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Traumaüc Spinal Cord Injury: Unusual Recovery in 3 Children M. Meuli 1, P. Sacher l , U. Lässer2, E. Boltshauser2 1Departrnent of Surgery (Director: Prof. Dr. U. G. Stauffer) and 2Department of Pediatric Neurology (Prof. Dr. E. Boltshauser), University Children's Hospital, Zürich
We report on 3 children with traumatic spinal cord injury. All of them had normal x-rays of the vertebral column. There were no abnormalities of the spinal cord in myelography or magnetic resonance imaging. Although these situations are often associated with a poor neurological prognosis, we observed very unusual recoveries in these 3 cases.
Keywords Spinal cord injury - SCIWORA syndrome, child, recovery
Resume Les auteurs rapportent sur trois enfants observes a la Clinique Chirurgicale pour un aspect de section traumatique de la moelle. Chez ces trois patients, aucune lesion de la colonne vertebrale ne put etre diagnostiquee a la radiographie. Il n'y avait pas non plus d'anomalie de la moelle epiniere a la myelographie ou ala resonnance magnetique nucleaire. Quoi que le pronostic soit mauvais en gene-
Introduction Traumatic paraplegia and tetraplegia in children are fortunately rare. The prognosis for these severe conditions, even in the absence of radiological abnormalities, is generally judged as poor. We report on 3 children with traumatic spinal cord syndrome without radiologically proven pathology of vertebral column or spinal cord (SCIWORA-syndrome = Spinal Cord Injury Without Radiographie Abnormalities). Each of these children made an almost full recovery.
ral nous avons observe dans ces trois cas une guerison absolument inhabituelle. Mots-cles Seetion traumatique de la moelle - Enfant Syndrome SCIWORA - Guerison Zusammenfassung Wir berichten über 3 Kinder, die an der Chirurgischen Klinik des Universitäts-Kinderspitals Zürich wegen einer traumatischen Querschnittslähmung behandelt wurden. Bei allen 3 Patienten konnte weder im Bereich der Wirbelsäule ein pathologischer Befund erhoben werden, noch ließ sich durch Myelographie bzw. Magnetresonanzuntersuchung ein morphologisches Korrelat im Bereich des Rückenmarkes darstellen. Obwohl die Prognose im allgemeinen schlecht ist, haben wir bei allen 3 Patienten eine ungewöhnliche Erholung beobachtet. Schlüsselwörter Traumatische Querschnittslähmung, Kind SCIWORA-Syndrom, Heilung
Case reports
Case 1 H. P., Age: 11 2/12, male The boy fell from a low height onto his back on the edge of a step and immediately lost sensibility and motor function in his lower extremities. On admission incomplete sensorimotor paraplegia at T8 was found. Conventional x-rays showed no pathological finding in the vertebral column. One and a half hours after the accident a reduction in the loss of sensibility and motility could be seen. Five hours later the symptoms had completely disappeared. The boy's neurological status was normal one month later.
Received January 5, 1991 Eur J Pediatr Surg 1 (1991) 240-241 C Hippokrates Verlag Stuttgart . Masson Editeur Paris
Diagnosis Commotio spinalis
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Summary
Eur J Pediatr Surg 1 (1991)
Traumatic Spinal Cord Injury: Unusual Recovery in 3 Children
K. 1., Age: 2 3/12, male The lower torso of the boy was pinned down by a rolling tree trunk. On admission thoraco-abdominal Perthes'compression-syndrome was diagnosed. His neurological status, apart from somnolence, was normal. Five hours after the accident total sensorimotor paraplegia at TI0 developed. Conventional x-rays showed no pathological findings. Myelography was also normal. 10 days after the accident there was a gradual resolution of the neurological deficits. Eight weeks after the accident there was a moderate spastic paraparesis; however, the patient could walk with assistance and was bladder and bowel continent. Fourteen months after the accident the patient could walk without difficulty, could run, hop, jump and climb.
Diagnosis Ischemic paraplegia due to thoraco-abdominal compression-trauma
Case 3 S. J., Age: 5 2/12, female About three hours after falling head-first down a 1.5 meter air shaft the girl developed an incomplete sensorimotor tetraplegia at C4. In addition she suffered from severe dyspnoea due to diaphragmatic paresis on the right. Conventional x-rays and CT scan of the cervical vertebrae showed 00 pathological findings. MRIinvestigations on the 3rd day after the accident and 3 weeks later also were normal. One week after the accident sensibility as weIl as bladder and bowel continence returned. At the same time there was gradual recovery of her motor function. Eight weeks after the accident she had a slight spastic hemisyndrome on the right and the patient could walk by help of a splint. One year after the accident the girl could walk without difficulty and could use her right hand nearly normally.
The full recovery in the patient with eommotio spinalis has to be interpreted as analogous to that of patients with commotio cerebri. The kinetic energy which is absorbed within fractions of a second causes tissue concussion which leads to transient funetional deficits. Temporary disorders of binding of neurotransmitters to the appropriate receptors may possibly playa role (5). Another explanation for the temporary functional deficits postulates a lengthened absolute refraction period for the affected axons (10). In the two patients with ischemic spinal cord injury and contusio spinalis respectively no abnormalities could be demonstrated in myelography, CT-scan nor MRI. Normal findings from myelography and MRI are known (2, 6). The absence of demonstrable findings can be explained by the fact that the pathophysiological processes are taking place on an electri· cal, chemical or ultra-structurallevel (5). The reasons for recovery are based on the largely reversible nerve cell damage; however, we were unable to find more exact information in the availahle literature. Although general experienee indicates that neurological recovery following traumatic spinal eord syndrome in children is poor, we suggest that the prognosis in the first few weeks after the aceident should be formulated with reservation of extensive recovery in exeeptional cases.
References 1 2
Andrews LG,]ung SK: Spinal cord injuries in children in British Columbia. Paraplegia 17 (1979) 442-451 Boltshauser E, Isler W, Bucher HU, Friderieh H: ·'Permanent flaccid paraplegia in children with thoracic spinal cord injury. Paraplegia 19 (1981) 227-234
Diagnosis
3
Spinal contusion without morphological correlate
Bucher HU, Boltshauser E, Friderkh ], Isler W: Traumatische Quersehnittslähmungen im Kindesalter. Schweiz med W sehr 110 (1980) 331-337
Burke DC: Spinal cord trauma in children. Proceedings of the Annual Scientific Meeting of the International Medical Society of Paraplegia held at Stoke Mandeville Hospital on July 22-24, 1970 5 Del Rigio MR, ]ohnson GE: Clinical presentation of spinal cord concussion. Spine 14 (1989) 37-39 6 Hadley MN, Zabramski JM, Browner CM, Rekate H, Sonntag VKH: Pediatric spinal trauma: Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg 68 (1988) 18-24 7 Pang D, Wilberger JEJr: Spinal cord injury without radiographie abnormalities in children. J Neurosurg 57 (1982) 114-129 8 Ruge]R, Sinson GP, MeLone DG, Cerullo LJ: Pediatric spinal injury: the very young. J Neurosurg 68 (1988) 25-30 9 Walsh JW, Stevens DB, Young AB: Traumatic paraplegia in children without contiguous spinal fracture or dislocation. Neurosurgery 12 4
Discussion
Traumatic spinal cord syndrome in ehildhood is fortunately rare (0.5-10 % of all patients) (8). The prognosis for these severe injuries, especially when no pathology of the vertebral column and spinal cord ean be demonstrated, is generally thought to be poor by most authors since eomplete or at least nearly complete neurological recovery has rarely been observed (1, 3,4,8,9). We report on 3 eases whieh contradiet this general experience in that complete or nearly complete neurological recovery was observed in all of them - in the case of commotio spinalis recovery began within hours, and in the other two cases within a few weeks. All patients demonstrated the SCIWORAsyndrome (Spinal Cord Injury Without Radiographie Abnormalities) . This syndrome occurs frequently in children whereas in adults it is rarely found (8). As is typical, neurological symptoms in two of our patients appeared after a delay of several hours (7, 8). In contrast to the reports whieh indicated a poor prognosis (7, 8), our patients demonstrated an unusual recovery.
(1983) 439-445 10
Zwimpfer T], Bernstein M: Spinal cord concussion. J Neurosurg 72 (1990) 894-900
Dr.M. Meuli
Chirurgische Klinik Universitäts-Kinderspital Zürich Steinwiesstraße 75 CH -8032 Zürich
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Case2
241
Traumaüc Spinal Cord Injury: Unusual Recovery in 3 Children M. Meuli 1, P. Sacher l , U. Lässer2, E. Boltshauser2 1Departrnent of Surgery (Director: Prof. Dr. U. G. Stauffer) and 2Department of Pediatric Neurology (Prof. Dr. E. Boltshauser), University Children's Hospital, Zürich
We report on 3 children with traumatic spinal cord injury. All of them had normal x-rays of the vertebral column. There were no abnormalities of the spinal cord in myelography or magnetic resonance imaging. Although these situations are often associated with a poor neurological prognosis, we observed very unusual recoveries in these 3 cases.
Keywords Spinal cord injury - SCIWORA syndrome, child, recovery
Resume Les auteurs rapportent sur trois enfants observes a la Clinique Chirurgicale pour un aspect de section traumatique de la moelle. Chez ces trois patients, aucune lesion de la colonne vertebrale ne put etre diagnostiquee a la radiographie. Il n'y avait pas non plus d'anomalie de la moelle epiniere a la myelographie ou ala resonnance magnetique nucleaire. Quoi que le pronostic soit mauvais en gene-
Introduction Traumatic paraplegia and tetraplegia in children are fortunately rare. The prognosis for these severe conditions, even in the absence of radiological abnormalities, is generally judged as poor. We report on 3 children with traumatic spinal cord syndrome without radiologically proven pathology of vertebral column or spinal cord (SCIWORA-syndrome = Spinal Cord Injury Without Radiographie Abnormalities). Each of these children made an almost full recovery.
ral nous avons observe dans ces trois cas une guerison absolument inhabituelle. Mots-cles Seetion traumatique de la moelle - Enfant Syndrome SCIWORA - Guerison Zusammenfassung Wir berichten über 3 Kinder, die an der Chirurgischen Klinik des Universitäts-Kinderspitals Zürich wegen einer traumatischen Querschnittslähmung behandelt wurden. Bei allen 3 Patienten konnte weder im Bereich der Wirbelsäule ein pathologischer Befund erhoben werden, noch ließ sich durch Myelographie bzw. Magnetresonanzuntersuchung ein morphologisches Korrelat im Bereich des Rückenmarkes darstellen. Obwohl die Prognose im allgemeinen schlecht ist, haben wir bei allen 3 Patienten eine ungewöhnliche Erholung beobachtet. Schlüsselwörter Traumatische Querschnittslähmung, Kind SCIWORA-Syndrom, Heilung
Case reports
Case 1 H. P., Age: 11 2/12, male The boy fell from a low height onto his back on the edge of a step and immediately lost sensibility and motor function in his lower extremities. On admission incomplete sensorimotor paraplegia at T8 was found. Conventional x-rays showed no pathological finding in the vertebral column. One and a half hours after the accident a reduction in the loss of sensibility and motility could be seen. Five hours later the symptoms had completely disappeared. The boy's neurological status was normal one month later.
Received January 5, 1991 Eur J Pediatr Surg 1 (1991) 240-241 C Hippokrates Verlag Stuttgart . Masson Editeur Paris
Diagnosis Commotio spinalis
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Summary
Eur J Pediatr Surg 1 (1991)
Traumatic Spinal Cord Injury: Unusual Recovery in 3 Children
K. 1., Age: 2 3/12, male The lower torso of the boy was pinned down by a rolling tree trunk. On admission thoraco-abdominal Perthes'compression-syndrome was diagnosed. His neurological status, apart from somnolence, was normal. Five hours after the accident total sensorimotor paraplegia at TI0 developed. Conventional x-rays showed no pathological findings. Myelography was also normal. 10 days after the accident there was a gradual resolution of the neurological deficits. Eight weeks after the accident there was a moderate spastic paraparesis; however, the patient could walk with assistance and was bladder and bowel continent. Fourteen months after the accident the patient could walk without difficulty, could run, hop, jump and climb.
Diagnosis Ischemic paraplegia due to thoraco-abdominal compression-trauma
Case 3 S. J., Age: 5 2/12, female About three hours after falling head-first down a 1.5 meter air shaft the girl developed an incomplete sensorimotor tetraplegia at C4. In addition she suffered from severe dyspnoea due to diaphragmatic paresis on the right. Conventional x-rays and CT scan of the cervical vertebrae showed 00 pathological findings. MRIinvestigations on the 3rd day after the accident and 3 weeks later also were normal. One week after the accident sensibility as weIl as bladder and bowel continence returned. At the same time there was gradual recovery of her motor function. Eight weeks after the accident she had a slight spastic hemisyndrome on the right and the patient could walk by help of a splint. One year after the accident the girl could walk without difficulty and could use her right hand nearly normally.
The full recovery in the patient with eommotio spinalis has to be interpreted as analogous to that of patients with commotio cerebri. The kinetic energy which is absorbed within fractions of a second causes tissue concussion which leads to transient funetional deficits. Temporary disorders of binding of neurotransmitters to the appropriate receptors may possibly playa role (5). Another explanation for the temporary functional deficits postulates a lengthened absolute refraction period for the affected axons (10). In the two patients with ischemic spinal cord injury and contusio spinalis respectively no abnormalities could be demonstrated in myelography, CT-scan nor MRI. Normal findings from myelography and MRI are known (2, 6). The absence of demonstrable findings can be explained by the fact that the pathophysiological processes are taking place on an electri· cal, chemical or ultra-structurallevel (5). The reasons for recovery are based on the largely reversible nerve cell damage; however, we were unable to find more exact information in the availahle literature. Although general experienee indicates that neurological recovery following traumatic spinal eord syndrome in children is poor, we suggest that the prognosis in the first few weeks after the aceident should be formulated with reservation of extensive recovery in exeeptional cases.
References 1 2
Andrews LG,]ung SK: Spinal cord injuries in children in British Columbia. Paraplegia 17 (1979) 442-451 Boltshauser E, Isler W, Bucher HU, Friderieh H: ·'Permanent flaccid paraplegia in children with thoracic spinal cord injury. Paraplegia 19 (1981) 227-234
Diagnosis
3
Spinal contusion without morphological correlate
Bucher HU, Boltshauser E, Friderkh ], Isler W: Traumatische Quersehnittslähmungen im Kindesalter. Schweiz med W sehr 110 (1980) 331-337
Burke DC: Spinal cord trauma in children. Proceedings of the Annual Scientific Meeting of the International Medical Society of Paraplegia held at Stoke Mandeville Hospital on July 22-24, 1970 5 Del Rigio MR, ]ohnson GE: Clinical presentation of spinal cord concussion. Spine 14 (1989) 37-39 6 Hadley MN, Zabramski JM, Browner CM, Rekate H, Sonntag VKH: Pediatric spinal trauma: Review of 122 cases of spinal cord and vertebral column injuries. J Neurosurg 68 (1988) 18-24 7 Pang D, Wilberger JEJr: Spinal cord injury without radiographie abnormalities in children. J Neurosurg 57 (1982) 114-129 8 Ruge]R, Sinson GP, MeLone DG, Cerullo LJ: Pediatric spinal injury: the very young. J Neurosurg 68 (1988) 25-30 9 Walsh JW, Stevens DB, Young AB: Traumatic paraplegia in children without contiguous spinal fracture or dislocation. Neurosurgery 12 4
Discussion
Traumatic spinal cord syndrome in ehildhood is fortunately rare (0.5-10 % of all patients) (8). The prognosis for these severe injuries, especially when no pathology of the vertebral column and spinal cord ean be demonstrated, is generally thought to be poor by most authors since eomplete or at least nearly complete neurological recovery has rarely been observed (1, 3,4,8,9). We report on 3 eases whieh contradiet this general experience in that complete or nearly complete neurological recovery was observed in all of them - in the case of commotio spinalis recovery began within hours, and in the other two cases within a few weeks. All patients demonstrated the SCIWORAsyndrome (Spinal Cord Injury Without Radiographie Abnormalities) . This syndrome occurs frequently in children whereas in adults it is rarely found (8). As is typical, neurological symptoms in two of our patients appeared after a delay of several hours (7, 8). In contrast to the reports whieh indicated a poor prognosis (7, 8), our patients demonstrated an unusual recovery.
(1983) 439-445 10
Zwimpfer T], Bernstein M: Spinal cord concussion. J Neurosurg 72 (1990) 894-900
Dr.M. Meuli
Chirurgische Klinik Universitäts-Kinderspital Zürich Steinwiesstraße 75 CH -8032 Zürich
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
Case2
241
