Paediatric Spinal Sub Guideline
Overview
Injuries to the spinal cord in paediatric patients are fortunately rare; however, they may be a component of multitrauma injuries or associated with traumatic brain injury. Spinal cord injury (SCI) in children is often the result of a road traffic accident, significant fall or mishap around water.
The spinal cord can be injured by transection, distraction, compression, bruising, haemorrhage or ischemia of the cord or by injury to blood vessels supplying the cord. These injuries can all result in permanent cord injury and may be complete or incomplete.
Concussion of the spinal cord can result in temporary loss of function for hours to weeks. Complete spinal cord injury presents with complete spinal cord dysfunction and frequently spinal shock and may indicate an irreversible injury. Incomplete injury indicates some sparing of spinal cord motor and or sensory function.
Management in the acute phase of injury is focussed on stabilisation and safe transfer to a facility offering advanced spinal care for children. The priorities for safe transfer include: preventing further injury to the spinal cord and bony structures; supporting the patient’s physiological functions when required; and protective manoeuvres for other injuries sustained; and protecting skin integrity.
Assessment
Primary assessment does not vary greatly from the standard model. The most immediate priorities and the primary threat to life are hypotension and hypoxia, which must be treated with appropriate intervention and management.
Airway, breathing and circulation assessments in the primary survey in SCI patients are unchanged from paediatric trauma assessment.
Secondary survey assessment should include assessment of sensory level and documentation of apparent motor deficits. These are crucial to communications with retrieval services and the Major Trauma Service providing subsequent further management of the patient.
Considerations
Two important outcomes of an SCI are neurogenic shock and spinal shock.
Neurogenic shock is seen in SCI at 6th thoracic vertebrae or above, typically occurring within 30 minutes of injury and lasting six to eight weeks following injury. It is a result of the loss of vasomotor and sympathetic nervous system tone or function. Its critical features are hypotension, bradycardia and poikilothermia (inability to maintain a constant core temperature independent of ambient temperature.)[1] Bradycardia in cervical cord injury may be spontaneous or provoked by artificial stimulation (e.g. pharyngeal suction) of tissues whose sensory functions are via the vagus and glossopharyngeal cranial nerves.
Spinal shock is a combination of loss of and decreased reflexes and autonomic dysfunction that accompanies SCI. Skeletal and smooth muscles are therefore flaccid from hours to weeks.
Significant spinal injury may still occur without fracture. SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) is an outdated term, but refers to a patient sustaining significant spinal injury without bony fractures. Therefore, a “normal” x-ray and CT does not exclude spinal injury. This occurs in children, predominantly less than eight years of age, and may be the result of lax ligamentous support and immature bony structures or cord ischemia due to vascular injury or hypoperfusion.
This may occur in 1% to 10% of all child spinal injury presentations.
Triage and transfer
Ambulance services should transport paediatric major trauma patients and suspected major trauma patients directly to the Royal Children’s Hospital when travel time is less than 45 minutes.
In Victoria, the Paediatric Infant Perinatal Emergency Retrieval (PIPER) service is available to retrieve critically injured children from referral hospitals and provide safe, expert, emergency inter-hospital retrieval. The earlier contact is made with PIPER, they earlier assistance can be dispatched to the hospital.
Management
Fluid resuscitation may be commenced at 10–20 mL/kg to replace relative hypovolaemia.
Atropine and adrenaline may assist in managing bradycardia in the first instance.
Bradycardia and hypotension may be significant. This is a highly specialised area of management. In any patient where SCI is suspected, and specifically in any patient manifesting signs of spinal shock – PIPER should be contacted without delay to provide specific assistance with inotropes/vasoactive agents and /or sedation.
See guide: American Spinal Injury Association classifications of spinal cord injury.