Pediatric Spinal Cord Injury: Recognition of Injury and Initial Resuscitation, in Hospital Management, and Coordination of Care

Factors influencing on functional independence outcomes after hospitalization and rehabilitation in children with spinal cord injury

OBJECTIVE

This study is to investigate the factors that influence functional autonomy outcomes in children who have undergone rehabilitation for spinal cord injury. The aim is to enhance the clinical guidance provided to inpatients at the China Rehabilitation Research Center, Beijing Bo-ai Hospital. Furthermore, the objective is to optimize rehabilitation interventions and establish a scientific basis.

METHODS

This study employed a retrospective survey method for data collection and analysis. Descriptive analysis, one-way ANOVA analysis, and Multiple logistic regression analysis were utilized to examine the influencing factors associated with the prognosis of functional independence outcomes in children with SCI. The degree of influence of each independent variable on functional independence outcomes was ultimately determined.

RESULTS

The total score of SCIM-III at admission was 41.48 ± 4.089, and the total score of SCIM-III at discharge was 50.05 ± 25.028, resulting in a significant difference in the total score of SCIM-III was (8.57 ± 7.000, p < 0.001).In one-way ANOVA analysis, Self-care: injury segments, damage plane, ASIA, assistive devices, complications, rehabilitation duration treatment, WISCI-II, UEMS and LEMS, BI, and 6WMD groups were statistically significant (p < 0.001). Respiratory and sphincter management: injury segments, ASIA, complications, injury to recovery time interval, rehabilitation duration treatment, WISCI-II, UEMS and LEMS, BI, and 6WMD groups were statistically significant (p < 0.05). Move: age, injury segments, damage plane, rehabilitation duration treatment, WISCI-II, UEMS and LEMS groups were statistically significant (p < 0.05). SCIM-III total score: age, AISA, assistive devices, injury to recovery time interval, rehabilitation duration treatment were statistically significant (p < 0.05). Multiple logistic regression analysis, revealed that the injury to recovery time interval had a negative correlation with the total difference in SCIM-III scale (t = -9.893, p < 0.001; 95%CI-12.006~-7.780), while the duration of rehabilitation treatment (t = 4.245, p < 0.001, 95%CI 2.636 ~ 5.854) had a positive correlation with different age groups (t = 4.002, p < 0.001, 95%CI 2.421 ~ 5.583).

CONCLUSION

The shorter the interval between the time of spinal cord injury and the time of intervention for rehabilitation, the more favorable the functional recovery of the children. Children with SCI who were hospitalized for rehabilitation and achieved 3-month daily functional independence scores were more successful. It is recommended that rehabilitation interventions for children with SCI in this institution should be initiated as early as possible and maintained over time. Among the subjects, the prognosis of functional independence was more favorable in the school-age group (6-18y) than in the preschool group (3-6 y).

Comparison of cervical versus thoracic spinal cord injury outcomes in pediatric trauma patients

PURPOSE

To explore differences based on level of pediatric spinal cord injury (SCI), we compared cervical and thoracic SCI in pediatric trauma patients (PTPs), hypothesizing higher mortality and length of stay (LOS) for cervical SCI.

METHODS

The 2017-2021 Trauma Quality Improvement Program was queried for all PTPs ≤ 17 years-old with cervical or thoracic SCI. Bivariate analyses compared the two groups. The primary outcome was mortality and secondary outcomes included hospital LOS and injury severity scores (ISS). Logistic regression models were used to determine independent risk factors for death and prolonged ventilation.

RESULTS

Of 5280 PTPs, 2538 (65.9%) had cervical SCI and 1316 (34.1%) had thoracic SCI. Motor vehicle collisions were the most common cause of both cervical and thoracic SCI (37.8 and 41.9%). PTPs with thoracic SCI had higher rates of positive drug screen as compared to cervical SCI (39.2 vs 29.8%, p = 0.001). PTPs with thoracic SCI had higher median ISS (25 vs 16, p < 0.001), while cervical SCI had higher mortality (13 vs 6.1%, p < 0.001) but decreased hospital LOS (median 9 vs 5 days, p < 0.001. Cervical SCI were associated with a nearly fourfold increase in the risk of death (95% CI 2.750-5.799, p < 0.001) and a 1.6-fold increase in the risk of prolonged ventilator requirement (95% CI 1.228-2.068, p < 0.001).

CONCLUSIONS

PTPs with cervical SCI have higher mortality while those with thoracic SCI have higher ISS and hospital LOS. Cervical SCI were associated with a fourfold higher risk of death. MVC was the most common cause of injury, and both groups had high rates of positive drug screens. Understanding differing outcomes may assist providers with prognostication and injury prevention.

Prehospital Trauma Compendium: Pediatric Severe and Inflicted Trauma - A Position Statement and Resource Document of NAEMSP

Pediatric trauma patients have unique physiology and anatomy that impact the severity and patterns of injury. There is a need for updated, holistic guidance for Emergency Medical Services (EMS) clinicians and medical directors to optimize prehospital pediatric trauma guidelines based on evidence and best practice. This is especially pertinent to pediatric severe and inflicted trauma, where prehospital evaluation and management determine the overall quality of care and patient outcomes. This position statement addresses the prehospital evaluation and management of pediatric severe and inflicted trauma and is based on a thorough review and analysis of the current literature.

Pediatric Cervical Spine Trauma: A Narrative Review

STUDY DESIGN

Narrative review.

OBJECTIVE

To provide an updated overview of pediatric cervical spine trauma.

SUMMARY OF BACKGROUND DATA

Pediatric cervical spine trauma can cause debilitating morbidity and mortality and neurological impairment. The unique anatomic features of the developing cervical spine can predispose children to injuries.

METHODS

We reviewed the pediatric cervical spine trauma literature in PubMed and EMBASE.

RESULTS

Pediatric cervical spine injury occurs in 1%-2% of pediatric trauma. The most frequent cause is motor vehicle collisions, with sports-related injuries being more common in older children. Larger head-to-body ratios and tissue elasticity can predispose young children to a greater risk of injury higher in the craniocervical junction and cervical spine. Standardized protocols and classification systems, such as the Pediatric Cervical Spine Clearance Working Group protocol and the AO Spine Injury and Subaxial Cervical Spine Injury Classifications, are valuable in triage as well as for assessing the need for operative versus nonoperative management. In general, operative approaches and principles are similar to those in adults, with modern instrumentation and fusion techniques achieving high rates of successful arthrodesis.

CONCLUSIONS

Effective management and treatment of pediatric cervical spine injuries depends on early and accurate diagnosis, a thorough understanding of pediatric spinal anatomy, and a versatile surgical armamentarium.

Triage tools for detecting cervical spine injury in paediatric trauma patients

BACKGROUND

Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy.

OBJECTIVES

To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions.

SELECTION CRITERIA

We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

A call for action: Increasing the pediatric rehabilitation medicine workforce

Pediatric Rehabilitation Medicine (PRM) is a unique blend of traditional medical rehabilitation knowledge and skills primarily focused on temporary and/or permanent disability conditions of childhood onset throughout the age continuum, with an emphasis on promoting function and participation. Although there are two established pathways to enhance knowledge and skills in PRM, one a combined residency with Pediatrics and the other a PRM fellowship, there has been a relative decline in participants in this training, as has been seen across other subspecialties in Physical Medicine and Rehabilitation (PM&R) and other medical specialties. Based on pediatric rehabilitation physician surveys and the increasing prevalence of children with disabilities, there has been a call to consider opening PRM fellowships to physicians not trained in PM&R. This commentary proposes establishing a commission to lead a transparent and inclusive process to assure that all options to address issues related to optimizing PRM care are considered and provide a course of action to address the needs of children and adults with childhood onset disabilities.

Management and Outcomes of Traumatic Pediatric Spinal Cord Injuries in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

Traumatic spinal cord injury (TSCI) is a subset of neurotrauma, which is a significant contributor to global trauma mortality and morbidity in children. The management and outcomes of pediatric TSCI in low- and middle-income countries (LMICs) is unknown. We conducted a scoping review to characterize the methods of management and outcomes of TSCI in LMICs.

METHODS

MEDLINE, Embase, and Global Index Medicus were searched from database inception to February 15, 2021. Studies reporting management or outcomes of pediatric TSCI in LMICs were included. Pooled statistics were calculated using measures of central tendency and spread.

RESULTS

A total of 1171 studies were identified, of which 5 were included. A total of 212 patients were included in our review with age of participants ranging from 2.5 to 18 years (mean, 15.4 years). Most patients were male (n = 162; 76.4%). The commonest cited cause of injury were falls (n = 104/212; 49.1%). The most common level of injury was cervical (n = 83; 39.2%). Most patients underwent surgery (n = 134/212; 63.2%). The extent of injury was quantified and classified using the American Spinal Injury Association chart in only 1 study. Long-term management data were not present in any of the included studies.

CONCLUSIONS

There is a scarcity of studies reporting the management and outcome of pediatric TSCI in LMICs. The paucity of studies in this domain provides insufficient data to be compared, reducing the ability to draw a strong conclusion. This situation hinders the development of guidelines to inform best practice.

A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries

CONTEXT

Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system.

EVIDENCE ACQUISITION

The data on pediatric traumatic spinal cord injuries has been narratively reviewed.

RESULTS

Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges.

CONCLUSION

Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.