Pediatric Spinal Cord Injury
Wise Young, Ph.D., M.D.
W. M. Keck Center for Collaborative Neuroscience
Rutgers University, Piscataway, New Jersey 08854
“I have heard about a young boy (4 or 5 years old) in hungary with a serious spinal cord injury eight months ago: as of my information, his spinal cord has broken between his skull and C1 totally (he is ventilator-dependent). What kind of therapies do you think, are suitable a person like him? Can we hope in some research that will help him to improve his condition? Are there any special problems in his care besides the usual important things like bladder and skin care to take attention? Thanks in advance. I will not give up the hope too!” - Message from a CareCure Reader (8 May 2003)
I received the above message. In answer, I wrote the following literature review of the emergency care, acute complications, chronic complications, and functional recovery in children with spinal cord injury. The abstracts of the cited papers are included because they indicate clinical centers that are experienced in pediatric spinal cord injury care.
Neurological injury represent 18% of pediatric injuries and accounted for 23% of pediatric traumatic deaths (Durkin, et al., 1998). However, spinal cord injury in young children is rare (Reynolds, 2000; Viccellio, et al., 2001), accounting for only 5% of spinal cord injuries (Apple, et al., 1995; Proctor, 2002). Spinal cord injury in children under 5 years are even more rare (Partrick, et al., 2000). This low incidence may be due to the flexibility of the young spinal column (Boockvar, et al., 2001) Nearly 80% of injuries in children less than 2 years old involve the C1-C2 cervical segments (Kokoska, et al., 2001; Sun, et al., 2000). By 8 years, the pattern begins to approach adult patterns.
The first and most important step in the emergency care of children with spinal cord injury is stabilization of the spine, to prevent further damage to the spinal cord. Care should be taken to use pediatric head boards that have an opening for the head so that there is no neck flexion due to the larger heads of children placed supine on the board (2002). A high degree of suspicion for cervical spinal cord injury is warranted in children with sporting injuries or signs of abuse (Brown, et al., 2001).
Surgical approaches to children with spinal cord injury differ from those of adults (Eleraky, et al., 2000; Lalonde, et al., 2001). Most of the time, because the injuries are to the upper cervical spine, closed reduction and halo immobilization are recommended for children younger than 8 years of age. However, posterior occipitovertebral fusions are usually necessary for atlanto-occipital dislocation (Kenter, et al., 2001; Rekate, et al., 1999; Shamoun, et al., 1999). Use of posterior instrumentation, such as the posterior screw, as well as internal fixation, is feasible (Rekate, et al., 1999). Transoral approaches for anterior decompression of the craniovertebral junction may be associated with long-term swallowing and speech difficulties (Tuite, et al., 1996).
Although there has not been any formal clinical trial assessing the effects of methylprednisolone for pediatric spinal cord injury, this is the standard therapy for adult spinal cord injury. In my opinion, children should also receive the high dose methylprednisolone treatment (30 mg/kg i.v. bolus within 8 hours followed by 5.4 mg/kg/hour for 24 hours). High dose methylprednisolone is frequently given to children and appears to be well-tolerated with little side-effects (Alehan, et al., 2002; Ancona, et al., 2002; Defresne, et al., 2001; Hicsonmez, et al., 2001; Matsui, et al., 2002; Shahar, et al., 2002; Sundel, 2002; Tenembaum, et al., 2002; Tunc, et al., 2003; Yetgin, et al., 2003).
The major goal of initial medical management for children with high cervical injuries is to wean them off the respirator if possible. A majority of children with cervical spinal cord injuries can be weaned off their respirators. A recent study from the Alfred I. duPont Hospital in Wilmington Delaware (Padman, et al., 2003) described a 20-year experience with managing tracheostomy and ventilator-dependent children. Many had concomitant brain injury and 52% had C1-C2 injuries while the remainder had C3-C5. However, they were able to successfully wean 63% of the patients from their respirators.
The acute physical care of children with spinal cord injury is similar to adult care. Bowel and bladder care, skin care to prevent decubiti ulcers, physical therapy to prevent atrophy and contractures, and careful pulmonary care prevent devastating complications that can reduce or even reverse neurological recovery. Note that young children, particularly those with head injuries and those on ventilators, may have low potassium levels (hypokalemia) that often predicts longer hospitalization times and longer ventilation times (Beal, et al., 2002).
Children with spinal cord injury tend to get autonomic dysreflexia (AD), a condition where blood pressure may go up to high levels (Hickey & Vogel, 2002). Sometimes, they can show self-injurious behavior (Vogel & Anderson, 2002) which may be a manifestation of dysesthesia or neuropathic pain and sometimes can be resolved with anti-convulsant therapies that may relieve such pain and psychological management (Colville & Mok, 2003).
Urinary tract infections and bladder spasticity are also common. In very young children, a suprapubic catheter may be more convenient and a mitrofanoff procedure (Ellsworth, et al., 1996; Hakenberg, et al., 2001; Sylora, et al., 1997) may be considered to provide independent access to the bladder. Older children can use sterile catheterization techniques (Van Hala, et al., 1997).
Although traumatic patients have predisposing risk factors for deep vein thromboses (DVT) or clots in the leg, DVT’s are very rare in the general pediatric trauma population. One study of 2746 pediatric traumatic patients (Grandas, et al., 2000) observed DVT in only 3 patients, suggesting that routine screening or prophylaxis is not indicated except for patients who remain immobile for extended periods, require prolonged rehabilitation, or have venous manipulations. Another study of 532 patients found a 2.2% overall incidence of DVT but those with spinal cord injury had 10% incidence (Radecki & Gaebler-Spira, 1994).
From a psychological point of view, children are not “small adults” (Merenda, 2001) and require different psychological and social support that is probably best provided at centers specialized for care of children (Betz, 1997; Mulcahey, 1997). Psychological and adaptive responses to spinal cord injury may also differ (Sammallahti, et al., 1996). In adolescents, cosmetic appearance may play an important role in acceptance of certain treatments. The approach should incorporate the child’s age, development level, and family (Keen, 1990).
Vogel, et al. (Vogel, et al., 2002b) studied the complications of spinal cord injury of 216 adults who had had spinal cord injury at 18 years or younger. They had all the usual complications of spinal cord injury, including pressure ulcers (decubiti), urinary tract infections, and spasticity. Severe urinary tract infections and pressure ulcers, pain, and respiratory complications markedly influenced life satisfaction (Vogel, et al., 2002a). Many of these complications contribute to low employment rates (Anderson & Vogel, 2002) and low life satisfaction (Anderson, et al., 2002; Kannisto & Sintonen, 1997).
Musculoskeletal problems are frequent in people who suffered spinal cord injury as children. According to Vogel, et al. (Vogel, et al., 2002c), the most common complaint was pain (69%), spasticity (57%), shoulder pain (48%), scoliosis (40%), hip contractures (23%), and back pain (22%). These rates of complications did not depend on gender. Younger age at injury were associated with higher rates of scoliosis and hip subluxation. Older ages were associated with more ankle pain and spasticity. Bone density is usually grossly decreased in the femoral region and caution should be observed in weight bearing training (Kannisto, et al., 1998a; Moynahan, et al., 1996a).
Scoliosis is a common and serious complication of pediatric spinal cord injury. Of 130 patients who were injured before and after the adolescent growth spurt, scoliosis developed in 97% and 52% respectively. Bracing was effective in delaying the curve progression in the preadolescent group (Dearolf, et al., 1990).
In kids who cannot be weaned off the ventilator, phrenic nerve stimulation should be considered (Giglio, et al., 2002). Abnormally increased sweating (hyperhydrosis) sometimes can occur in children after spinal cord injury and can be treated with gabapentin (Adams, et al., 2002). Artificial urinary sphincters may be useful for some patients (Holmes, et al., 2001). Surgical procedures can be considered to reduce urinary incontinence (Austin, et al., 2001). Most females who were injured before menarche showed normal onset of menarche with no significant menstrual problems (Anderson, et al., 1997).
The Shriner’s Hospitals (McCollough, 2000) for Children in Philadelphia has a long-standing program of upper and lower extremity stimulation in children (Bonaroti, et al., 1999; Moynahan, et al., 1996b; Mulcahey, et al., 1997; Partrick, et al., 2000; Smith, et al., 2001; Triolo, et al., 1994) to reduce atrophy and to promote independence. Children may benefit from earlier implantation of devices (Johnston, et al., 2003).
In young children, spinal cord injury without radiographic abnormalities (SCIWORA) can occur, accounting for as many as 32% of the spinal cord injuries and tended to be severe, i.e. 70% were “complete”, and traditionally associated with a “grim prognosis” (Pang & Wilberger, 1982). In contrast, in children over 12 years old, it occurred in only 12% of patients, was rarely associated with “complete” spinal cord injury, and they have an excellent prognosis for complete recovery of neurological function (Dickman, et al., 1991). As with other types of spinal cord injury, kids with complete neurological lesions tend to have a poorer prognosis for recovery than those with some neurological function below the injury site (Hamilton & Myles, 1992). However, in another study, as many as 20% of pediatric patients with “complete” myelopathy had evidence of significant functional recovery (Hadley, et al., 1988). More recent studies, using more stringent radiological criteria, however, suggest that SCIWORA is very rare (Bosch, et al., 2002).
The patterns of recovery of children tend to follow those of adults but may be more variable (Garcia, et al., 2002). Thus, for example, children with “incomplete” spinal cord injuries tend to recover more than those with “complete” loss of neurological function below in the injury site at the time of admission (Turgut, et al., 1996). The degree of recover does not appear to be significantly related to age, sex, length of inpatient rehabilitation, or cause of injury. Recovery of household ambulation is common (Vogel & Lubicky, 1995a; . In general, children with C1 through C7 injuries have a high likelihood of achieving reasonable independent functioning (Partrick, et al., 2000).
People with pediatric spinal cord injury tend to assign lower priority to self-mobility and have the higher level of health-related quality of life (Kannisto, et al., 1998b) than people who were injured as adults. Like adults, however, pediatric tetraplegics have lower satisfaction ratings than paraplegics. Several studies suggest that people with pediatric spinal cord injury have the greatest opportunity for a satisfying adult life if rehabilitation emphasizes psychosocial factors such as education, employment, and long-term health management (Vogel, et al., 1998).
Children with spinal cord injury also tend to do well in school. For example, an analysis of 144 people who had pediatric spinal cord injury in Seattle (Massagli, et al., 1996) showed that above average student participation and performance compared to peers; 84% of those in secondary schools planned to attend college and 91% graduated from high school. About 71% of college graduates held jobs and 36% of the people surveyed were in college.
• (2002). Management of pediatric cervical spine and spinal cord injuries. Neurosurgery 50:S85-99. Summary: DIAGNOSTIC: Standards: There is insufficient evidence to support diagnostic standards. Guidelines: In children who have experienced trauma and are alert, conversant, have no neurological deficit, no midline cervical tenderness, and no painful distracting injury, and are not intoxicated, cervical spine x-rays are not necessary to exclude cervical spine injury and are not recommended. In children who have experienced trauma and who are either not alert, nonconversant, or have neurological deficit, midline cervical tenderness, or painful distracting injury, or are intoxicated, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. Options: In children younger than age 9 years who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior and lateral cervical spine x-rays be obtained. In children age 9 years or older who have experienced trauma, and who are nonconversant or have an altered mental status, a neurological deficit, neck pain, or a painful distracting injury, are intoxicated, or have unexplained hypotension, it is recommended that anteroposterior, lateral, and open-mouth cervical spine x-rays be obtained. Computed tomographic scanning with attention to the suspected level of neurological injury to exclude occult fractures or to evaluate regions not seen adequately on plain x-rays is recommended. Flexion/extension cervical x-rays or fluoroscopy may be considered to exclude gross ligamentous instability when there remains a suspicion of cervical spine instability after static x-rays are obtained. Magnetic resonance imaging of the cervical spine may be considered to exclude cord or nerve root compression, evaluate ligamentous integrity, or provide information regarding neurological prognosis. TREATMENT: Standards: There is insufficient evidence to support treatment standards. Guidelines: There is insufficient evidence to support treatment guidelines. Options: Thoracic elevation or an occipital recess to prevent flexion of the head and neck when restrained supine on an otherwise flat backboard may allow for better neutral alignment and immobilization of the cervical spine in children younger than 8 years because of the relatively large head in these younger children and is recommended. Closed reduction and halo immobilization for injuries of the C2 synchondrosis between the body and odontoid is recommended in children younger than 7 years. Consideration of primary operative therapy is recommended for isolated ligamentous injuries of the cervical spine with associated deformity.
• Adams BB, Vargus-Adams JN, Franz DN and Kinnett DG (2002). Hyperhidrosis in pediatric spinal cord injury: a case report and gabapentin therapy. J Am Acad Dermatol 46:444-6. Summary: Hyperhidrosis is a relatively common condition with a multitude of causes. Spinal cord injury may be complicated by hyperhidrosis. Many forms of therapy have been reported for this phenomenon but few have been demonstrated to be efficacious. We describe a case of a child with hyperhidrosis from a spinal cord injury and report the first therapeutic use, to our knowledge, of gabapentin for hyperhidrosis. Department of Dermatology, College of Medicine, University of Cincinnati, PO Box 670592, Cincinnati, OH 45267-0592, USA. email@example.com
• Alehan FK, Boyvat F, Baskin E, Derbent M and Ozbek N (2002). Focal cerebral vasculitis and stroke after chickenpox. Eur J Paediatr Neurol 6:331-3. Summary: Cerebral infarcts are rather rare in children and can be caused by a number of diverse conditions. We report a case of cerebral infarct associated with a recent varicella infection. A 5-year old girl presented with an acute central facial palsy 1 month after a chickenpox infection. The infarction was revealed by magnetic resonance imaging and laboratory studies ruled out all known causes of stroke. Cerebral angiogram demonstrated segmental narrowing and irregularity of the wall of the right internal carotid artery, compatible with focal vasculitis. With the presumed diagnosis of varicella-associated focal angiitis, the patient was treated with high-dose methylprednisolone, acyclovir and aspirin. Magnetic resonance angiogram performed 6 weeks after the stroke demonstrated the resolution of the vasculitis. Varicella infection should be considered one of the possible causes of acute ischaemic strokes in children. Department of Paediatrics, Baskent University, Ankara, Turkey. firstname.lastname@example.org
• Ancona KG, Parker RI, Atlas MP and Prakash D (2002). Randomized trial of high-dose methylprednisolone versus intravenous immunoglobulin for the treatment of acute idiopathic thrombocytopenic purpura in children. J Pediatr Hematol Oncol 24:540-4. Summary: BACKGROUND: Idiopathic thrombocytopenic purpura (ITP) is an acquired disorder characterized by immune-mediated platelet destruction. The authors performed a prospective, randomized trial comparing intravenous immunoglobulin (IVIG) with high-dose intravenous methylprednisolone in the treatment of children with acute ITP. The primary aim of the study was to compare the rate of platelet increase produced by either intervention. A decision to treat was based on the clinical presentation and not an arbitrary platelet count. In general, enrolled patients exhibited extensive bruising and platelet counts less than 10 x 10 /L (10,000/microL). PATIENTS AND METHODS: Seventy-seven consecutive patients, for whom the attending hematologist determined acute treatment was warranted, were studied. Forty-two patients received IVIG (1 g/kg/dose x2) and 35 received methylprednisolone (30 mg/kg/dose x3). Patients who exhibited an increase in platelet count of more than 50,000/microL after the first IVIG dose or the second methylprednisolone dose did not receive the second IVIG dose or the third methylprednisolone dose, respectively. Patients' ages ranged from 6 months to 15 years. Platelet counts were evaluated at presentation, 24, 48, 72 hours, 1 week, and 2 to 4 weeks. RESULTS: Eighty percent of patients treated with IVIG and 60% of patients treated with methylprednisolone demonstrated an increase in platelet count of 50,000/microL or more within 48 hours. Both IVIG and methylprednisolone therapy increased platelet counts significantly above pretreatment values. In the methylprednisolone group, the mean baseline platelet count was 4,600/microL, which rose to 14,000/microL after 24 hours, 38,000/microL after 48 hours, and 65,000/microL after 72 hours. The IVIG group had a mean baseline platelet count of 4,200/microL, which rose to 32,000/microL after 24 hours, 69,000/microL after 48 hours, and 146,000/microL after 72 hours. When compared with methylprednisolone, IVIG therapy produced a greater rise in platelet counts at 24, 48, and 72 hours, with no difference at 1 week or later time points. No serious bleeding was noted in either treatment group. CONCLUSIONS: Both IVIG and methylprednisolone produce a significant early rise in platelet count that is somewhat greater with IVIG. However, the higher platelet counts produced by IVIG may not justify the additional cost and potential risks of this agent. Deparmtent of Pediatrics, SUNY-Stony Brook, New York 11794, USA.
• Anderson CJ, Krajci KA and Vogel LC (2002). Life satisfaction in adults with pediatric-onset spinal cord injuries. J Spinal Cord Med 25:184-90. Summary: OBJECTIVE: To determine the level of life satisfaction of adults with pediatric-onset spinal cord injuries (SCI) and the factors associated with life satisfaction. METHOD: A structured interview including standardized measures. PARTICIPANTS: Participants were individuals who sustained SCI at age 18 years or younger, were 24 years of age or olderat interview, did not have significant brain injury, and were living in the United States or Canada. OUTCOME MEASURES: A structured interview, the Functional Independence Measure (FIM), the Craig Handicap Assessment and Reporting Technique (CHART), the Short-Form 12 (SF-12), and the Satisfaction with Life Scale (SWLS). Results: Two hundred sixteen individuals were interviewed. Mean age at injury was 1 4 years, mean age at interview was 29 years, and mean duration of injury was 14 years. The mean SWLS score was 23.6, and the median score was 25. There was not a significant difference between men and women, but those with tetraplegia were significantly less satisfied than were those with paraplegia. A regression model identified age at injury, community mobility (CHART), marital status, use of street drugs, perceived mental health (SF-12), and medical complications as predictors of life satisfaction. Other factors strongly associated with SWLS were employment, income, independent living, FIM total plus physical and sociocognitive domain scores, perceived physical health (SF-12), and CHART total plus the subscales of physical independence, cognitive independence, and occupation. Conclusions: Life satisfaction in adults with pediatric-onset SCI is associated with demographic, injury-related, and functional limitation factors, as well as with health status and community integration outcomes. Shriners Hospital for Children, Chicago, Illinois, USA. email@example.com
• Anderson CJ, Mulcahey MJ and Vogel LC (1997). Menstruation and pediatric spinal cord injury. J Spinal Cord Med 20:56-9. Summary: Menstrual characteristics were studied in young women who sustained spinal cord injuries (SCI) prior to puberty or in early adolescence. Subjects were 37 females who were injured prior to age 16 years and who were at least 10 years old at the time of interview; 22 were injured prior to menarche and 15 after menarche. Average age of menarche for females injured before puberty was 12.3 years which is similar to their mothers (mean 12.6 years) and to patients injured after menarche (mean 12.0 years). Of 15 females injured after menarche, seven reported no interruption in menses while eight had interruptions ranging from one to seven months. No significant menstrual problems were noted in either group. This information about menstruation should be included in sexuality teaching of parents and patients when an SCI occurs to a child or adolescent. Shriners Hospitals, Chicago Unit, IL 60707, USA.
• Anderson CJ and Vogel LC (2002). Employment outcomes of adults who sustained spinal cord injuries as children or adolescents. Arch Phys Med Rehabil 83:791-801. Summary: OBJECTIVES: To determine employment outcomes of adults with pediatric-onset spinal cord injury (SCI) and factors associated with those outcomes. DESIGN: Structured interview, including standardized measures. SETTING: Community. PARTICIPANTS: Individuals who sustained an SCI at age 18 years or younger, were 24 years or older at follow-up, did not have a significant brain injury, and were living in the United States or Canada. A total of 195 subjects were interviewed. Mean age at injury was 14 years (0-18 y), mean age at interview was 29 years (24-37 y), and mean duration of injury was 15 years (7-28 y). All participants had been enrolled in SCI programs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A structured interview, the FIM instrument, the Craig Handicap Assessment and Recording Technique, the Medical Outcomes Study 12-Item Short-Form Health Survey, and the Satisfaction with Life Scale. RESULTS: Of the participants, 99 (51%) were employed, 78 (40%) were unemployed, 12 (6%) were students, and 6 (3%) were homemakers. A predictive model of employment identified 4 factors associated with employment: education, community mobility, functional independence, and decreased medical complications. Other variables significantly associated with employment included community integration, independent driving, independent living, higher income, and life satisfaction. CONCLUSIONS: Compared with the general population, the high rate of unemployment among adults with pediatric-onset SCI is a cause for concern. Risk factors associated with adult unemployment provide guidelines for targeting rehabilitation resources and strategies. Shriners Hospital for Children, Chicago, IL 60707, USA. firstname.lastname@example.org
• Apple DF, Jr., Anson CA, Hunter JD and Bell RB (1995). Spinal cord injury in youth. Clin Pediatr (Phila) 34:90-5. Summary: To identify special characteristics of the pediatric spinal cord-injured (SCI) population, we analyzed a database of 1,770 traumatic SCI patients; 88 (5%) fell into the two pediatric subgroups: 0-12 years (n = 26) and 13-15 years (n = 62) at time of injury. Differences between age groups were identified with regard to demographics, neurologic characteristics, associated injuries and complications, and management. Mode level of bony injury was C2 in preteens, C4 in teens, and C4-C5 in adults. Scoliosis developed far more frequently in children, particularly preteens (23%), than in adults (5%). Violent etiologies, predominantly gunshots, accounted for a disproportionate share of injuries to preteens (19%) and African-Americans (28%), as compared with adults (12%) and Caucasians (7%). This last finding underscores the urgent need to mount a response to the nationwide proliferation of gunshot-related SCI in children and minorities. Clinical Research Department, Shepherd Spinal Center, Atlanta, Georgia 30309, USA.
• Austin PF, Westney OL, Leng WW, McGuire EJ and Ritchey ML (2001). Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders. J Urol 165:2369-71; discussion 2371-2. Summary: PURPOSE: Many surgical procedures to improve outlet resistance in children with neuropathic bladders are obstructive and increase the detrusor leak point pressure. In contrast, fascial slings are designed to achieve continence by increasing the Valsalva or stress leak point pressure without altering the detrusor leak point pressure. We evaluate the effectiveness of fascial slings in achieving continence in pediatric patients with neuropathic bladder. MATERIALS AND METHODS: From October 1994 until February 1999, 10 females and 8 males with neuropathic bladder secondary to myelodysplasia or traumatic spinal cord injury underwent fascial sling procedures. Mean patient age was 14 years (range 8 to 18) and all were incontinent despite aggressive medical management. Urodynamic evaluation was performed preoperatively and postoperatively. Specific urodynamic measurements included detrusor leak point pressure, stress leak point pressure and detrusor compliance. Compliance was only compared in the 12 nonaugmented cases. RESULTS: With a mean followup of 21.2 months (range 6 to 57), preoperative and postoperative urodynamics revealed little change in mean detrusor leak point pressure (23.2 versus 23.22 cm. H2O) but a substantial increase in mean stress leak point pressure (41.6 versus 64.5 cm. H2O). Mean compliance was unchanged in the nonaugmented group (22.00 versus 26.78 ml/cm. H2O). Four patients (22.22%) remained wet after surgery, of whom 2 were successfully treated with a repeat sling procedure and 1 with collagen injection for an overall continence rate of 94.44%. CONCLUSIONS: Fascial slings can be effectively used in pediatric patients for neuropathic incontinence. Furthermore, stress urinary incontinence is corrected by increasing the Valsalva or stress leak point pressure with preservation of the detrusor leak point pressure. Preservation of detrusor leak point pressure is particularly advantageous because other forms of bladder outlet procedures achieve continence at the expense of increasing detrusor pressures, thus placing the upper tracts at risk for damage. Division of Urology, University of Texas, Houston Medical School, Texas, USA.
• Beal AL, Scheltema KE, Beilman GJ and Deuser WE (2002). Hypokalemia following trauma. Shock 18:107-10. Summary: Frequent hypokalemia was noted immediately after trauma, and it was hypothesized that hypokalemia occurred more frequently in the more severely injured. A retrospective trauma registry and chart review was done on 546 trauma patients looking at admission potassium, a variety of lab tests related to potassium, specific injuries, hospital/ICU lengths of stay, and general patient demographics. Admission hypokalemia (K < 3.6 meq/l) was more frequent in those with closed head injuries (41.1% vs. 27.5%, P < .001) and in those who suffered spinal cord injuries (54.5% vs. 33.6%, P < .05). Hyperglycemia was more frequent with admission hypokalemia (45.2% vs. 29.7%, P < .001). Hypokalemia occurred more frequently in younger patients (28.6 vs. 37.7 y, P < .001). Also, the pediatric group, ages 5-14, had admission hypokalemia more frequently than those ages 15-59, or those ages > 59 (54.9% vs. 34.5% vs. 16.7%, P < .001). Glasgow Coma Scores (GCS) were significantly lower (12.0 vs. 13.5, P < .001) and Injury Severity Scores (ISS) were higher (17.4 vs. 13.4, P < .001), with admission hypokalemia. Additionally, hypokalemia was a positive predictor of ISS (P = .05). Hypokalemic patients more likely needed a ventilator, (26.6% vs. 16.5%, P < .01) but did not have significantly more ventilator days (P > .05). Subsequently, hypokalemic patients had longer ICU lengths of stay (LOS) (2.6 vs. 1.5 days, P < .005) and longer hospital LOS (8.5 vs. 5.6 days, P < .001). When stratified into categories of "severe": (K < 3.1 meq/l), "moderate": (K = 3.1-3.3 meq/l), and "mild": (K = 3.4-3.5 meq/l) hypokalemia, those with severe hypokalemia had significantly lower GCS (10.0 vs. 13.1, p < .05), higher serum glucose levels (167 vs. 137 mg/dl, P < .05), lower creatinine levels (.77 vs. .95 mg/dl, P < .05), and longer hospital lengths of stay (13.1 days vs. 7.6 days, P < .05 results). North Memorial Health Care, Robbinsdale, Minnesota, 55422, USA.
• Betz RR (1997). Unique management needs of pediatric spinal cord injury patients: orthopedic problems in the child with spinal cord injury. J Spinal Cord Med 20:14-6. Summary:
• Bonaroti D, Akers JM, Smith BT, Mulcahey MJ and Betz RR (1999). Comparison of functional electrical stimulation to long leg braces for upright mobility for children with complete thoracic level spinal injuries. Arch Phys Med Rehabil 80:1047-53. Summary: OBJECTIVE: To prospectively compare functional electrical stimulation (FES) to long leg braces (LLB) as a means of upright mobility for children with motor-complete thoracic level spinal cord injuries (SCIs). DESIGN: Intrasubject group comparison of two interventions. SETTING: Nonprofit pediatric orthopedic rehabilitation facility specializing in SCI. PATIENTS OR OTHER PARTICIPANTS: Convenience sample of five children between 9 and 18 years old with motor-complete thoracic level SCI. The hip and knee extensors were excitable by electrical stimulation. INTERVENTIONS: The FES system consisted of percutaneous intramuscular electrodes implanted to the hip and knee extensors and a push-button activated stimulator worn about the waist. Standing was accomplished by simultaneous stimulation of all implanted muscles. For foot and ankle stability, either ankle-foot orthoses (AFO) or supramalleolar orthoses were used. The LLB system consisted of a custom knee-ankle foot orthosis (KAFO) for four subjects and a custom reciprocating gait orthosis (RGO) for one subject who required bracing at the hip. For both interventions, either a front-wheeled walker or Lofstrand crutches were used as assistive devices. Each subject was trained in the use of both FES and LLB in seven standardized upright mobility activities: stand and reach, high transfer, toilet transfer, floor to stand, 6-meter walk, stair ascent, and stair descent. MAIN OUTCOME MEASURES: For each mobility activity, five repeated measures of level of independence, using the 7-point Functional Independence Measure (FIM) scale, and time to completion were recorded for each intervention. Subjects were also asked which intervention they preferred. RESULTS: For 94% of comparisons, subjects required equal (70%) or less (24%) assistance using FES as compared with LLB. Six of the seven mobility activities required less time to complete using FES, two activities at significant levels. The FES system was preferred in 62% of the cases, LLB were desired 27% of the time, and there was no preference in 11% of the cases. CONCLUSIONS: The FES system generally provided equal or greater independence in seven mobility activities as compared with LLB, provided faster sit-to-stand times, and was preferred over LLB in a majority of cases. Follow-up evaluations of both modes of upright mobility are needed to compare long-term performance and satisfaction. Research Department, Shriners Hospitals for Children, Philadelphia, PA 19140, USA.
• Boockvar JA, Durham SR and Sun PP (2001). Cervical spinal stenosis and sports-related cervical cord neurapraxia in children. Spine 26:2709-12; discussion 2713. Summary: STUDY DESIGN: Congenital spinal stenosis has been demonstrated to contribute to cervical cord neurapraxia after cervical spinal cord injury in adult athletes. A sagittal canal diameter <14 mm and/or a Torg ratio (sagittal diameter of the spinal canal: midcervical sagittal vertebral body diameter) of <0.8 are indicative of significant cervical spinal stenosis. Although sports-related cervical spine injuries are common in children, the role of congenital cervical stenosis in the etiology of these injuries remains unclear. OBJECTIVES: The authors measured the sagittal canal diameter and the Torg ratio in children presenting with cervical cord neurapraxia resulting from sports-related cervical spinal cord injuries to determine the presence of congenital spinal stenosis. METHODS: A total of 13 children (9 male, 4 female) presented with cervical cord neurapraxia after a sports-related cervical spinal cord injury. Age ranged from 7 to 15 years (mean +/- SD, 11.5 +/- 2.7 years). The sports involved were football (n = 4), wrestling (n = 2), hockey (n = 2), and soccer, gymnastics, baseball, kickball, and pogosticking (n = 1 each). Lateral cervical spine radiographs were used to determine the sagittal canal diameter and the Torg ratio at C4. RESULTS: The sagittal canal diameter (mean +/- SD, 17.58 +/- 1.63 mm) and the Torg ratio (mean +/- SD, 1.20 +/- 0.24) were normal in all of these children. CONCLUSION: Using the sagittal canal diameter and the Torg ratio as a measurement of congenital spinal stenosis, the authors did not find evidence of congenital cervical spinal stenosis in a group of children with sports-related cervical spinal cord neurapraxia. The occurrence of cervical cord neurapraxia in pediatric patients can be attributed to the mobility of the pediatric spine rather than to congenital cervical spinal stenosis. Division of Neurosurgery, Children's Hospital of Philadelphia and University of Pennsylvania Medical Center, USA. email@example.com
• Bosch PP, Vogt MT and Ward WT (2002). Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing. Spine 27:2788-800. Summary: STUDY DESIGN: A retrospective review of medical records and imaging studies of children diagnosed with spinal cord injury without radiographic abnormality (SCIWORA) or SCIWORA-like symptoms at Children's Hospital of Pittsburgh between 1965 and 1999 was undertaken. OBJECTIVES: To evaluate the existence of occult segmental spinal instability and a role for bracing as treatment for SCIWORA, we contrasted the Children's Hospital of Pittsburgh experience with literature reports on SCIWORA. SUMMARY OF BACKGROUND DATA: There is a great deal of confusion and conflicting evidence regarding pediatric SCIWORA in the literature. Previous reports from our institution reported unique findings, including the only description of serious, recurrent SCIWORA in the literature. These findings have frequently been cited as the justification for long-term immobilization in all cases of SCIWORA. METHODS: All records on patients coded as spinal cord injury without fracture or dislocation (ICD-9 code 952.xx) were reviewed. Children 17 years of age or younger with traumatic spinal cord injury and normal plain radiographic findings were included. Penetrating trauma, infection, or metabolic diseases were excluded. RESULTS: A total of 189 patients were diagnosed with SCIWORA at our institution over the 35-year review period. These patients differed from those reported in the literature with respect to a higher incidence, older age, less involved neurologic injury, and more low-energy mechanisms, such as sports and falls. There were no cases of a patient with SCIWORA who deteriorated and developed a permanent neurologic deficit after having either recovered or plateaued from an initial SCIWORA. All recurrent SCIWORA recovered to normal neurologic function. Bracing did not demonstrate any benefit in preventing these minor recurrent SCIWORAs. CONCLUSION: We identified no cases of serious, recurrent SCIWORA at our institution from 1965 to 1999. A case-by-case evaluation is required for the treatment of spinal cord injury without apparent spinal column injury, and bracing is not uniformly indicated. Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
• Brown RL, Brunn MA and Garcia VF (2001). Cervical spine injuries in children: a review of 103 patients treated consecutively at a level 1 pediatric trauma center. J Pediatr Surg 36:1107-14. Summary: PURPOSE: Cervical spine (C-spine) injuries occur infrequently in children but may be associated with significant disability and mortality. The purpose of this study was to review the experience of a level 1 pediatric trauma center to determine the epidemiology, risk factors, mechanisms, levels, types of injury, comorbid factors, and outcomes associated with these potentially devastating injuries. METHODS: A retrospective analysis of 103 consecutive C-spine injuries treated at a level 1 pediatric trauma center over a 9(1/2)-year period (January 1991 through August 2000) was performed. RESULTS: The mean age was 10.3 +/- 5.2 years, and the male-to-female ratio was 1.6:1. The most common mechanism of injury was motor vehicle related (52%), followed by sporting injuries (27%). Football injuries accounted for 29% of all sports-related injuries. Sixty-eight percent of all children sustained injuries to C1 to C4; 25% to C5 to C7; and 7% to both. Spinal cord injury without radiographic abnormality (SCIWORA) occurred in 38%. Five patients had complete cord lesions involving the lower C-spine (C4 to C7); 4 of these were motor vehicle related, and all 4 patients died. Isolated C-spine injuries occurred in 43%, whereas 38% had associated closed head injuries (CHI). The overall mortality rate was 18.5%, most commonly motor vehicle related (95%), occurring in younger children (mean and median age 5 years) and associated with upper C-spine injuries (74%) and CHI (89%). C1 dislocations occurred in younger children (mean age, 6.6 years), most often as a result of motor vehicle-related trauma (especially pedestrians) and were associated with the highest injury severity score (ISS), longest length of stay (LOS), most CHIs, and the highest mortality rate (50%). C-spine fractures with or without SCI occurred most commonly as a result of falls and dives. Sporting injuries occurred almost exclusively in adolescent boys (mean age, 13.8 years) and were isolated injuries associated with a relatively low ISS and shorter LOS. Interestingly, 75% of sporting injuries showed SCIWORA, and all infants suffering from child abuse had SCIWORA. CONCLUSIONS: Mechanisms of injury are age related, with younger children sustaining C-spine injuries as a result of motor vehicle-related trauma and older adolescents commonly injured during sporting activities. C-spine injuries in children most commonly involve the upper C-spine, but complete lesions of the cord are associated more frequently with lower C-spine injuries. The type of C-spine injury is related to the mechanism of injury: SCIWORA is associated with sporting activities and child abuse, C-spine dislocations most commonly result from motor vehicle-related trauma (especially among pedestrians), and C-spine fractures occur most commonly as a result of falls and dives. Predictors of mortality include younger age, motor vehicle-related mechanism, C1 dislocations, high ISS greater than 25, and associated CHI. A high index of suspicion for SCIWORA is essential when evaluating adolescents with neck trauma associated with sporting injuries or victims of child abuse. Children's Hospital Medical Center, Division of Trauma Services, Cincinnati, OH 45229-3039, USA.
• Colville GA and Mok Q (2003). Psychological management of two cases of self injury on the paediatric intensive care unit. Arch Dis Child 88:335-6. Summary: Self injury has not been previously reported in an intensive care setting. Two cases are presented of ventilator dependent children with high spinal cord lesions who exhibited an unusual form of self mutilation, namely lip biting. The key to extinguishing this behaviour was to address the children's psychological needs. Department of Psychology, St George's Hospital Medical School, London, UK. firstname.lastname@example.org
• Dearolf WW, 3rd, Betz RR, Vogel LC, Levin J, Clancy M and Steel HH (1990). Scoliosis in pediatric spinal cord-injured patients. J Pediatr Orthop 10:214-8. Summary: One hundred thirty children who sustained spinal cord injuries between birth and age 21 years were reviewed to determine the progression rate of paralytic scoliosis and the effects of bracing and surgery. Patients were divided into two groups: those injured before and those injured after the adolescent growth spurt. Scoliosis developed in 97 and 52%, respectively. Bracing was effective in delaying progression in the preadolescent group. The progressive paralytic spinal deformity did not appear to be related to the level of injury. The older patient is at much less risk for paralytic scoliosis, but still requires routine examination. Shriners Hospital for Crippled Children, Philadelphia, Pennsylvania 19152.
• Defresne P, Meyer L, Tardieu M, Scalais E, Nuttin C, De Bont B, Loftus G, Landrieu P, Kadhim H and Sebire G (2001). Efficacy of high dose steroid therapy in children with severe acute transverse myelitis. J Neurol Neurosurg Psychiatry 71:272-4. Summary: No effective treatment has been demonstrated for patients with acute transverse myelopathy. In a multicentre controlled study, 12 children with severe acute transverse myelopathy were treated with intravenous methylprednisolone (IVMP) and compared with a historical group of 17 patients. The treatment had a significant effect on the proportion of patients walking independently at 1 month and on the proportion with full recovery at 1 year, with no differences in the frequency of complications between the two groups. Service de Neurologie, Departement de Pediatrie, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, Avenue Hippocrate 10, 1200 Bruxelles, Belgium. email@example.com
• Dickman CA, Zabramski JM, Hadley MN, Rekate HL and Sonntag VK (1991). Pediatric spinal cord injury without radiographic abnormalities: report of 26 cases and review of the literature. J Spinal Disord 4:296-305. Summary: Spinal cord injury without radiographic abnormality (SCIWORA) occurs primarily in the pediatric population but is less common than other forms of spinal injury among children. Between 1972 and 1990, 159 pediatric patients were admitted to the Barrow Neurological Institute with acute traumatic spinal cord or vertebral column injuries. Of these, 26 children (16%) sustained SCIWORA. The mechanism of injury, its severity, and the prognosis for recovery were related to the patient's age. In young children, SCIWORA accounted for 32% of all spinal injuries and tended to be severe; 70% were complete injuries. In older children, SCIWORA accounted for only 12% of the spinal injuries, was rarely associated with a complete injury, and had an excellent prognosis for complete recovery of neurologic function. As with other types of spinal cord injuries, the severity of neurological injury was the most important predictor of outcome. Patients with complete neurological deficits from SCIWORA had a poor prognosis for recovery of neurological function. Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona.
• Durkin MS, Olsen S, Barlow B, Virella A and Connolly ES, Jr. (1998). The epidemiology of urban pediatric neurological trauma: evaluation of, and implications for, injury prevention programs. Neurosurgery 42:300-10. Summary: OBJECTIVE: To describe the incidence and causes of pediatric head, spinal cord, and peripheral nerve injuries in an urban setting and to assess the implications of these data for injury prevention programs. METHODS: Pediatric deaths and hospital admissions secondary to neurological trauma included in the Northern Manhattan Injury Surveillance System from 1983 to 1992 were linked to census counts to compute incidence rates. Rates before the implementation of a nonspecific injury prevention program were compared with rates after the implementation, and rates for the target population were compared to rates for the control population. Rates were analyzed on the basis of the cause of injury as well as the age, gender, and neighborhood income level of the injured. RESULTS: The incidence of neurological injuries resulting in hospitalization or death was 155 incidents per 100,000 population per year; the mortality rate was 6 people per 100,000 population per year. Neurological injuries represented 18% of all pediatric injuries and accounted for 23% of all traumatic deaths. Spinal cord and peripheral nerve injuries were relatively rare (5%) compared to head injuries (95%). Minor head injuries, including isolated cranial fractures, minor concussions (<1 h loss of consciousness), and unspecified minor head injuries, accounted for the majority of neurological injuries (76%), whereas severe head injuries, including severe concussion (>1 h loss of consciousness), cerebral laceration/contusion, intracerebral hemorrhage, and unspecified major injuries, were less common (18% of all neurological injuries). Boys were more often affected than girls at every age, and this preference increased with age. Children younger than 1 year showed the highest incidence of both major and minor injuries. One- to 4-year olds showed the lowest rates, with steady increases thereafter. Traffic accidents and falls were the leading causes (38 and 34%, respectively), and assaults were the next leading causes (12%). Among children admitted to surveillance system hospitals, falls were most common in children younger than 4 years, pedestrian motor vehicle accidents were most common in late childhood, and assaults were most common in early adolescence. Case:fatality rates were 5 to 7% for all age groups except 5- to 12-year-olds, for whom the case:fatality rate was 1.9%. Residence in a low-income neighborhood was associated with an increased risk of injury (rate ratio, 1.71; confidence interval, 95%, 1.54, 1.89). The average hospitalization cost per injury was $8502. Medicaid (54%) and other government sources (5%) covered the majority of expenses, including indirect reimbursement of usually uncollected self-pay billing (19%). Although injury incidence rates fell in both the control and intervention cohorts during implementation of a nonspecific injury prevention program, targeted age and population groups demonstrated greater relative reductions in injuries than nontargeted ones, suggesting a positive effect. CONCLUSIONS: Deaths and hospital admissions secondary to pediatric neurological trauma represent a significant public health problem, with the majority of the direct cost being born by government agencies. Future efforts to prevent neurological trauma in children who live in inner cities should focus on families with low incomes and provide novel education programs regarding infant abuse, infant neglect, and infant injury avoidance. Age-appropriate school-based programs should also be developed to address traffic safety and conflict resolution. Division of Epidemiology, Gertrude H. Sergievsky Center, Columbia University, New York, New York, USA.
• Eleraky MA, Theodore N, Adams M, Rekate HL and Sonntag VK (2000). Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg 92:12-7. Summary: OBJECT: To evaluate and review their experience with pediatric cervical injuries and factors affecting outcome, the authors conducted a retrospective clinical study of 102 cases (65% boys, 35% girls) of pediatric cervical spine injuries treated in the last decade. This study is an extension of and comparison with their earlier experience. METHODS: Patients were divided into two age groups-birth to 9 years (Group I) and 10 to 16 years of age (Group 2)- and managed according to status at presentation and type of injury. Thirty patients were managed surgically and 72 non-surgically (42 wore a halo brace and 30 wore hard collars or custom-molded braces). Motor vehicle accidents were the most common cause of injury, and 40% were associated with head injury. Patients in the younger-age group (Group 1) sustained more neurological injuries than the older patients in Group 2, and most injuries were in the upper cervical spine. Of the 38 children in Group 1, in 39% a subluxation was present and in 29% a fracture or fracture/subluxation was demonstrated. Of the patients in Group 2, 80% had sustained fractures or fracture/subluxations. Vertebral fractures were the most common radiological findings (32%). At late follow-up review (mean 5 years), solid fusions were demonstrated in all patients. Neurological deterioration did not occur in any patient. The mortality rate was 16%. Compared with the authors' earlier report, the incidence of cases with pediatric cervical injuries increased, as did the number managed surgically. Various fusion techniques were used, and neurological and fusion outcomes improved as compared with the previous report. CONCLUSIONS: The prognosis of neurological recovery from pediatric cervical spine injuries is related to the severity of the initial neurological injury. Management must be tailored to the patient's age, neurological status, and type and level of injury. Compared with our earlier experience, fusion and instrumentation procedures were used more frequently. Different types of fusion and instrumentation procedures can be performed safely in children and produce good outcomes. Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
• Ellsworth PI, Webb HW, Crump JM, Barraza MA, Stevens PS and Mesrobian HG (1996). The Malone antegrade colonic enema enhances the quality of life in children undergoing urological incontinence procedures. J Urol 155:1416-8. Summary: Purpose: Functional alterations of the gastrointestinal and genitourinary tracts, and physical limitations in children with spina bifida, imperforate anus and spinal cord injury challenge the ability to have independent fecal and urinary continence. Urologists have successfully helped these patients achieve urinary continence. We report our experience with the antegrade colonic enema procedure, which allows select individuals to achieve continence of stool, enhancing quality of life. Materials and Methods: Since December 1992, 18 antegrade colonic enema procedures were performed in 12 female and 6 male patients 5 to 31 years old of whom 14 had spina bifida, 2 had imperforate anus and 2 had spinal cord injury. Simultaneous urological continence procedures were performed in 8 patients, including appendicovesicostomy in 4, augmentation cystoplasty in 2 and augmentation cystoplasty plus an ileal Mitrofanoff procedure in 2. Four patients previously underwent urological reconstruction. Results: In 24 months of followup (average 6.6) all patients with a functioning stoma remained continent of stool and 17 were continent of urine. Complications related to the antegrade colonic enema procedure occurred in 4 children (22%) of whom 3 required further surgery. Three patients (17%) had minor stomal stenosis. Conclusions: The antegrade colonic enema procedure is easily performed and it should be considered for any child with significant physical limitations and/or refractory fecal incontinence before urological continence promoting procedures are done. Division of Urology, University of Florida, Jacksonville, Florida, USA.
• Garcia RA, Gaebler-Spira D, Sisung C and Heinemann AW (2002). Functional improvement after pediatric spinal cord injury. Am J Phys Med Rehabil 81:458-63. Summary: OBJECTIVE: To describe the functional gain (FGain) with pediatric spinal cord injury inpatient rehabilitation and to identify the relationship of various factors to FGain in pediatric spinal cord injury inpatient rehabilitation. DESIGN: Retrospective chart review of a series of 91 children with spinal cord injury admitted from 1993 to 1998 in a freestanding rehabilitation hospital. Admission and discharge functional status were assessed with the Pediatric Functional Independence Measure (WeeFIM) instrument for children <or=7 yr and the Adult Functional Independence Measure (FIM) instrument for children >7 yr. The outcome measure is the FGain (difference between the discharge and admission functional status). RESULTS: Significant gains in functional status were observed in all patients. FGain was not significantly related to age, sex, length of inpatient rehabilitation, pathogenesis, or completeness or neurologic level of injury. However, there was a trend for higher FGain for patients with incomplete spinal cord injury and traumatic spinal cord injury. CONCLUSIONS: Functional improvement occurs with pediatric spinal cord injury inpatient rehabilitation. There is a trend for higher FGain in patients with less severe injury and traumatic injury. The lack of relationship between FGain and length of inpatient rehabilitation suggests that a variety of other factors influence the relationship between FGain and length of inpatient rehabilitation. Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, and the Rehabilitation Institute of Chicago, Illinois, USA.
• Giglio AM, Rovella C, Botindari E and Alba M (2002). [The phrenic nerve stimulator, a valid ventilatory support in the management of quadriplegic patients receiving home health care services. A case report]. Minerva Anestesiol 68:567-71. Summary: The authors describe the case of a quadriplegic child with post-traumatic respiratory insufficiency and total dependency on mechanical ventilation. The child was a long-term inpatient at the Pediatric Intensive Care Unit of Palermo. Considering the patient's long life expectancy, psychological distress and determination of the patient and family members to have the patient at home again, the plan for dehospitalization included the use of a phrenic stimulator as a supplement to conventional mechanical ventilation that would simplify home health care and improve the patient's quality of life. Electromyography, fluoroscopy and gas analysis were conducted to evaluate whether the patient was physically fit to receive a stimulator. The device was then implanted at the Spinal Cord Injury Treatment Unit in Sondalo. The stimulator is compact in design, operates silently, and affords more natural ventilation without interfering with breathing rhythm, and maintains muscle trophism. In combination with mechanical ventilation, the pacing device is an ideal system for home respiratory assistance. Additional benefits include increased patient mobility outside the home and improved quality of life. The system provides good respiration, as shown by EtCO2 and SpO2 measurements and long-term monitoring performed at our unit. Servizio di Anestesia e Rianimazione Pediatrica, Ospedale dei Bambini G. Di Cristina, Palermo, Italy.
• Grandas OH, Klar M, Goldman MH and Filston HC (2000). Deep venous thrombosis in the pediatric trauma population: an unusual event: report of three cases. Am Surg 66:273-6. Summary: The incidence of deep venous thrombosis (DVT) in the pediatric population has been reported to be lower than in adults. Pediatric trauma patients have predisposing risk factors for DVT similar to those in the general trauma population. We reviewed the records of 2746 children under 16 years of age admitted to our Level I pediatric trauma service from 1989 to 1997. Only three cases of DVT were documented, all adolescents. DVT was located in the upper (n = 1) and lower (n = 1) extremity venous system. One patient presented with pulmonary embolism alone without identifiable DVT. Risk factors found were venous system manipulations, including atriocaval shunt, subclavian central line, and hyperinflated medical antishock trousers garment. Therapy consisted of heparin followed by warfarin anticoagulation. A vena cava filter was inserted in one patient for whom systemic anticoagulation was contraindicated. No DVT was seen in 1123 closed head injury patients or 29 spinal cord injury patients without associated risk factors. The thrombotic risk in pediatric trauma patients is low. Routine screening or prophylaxis is not indicated except for patients who are likely to remain immobile for an extended period of time and require prolonged rehabilitation, have venous manipulations, or present with clinical symptoms. Hematologic evaluation in patients with diagnosed DVT is necessary to identify individual risk factors. Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, USA.
• Hadley MN, Zabramski JM, Browner CM, Rekate H and Sonntag VK (1988). Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg 68:18-24. Summary: A review of 122 pediatric cases of vertebral column and spinal cord injuries is presented. These relatively uncommon injuries can be characterized by four distinct injury patterns: fracture only, fracture with subluxation, subluxation only, and spinal cord injury without radiographic abnormality. The immature pediatric spine has several anatomical and biomechanical features that distinguish it from the mature adolescent spine and, accordingly, the frequency of the injury type, the level of spine injury, and the incidence of neurological compromise were found to vary with the age of the patient. Follow-up data were obtained in 93% of the cases (median duration 44 months). No patient was made worse by treatment, 89% of the patients with incomplete myelopathy on admission were improved on their last examination, and 20% of the patients with a complete myelopathy had evidence of significant recovery of function. The authors conclude that the outcome after pediatric spinal trauma is good. Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona.
• Hakenberg OW, Ebermayer J, Manseck A and Wirth MP (2001). Application of the Mitrofanoff principle for intermittent self-catheterization in quadriplegic patients. Urology 58:38-42. Summary: OBJECTIVES: Patients with cervical spinal cord lesions have impaired hand function, which often prohibits clean intermittent self-catheterization (CIC), especially in female patients. Enabling these patients to perform CIC gives them control of their bladder management and can improve their quality of life considerably. We have used an appendicovesicostomy to provide easy access for CIC in such patients. METHODS: Five patients (4 women, 1 man) with a mean age of 31 years (range 20 to 52) and a mean duration of the cervical cord lesion of 22 months (range 7 to 37) underwent appendicovesicostomy. Three patients were young victims of motor vehicle accidents, 1 patient had a progressive rheumatoid arthritic disorder, and 1 patient had a complex functional paraplegia syndrome and underwent bladder augmentation at the same time. RESULTS: The surgical procedure with the creation of a catheterizable stoma in the right lower abdominal quadrant was successful in all cases but was complicated by mechanical ileus in the patient with simultaneous bladder augmentation. All patients learned to perform independent CIC with continuing anticholinergic medication. Stomal stenosis did not occur in any of the 5 patients, and urinary tract infections occurred once in 2 patients and repeatedly in 1 patient. Three of 5 patients have been enabled by independent bladder management to achieve occupational rehabilitation. CONCLUSIONS: Appendicovesicostomy is a suitable procedure in patients with cervical spinal cord lesions who are otherwise unable to perform independent CIC. The creation of a catheterizable abdominal stoma enables these patients to gain independent control of their bladder management. However, caution in patient selection is advisable as probably the best results are achieved in highly motivated, younger patients with traumatic cervical cord lesions. Department of Urology, University Hospital Carl-Gustav Carus, Dresden, Germany.
• Hamilton MG and Myles ST (1992). Pediatric spinal injury: review of 174 hospital admissions. J Neurosurg 77:700-4. Summary: Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. A review of 174 pediatric patients is presented, representing 5.4% of all patients admitted with spinal injury. Spinal cord injury was present in 45% of patients. A distinct injury profile, explained by anatomical and biomechanical features, distinguishes the young patient with an immature spine from older adolescents with a more mature, adult-like spine. The younger patients, while less likely to have spinal injury, had a higher incidence of neurological injury, in addition to a higher frequency of both spinal cord injury without radiological abnormality and upper cervical cord injury. In addition, younger patients with spinal cord injury and no radiological abnormality were more likely to have complete or severe cord injury. Prognosis was determined by the severity of spinal cord injury. Patients with complete cord injuries showed little improvement, while patients with incomplete injuries generally fared much better, with 74% showing significant improvement and 59% experiencing a complete recovery of neurological functions. There were six deaths, but none was attributed solely to spinal injury. The authors conclude that outcome is quite good after pediatric spinal cord injury that does not produce a physiologically complete cord deficit. Department of Clinical Neurosciences, University of Calgary, Alberta, Canada.
• Hickey KJ and Vogel LC (2002). Autonomic dysreflexia in pediatric spinal cord injury. SCI Nurs 19:82-4. Summary: Shriners Hospitals for Children, Chicago, Illinois, USA.
• Hicsonmez G, Tunc B, Olcay L and Tuncer MA (2001). Effect of short-course, high-dose steroid therapy in a child with myelodysplastic syndrome. Pediatr Hematol Oncol 18:525-9. Summary: High-dose methylpred