MADRID — Every child admitted with trauma-related myelopathy should have magnetic resonance imaging of the spine, because x-rays may not show even serious spinal cord injuries.
The juvenile spinal cord is less resilient than the malleable youthful vertebrae and ligaments to withstand the forces of an injury, Dr. Michael Vassilyadi said at the annual congress of the European Federation of Neurological Societies.
The incidence of spinal cord injury without radiographic abnormality (SCIWORA) is low in children, but the consequences of missing such an injury can be devastating.
Dr. Vassilyadi conducted a retrospective review to determine the incidence of SCIWORA at the facility over a 15-year period. Because there is no universally accepted criteria for the SCIWORA, he defined it as traumatic myelopathy (objective sensorimotor or motor deficits) that is either transient (but of at least 24 hours' duration) or permanent without radiologic evidence of spinal injury (no vertebral fracture or ligament instability, with normal flexion and extension cervical spine x-rays).
From 1990 to 2005, 22 children presented at the hospital with trauma-related myelopathy.
Of these, eight had both a spinal cord and head injury; four had spine fracture and four did not. Of those with fractures, only two had abnormal x-rays.
Fourteen additional children had spinal cord injuries without head injury. Of these, 12 had spine fractures and 2 did not; both of these 2 had abnormal x-rays.
“That left us with just two patients who had SCIWORA,” said Dr. Vassilyadi, a neurosurgeon at the Children's Hospital of Eastern Ontario. The first patient had been tackled while playing football and sustained the hit on the left side of his head and neck. He presented with partial anterior cord syndrome, complaining of a left extremity parasthesis that lasted about 45 minutes and left extremity weakness that persisted for 2 or 3 days. Both his cervical-spine and thoracic-spine x-rays were normal, although he complained of pain to palpation in the area of the lower cervical spine.
An MRI showed a small central disc herniation between C5 and C6. This patient recovered with no neurologic deficits.
The second patient was a 12-year-old boy who was involved in a motor vehicle accident.
He was admitted with paraplegia and no sensation below T3, although all of his spine x-rays were negative.
An MRI showed increased signal intensity on T2-weighted images between T1 and T3.
Five years later, the boy was still paraplegic. An MRI at that time showed the cord in the upper thoracic area had developed multiple syrinxes that tracked the original injury.
Although this patient has not experienced significant improvement in his neurologic status, children do have remarkable recovery ability, and families should be counseled to keep an eye out for improvement, Dr. Vassilyadi commented.
“We give the kids at least 2 years [before determining an injury as permanent],” he said.
A normal spine x-ray (top) after a car accident: Serious damage became apparent only with an MRI (bottom). Images courtesy Dr. Michael Vassilyadi