|Year : 2022 | Volume
| Issue : 2 | Page : 66-68
Complete traumatic transection of thoracic spinal cord in a pediatric patient
Rachit Garg, Bhakti U Sarangi, Guruprasad Hassan Shankar, Ajay Walimbe
Department of Pediatrics, Bharati Vidyapeeth Medical College and Hospital, Pune, Maharashtra, India
|Date of Submission||11-Jan-2022|
|Date of Decision||07-Feb-2022|
|Date of Acceptance||14-Feb-2022|
|Date of Web Publication||30-Mar-2022|
Dr. Guruprasad Hassan Shankar
Department of Pediatrics, Bharati Vidyapeeth Medical College and Hospital, Pune - 411 043, Maharashtra
Source of Support: None, Conflict of Interest: None
With pediatric spinal cord injuries themselves being an infrequent event worldwide, complete transection of the spinal cord forms an extremely small subset of the same. Moreover, complete transection of spinal cord without the concurrent presence of vertebral compression fractures has rarely been reported in the pediatric age group. We hereby present a pediatric case with traumatic brain injury as well as complete thoracic spinal cord transection and probe the possible mechanisms that contribute to these injuries in the pediatric age group. We also discuss the challenges faced in the diagnostic evaluation as well as the therapeutic dilemmas in the given scenario due to the multiple ongoing issues.
Keywords: Hyperflexion-distraction injury, thoracic spinal cord injury, transection
|How to cite this article:|
Garg R, Sarangi BU, Shankar GH, Walimbe A. Complete traumatic transection of thoracic spinal cord in a pediatric patient. J Pediatr Crit Care 2022;9:66-8
|How to cite this URL:|
Garg R, Sarangi BU, Shankar GH, Walimbe A. Complete traumatic transection of thoracic spinal cord in a pediatric patient. J Pediatr Crit Care [serial online] 2022 [cited 2023 Feb 8];9:66-8. Available from: http://www.jpcc.org.in/text.asp?2022/9/2/66/341448
| Introduction|| |
Pediatric spinal cord injuries are fortunately very uncommon, with incidences reported as low as 2.4 per million population internationally. Indian data show a statistically significant low incidence of spinal injuries in younger age group (0–9 years), forming only 3% of pediatric trauma cases from a single-center experience. Among spinal cord injuries, cervical cord is involved much more commonly than thoracic region, especially in spinal cord injury without radiological abnormality (SCIWORA) (87% vs. 9.5%). Among these, very few cases of complete transection of the thoracic spinal cord with a noncompressive vertebral injury have been reported till date., We, therefore, consider it important to add to the literature, a summary of our case.
| Case Report|| |
A 2-year-old female was brought to our institute 9 h post road traffic accident involving a head on collision of two cars. The patient was seated on the lap of an adult, face facing forward with arms around the torso. Since multiple persons involved in the incident were severely injured, a through history was not forthcoming except that there was a progressive drowsiness. Surprisingly, no external injuries were noted.
On arrival, the Glasgow Coma Score (GCS) was 10/15. The patient was started on hyperosmolar therapy, prophylactic anticonvulsant (levetiracetam) with working diagnosis of severe traumatic brain injury (TBI) with raised intracranial pressure. On secondary survey, she was noted to have abdominal distension due to urinary retention for which further investigations for local obstructive causes and spinal cord involvement were done. Urethral injury was ruled out, and a urinary catheter was inserted. Computed tomography (CT) brain with cervical spine revealed focal hyperdensity in the right high parietal lobe at the gray-white matter junction. Ultrasonography revealed bilateral pleural effusion. A diagnostic pleural tap confirmed hemothorax. Loss of power in both lower limbs was suspicious but difficult to ascertain in view of poor GCS, however, a seesaw type of breathing was present. A distributive type of shock with wide pulse pressure was noted as well. The patient was intubated as per modified RSI protocol, and started on vasopressor support (noradrenaline). Suspecting SCIWORA, magnetic resonance imaging (MRI) of the spine was planned but deferred in view of systemic instability and risks of transport. Pulse methylprednisolone (30 mg/kg) was given suspecting spinal cord injury for 48 h.
Noradrenaline was weaned and stopped on day 4 of admission, after which MRI brain and spine revealed cord transection at D2–D3 level with superiorly extending cord edema till C5–C6 and diffuse cerebral edema [Figure 1]a and [Figure 1]b. The child needed mechanical ventilation for 2 weeks, after which she tolerated extubation. However, she maintained a seesaw type of breathing pattern as a baseline.
|Figure 1: (a and b) Abnormal irregular hyperintensities in dorsal cord at D2–D3 levels, indicating cord transection. Length of this abnormal cord measures about 11.5 mm|
Click here to view
Autonomic dysfunction in the form of temperature instability and episodes of bradycardia continued for 3 weeks. Since sitting position was eventually tolerated without any autonomic instability, surgery for spine stabilization was deferred. Deep vein thrombosis prophylaxis was given and clean intermittent catheterization was instituted. The patient was discharged after 33 days of hospital stay with no improvement in deficits.
| Discussion|| |
Complete avulsion of thoracic spinal cord has been reported in children with improper lap-belt restraint (seat belt syndrome). Similarly, a hyperflexion injury can occur during sudden deceleration for a child seated in the lap of an adult and restrained by the adult's arms around the torso. A sudden hyperflexion of the spinal column around a fulcrum in the thorax with a significant distracting force on the adjacent segments may be the mechanism in our case. To our knowledge, only one other case has been reported with this mechanism in a 5 month old. Several anatomical factors in the pediatric age group predispose for neural injury in the spinal cord without an accompanying compressive fracture. These include increased elasticity of ligaments and joint capsules along with longitudinal expansibility of intervertebral disc and annulus to withstand considerable stretching without tearing, and shallow facet joints and their horizontal orientation, allowing for easy gliding in both flexion and extension. The vertebral bodies also are wedged anteriorly enhancing forward slippage between segments. Finally, the uncinate of adult vertebrae which restricts lateral and rotational movements is absent in children <10 years of age.
In polytrauma, the presence of TBI with altered consciousness makes it difficult to clinically evaluate for signs of spinal cord involvement. Point spinal tenderness, paraplegia, sensory examination including bladder sensation, etc., are difficult to elicit in unconscious patients. Urinary retention may also go unnoticed due to catheterization. Mechanical ventilation with sedation and paralysis precludes clinical examination. Most trauma protocols including ours perform a routine screening for cervical cord involvement in polytrauma patients but not thoracolumbar levels. Systemic instability may delay transport for radiologic evaluation. Hence, a high index of suspicion, quick secondary survey prior to intubation if clinical condition allows, thoroughness of evaluation later in the course of hospital stay, and including rare differentials in the findings noted may help reduce missed/delayed diagnoses. In our case, though spinal involvement was suspected, level could not be ascertained and only cervical cord was screened due to rarity of thoracic injuries.
Spinal shock is defined as a transient physiologic and reflex depression of spinal cord function (loss of reflexes, detrusor activity, and muscle tone) below the level of injury, whereas neurogenic shock refers to the hemodynamic changes as part of autonomic dysfunction from loss of sympathetic tone. This is more common if the injury level is above D6 as in our case.
CT may be superior in initial screening of suspected spinal injuries, but in unconscious patients or in whom a reliable physical examination cannot be done, it is prudent to perform an MRI before spinal clearance. MRI abnormalities can be intraneural as well as extraneural in such cases which were present in our case in the form of interspinous soft-tissue hyperintensity from C7–D1 revealing possibility of tears of supra/interspinous ligaments with no suggestion of a compressive fracture. These findings along with bilateral hemothorax indicated the severity of thoracic trauma which led to transection. Autonomic instability in the form of bradycardia episodes and fever (due to inability to lose heat through sweating) occurs as a result of loss of supraspinal control over the sympathetic nervous system and may be present in the initial 2–3 weeks of injury.
We add to literature the possibility of a hyperflexion-distraction injury without a seat belt restraint in younger patients in high-speed motor accidents and urge the importance of keeping a high index of suspicion for spinal injuries in such cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
We would like to thank the pediatric intensive care and orthopedic teams at Bharati Vidyapeeth Medical College, Hospital and Research Centre, Pune.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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