note: * – p < 0.05.


The odds ratio and χ2 test showed the following results. The chances were higher in the group B for such injuries as compression flexion (OR = 0.448), distraction flexion (OR = 0.391), vertical compression (OR = 0.05), unidentified type (OR = 0.543). At the same time, the probability of such injuries as distraction extension (OR = 8.918) and torsion flexion (OR = 2.91) were significantly higher in the group A.
The correlation analysis showed a quite close direct relationship between the groups A and B (correlation ratio r = 0.83).
In our study, compression flexion prevailed in the patients. It is confirmed by the data from other researchers. Injury mechanism was not identified in some cases.
All patients had some complaints on pain in the injury site. The children in the group B often (82.5 %) had complaints on respiratory disorders after injury. The main proportion of the children (96.4 %) had some additional complaints on transitory weakness in extremities, disordered sensitivity and feeling of current flow. In preschool age children, their parents often observed disordered supporting ability to the feet and complicated movement. However these complaints sometimes were not considered at prehospital stage. At admission, moderate neurological deficiency was observed. The group A demonstrated more severe clinical manifestations, especially in the group A1. It is related to the anatomical and physiological features of childhood and to the role of anamnesis in identification of injuries (the table 2).

Table 2. Neurological deficiency degree at admission (according to Frankel)

Group

Injury type according to Frankel

Total amount

А

В

С

D

Е

Group A

4 (5.60 %)

25 (34.70 %)

43 (59.70 %)

72 (64.30 %)

Group A1

2 (18.20 %)

5 (45.50 %)

4 (36.40 %)

11 (9.80 %)

Group A2

2 (3.30 %)

20 (32.80 %)

39 (63.90 %)

61 (54.50 %)

Группа В

Group B

11 (27.50 %)

29 (72.50 %)

40 (35.70 %)

Group B1

2 (33.30 %)

4 (66.70 %)

6 (5.40 %)

Group B2

9 (26.50 %)

25 (73.50 %)

34 (30.40 %)

Odds ratio (OR)*

1.402

0.562

Confidence limits*

0.556-2.249

0.276-1.401

Note: * – p < 0.05.

The analysis of the groups with use of odds ratio technique shows thatmore severe degree corresponds to the group A (type D, OR = 1.402), more mild degree – to the group B (type E, OR = 0.562).
Spinal cord injury was accompanied by spinal injury at different levels (the table 3).

Table 3. Location of spinal injury

 

Cervical spine

Thoracolumbar spine

Unclear location

Group A

36 (50.00 %)

31 (43.10 %)

5 (6.90 %)

Group B

1 (2.50 %)

39 (97.50 %)

0 (0.00 %)


For the group B, absolute number of injuries was related to the thoracolumbar spine (97.5 %), whereas the group A demonstrated trends to location of injuries in the cervical spine (50 %).
MRI identified some changes in the spinal cord in 1 patient in the group A (Fig. 1) and did not find any changes in the group B. Spinal fractures of type 2 and 3 according to Ignatyev Yu.T. (2000) were identified. It corresponded to A1 type according to AO spinal fracture classification. One case showed cervical spinal fractures with hemorrhage to the posterior longitudinal ligament (Fig. 2).

Figure 1. Patient P., female, age of 9. Cervical spine MRI in the first day. Hyperintensive signal at C6-C7 in T2 mode. No signs of spinal injury. Clinically moderate tetraparesis. Horner's syndrome. Injury type according to Frankel scale.



Figure 2. MRI of patient, age of 9. Compression fracture of C4, C5, C6 and C7 vertebral bodies, posttraumatic discopathy of C4-C5, C6-C7, hematoma in region of posterior longitudinal ligament. Spinal cord concussion. Level E according to Frankel. The second image – MRI control after 34 days.

  

All cases showed sufficiently fast regression of neurological signs, except for the case with spinal cord hemorrhage. At the moment of discharge, the estimation showed the type D according to Frankel’s score in this patient. One child without MRI changes (SCIWONA) recovered within 3 weeks. 

DISCUSSION

We observed 112 children with spinal cord injuries. More often (64.3 %), spinal cord injuries without spine injury (SCIWORA) were identified. Moreover, injuries without MRI changes in the spinal cord (SCIWONA) were found in most cases that differ from the data from foreign researchers [8, 9]. First of all, it is explained by injury mechanisms. Foreign authors note the significant amount of road and sport injuries in children, especially in combative sports [10, 11]. Our observations show the dominance of home injuries, which are mostly related to desipience. Cervical spinal cord injuries were in most cases. It is explained by high mobility in this part of the spine [3, 4]. The quite high number of spinal cord injuries in the thoracic region without spine injuries generates interest. Probably, the vascular factor plays the role here [12, 13]. The literature shows some delayed clinical manifestations of SCIWORA [14].
The analysis of clinical features in the group A showed higher amount of movement disorders as compared to sensitive ones. Superficial sensitivity disorders were identified in only 12 patients, and they demonstrated the segmental characteristics. We did not find any disorders of deep sensitivity. It can be explained by a well-known feature of spinal cord perfusion (anterior spinal artery spasm in traction injury).
Spinal cord injuries with stable spine injuries were characterized by relatively fast regression of neurological deficiency. 

CONCLUSION

1. Spinal cord injury without radiographic abnormality (SCIWORA, up to 64.3 % according to our data) prevails in children. The main mechanism – compression flexion and distraction extension.
2. Preschool age demonstrates more severe spinal cord injuries. The feature of neurological deficiency in such injury is dominance of movement disorders over sensitive ones.
3. MRI spinal cord traumatic changes are identified quite rarely and show favorable outcomes. 

Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of clear or potential conflicts of interests relating to publication of this article.

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