Spinal cord injury in children is, thankfully, a rare occurrence, with less than 4% of all spinal cord injuries in the United States. In the immediate chaos after such an injury, the family looks for someone to be a calm port in the storm, someone who can guide the decision-making process. A neurosurgeon with years of experience caring for children with spinal cord injuries often fills this role. Expert knowledge and in-depth understanding of the most current research allows the neurosurgeon to prioritize goals and reassure the family that appropriate steps are being taken to achieve the best possible outcome.
When caring for children after spinal cord injury, neurosurgeons have two primary goals:
First, they want to stop any ongoing damage to the spinal cord. The initial injury can create circumstances that put the spinal cord at further risk, such as a blood clot crushing the cord, or a bone fragment pushing into it. This is considered an emergency, and the neurosurgeon will surgically “decompress” the spinal cord to correct the situation and stop further damage.
Second, they want to stabilize any structural injuries so the patient will be able to begin rehabilitation as soon as possible. With an unstable spine caused by broken vertebrae (spinal bones) or damaged muscles and ligaments, rehabilitation activities could put the patient at risk for another injury. Efforts to stabilize the spine, including surgery, may be delayed due to medical concerns that make surgery too dangerous, such as low blood pressure or lung problems. The neurosurgeon constantly balances the risks of surgery with the need to move forward in rehabilitation.
This two-goal approach offers a simple framework to guide the complex care needed by a child with spinal cord injury: stop ongoing injury, and correct issues that could cause further injury later. Ideally, a physician relies on the best available evidence from medical research, along with their own experience and understanding of the patient’s specific medical concerns, to achieve these goals. But for the neurosurgeon, caring for a child with spinal cord injury is complicated by one major issue: Most research has been performed on adults with spinal cord injuries, not children. Because of the small number of spinal cord injuries in children each year, it is difficult to perform substantial research to assess treatment and progression of these injuries.
This lack of research matters because a child’s spine is not just a smaller version of an adult’s spine. There are differences in structure and proportion. For example, a child’s head is larger in relation to the body than an adult’s head. And any treatment or surgery must allow for the future growth and development of the child’s body, which isn’t the case when caring for an adult.
Dr. Richard C.E. Anderson of The Spine Hospital at the Neurological Institute of New York is often called to speak and teach about the many steps in the treatment of spinal cord injury in which the differences between children and adults must be considered.
These differences begin with the anatomy of a child. In addition to a child’s head being larger in relation to the body, the neck muscles and vertebrae are not fully developed. The discs between the vertebrae and ligaments are more elastic, allowing for greater movement of the spine. Put these differences together and for any given weight load, injury is more likely in a child.
Because of the specific anatomy of a child, differences in caring for a child with a suspected spinal cord injury begin with the emergency personnel who initially immobilize the child before transporting them to the hospital, and continue through diagnosis of the injury, how to study it with imaging and the use of surgical techniques and hardware.
The Congress of Neurological Surgeons has specific guidelines for identifying spinal cord injury in a child based on age, symptoms and method of injury. Often, a spinal cord injury can be ruled out based on these criteria, eliminating the need for imaging studies in some patients.
Dr. Anderson explains that when imaging is needed, X-rays do not necessarily show all abnormalities. A physician must review a variety of imaging studies to definitively rule out a visible abnormality. These may include X-rays, CT scans and MRIs, all taken at different points in time, with the neck in different positions (flexed and extended).
However, this procedure for identifying a potential spinal cord injury in children is not consistent across emergency departments, and less than half of emergency departments have a written protocol for the task. This prompted Dr. Anderson to participate in the Pediatric Cervical Spine Clearance Working Group to establish a consensus statement regarding the procedure. This consensus statement was then used to create an algorithm to establish protocols for detecting a spinal cord injury.
If a spinal cord injury is detected, managing it surgically is the next consideration. In adults, greater use of surgically placed hardware to stabilize the spine provides optimal results. But in children the concern is that extensive placement of hardware will interfere with growth and development. There are certain methods that neurosurgeons can use to avoid this issue, and a neurosurgeon must be well versed in the most current research and techniques to balance the risks and rewards of this type of intervention.
Even after surgery, the differences between children and adults persist. Follow-up for a child who is continuously growing and developing is necessarily different than it is for an adult who has completed growth. A neurosurgeon needs to follow a child for a longer time to be sure that growth and development issues haven’t arisen.
Dr. Anderson regularly presents at events like the American Association of Neurological Surgeons to help other neurosurgeons become familiar with the latest information in pediatric spine care. The dissemination of valuable information from experts in the field helps ensure that all children receive the best care. This is particularly important in an area where the research is limited and families need a presence they can count on to guide them through the chaotic days after spinal cord injury.