Latent spinal cord and brain stem injury in newborn infants

DNA methylation and behavioral changes induced by neonatal spinal transection

Although the importance of epigenetic mechanisms in behavioral development has been gaining attention in recent years, research has largely focused on the brain. To our knowledge, no studies to date have investigated epigenetic changes in the developing spinal cord to determine the dynamic manner in which the spinal epigenome may respond to environmental input during behavioral development. Animal studies demonstrate that spinal cord plasticity is heightened during early development, is somewhat preserved following neonatal transection, and that spinal injured animals are responsive to sensory feedback. Because epigenetic alterations have been implicated in brain plasticity and are highly responsive to experience, these alterations are promising candidates for molecular substrates of spinal plasticity as well. Thus, the current study investigated behavioral changes in the development of weight-bearing locomotion and epigenetic modifications in the spinal cord of infant rats following a neonatal low-thoracic spinal transection or sham surgery on postnatal day (P)1. Specifically, global levels of methylation and methylation status of the brain-derived neurotrophic factor (Bdnf) gene, a neurotrophin heavily involved in both CNS and behavioral plasticity, particularly in development, were examined in lumbar tissue harvested on P10 from sham and spinal-transected subjects. Behavioral results demonstrate that compared to shams, spinal-transected subjects exhibit significantly reduced partial-weight bearing hindlimb activity. Molecular data demonstrate group differences in global lumbar methylation levels as well as exon-specific group differences in Bdnf methylation. This study represents an initial step toward understanding the relationship between epigenetic mechanisms and plasticity associated with spinal cord and locomotor development.

Syrinx Extending from Conus Medullaris to Basal Ganglia: A Clinical, Radiological, and Pathological Correlation

A 41-year-old woman with a history of birth injury to the brachial plexus suffered several delayed episodes of neurological deterioration. Magnetic resonance imaging studies revealed a syrinx extending from the conus medullaris into the brainstem and rostrally into both internal capsules. She died of an acute exacerbation of chronic respiratory failure. Autopsy demonstrated syringomyelia and syringobulbia with cavity extension bilaterally along the corticospinal tracts into the internal capsules. Islands of glial tissue in the subarachnoid space around the medulla caused obstruction of the subarachnoid space at the foramen magnum. These were probably the result of birth injury to the cerebellum. A detailed clinico-pathological correlation is provided to explain her neurological deficits. The pathogenesis of syrinx formation is discussed in terms of a late manifestation of birth trauma.

Spinal cord injuries at birth: A multicenter review of nine cases

OBJECTIVE

To report a multicenter study of nine cases of children presenting with a birth-related spinal injury.

METHODS

The medical charts of nine patients identified by a questionnaire sent to the members of the French Society of Pediatric Orthopedics (SOFOP) were reviewed.

RESULTS

The pregnancy was uneventful in all cases. The fetal presentation was cephalic in three cases, a breech presentation in four cases, and a face presentation in two cases. The lesion involved the cervical spine in six cases. Three patients presenting upper cervical injuries died before the age of six years. The six remaining patients experienced no neurological improvement.

CONCLUSIONS

These rare conditions occur during difficult deliveries with abnormal presentations, the most common being a breech presentation with entrapment of the fetal head. In a child with hypotonia, flaccid quadriplegia or high thoracic paraplegia after a difficult delivery, a spinal cord injury must be suspected and plain radiographs and MRI must be performed.

Birth injury of the cranium and central nervous system

Birth injury of the scalp, skull and central nervous system (CNS) is a well-recognized complication of a difficult delivery. The rate of birth trauma has dropped precipitously and now accounts for less than 2% of neonatal deaths. Despite this dramatic decrease in birth-trauma mortality significant injuries still occur. A variety of risk factors clearly predispose certain infants to birth-related injury. Recent neuroradiology studies indicate that intracranial hemorrhage, even in asymptomatic infants, is not rare. Pathologists' (neuropathologists and forensic pathologists) appreciation of the spectrum of birth injuries and their sequelae is critical in order to be able to distinguish these from inflicted injuries and post-mortem changes.

MRI of the neonatal and paediatric spine and spinal canal

Today several modalities for imaging the spine, the spinal canal and the spinal cord are available. Since children represent one of the most vulnerable patient groups, care has to be taken and imaging assessment should start always with less invasive procedures. Thus, in neonates and infants ultrasound should be used as first line imaging procedure due to their unique features of more cartilaginous parts of the yet non-ossified bones. Beyond this age group Magnetic Resonance Imaging (MRI) represents the modality of choice for radiological assessment of the spine, the spinal canal and the spinal cord. The purpose of this review is to present MRI and common MRI findings of typical diseases in children-ranging from congenital to acquired conditions. In addition, general imaging details will be given as well as a brief embryological description of the spine and spinal canal.

Spinal cord injury at birth: a hidden causative factor

A case of perinatally acquired spinal cord injury (SCI) is presented. The foetus was vigorous until birth, the breech presented and delivery was performed by a non-traumatic Caesarean section. The infant displayed symptoms of severe SCI but diagnosis was delayed due to severe co-morbidity. Diagnostic considerations are briefly reviewed. Ventilatory support was withdrawn at the age of 20 days when the infant had still not exhibited any respiratory effort or spontaneous movements. Autopsy revealed a serious congenital malalignment of the upper cervical vertebrae and at the histological examination extensive reactive changes were observed in the same area. To our knowledge such findings have not been published previously.

CONCLUSION

In cases of serious perinatally acquired SCI, claim of malpractice is often apparent. In this case a hidden congenital malformation of the cervical vertebrae was revealed, highlighting the need of careful postmortem examinations in such cases.

Classification of major newborn birth injuries

A classification system of various forms of major newborn birth injuries is clearly lacking in the literature. Currently, no scales exist for distinguishing degrees, extent, or distinctions of major birth injuries. The purpose of this study was to use published and online literature to explore the timing, prediction, and outcomes of major newborn birth injuries. Potential antecedents and causes were used in depicting what were reported to be major birth injuries. The outcome of this literature search was the development of a classification table synthesizing the most frequently reported (n = 20) major newborn birth injuries. This classification was developed according to (1) types of tissue involved in the primary injury, (2) how and when the injury occurred, and (3) the relationship of the injury to birth outcomes. A classification scheme is critically needed as the first step to achieving preventive interventions and plans for long-term recovery from birth injuries. Because major birth trauma contributes to increased neonatal morbidity and mortality, its occurrence requires careful study and preventive efforts to better promote newborn health.

Birth-related spinal cord injuries: a multicentric review of nine cases

OBJECTIVE

The objective of this study was to report a multicentric study of nine cases of children presenting with a birth-related spinal injury.

MATERIALS AND METHODS

The medical charts of nine patients identified by a questionnaire sent to the members of the French Society of Paediatric Orthopaedics (SOFOP) were reviewed.

CONCLUSIONS

The pregnancy was uneventful in all cases. The fetal presentation was cephalic in three cases, a breech presentation in four cases, a face presentation in two cases. The lesion involved the cervical spine in six cases. Three patients presenting upper cervical injuries died before the age of 6 years. The six remaining patients experienced no neurological improvement. These rare conditions occur during difficult deliveries with abnormal presentations, the most common being a breech presentation with entrapment of the fetal head. In a child with hypotonia, flaccid quadriplegia or high thoracic paraplegia after a difficult delivery, a spinal cord injury must be suspected and plain radiographs and magnetic resonance imaging (MRI) must be performed.

Neonatal trauma

A variety of traumatic lesions can occur during the neonatal period. Some of those lesions are clearly birth injuries due to delivery and others are caused by necessary procedures during intensive care in critically ill neonates. As usual patient history must be known and knowledge about the typical complications is necessary in order to select the appropriate imaging modality and thus enabling correct interpretation of those investigations by the radiologist. The purpose of this article is to present typical neonatal injuries, describe the underlying pathomechanisms and aetiology as well as the imaging findings.

A case of spinal cord injury that occurred in utero

Spinal cord injury is a rare occurrence that is often difficult to diagnose. This report describes a 2-year-old male with cervicothoracic spinal cord injury. The injury is thought to have occurred in the fetal period because the patient's thorax was markedly hypoplastic at birth and his mother had noticed a decrease in fetal movements for several weeks before the birth. The deep tendon reflex of the upper and lower extremities was absent at birth, as observed in other cases of spinal cord injury. It was noteworthy that deep tendon reflex of the upper and lower extremities remained decreased at 2 years of age despite the injury being located at C(7)-T(1). Based on this case, we propose that spinal cord injuries occurring in utero display different reflex responses from those occurring at birth.

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.

Part 1: recognizing neonatal spinal cord injury

Neonatal spinal cord injury can occur in utero, as well as after either a difficult delivery or a nontraumatic delivery. Spinal cord injury can also be related to invasive nursery procedures or underlying neonatal pathology. Early clinical signs of spinal cord injury that has occurred in utero or at delivery includes severe respiratory compromise and profound hypotonia. Knowledge of risk factors and awareness of symptoms is required for early recognition and appropriate treatment. This article reviews the embryological development of the spinal column highlighting mechanisms of injury and identifying underlying factors that increase the risk of spinal cord injury in newborns. Signs and symptoms of injury, cervical spine immobilization, and the differential diagnosis are discussed. Nursing implications, general prognosis, and research in spinal cord injury are provided.

US of the spinal cord in newborns: spectrum of normal findings, variants, congenital anomalies, and acquired diseases

Ultrasonography (US) of the spinal cord is performed in newborns with signs of spinal disease (cutaneous lesions of the back, deformities of the spinal column, neurologic disturbances, suspected spinal cord injury due to traumatic birth, and syndromes with associated spinal cord compression). The examination is performed with high-frequency linear- and curved-array transducers in the sagittal and axial planes from the craniocervical junction to the sacrum. Normal variants such as transient dilatation of the central canal and ventriculus terminalis can be demonstrated with US. US allows detection of congenital malformations, such as myelocele or myelomeningocele, spinal lipoma, dorsal dermal sinus, tight filum terminale syndrome, diastematomyelia, terminal myelocystocele, lateral meningocele, caudal regression syndrome, and hydromyelia or syringomyelia. Acquired intraspinal diseases following birth trauma and transient alterations after lumbar puncture can also be detected with US. US can demonstrate the entire spectrum of intraspinal anatomy and pathologic conditions with high geometric resolution. Therefore, US should be considered the initial imaging modality of choice for investigating the spinal cord in newborns.

A case of neonatal spinal cord injury: magnetic resonance imaging and somatosensory evoked potentials

This is the first case report on the diagnosis of spinal cord injury due to hemorrhage during the neonatal period using magnetic resonance imaging (MRI). Somatosensory evoked potentials are also helpful in the functional demonstration of this lesion. When discrepant signs, alert consciousness and intact cranial nerves are observed in newborn babies with flaccid extremities and respiratory disturbance, the immediate carrying out of MRI is mandatory in order to differentiate spinal cord injury from hypoxic-ischemic encephalopathy, cerebral hemorrhage, and neuromuscular disease.

Sonographic evaluation of traumatic spinal cord lesions in the newborn infant

We present a case of spinal cord injury due to birth trauma and assess the value of sonography for diagnosis, lesion characterization, and follow-up. Sonography is a non-invasive and easily reproducible imaging method for examining a ventilated child, and its initial sensitivity is comparable to that of MRI. Sonography is the method of choice for guiding diagnosis in this type of traumatic lesion to the newborn.

Spinal cord injury at birth: diagnostic and prognostic data in twenty-two patients

OBJECTIVES

To establish criteria, evident soon after birth, that predict long-term outcome of neonates with spinal cord injury (SCI) at birth.

DESIGN

Retrospective case-series.

SETTING

Five Canadian regional neonatal tertiary care centers.

PATIENTS

Consecutive samples of patients referred to five centers for a total of 22 subjects, in whom SCI was diagnosed during life. Sites of lesions were above the fourth cervical vertebrae (n = 14), at the fourth cervical to the fourth thoracic vertebrae (n = 6), and at the thoracolumbar region (n = 2).

MEASUREMENTS AND MAIN RESULTS

All 14 patients with upper cervical SCI had cephalic presentations, whereas all 6 patients with cervicothoracic SCI had breech presentations (p < 0.0001). The site and extent of lesion were best diagnosed by clinico-imaging correlations. Ultrasonography appeared to be the most useful imaging study. In patients with upper cervical SCI who had no coexistent central nervous system abnormality associated with early death, long-term outcome in survivors (dependency on mechanical ventilation and on aids for upper limb activity and for ambulation) was best predicted by age when breathing was first observed and by rate of recovery of limb motor function in the first 3 months. The presence of breathing movements on day 1 (n = 2) was associated with mild disability. The absence of breathing movements on day 1 and little or no recovery of motor function in the first 3 months was associated with permanent total dependency on mechanical ventilation and severe quadriplegia (n = 5). Apnea on day 1 and intermediate recovery rates in the first 3 months was associated with variable long-term prognoses (n = 3).

Traumatic cervical syringomyelia related to birth injury

A rare case of cervical syringomyelia related to breech delivery is reported. The initial diagnosis was bilateral brachial plexus palsy due to birth injury, which was revealed by magnetic resonance imaging (MRI) to be traumatic syringomyelia. The usefulness of MRI in the early diagnosis of cervical cord birth injury, especially in differentiating between brachial plexus palsy due to birth injury and spinal cord trauma due to birth injury in infancy, is emphasized.

Spontaneous spinal epidural hematoma in a 7-year-old girl. Diagnostic value of magnetic resonance imaging

The authors report a 7-year-old girl who developed neck pain and stiffness over a four-day period. There was no fever, trauma, systemic illness or headache. Physical examination demonstrated subtle neurologic deficits indicative of cervical cord compression. CAT scan and subsequent Magnetic Resonance Imaging (MRI) of the cervical spine demonstrated a spinal epidural hematoma, which was evacuated surgically. Post-operative angiography failed to demonstrate a vascular abnormality. The child recovered without neurologic deficit. MRI proved to be a sensitive tool in identifying the nature and extent of this lesion, and may be considered in lieu of myelography.

Congenital spinal cord haemangioblastoma: another cause of spinal cord section syndrome in the newborn

A newborn infant with negative perinatal history and characteristic clinical findings of upper cervical spinal cord section is described. Metrizamide myelography performed on the 7th and 22nd days of life was negative. Peroneal somatosensory evoked responses showed a conduction block at the cervical level. Necropsy revealed a haemangioblastoma extending from levels C1 to C5.

Spinal cord birth injury: value of computed tomographic myelography

The value of myelography in the assessment of spinal cord injury in the early neonatal period has not been documented, although this study has been recommended frequently in the literature. Eight neonates are reviewed who presented with the clinical features of spinal cord injury and who had myelography performed. Clinical features included difficult delivery, absent respiration, flaccid paralysis, sensory level, and neurogenic bladder. Myelography revealed that 7 patients had the early changes of swollen cord and 1 patient had the late changes of cord atrophy. None of the neonates had surgical intervention. One neonate died at 3 days of age, while 2 others died after prolonged ventilation. Of the 5 infants who survived, 3 still require ventilation and have spastic quadriparesis, 1 has almost recovered completely and 1 had spontaneous respiration and limb movement but brisk deep tendon reflexes when last examined at 1 month of age. Myelography, which was performed in the early neonatal period in our infants, was abnormal in all patients. Myelography is useful in confirming the diagnosis, outlining the level and extent of the lesion, and excluding extramedullary compression. Myelography may assist in the assessment of prognosis but did not alter management in our patients.

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.

Perinatal hypoxic/ischemic spinal cord injury

We have reviewed our experience in 900 consecutive necropsies performed on infants who died in the first 4 weeks of life. The neuropathologic characteristics of acute hypoxic/ischemic spinal cord injury are described in 21 infants who expired in the perinatal period. Several distinct patterns of spinal cord injury were apparent in asphyxiated neonates. Cord infarction, rare in older age groups, was the commonest lesion and was associated with prematurity and with documented episodes of systemic hypotension. Lumbosacral cord segments were more severely affected, and at affected levels central cord parenchyma was completely necrotic with relative sparing of the periphery. Diffuse neuronal necrosis was more typical of infants delivered at or after term. In these neonates ventromedial neurons were most profoundly injured. Hematomyelia dissecting into spinal cord parenchyma was a consequence of germinal matrix hemorrhage in very premature infants. "Watershed zones" in the cord appear to be most severely affected in these infants. The patterns of spinal cord infarction and the association of this lesion with prematurity and systemic hypotension suggest that the absence or failure of spinal cord blood flow autoregulation may play a role in the etiopathogenesis of perinatal hypoxic/ischemic spinal cord injury.

Spontaneous spinal epidural haematoma. Etiological considerations

Four cases with the typical clinical picture of spinal epidural haematoma are reported. The exact cause of the haemorrhage is generally unknown. A survey is presented of the various causative factors as put forward in the literature so far. The authors point out the possible etiology of this entity and emphasize the need for routine histological examination.

Hyperextension of the fetal head in breech presentation. A study with long-term follow-up

The attitude of the fetal head was determined in 445 women with breech presentations. Thirty-three women (7.4 per cent) were found to have a fetus with the head in various degrees of hyperextension. Of these 26 were born vaginally and seven by Caesarean section. At follow-up (2 to 4 years) five of the vaginally born infants (22 per cent) had neurological sequelae referable to spinal, supraspinal and cerebellar injuries but all infants born by Caesarean section were normal. The results emphasise the value of an abdominal X-ray examination of all women with breech presentations. Caesarean section is recommended if the fetal head is hyperextended.

Spinal cord injury in children and adolescents: diagnostic pitfalls and therapeutic considerations in the acute stage [proceedings]

Traumatic spinal cord lesions in children are infrequent (2 to 5 per cent of all cases admitted to specialised paraplegic centres depending on whether the upper age limit is set at 10 or 15 years). Traffic accidents are responsible for at least 50 per cent of the lesions; playground accidents and various sports add another 35 per cent. A large proportion of the accidents have been found to be related to the child's normal desire for adventure and exploration. The segment most frequently involved in our own series of 18 cases was the cervical and upper thoracic spine. Histopathological studies have shown that splitting of the cartilaginous end-plate in the growth zone of the vertebrae is a common finding. Radiological signs of spinal trauma are less evident than in adults; they may be totally missing. Precise neurological assessment must rely on repeated examination and close clinical observation, especially in the comatous child with a head injury. Spinal cord involvement must be suspected and the child treated as a paraplegic until definite proof of a normal neurological status is available. Due to a highly labile water electrolyte balance in the early post-traumatic stage and considerable fluctuations in plasma volume and temperature regulation, permanent monitoring of the cardiovascular function, body temperature and diuresis is mandatory. In children below the age of 10, deep vein thrombosis and embolism are exceptional (sepsis creates a high-risk situation requiring anticoagulation). In the initial treatment of spinal injury only conservative measures should be considered; there are no indications for laminectomy, nor for spinal fusion. In the tetraplegic child below the age of 6, skull-traction should be avoided and immobilisation of the cervical segment achieved by bilateral padded head-rests.

Case report: injury of the spinal cord at birth

Spinal cord injury may occur as a severe complication to delivery. In the vast majority of such cases the injury results from a traumatic breech delivery, but cases of injuries after cephalic presentation and fetal malposition have also been described. Two cases were reported. One of the infants died at the age of 8 months and neuropathological examination of the brain and spinal cord was performed. The other child, now 6 years old, is still alive. Incidence, mechanism of injury, clinical and morphological features, and treatment are briefly discussed.

Spinal cord injury in the newborn infant

Birth injury to the spinal cord secondary to traction forces during delivery is a common but frequently undiagnosed disorder. The injury usually affects the cervicodorsal junction, with both extradural hematoma and direct cord damage at that level. Clinical findings of a paraplegic infant with abdominal breathing are sometimes obscured by secondary pneumonia and/or hypoxia. Radiologic manifestations include a bell shaped chest indicative of loss of the external muscles of respiration; spinal roentgenograms are usually normal. Myelography in neonatal spinal injury demonstrates a block in the subarachnoid space; infrequently localized cord atrophy may be identified.