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    Regarding children with SCI

    Doctor Young
    Is there research regarding the different reaction of children bodies in comparison with adult bodies?. The growth of the body, and, I imagine, of the spinal cord – that should get longer and larger -, does have an effect on function and recovery? I think a child cord should contain many less axons than an adult one. So what happens when other axons grow naturally as an effect of body enlargement? Or am I totally wrong?. One doc told me that my 6 y.o. son injury, at C7-8 level, indeed had effects as a T5-6 lesions because children cord is more than proportionally shorter than the adult one? Is that true?


    You are asking very good questions for which relatively few good answers are available. Over the years, I have tried hard to keep up with the literature on this subject and have some biases based on personal experience. I will try to summarize the literature in an article below.


    Spinal Cord Injury in Children versus Adults
    Wise Young, Ph.D., M.D.
    W. M. Keck Center for Collaborative Neuroscience, Rutgers University, Piscataway, NJ
    10 December 2006

    Many scientists and doctors assume that children recover better from spinal cord injury than adults, because of the greater plasticity of their spinal cords. The extent to which is true is unclear. I therefore reviewed recently published studies of recovery in children and adults after spinal cord injury. At least for me, the results are not yet convincing that children recover better than adults.

    Relatively few children get spinal cord injury. Children (<16 years old) account for only about 10% of spinal cord injuries in the United States (Source). This may be partly due to three reasons. First, there are fewer children than adults. Second, children are smaller. There may be truth to the old adage: the bigger you are, the harder you fall. Kids fall all the time without apparent harm. Third, the young spinal column is more elastic and flexible than the adult spinal cord (Source). There is a higher incidence of SCIWORA or "spinal cord injury without radiographic abnormality" in kids (Liao, et al., 2005). As many as 40% of spinal cord injuries in children may be due to SCIWORA (Marinier, et al., 1997).

    Spinal cord injury in the prenatal, perinatal, and neonatal periods are quite rare. For example, Ruggieri, et al. (1999) sent questionnaires to pediatric neurologists, urologists, and neonatologists in the UK and Ireland. They identified 51 perinatal cases of spinal cord injury (33 males, 17 females, one unknown) occurring between 1972-1996. Outcome data were available for 47 cases: 9 (19%) died within 20 months. In 40 cases where neurological outcomes were known, one (2.5%) recovered completely, 26 were paraparetic (65%), 13 were tetraparetic (32%), and 17 of 39 recovered ambulation (44%). Babies that were spinal-injured before they walk may have a much more difficult time learning to walk.

    Evaluating recovery of children from traumatic spinal cord injury is complicated by the presence of head injuries. Partrick, et al. (2000) had reported a 13% mortality rate in children with cervical spinal cord injury. Eleraky, et al. (2000) likewise found a mortality rate of 16% in a retrospective study of 102 cases (65% boys, 35% girls). In adults, the mortality rate is about 5%. The explanation may be that some 40% of the pediatric spinal cord cases are associated with head injury. Young children (<10 years old) usually have more neurological injuries than older children and most get cervical spinal injuries. Meyer, et al. (2005) reported that high cervical injuries in children are often associated with brainstem injuries.

    Children with spinal cord injury are often severely disabled. Polinder, et al. (2005) published an extensive study of the prevalence and prognostic factors for disability after childhood injury. They analyzed the long-term followup of 1221 injured children aged 5-14 years of age. As one might expect, injuries of the spinal cord and peripheral nerves had worse outcomes than broken bones. Surprisingly, girls have a 3-fold greater risk than boys for long-term disability after childhood injuries. While there are a few reports of children who have recovered "completely" from spinal cord injury (Sakayama, et al. 2005), such reports are rare and usually associated with children with incomplete spinal cord injuries.

    Many children do not recover significantly when the spinal cord injury is evident on MRI, particularly when hemorrhage is present in the spinal cord. Johnston, et al. (2005) found that the ASIA classification is a good independent predictor of lower extremity function in children. Launay, et al. (2005) assessed the outcomes of 392 published cases of SCIWORA (90% pediatric) and found that 44% of the patients did not recover and good recovery occurred in only 29% of the population. Pang, et al. (2005) reported that MRI findings after SCIWORA were highly predictive of recovery. Children with major hemorrhage had "profoundingly poor outcome" while 40% with "minor hemorrhage" had improved recovery. However, 75% of those with "only edema" recovered substantially and 25% of these became normal. Elrai, et al. (2006) found similar results in 7 children with SCIWORA, reporting 2 with complete recovery but 5 showed “lack of significant neurological recovery". Liao, et al. (2005) reviewed 9 cases of SCIWORA in children younger than 8 years old and found that the presence of MR evidence of spinal cord lesions was associated with “permanent deficits with functional disability”.

    Children who present with severe motor deficits due to spinal cord compression by tumors (neuroblastoma) seldom recover significantly. De Bernardi, et al. (2001) reviewed the recovery of 76 cases of children who had spinal cord compression due to neuroblastoma. Ten patients presented with severe (or developing) motor deficits and none recovered significant neurological function, compared to full neurological recovery in 33 of the 76 patients who did not have severe motor deficits at the time of operation. Many (44%) of the patients showed late complications, including scoliosis and continued bowel and bladder dysfunction. Hoover, et al. (1999) likewise found a low incidence of neurologic recovery in children with neuroblastoma compression of the spinal cord associated with motor deficits at the time of surgery. Of 26 cases, 24 were alive and disease-free 2-29 years after surgery. Those who had mild to moderate deficits at the time of surgery recovered neurologic function but those who had severe motor deficits associated with longstanding severe cord compression seldom recovered.

    Some investigators, however, have reported better recovery in children with spinal cord injury. Carreon, et al. (2004) reviewed 137 hospital admissions for pediatric spine fractures in Louisville, KY. Only 19% had spinal cord injury. Of the 21 "complete" neurologic injuries in the series, 13 improved. This is better recovery than would be expected from adults with “complete” injuries. Wang, et al. (2004) studied neurological improvement in 91 children after severe traumatic spinal cord injury. Of 20 patients who had ASIA A (complete), 7 died, 7 had no neurologic recovery, and 6 experienced neurological recovery with 5 of these becoming ambulatory over a 4-50 week period. Cakir, et al. (2004) described a case of a 9-year old female child who had a thoracic epidural hematoma for 3 days and made a full recovery within 2 weeks after decompression. Patrick, et al (2000) described 52 children with traumatic cervical spinal cord injury, finding an overall mortality rate of 13%. On long-term followup of 18 of the children, 17 (94%) were able to communicate independently, 14 (78%) fed themselves independently, and 12 (67%) were able to achieve independent locomotion.

    Certain functions, however, don't seem to recover in a majority of children. For example, Tanaka, et al. (2006) described the long-term urological outcomes of 22 children who had transverse myelitis. At 7 years after, 86% of the children had persistent bladder dysfunction and 77% had persistent bowel dysfunction. A significant proportion of the patients develop scoliosis. For example, Hoover, et al., (1999) reported that 11 out of 15 children who had laminectomies for treatment of neuroblastoma compression of the spinal cord developed scoliosis, compared to only 4 of 11 children who did not have laminectomies. Scoliosis and residual bladder dysfunction are common in children with spinal cord injury.

    A few studies suggest that children do recover better from other types of neurological injuries. For example, Anand & Birch (2002) described 16 of 24 young patients (ages 3-23) who had severe brachial plexus avulsion who had substantial recovery, apparently considerably better than adult brachial plexus injuries. Carlstedt, et al. (2004) described a case of a 9-year old boy who sustained a complete right-sided C5-T1 brachial plexus avulsion injury who received spinal cord implantation peripheral nerves at 4 weeks. They observed good recruitment of regenerated motor units in all parts of the arm, with some co-contractions and also respiration evoked muscle activity (so-called “breathing arm”), but with restoration of arm function.

    Do young adults recover more than older adults after spinal cord injury? Scivoletto, et al. (2003) studied the effects of age on recovery from spinal cord injury, examining 284 consecutive newly injured patients in Italy, using a block design to control for injury severity. They found that older subjects had a higher probability of incomplete tetraplegia of non-traumatic origin, shorter length of stay, and a higher rate of complications. Young subjects showed better neurologic recovery with significantly less disability and a higher level of independence in spontaneous bladder and bowel management, and a higher frequency of independent walking.

    In the only study of its kind, Huang, et al. (2003) found no significant effect of age on neurological changes in 171 patients after intraspinal implantations of olfactory ensheathing cells and compared the recoveries of patients in each decade of age from <20 years, 21-30, 31-40, 41-50, and >51 years. Older patients seem to recover as much motor score (5-8 motor points) as younger patients. Surprisingly, restoration of pinprick sensation was better in older patients >51 years of age than any other age group except for 21-30 year-old. This seems to suggest that age is not a good predictor of neurological recovery after cell transplantation in chronic spinal cord injury.

    There is general agreement that "complete" traumatic spinal cord injury indicate a poor prognosis for significant spontaneous recovery, regardless of age. For example, Scivoletto, et al. (2004) found that only 2 of 84 subjects with ASIA A recovered to ASIA D compared to 71 of 129 who recovered to ASIA D from ASIA C on admission. Fisher, et al. (2005) examined patients admitted to Vancouver hospital with a "complete SCI" between 1994 and 2001. Of 133 patients identified, 70 had 2-year followup examinations and they concluded that "motor recovery does not occur below the zone of injury for patients with complete spinal cord injury" although varying degrees of local recovery could be expected for tetraplegic individuals.

    Both children and adults with "incomplete" spinal cord injuries recover substantially. The incidence of "incomplete spinal cord injury" seems to be increasing in the United States (Calancie, et al., 2005) and around the world. Kuptniratsaikul (2003) studied 83 patients with spinal cord injury in Bangkok, finding that 34 (41%) had ASIA D, 28 (33.7%) were paraplegic and 21 (25.3%) were tetraplegic with ASIA A, B, or C. In Turkey, Muslumanoglu, et al. (1997) described 45 cases of spinal cord injury due to trauma. Of 28 paraplegics, only 6 (20%) were “complete”. Of 24 tetraplegics, only 9 (38%) were “complete”. SCIWORA is more common in children than adults. While SCIWORA is relatively rare in adults, it appears to be associated with a high rate of recovery. For example, in India, Bhatoe, et al. (2000) described 17 cases of adult SCIWORA without accompanying fractures of the spinal canal rim or vertebral dislocation. All the patients had weakness of all four limbs and showed spinal cord changes on MRI scans. With conservative management 15 (88%) showed neurological improvement, 1 (6%) remained quadriplegic, and 1 died.

    Since publication of the second and third NASCIS studies (Bracken, 2001; Bracken, et al., 2003; Bracken, et al. 1997; Bracken, et al. 1990), many spinal cord injury centers have used high-dose methylprednisolone to treat acute traumatic spinal cord injury. Some centers have reported an increase in the incidence of good recovery after “complete” spinal cord. For example, Gabler & Maier (1995) reported that of 31 patients with spinal cord injury given methylprednisolone between 1991 and 1993, 100% of those with “incomplete” injuries showed significant recovery and even 3 of 13 (23.1%) patients with initial “complete” tetraplegia showed “nearly entire recovery”. Unfortunately, it seems that children with spinal cord injury do not often get methylprednisolone. For example, the Wang, et al. (2004) study reported that only 8 of 30 (27%) children with spinal cord injury received methylprednisolone at the Children’s Hospital of Los Angeles between 1993-2001.

    Methylprednisolone treatment of spinal cord injury even in adults has been inconsistent. One study suggests that most emergency rooms in the state of Colorado do treat acute spinal cord injuries with methylprednisolone (Peter Vellman, et al., 2003) but McCutcheon, et al. (2004) reported that only 48.7% of 1,227 randomly selected patients with traumatic spinal cord injury received high-dose methylprednisolone in South Carolina between 1993 and 2001. In Germany, Botel, et al. (1997) reported that only 64.4% of patients arrived within the 8-hour time frame for methylprednisolone treatment. In Ireland, O’Connor, et al. (2003) found that of 196 patients admitted to hospital during a one year period, only 14% received intravenous methylprednisolone and only 6 received the correct dose and for the appropriate duration.

    Some investigators have suggested that non-traumatic spinal cord injuries may be associated with better neurologic recovery in adults. For example, Catz, et al. (2004) studied the neurological recovery of 1,084 cases of non-traumatic spinal cord injuries in Israel and found complete of substantial recovery (Frankel D or greater) in 51% of patients who were grade A, B, or C on admission, better than would be expected for traumatic spinal cord injuries. Catz, et al. (2002) had previously examined the recovery of 250 traumatic SCI patients in Israel, finding that 27% of patients with A, B, or C on admission and 54% of those with grade C recovered to Frankel D. De Seze, et al. (2003) examined the functional prognosis of 23 patients with spinal cord ischemia, finding that lack of extension of ischemic injury to the medullary core predicted better functional recovery. Care, however, must be taken to correct the statistical analyses for differences in age, gender, and injury severity between traumatic and non-traumatic cases. Pagliacci, et al., (2003) compared traumatic and non-traumatic spinal cord injuries. In 1014 patients, 67.5% were due to traumatic causes and 32.5% were due to non-traumatic cuases. The traumatic injuries tended to be younger (median 34 years old versus 58), had a higher probability of cervical involvement (2.47x higher probability), and were more severely injured (3.0x higher probability of complete injury). One report suggested that women recover better than men (Sipski, et al. 2004).

    Comparisons of recovery by children and adults are tenuous because of the difficulties of standardizing injury severity. Because of their smaller size and more flexible spinal columns, children generally do not get as severe spinal cord injuries as adults. In children who have spinal cord injuries that are evident on MRI scans, particularly associated with hemorrhage in the spinal cord, their prognosis for recovery do not appear to be significantly better than adults. Likewise, children who present with severe motor deficits due to tumor compression of the spinal cord do not recover very much. Children with spinal cord injury are also prone to long-term urological dysfunction and scoliosis. Although a few investigators have claimed that children recover better from spinal cord injury, these are based on small series and anecdotal cases. Due to the difficulty of neurological examination in children, classification of initial injury severity is unreliable. So, it is not clear that children recover better from spinal cord injury than adults.

    In summary,[list][*] Relatively few children get spinal cord injury, accounting only 10% of the annual incidence of spinal cord injury in the United States. Perinatal spinal cord injuries are very rare. [*] Evaluating recovery of children from spinal cord injury is complicated by the the presence of head injury in 40% of the cases, particularly in young children.[*] When spinal cord injury was clearly present on MRI scans, particularly hemorrhage in the spinal cord, most children do not recover significantly, similar to adults. [*] Children do not recover well from non-traumatic spinal cord injuries, such as from tumors compressing the cord. If they present with severe motor deficits, they do not recovery very much. [*] Residual urological dysfunction and progressive scoliosis are common in children after spinal cord injury and spinal surgery, particularly laminectomy. [*] Some investigators, have reported better recovery in children with spinal cord injury and brachial plexus injuries but these were small series or anecdotal cases.[*] Over 50% of adults and children recover substantial function including locomotion after "incomplete" spinal cord injuries. Only 5% of those with "complete" spinal cord injury recover significantly. [*] Confirmation of neurologically "complete" spinal cord injury are difficult in children, particularly in very young children. This may account for apparently "better" recovery of some children from spinal cord injury. [*] Evidence for better recovery of young adults from spinal cord injury is limited and difficult to interpret due to differences in both cause and severity of injury. [*] Initial neurological loss is the best predictor of recovery. Only 5% of adults with initial ASIA A recover to ASIA D compared to over 55% of those with initial ASIA C injuries. This appears to be similar in children. [*] Methylprednisolone treatment may contribute to differences between adult and children since fewer children receive methylprednisolone (20%) compared to adults (>50%). [*] Adults may recover more function after non-traumatic spinal cord injuries than those due to trauma in adults but many factors may play a role in this difference. [*] The evidence for better recovery by children from spinal cord injuries is not convincing.

    References Cited
    1. Anand P and Birch R (2002). Restoration of sensory function and lack of long-term chronic pain syndromes after brachial plexus injury in human neonates. Brain 125: 113-22. Obstetric complications are a common cause of brachial plexus injuries in neonates. Failure to restore sensation leads to trophic injuries and poor limb function. It is not known whether the infant suffers chronic neuropathic or spinal cord root avulsion pain; in adults, chronic pain is usual after spinal root avulsion injuries, and this is often intractable. The plexus is repaired surgically in severe neonatal injures; if no spontaneous recovery has occurred by 3 months, and if neurophysiological investigations point to poor prognosis, then nerve trunk injures are grafted, while spinal cord root avulsion injuries are treated by transferring an intact neighbouring nerve (e.g. intercostal) to the distal stump of the damaged nerve, in an attempt to restore sensorimotor function. Using a range of non-invasive quantitative measures validated in adults, including mechanical, thermal and vibration perception thresholds, we have assessed for the first time sensory and cholinergic sympathetic function in 24 patients aged between 3 and 23 years, who had suffered severe brachial plexus injury at birth. While recovery of function after spinal root avulsion was related demonstrably to surgery, there were remarkable differences from adults, including excellent restoration of sensory function (to normal limits in all dermatomes for at least one modality in 16 out of 20 operated cases), and evidence of exquisite CNS plasticity, i.e. perfect localization of restored sensation in avulsed spinal root dermatomes, now presumably routed via nerves that had been transferred from a distant spinal region. Sensory recovery exceeded motor or cholinergic sympathetic recovery. There was no evidence of chronic pain behaviour or neuropathic syndromes, although pain was reported normally to external stimuli in unaffected regions. We propose that differences in neonates are related to later maturation of injured fibres, and that CNS plasticity may account for their lack of long-term chronic pain after spinal root avulsion injury. Peripheral Neuropathy Unit, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, UK.
    2. Bhatoe HS (2000). Cervical spinal cord injury without radiological abnormality in adults. Neurol India 48: 243-8. Spinal cord injury occurring without concomitant radiologically demonstrable trauma to the skeletal elements of the spinal canal rim, or compromise of the spinal canal rim without fracture, is a rare event. Though documented in children, the injury is not very well reported in adults. We present seventeen adult patients with spinal cord injury without accompanying fracture of the spinal canal rim, or vertebral dislocation, seen over seven years. None had preexisting spinal canal stenosis or cervical spondylosis. Following trauma, these patients had weakness of all four limbs. They were evaluated by MRI (CT scan in one patient), which showed hypo / isointense lesion in the cord on T1 weighted images, and hyperintensity on T2 weighted images, suggesting cord contusion or oedema. MRI was normal in two patients. With conservative management, fifteen patients showed neurological improvement, one remained quadriplegic and one died. With increasing use of MRI in the evaluation of traumatic myelopathy, such injuries will be diagnosed more often. The mechanism of injury is probably acute stretching of the cord as in flexion and torsional strain. Management is essentially conservative and prognosis is better than that seen in patients with fracture or dislocation of cervical spine. Department of Neurosurgery, Command Hospital (Central Command), Lucknow, 226002, India.
    3. Botel U, Glaser E and Niedeggen A (1997). The surgical treatment of acute spinal paralysed patients. Spinal Cord 35: 420-8. Following the basic principles of Sir Ludwig Guttmann in respect of the comprehensive care and management of spinal cord injured patients, the German SCI centers try to admit those freshly injured preferably on the first day of onset, providing spinal surgery and intensive care. In our series of recent comprehensive spinal paralysed patients admitted from Jan 1st 1993 to Dec 31st 1995 178 patients requested operative decompression and stabilization out of a total of 255 patients. 51.4% of the patients had been operated within the first 24 h, but 10.5% later than 2 weeks. A high incidence of reoperations (45.2%) must be noted in cases operated prior to the admittance to the SCI center due to failures of instrumentation or lack of anterior reconstruction. Nineteen patients with various spinal tumors underwent surgical treatment, and seven patients with spondylitis and severe neurological deficit. Only 64.4% of the 1st day admissions came in time for administration of high dose methylprednisolone according to the NASCIS II study. The additional pelvic and long bone fractures were operated on following the principles of the Swiss AO, thus achieving immediate mobilization as was also possible after surgical spine stabilization. Neurological recovery could only be found in those with incomplete lesions in more than 50% but also two with neurological deterioration had to be accepted in the paraplegic cohort. Eight who were tetraplegic and 14 with paraplegia died within the first 3 months, but nine with paraplegia had a tumor or spondylitis. Department of Neurotraumatology and Spinal Cord Injuries, BG Kliniken Bergmannsheil, University Hospital, Bochum, Germany.
    4. Bracken MB (2001). Methylprednisolone and acute spinal cord injury: an update of the randomized evidence. Spine 26: S47-54. OBJECTIVES: Randomized trials are widely recognized as providing the most reliable evidence for assessing efficacy and safety of therapeutic interventions. This evidence base is used to evaluate the current status of methylprednisolone (MPSS) in the early treatment of acute spinal cord injury. METHODS: Medline, CINAHL, and other specified databases were searched for MeSH headings "methylprednisolone and acute spinal cord injury." The Cochrane Library and an existing systematic review on the topic were also searched. RESULTS: Five randomized controlled trials were identified that evaluated high-dose MPSS for acute spinal cord injury. Three trials by the NASCIS group were of high methodologic quality, and a Japanese and French trial of moderate to low, methodologic quality. Meta-analysis of the final result of three trials comparing 24-hour high-dose MPSS with placebo or no therapy indicates an average unilateral 4.1 motor function score improvement (95% confidence interval 0.6-7.6, P = 0.02) in patients treated with MPSS. This neurologic recovery is likely to be correlated with improved functional recovery in some patients. The safety of this regimen of MPSS is evident from the spinal cord injury trials and a systematic review of 51 surgical trials of high-dose MPSS. CONCLUSION: High-dose MPSS given within 8 hours of acute spinal cord injury is a safe and modestly effective therapy that may result in important clinical recovery for some patients. Further trials are needed to identify superior pharmacologic therapies and to test drugs that may sequentially influence the postinjury cascade. Department of Epidemiology, Yale University School of Medicine, 60 College Street, New Haven, Connecticut 06520, USA.
    5. Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS, Eisenberg HM, Flamm E, Leo-Summers L, Maroon J and et al. (1990). A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 322: 1405-11. Studies in animals indicate that methylprednisolone and naloxone are both potentially beneficial in acute spinal-cord injury, but whether any treatment is clinically effective remains uncertain. We evaluated the efficacy and safety of methylprednisolone and naloxone in a multicenter randomized, double-blind, placebo-controlled trial in patients with acute spinal-cord injury, 95 percent of whom were treated within 14 hours of injury. Methylprednisolone was given to 162 patients as a bolus of 30 mg per kilogram of body weight, followed by infusion at 5.4 mg per kilogram per hour for 23 hours. Naloxone was given to 154 patients as a bolus of 5.4 mg per kilogram, followed by infusion at 4.0 mg per kilogram per hour for 23 hours. Placebos were given to 171 patients by bolus and infusion. Motor and sensory functions were assessed by systematic neurological examination on admission and six weeks and six months after injury. After six months the patients who were treated with methylprednisolone within eight hours of their injury had significant improvement as compared with those given placebo in motor function (neurologic change scores of 16.0 and 11.2, respectively; P = 0.03) and sensation to pinprick (change scores of 11.4 and 6.6; P = 0.02) and touch (change scores, 8.9 and 4.3; P = 0.03). Benefit from methylprednisolone was seen in patients whose injuries were initially evaluated as neurologically complete, as well as in those believed to have incomplete lesions. The patients treated with naloxone, or with methylprednisolone more than eight hours after their injury, did not differ in their neurologic outcomes from those given placebo. Mortality and major morbidity were similar in all three groups. We conclude that in patients with acute spinal-cord injury, treatment with methylprednisolone in the dose used in this study improves neurologic recovery when the medication is given in the first eight hours. We also conclude that treatment with naloxone in the dose used in this study does not improve neurologic recovery after acute spinal-cord injury. Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06510.
    6. Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M, Fehlings M, Herr DL, Hitchon PW, Marshall LF, Nockels RP, Pascale V, Perot PL, Jr., Piepmeier J, Sonntag VK, Wagner F, Wilberger JE, Winn HR and Young W (1997). Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. Jama 277: 1597-604. OBJECTIVE: To compare the efficacy of methylprednisolone administered for 24 hours with methyprednisolone administered for 48 hours or tirilazad mesylate administered for 48 hours in patients with acute spinal cord injury. DESIGN: Double-blind, randomized clinical trial. SETTING: Sixteen acute spinal cord injury centers in North America. PATIENTS: A total of 499 patients with acute spinal cord injury diagnosed in National Acute Spinal Cord Injury Study (NASCIS) centers within 8 hours of injury. INTERVENTION: All patients received an intravenous bolus of methylprednisolone (30 mg/kg) before randomization. Patients in the 24-hour regimen group (n=166) received a methylprednisolone infusion of 5.4 mg/kg per hour for 24 hours, those in the 48-hour regimen group (n=167) received a methylprednisolone infusion of 5.4 mg/kg per hour for 48 hours, and those in the tirilazad group (n=166) received a 2.5 mg/kg bolus infusion of tirilazad mesylate every 6 hours for 48 hours. MAIN OUTCOME MEASURES: Motor function change between initial presentation and at 6 weeks and 6 months after injury, and change in Functional Independence Measure (FIM) assessed at 6 weeks and 6 months. RESULTS: Compared with patients treated with methylprednisolone for 24 hours, those treated with methylprednisolone for 48 hours showed improved motor recovery at 6 weeks (P=.09) and 6 months (P=.07) after injury. The effect of the 48-hour methylprednisolone regimen was significant at 6 weeks (P=.04) and 6 months (P=.01) among patients whose therapy was initiated 3 to 8 hours after injury. Patients who received the 48-hour regimen and who started treatment at 3 to 8 hours were more likely to improve 1 full neurologic grade (P=.03) at 6 months, to show more improvement in 6-month FIM (P=.08), and to have more severe sepsis and severe pneumonia than patients in the 24-hour methylprednisolone group and the tirilazad group, but other complications and mortality (P=.97) were similar. Patients treated with tirilazad for 48 hours showed motor recovery rates equivalent to patients who received methylprednisolone for 24 hours. CONCLUSIONS: Patients with acute spinal cord injury who receive methylprednisolone within 3 hours of injury should be maintained on the treatment regimen for 24 hours. When methylprednisolone is initiated 3 to 8 hours after injury, patients should be maintained on steroid therapy for 48 hours.
    7. Cakir E, Karaarslan G, Usul H, Baykal S, Kuzeyli K, Mungan I, Yazar U, Peksoylu B, Aynaci M and Cakir F (2004). Clinical course of spontaneous spinal epidural haematoma mimicking Guillain-Barre syndrome in a child: a case report and literature review. Dev Med Child Neurol 46: 838-42. We describe a 9-year-old female with thoracic epidural haematoma. The clinical course simulated Guillain-Barre syndrome (GBS) so intravenous immunoglobulin therapy was started at the paediatric clinic. Magnetic resonance imaging (MRI) 3 days after admission showed thoracic epidural haematoma between T2 and T8. An emergency laminectomy was performed and the patient's neurological symptoms began to improve immediately after surgery and she made a full recovery during the 2 weeks of follow-up. Time is a very important factor in achieving reversibility of symptoms of compressive cord lesions, such as spinal epidural haematoma, and MRI is mandatory for patients with progressive paraplegia, even though the signs and symptoms might suggest GBS. Technical University School of Medicine, Trabzon, Turkey.
    8. Calancie B, Molano MR and Broton JG (2005). Epidemiology and demography of acute spinal cord injury in a large urban setting. J Spinal Cord Med 28: 92-6. OBJECTIVE: In a large, single-center study of subjects with acute traumatic spinal cord injury (SCI), we describe the sample population with respect to gender, age, cause of injury, and severity of injury, to see whether these properties are similar to those of other large-scale studies of acute SCI conducted in the past. METHODS: As part of a study to examine the natural pattern of recovery after acute SCI (presented elsewhere), descriptive information was gathered in relation to subject population and injury properties. RESULTS: A total of 229 subjects were recruited. The study population had a higher percentage of women and a higher mean age of men and women than those of most other published studies of acute SCI. A greater percentage of incomplete subjects was also encountered. The incidence of gunshot injury as a cause of SCI was considerably lower in this study than had been the case 10 years previously in Dade County, Florida. CONCLUSIONS: The demography of acute SCI within a major urban center of South Florida suggests a trend toward less severe injury than in years past. These findings support the development of animal models for testing SCI treatment that include cohorts having mild to moderate injury severity, in order to achieve greater clinical relevance. The Miami Project to Cure Paralysis, Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida 13210, USA.
    9. Carlstedt T, Anand P, Htut M, Misra P and Svensson M (2004). Restoration of hand function and so called "breathing arm" after intraspinal repair of C5-T1 brachial plexus avulsion injury. Case report. Neurosurg Focus 16: E7. This 9-year-old boy sustained a complete right-sided C5-T1 brachial plexus avulsion injury in a motorcycle accident. He underwent surgery 4 weeks after the accident. The motor-related nerve roots in all parts of the avulsed brachial plexus were reconnected to the spinal cord by reimplantation of peripheral nerve grafts. Recovery in the proximal part of the arm started 8 to 10 months later. Motor function was restored throughout the arm and also in the intrinsic muscles of the hand by 2 years postoperatively. The initial severe excruciating pain, typical after nerve root avulsions, disappeared completely with motor recovery. The authors observed good recruitment of regenerated motor units in all parts of the arm, but there were cocontractions. Transcranial magnetic stimulation produced response in all muscles, with prolonged latency and smaller amplitude compared with the intact side. There was inspiration-evoked muscle activity in proximal arm muscles--that is, the so-called "breathing arm" phenomenon. The issues of nerve regeneration after intraspinal reimplantation in a young individual, as well as plasticity and associated pain, are discussed. To the best of the authors' knowledge, the present case demonstrates, for the first time, that spinal cord surgery can restore hand function after a complete brachial plexus avulsion injury. The Periphery Nerve Injury Unit, The Royal National Orthopaedic Hospital, Stanmore, United Kingdom.
    10. Carreon LY, Glassman SD and Campbell MJ (2004). Pediatric spine fractures: a review of 137 hospital admissions. J Spinal Disord Tech 17: 477-82. OBJECTIVE: The anatomy and biomechanics of the growing spine produce failure patterns different from those in adults. Spinal injury in the pediatric patient is a concern as prevention of further neurologic damage and deformity and the good potential for recovery make timely identification and appropriate treatment of such injury critical. A retrospective clinical case series was conducted to present data from a large series of pediatric patients with spine injuries from a single regional trauma center. METHODS: One hundred thirty-seven children with spine injuries were seen over 10 years and were divided into three age groups: 0-9, 10-14, and 15-17 years. Analysis of variance and chi2 were used to analyze differences between groups. RESULTS: There were 36 patients aged 0-9, 49 aged 10-14, and 52 aged 15-17. Spine injury incidence increased with age. Motor vehicular accidents were the most common cause in this series. There were 36% cervical, 34% thoracic, 29% lumbar, 34% multilevel contiguous, and 7% multilevel noncontiguous involvement. Nineteen percent had spinal cord injury. Thirteen of 21 complete neurologic injuries and all 3 incomplete injuries improved. Cord injury was more common in the 0-9 age group. Four of five patients with spinal cord injury without radiographic abnormality (SCIWORA) were in the 0-9 age group and had complete neurologic injuries. Young children with cervical injuries were more likely to die than older children. Fifty-three percent had associated injuries. Eighteen percent underwent decompression, fusion, and instrumentation. Two patients developed scoliosis. The complication rate in surgical patients was higher than in patients treated nonsurgically and in polytrauma patients. This may be related to the severity of the initial injury. CONCLUSIONS: Our results suggest age-related patterns of injury that differ from previous work. The incidence of cord injury is 20% with higher frequencies in the young child. Potential for neurologic recovery is good. Young children have a higher risk for death than older children. There was no predominance of cervical injuries in the young child. The incidence of SCIWORA was low. Higher complication rates were seen in polytrauma and surgical patients. Leatherman Spine Center, Louisville, Kentucky 40202, USA.
    11. Catz A, Goldin D, Fishel B, Ronen J, Bluvshtein V and Gelernter I (2004). Recovery of neurologic function following nontraumatic spinal cord lesions in Israel. Spine 29: 2278-82; discussion 2283. STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess neurologic recovery and the manner in which it is affected by various factors following nontraumatic spinal cord lesions (NTSCLs). SUMMARY OF BACKGROUND DATA: NTSCLs comprise a considerable portion of spinal cord lesions. However, information about neurologic recovery in these lesions is scarce. METHOD: The study sample included 1,085 patients with NTSCL treated between 1962 and 2000 at the premier referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from hospital charts. The degree of neurologic recovery was determined by comparing each patient's Frankel grades of neurologic deficit at first admission to rehabilitation and at discharge from the same hospitalization. The study population was also compared with previously studied 250 patients with traumatic spinal cord lesions (TSCLs). RESULTS: Complete or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred during rehabilitation in 51% of patients who were Grade A, B, or C on admission, and in 57% of those who were Grade C. Neurologic recovery in NTSCL during rehabilitation was significantly affected by initial Frankel grade and by NTSCL etiology. Age had a borderline effect. Gender, lesion level, and the decade of rehabilitation did not affect recovery. Recovery rate was usually higher in NTSCLs than in TSCLs. CONCLUSIONS: The prognosis for neurologic recovery is affected mainly by SCL severity and etiology, and is usually better in NTSCLs than in TSCLs. Department IV, Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel.
    12. Catz A, Thaleisnik M, Fishel B, Ronen J, Spasser R, Folman Y, Shabtai EL and Gepstein R (2002). Recovery of neurologic function after spinal cord injury in Israel. Spine 27: 1733-5. STUDY DESIGN: A retrospective cohort study was conducted. OBJECTIVE: To assess neurologic recovery and the manner in which it is affected by the severity of the neurologic damage after spinal cord injury. SUMMARY OF BACKGROUND DATA: Studies from various countries, but not from Israel, have shown considerable potential for recovery of the damaged human spinal cord. METHODS: The study sample included 250 patients with a traumatic spinal cord lesion treated between 1962 and 1992 at the major referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from the hospital charts. The degree of neurologic recovery in each patient was determined by comparing the Frankel grade of neurologic deficit at first admission for rehabilitation with the grade at discharge from that hospitalization. RESULTS: There was median delay of 36 days between injury and admission for rehabilitation. During rehabilitation, full or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred in 27% of all the patients who were Grade A, B, or C on admission, and in 54% of those who were Grade C. The neurologic recovery was negatively associated with severity of the neurologic deficit. CONCLUSIONS: The outcome findings are similar to those reported from spinal rehabilitation units in other countries. The study is a further demonstration of the considerable potential for neurologic recovery after spinal cord injury, when posttraumatic or postsurgical management is focused on prevention of complications and maximal use of functional ability. Loewenstein Rehabilitation Hospital, Raanana, the; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
    13. De Bernardi B, Pianca C, Pistamiglio P, Veneselli E, Viscardi E, Pession A, Alvisi P, Carli M, Donfrancesco A, Casale F, Giuliano MG, di Montezemolo LC, Di Cataldo A, Lo Curto M, Bagnulo S, Schumacher RF, Tamburini A, Garaventa A, Clemente L and Bruzzi P (2001). Neuroblastoma with symptomatic spinal cord compression at diagnosis: treatment and results with 76 cases. J Clin Oncol 19: 183-90. PURPOSE: To report on the treatment of patients with newly diagnosed neuroblastoma presenting with spinal cord compression (SCC). PATIENTS AND METHODS: Of 1,462 children with neuroblastoma registered between 1979 and 1998, 76 (5.2%) presented with signs/symptoms of SCC, including motor deficit in 75 patients (mild in 43, moderate in 22, severe [ie, paraplegia] in 10), pain in 47, sphincteric deficit in 30, and sensory loss in 11. Treatment of SCC consisted of radiotherapy in 11 patients, laminectomy in 32, and chemotherapy in 33. Laminectomy was more frequently performed in cases with favorable disease stages and in those with severe motor deficit, whereas chemotherapy was preferred in patients with advanced disease. RESULTS: Thirty-three patients achieved full neurologic recovery, 14 improved, 22 remained stable, and eight worsened, including three who become paraplegic. None of the 10 patients with grade 3 motor deficit, eight of whom were treated by laminectomy, recovered or improved. In the other 66 patients, the neurologic response to treatment was comparable for the three therapeutic modalities. All 11 patients treated by radiotherapy and 26 of 32 patients treated by laminectomy, but only two of 33 treated by chemotherapy, received additional therapy for SCC. Fifty-four of 76 patients are alive at time of the analysis, with follow-up of 4 to 209 months (median, 139 months). Twenty-six (44%) of 54 survivors have late sequelae, mainly scoliosis and sphincteric deficit. CONCLUSION: Radiotherapy, laminectomy, and chemotherapy showed comparable ability to relieve or improve SCC. However, patients treated with chemotherapy usually did not require additional therapy, whereas patients treated either with radiotherapy or laminectomy commonly did. No patient presenting with (or developing) severe motor deficit recovered or improved. Sequelae were documented in 44% of surviving patients. Department of Hematology-Oncology, Giannina Gaslini Children's Hospital, and Clinical Epidemiology Unit, National Institute for Cancer Research, Genova, Italy.
    14. de Seze M, Joseph PA, Wiart L, Nguyen PV and Barat M (2003). [Functional prognosis of paraplegia due to cord ischemia: a retrospective study of 23 patients]. Rev Neurol (Paris) 159: 1038-45. The functional prognosis of spinal cord infarct is not well known, complicating care of patients suffering from ischemic paraplegia. The aim of this study was to evaluate the clinical and functional outcome of patients with spinal cord infarct treated in rehabilitation centers in order to identify factors influencing functional outcome. We studied cases of non-trauma-related paraplegia treated between 1992 and 1999. Spinal compression and infectious and inflammatory myelopathy were excluded. Age, gender, cardiovascular risk factors, initial and final clinical findings according to the American Spinal Injury Association (ASIA/IMSOP) criteria, MRI findings, and initial urodynamic findings were analyzed. Two groups were identified regarding extension of the spinal cord infarct to the cone or not. Assessment of functional outcome was based on the Frankel classification, ambulatory ability, wheelchair use, and bladder control. Cases of spinal cord infarct were then classified according to extension to the cone or not, determined on the basis of initial clinical, MRI, and urodynamic findings. Twenty-three patients (19 males and 4 females) were selected for analysis. Mean age was 54 years, with no mortality during the follow-up period. At discharge, the group of nine patients whose infarct had not extended to the medullary cone had a significantly better motor recovery using the ASIA motor score (p<0.01). Patients whose infarct did not extend to the cone used wheelchairs less often, were more often in Frankel class D (p<0.05), and had normal bladder control more often (p<0.05) than patients whose infarct extended to the cone. Lack of extension to the medullary cone appeared to be a factor predictive of better functional outcome. Service de Medecine Physique et Readaptation, Centre Hospitalier Universitaire de Bordeaux, France.
    15. Eleraky MA, Theodore N, Adams M, Rekate HL and Sonntag VK (2000). Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg 92: 12-7. OBJECT: To evaluate and review their experience with pediatric cervical injuries and factors affecting outcome, the authors conducted a retrospective clinical study of 102 cases (65% boys, 35% girls) of pediatric cervical spine injuries treated in the last decade. This study is an extension of and comparison with their earlier experience. METHODS: Patients were divided into two age groups-birth to 9 years (Group I) and 10 to 16 years of age (Group 2)- and managed according to status at presentation and type of injury. Thirty patients were managed surgically and 72 non-surgically (42 wore a halo brace and 30 wore hard collars or custom-molded braces). Motor vehicle accidents were the most common cause of injury, and 40% were associated with head injury. Patients in the younger-age group (Group 1) sustained more neurological injuries than the older patients in Group 2, and most injuries were in the upper cervical spine. Of the 38 children in Group 1, in 39% a subluxation was present and in 29% a fracture or fracture/subluxation was demonstrated. Of the patients in Group 2, 80% had sustained fractures or fracture/subluxations. Vertebral fractures were the most common radiological findings (32%). At late follow-up review (mean 5 years), solid fusions were demonstrated in all patients. Neurological deterioration did not occur in any patient. The mortality rate was 16%. Compared with the authors' earlier report, the incidence of cases with pediatric cervical injuries increased, as did the number managed surgically. Various fusion techniques were used, and neurological and fusion outcomes improved as compared with the previous report. CONCLUSIONS: The prognosis of neurological recovery from pediatric cervical spine injuries is related to the severity of the initial neurological injury. Management must be tailored to the patient's age, neurological status, and type and level of injury. Compared with our earlier experience, fusion and instrumentation procedures were used more frequently. Different types of fusion and instrumentation procedures can be performed safely in children and produce good outcomes. Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
    16. Elrai S, Souei Mhiri M, Arifa Achour N, Mrad Daly K, Ben Hmida R, Jemni Gharbi H and Tlili Graiess K (2006). [MR imaging in spinal cord injury]. J Radiol 87: 121-6. PURPOSE: To describe MR features of spinal trauma and assess the value of MR imaging in the prognosis. MATERIAL AND METHODS: Retrospective confrontation between initial and follow up MRI findings and clinical features in 7 young patients with spinal cord injury. RESULTS: Five lesions were due to motor vehicle accidents and 2 lesions were secondary to falls. Five patients had multiple associated injuries, 1 patient had associated spinal vertebrae injury, the last had Spinal Cord injury Without Radiological Abnormalities (SCIWRA). A motor deficit was noted in 5 cases of paraplegia, a case of monoplegia and a case of tetraparesia. The initial MRI showed in 3 cases intramedullary hemorrhage, cord edema in 2 cases and spinal cord compression and contusion in 1 case. Initial MRI was not done in the remaining case. No cord transection was noted. Outcomes were marked by lack of significant neurological recovery with complications due to bed confinement in 5 cases, and complete neurolgical recovery in two cases. In follow up, MR findings included post traumatic cystic lesion (2 cases), "ad integrum" restitution (1 case), segmental atrophy with gliosis (2 cases) and myelomalacia in the 2 other cases. CONCLUSION: MR may offer new possibilities in establishing the prognosis for neurological recovery. Our study demonstrated a good correlation between imaging findings, clinical features and outcomes. A hemorrhagic contusion in the acute stage indicated a poor prognosis while a focal hyperintense area on T2-weighted images may resolve. Service d'Imagerie Medicale, CHU Sahloul, Route de ceinture 4051, Sousse, Tunisie.
    17. Gabler C and Maier R (1995). [Clinical experiences and results of high-dosage methylprednisolone therapy in spinal cord trauma 1991 to 1993]. Unfallchirurgie 21: 20-9. Studies in animals and especially the NASCIS II study illustrated the neuroprotective effects of methylprednisolone, but they are disputed. At the University Clinic of Traumatology, Vienna, 31 patients with spinal cord injuries were given methylprednisolone as a bolus of 30 mg/kg body weight followed by a maintenance dose of 5.4 mg/kg body weight/h for another 23 hours. Twenty-seven patients were stabilised within 8 hours, 2 patients were not operated on, because of their low prognosis. Two patients could be treated conservatively, because the spinal fractures were supposed to be stabile. Then follow-up studies of these patients were between 1 and 3.2 years. All patients (100%) with incomplete neurologic deficits (n = 18) showed a significant recovery and even 3 patients (23.1%) with primarily a complete tetraplegia (n = 13) showed a nearly entire recovery. Compared to these results we look back at 113 patients with complete and incomplete neurologic deficits who were treated at the I. University Clinic of Traumatology, Vienna, and would have got methylprednisolone following our current management procedures. Universitatsklinik fur Unfallchirurgie, Wien.
    18. Hoover M, Bowman LC, Crawford SE, Stack C, Donaldson JS, Grayhack JJ, Tomita T and Cohn SL (1999). Long-term outcome of patients with intraspinal neuroblastoma. Med Pediatr Oncol 32: 353-9. BACKGROUND: Chemotherapy, radiotherapy, and surgical decompression with laminectomy are effective therapeutic options in the treatment of cord compression from neuroblastoma (NB). We report the long-term outcome of patients with intraspinal NB treated with or without laminectomy at two large pediatric oncology centers. PROCEDURE: We reviewed the medical records and radiographs of 26 children with intraspinal NB treated at Children's Memorial Hospital in Chicago, Illinois, between 1985 and 1994 or at St. Jude Children's Research Hospital in Memphis, Tennessee, between 1967 and 1992. RESULTS: Twenty-four of the 26 patients are alive and disease-free (follow-up of 2-29 years; median, 10 years 2 months). Fifteen of the 23 patients with neurologic impairment underwent initial laminectomy. Nine of these 15 patients recovered neurologic function, including 3 patients who presented with paraplegia. Eleven of the 15 patients who underwent laminectomy have developed mild to severe spinal deformities. Eight patients with neurologic symptoms consequent to cord compression were treated with initial chemotherapy and/or surgery, but did not undergo laminectomy. Three patients with mild to moderate deficits recovered neurologic function. Four of 11 patients with intraspinal NB who did not undergo laminectomy have mild to severe scoliosis. CONCLUSIONS: A low incidence of neurologic recovery was seen in patients with long-standing severe cord compression regardless of treatment modality. For patients with partial neurologic deficits, recovery was seen in most patients following chemotherapy or surgical decompression with laminectomy. A higher incidence of spinal deformities was seen in the patients treated with initial laminectomy. Department of Pediatrics, Children's Memorial Hospital, Chicago, IL 60614, USA.
    19. Huang H, Chen L, Wang H, Xiu B, Li B, Wang R, Zhang J, Zhang F, Gu Z, Li Y, Song Y, Hao W, Pang S and Sun J (2003). Influence of patients' age on functional recovery after transplantation of olfactory ensheathing cells into injured spinal cord injury. Chin Med J (Engl) 116: 1488-91. OBJECTIVE: To evaluate the restoration of function after spinal cord injury (SCI) in patients of different ages who have underwent intraspinal transplantation of olfactory ensheathing cells (OECs). METHODS: One hundred and seventy-one SCI patients were included in this study. Of them, 139 were male and 32 were female, with age ranging from 2 to 64 years (mean, 34.9 years). In all SCI patients the lesions were injected at the time of operation with OECs. According to their ages, the patients were divided into 5 groups: </= 20 years group (n = 9), 21 - 30 years group (n = 54), 31 - 40 years group (n = 60), 41 - 50 years group (n = 34) and > 51 years group (n = 14). The spinal cord function was assessed based on the American Spinal Injury Association (ASIA) Classification System before and 2 - 8 weeks after OECs transplantation. One-way ANOVA and q test were used for statistical analysis, and the data were expressed as mean +/- SD. RESULTS: After surgery, the motor scores increased by 5.2 +/- 4.8, 8.6 +/- 8.0, 8.3 +/- 8.8, 5.7 +/- 7.3 and 8.2 +/- 7.6 in 5 age groups respectively (F = 1.009, P = 0.404); light touch scores increased by 13.9 +/- 8.1, 15.5 +/- 14.3, 12.0 +/- 14.4, 14.1 +/- 18.5 and 24.8 +/- 25.3 respectively (F = 1.837, P = 0.124); and pin prick scores increased by 11.1 +/- 7.9, 17.2 +/- 14.3, 13.2 +/- 11.8, 13.6 +/- 13.9 and 25.4 +/- 24.3 respectively (F = 2.651, P = 0.035). Restoration of pin prick in > 51 years group was better than other age groups except 21 - 30 years group. CONCLUSION: OECs transplantation can improve the neurological function of spinal cord of SCI patients regardless of their ages. Further research into the long-term outcomes of the treatment will be required. Department of Neurosurgery, Chaoyang Hospital, Capital University of Medical Sciences, Beijing 100020, China.
    20. Johnston TE, Greco MN, Gaughan JP, Smith BT and Betz RR (2005). Patterns of lower extremity innervation in pediatric spinal cord injury. Spinal Cord 43: 476-82. STUDY DESIGN: Retrospective review. OBJECTIVES: To identify relationships between lower extremity innervation and level of injury, mechanism of injury, and age at injury in a pediatric population with spinal cord injury (SCI). Secondarily, relationships between innervation and completeness of injury, time since injury, race, and sex were evaluated. SETTING: Pediatric orthopedic referral hospital, Philadelphia, Pennsylvania. METHODS: Records of 190 subjects, ages 1-21 years, were reviewed. Data collected from the medical record included lower extremity muscle innervation, American Spinal Injury Association (ASIA) level and class, mechanism of injury, age at injury, time since injury, race, and sex. To determine innervation, lower extremity muscles had been tested using surface electrical stimulation and identified as being innervated or denervated. If a muscle responded weakly, strength duration testing was performed. For analysis via logistic regression, subjects were grouped based upon level and mechanism of injury.Results:A relationship (P<0.0001) was found between ASIA level and lower extremity innervation of all muscles and between length of time since injury and lower extremity innervation for some muscles. Following multiple logistic regression, only ASIA level remained as an independent predictor of lower extremity innervation status. CONCLUSION: Our results show that lower extremity innervation does differ based on the level of the injury. Denervation began to be seen with injuries in the lower thoracic region and more predominantly with injuries in the lumbar region. This supports our hypothesis that the incidence of lower motor neuron injuries would increase as injuries became more caudal. Our hypotheses of a relationship between innervation status and mechanism of injury and age at injury were not supported. This information is important in determining treatment strategies, eligibility for electrical stimulation techniques, and potential regenerative strategies. SPONSORSHIP: This study was funded by Shriners Hospitals for Children, Grant #8530. Shriners Hospitals for Children, Philadelphia, PA 19140, USA.
    21. Kuptniratsaikul V (2003). Epidemiology of spinal cord injuries: a study in the Spinal Unit, Siriraj Hospital, Thailand, 1997-2000. J Med Assoc Thai 86: 1116-21. A prospective study of 83 patients with spinal cord injuries admitted to the Spinal Unit, Siriraj Hospital, Bangkok, Thailand from January 1997 to December 2000 was conducted. The average age was 33.2 +/- 11.7 years (range from 10 to 68 years) with a male: female ratio of 4 : 1. Most subjects (83.2%) were aged between 16-45 years. About half of them had no associated injuries and no financial problems. Three-fourths of the spinal injuries were caused by traffic accidents (49.4 and 25.3% car and motorcycle respectively). The other two causes were falls (16.9%) and gunshot wounds (8.4%). The neurological classification was as follows: 34 (41.0%) patients had ASIA D grade of injury, 28 (33.7%) were paraplegic with ASIA A, B or C grade and 21 (25.3%) were tetraplegic with ASIA A, B, or C grade. Traffic accidents most frequently resulted in an incomplete ASIA D grade (40.3%). Males were more predominant for all causes of injury especially motorcycle accidents. The average Barthel Index score was 24.3 +/- 24.7 and 51.9 +/- 31.8 at admission and discharge respectively. The prevalence of depression was 24.1 per cent. The average length of stay for the depressed and non-depressed groups was 117.4 +/- 59.1 and 73.4 +/- 54.4 days respectively. Department of Rehabilitation, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
    22. Launay F, Leet AI and Sponseller PD (2005). Pediatric spinal cord injury without radiographic abnormality: a meta-analysis. Clin Orthop Relat Res 166-70. Using a meta-analysis, we identified 392 published cases of patients recently diagnosed with spinal cord injuries without radiographic abnormalities (SCIWORA) and studied the epidemiologic, pathophysiologic, clinical, and radiologic data. To describe those at risk for this uncommon syndrome, mainly pediatric patients (90% of the cases) who sustain serious trauma in car accidents, serious falls, sports injuries, or child abuse, we analyzed the reported information in the literature. Magnetic resonance imaging scans may indicate neural (hemorrhages, edema, or both) or extraneural (disc protrusions, extradural hematomas) injuries, and the location and type of the injury. Every patient having magnetic resonance imaging scans had either intraneural or extraneural injury. However, followup magnetic resonance imaging scans are necessary because evidence of the injury might not appear immediately. Late and recurrent spinal cord injuries without radiographic abnormalities are reported. External immobilization for 12 weeks helps patients who are moderately injured and helps prevent recurrence of these types of injuries. Approximately 44% of the patients in our study did not recover whereas complete recovery occurred in 39% of the population. The prognosis can be improved if the syndrome is diagnosed early, so we recommend considering spinal cord injuries without radiographic abnormalities as a possible diagnosis for any child who has a mechanism of injury that suggests trauma to the spine. LEVEL OF EVIDENCE: Therapeutic study, Level III-3 (case-control study). See the Guidelines for Authors for a complete description of levels of evidence. Service d'Orthopedie Pediatrique, Hopital Enfants La Timone, Marseille, France.
    23. Levy ML, Gans W, Wijesinghe HS, SooHoo WE, Adkins RH and Stillerman CB (1996). Use of methylprednisolone as an adjunct in the management of patients with penetrating spinal cord injury: outcome analysis. Neurosurgery 39: 1141-8; discussion 1148-9. OBJECTIVE: Since the results of the Second National Acute Spinal Cord Injury Study were published in 1990, methylprednisolone has become a mainstay in the treatment of nonpenetrating spinal cord injury. Although potential significant relationships between the prompt administration of high-dose methylprednisolone after blunt spinal cord injury and outcome have recently been addressed, the relationship between the prompt administration of high-dose methylprednisolone after penetrating spinal cord injury and outcome remain unanswered. METHODS: To explore this relationship, we performed a retrospective nonrandomized study on a series of 252 patients with penetrating missile injuries to the spine who presented to our institution from March 1980 to July 1993. One hundred eighty-one patients (71%) were treated conventionally without adjunctive steroid therapy before 1990. Sixteen patients followed up during the 13-year study period received steroid protocols that were not consistent with the Second National Acute Spinal Cord Injury Study protocol and were excluded from the study. Since 1990, 55 patients (21%) were treated with intravenous methylprednisolone according to the Second National Acute Spinal Cord Injury Study protocol. All patients were subsequently transferred for rehabilitative care, and prospective evaluations of their neurological status were performed at admission and discharge. RESULTS: The study included 236 men and 16 women (mean age, 25.6 yr). The mean duration of stay for initial hospitalization was 94.6 days, and the mean duration of stay in rehabilitation was 78.6 days. Frankel scores were used to assess outcome (P < 0.05) and were assessed at admission and at the time of definitive discharge from the Spinal Cord Injury Care System. The hypothesis that methylprednisolone therapy significantly improves functional outcomes in patients with gunshot wound injuries to the spine was rejected. Only the total number of days in rehabilitation and the degree of neurological injury at admission contributed significantly to explaining outcome at discharge. CONCLUSION: The administration of methylprednisolone did not significantly improve functional outcomes in patients with gunshot wound injuries to the spine or increase the number of complications experienced by patients during their hospitalizations. Department of Neurological Surgery, University of Southern California School of Medicine, Los Angeles, USA.
    24. Liao CC, Lui TN, Chen LR, Chuang CC and Huang YC (2005). Spinal cord injury without radiological abnormality in preschool-aged children: correlation of magnetic resonance imaging findings with neurological outcomes. J Neurosurg 103: 17-23. OBJECT: Spinal cord injury without radiological abnormality (SCIWORA) was defined in the era when magnetic resonance (MR) images were not popularly used as diagnostic tools. Although it is generally accepted that MR imaging can effectively illustrate the level and severity of spinal cord injury in the acute phase of trauma, only a few reports of MR imaging studies of SCIWORA have been published. The authors retrospectively reviewed nine preschool-aged patients with SCIWORA to study the correlation between MR imaging findings and the outcomes of neurological deficits, with an elimination of the bias for age. METHODS: Clinical manifestations, radiological images, surgical records, and MR imaging studies were reviewed. The pre- and postoperative neurological statuses of the patients were reappraised using American Spinal Injury Association scores and Nurick grades. Nonparametric tests were used to analyze the correlations among the variables of patient characteristics, MR imaging appearances of the injured spinal cord, and neurological outcome. CONCLUSIONS: Among the patients with SCIWORA younger than 8 years old, the different patterns of the injured spinal cords could be identified using MR imaging as transection, contusive hemorrhage, traumatic edema, and concussion. The MR imaging patterns of SCIWORA had significant prognostic correlations with the neurological outcomes of these patients; that is, a normal spinal cord appearance was prognostic of a complete recovery of neurological deficits, and intramedullary lesions correlated with permanent deficits with functional disability. Department of Neurosurgery, Chang Gung University and Chang Gung Memorial Hospital,d Taoyuan, Taiwan.
    25. Marinier M, Rodts MF and Connolly M (1997). Spinal cord injury without radiographic abnormality (SCIWORA). Orthop Nurs 16: 57-63; quiz 64-5. Spinal cord injury without radiographic abnormality (SCIWORA) is associated with self-reducing transient subluxation or distraction of the juvenile spine. It accounts for about 40% of spinal injuries in children under sixteen. Children's anatomical features increase their susceptibility to hyperflexion, hyperextension and distraction mechanisms. Nursing management includes an awareness of two of its greatest dangers: a delay in onset of symptoms and a possible recurrence. If these dangers are identified early, the child's potential for recovery is maximized. Triton College in River Grove, Illinois, USA.
    26. McCutcheon EP, Selassie AW, Gu JK and Pickelsimer EE (2004). Acute traumatic spinal cord injury, 1993-2000A population-based assessment of methylprednisolone administration and hospitalization. J Trauma 56: 1076-83. BACKGROUND: Administration of methylprednisolone sodium succinate (MPSS) after acute traumatic spinal cord injury (TSCI) is controversial. This study compared differences in acute care charge, hospital stay, and related variables as a function of MPSS receipt. METHODS: Determinants of MPSS administration were examined after acute TSCI for South Carolina patients during the period 1993 to 2000 in a multivariate logistic regression model. RESULTS: Administration of MPSS was documented for 48.7% of 1,227 randomly selected patients with TSCI. Patients admitted via trauma centers and emergency departments were more likely to receive MPSS (trama center level 1 odds ratio [OR], 4.06; 95% CI confidence interval [CI], 2.11-7.83; emergency department OR, 1.64; 95% CI, 1.20-2.23). Hospital charge and length of stay were significantly higher for MPSS recipients. CONCLUSIONS: The study findings indicate MPSS use is associated with higher acute care charges and longer hospital stays. These findings suggest the need for outcome studies to assess the long-term benefits of MPSS administration. South Carolina Traumatic Head and Spinal Cord Injury Information System, Columbia, South Carolina, USA.
    27. Meyer PG, Meyer F, Orliaguet G, Blanot S, Renier D and Carli P (2005). Combined high cervical spine and brain stem injuries: a complex and devastating injury in children. J Pediatr Surg 40: 1637-42. BACKGROUND: In young children, high cervical spine injuries (HCSI) can result in inaugural reversible, cardiac arrest or apnea. We noted in children sustaining such injuries an unusual incidence of associated brain stem injuries and defined a special pattern of combined lesions. METHODS: Children with HSCI surviving inaugural cardiac arrest/apnea were selected for a retrospective analysis of a trauma data bank. Epidemiologic, clinical, and radiological characteristics, and outcome were reviewed and compared with those of the rest of the trauma population with severe neurologic injuries (defined by a Glasgow Coma Scale < 8). RESULTS: Thirteen children with HCSI above the C3 spinal level and inaugural cardiac arrest/apnea were identified and compared with 819 severely head injured children without HSCI. Mean age was 4.7 +/- 2.9 years, and median Glasgow Coma Scale was 3 (3-6) after resuscitation. Initial standard x-ray views missed spine injuries in 6 patients. Spiral computed tomographic (CT) scan showed cervical fracture-dislocations associated with diffuse brain lesions and brain stem injury in all patients. Children with combined lesions had more frequent severe facial and skull base fractures compared with the rest of the population. They also were younger and sustained more frequent severe distracting injury to the neck than the rest of the population. Mortality rate (69%) was 2.6-fold higher than that observed in children without HCSI. In survivors, none demonstrated spinal cord injury resulting in persistent peripheral neurologic deficits, but only one achieved a good recovery. CONCLUSIONS: Combined HCSI and brain stem injuries must be suspected in young children sustaining a severe distracting injury to the craniocervical junction. Early recognition of these catastrophic injuries by systematic spiral cervical spine and brain stem computed tomographic scan evaluation is mandatory. Department of Pediatric Anesthesiology, Hopital Necker Enfants Malades, Universite Rene Descartes-Paris 5, 75743 Paris, France. philippe.meyer@nck.ap-hop-paris
    28. Muslumanoglu L, Aki S, Ozturk Y, Soy D, Filiz M, Karan A and Berker E (1997). Motor, sensory and functional recovery in patients with spinal cord lesions. Spinal Cord 35: 386-9. The aim of this study is to evaluate the sensory, motor and functional improvement in patients with a Spinal Cord Lesion (SCL) by recording at admission, discharge and at 12 months after discharge. Fifty-five patients (29 with paraplegia and 26 with tetraplegia) admitted to our departments of Physical Medicine and Rehabilitation between December 1992-1995. Three patients were excluded as they did not give their consent. Each patient was evaluated at admission, before discharge and at 12 months after discharge. Motor status was evaluated by the motor score (MS), sensory status by the light touch score (LTS), and functional status by the Functional Independence Measure (FIM) score. Each patient was asked to complete a patient questionnaire which was developed according to the standards of the American Spinal Injury Association (ASIA) scale. Twelve patients (10 with paraplegia and two with tetraplegia) were evaluated at 12 months after discharge. Paired samples t-test was used for statistical analysis. The mean age of the patients group was 36.42 +/- 17.70 years, the mean duration of inpatient rehabilitation was 93.87 +/- 44.95 days. The SCL was due to trauma in 45 patients, 86.50% of the cases and was complete in nine patients (17.30%) and incomplete in 19 (36.53%) with paraplegia. Six tetraplegic patients (11.53%) had complete and 18 had (34.61%) incomplete lesions. The evaluation of MS, LTS and FIM scores at admission and discharge showed significant improvement in the MS and LTS in all of the patients with incomplete lesions (P < 0.001). FIM scores showed significant improvement only in those with complete or incomplete paraplegia (P < 0.05). At 12 months follow-up there was no significant change in the MS and the LTS whereas a significant change was noted in the FIM scores (P < 0.05) in 10 paraplegic patients. In summary, the results of this study indicate that rehabilitation was effective in our SCL series although the significant gain may also be attributed to the fact that 71.1% of the study group had incomplete neurological lesions. Department of Physical Medicine and Rehabilitation, Istanbul Medical School Istanbul-Turkey, Turkey.
    29. Peter Vellman W, Hawkes AP and Lammertse DP (2003). Administration of corticosteroids for acute spinal cord injury: the current practice of trauma medical directors and emergency medical system physician advisors. Spine 28: 941-7; discussion 947. OBJECTIVE: In 1997, the results from the Third National Acute Spinal Cord Injury Study (NASCIS 3) were published. We undertook the present study to determine the treatment protocols for patients with spinal cord injuries in Colorado and assess whether there were any barriers to the administration of corticosteroids. STUDY DESIGN: Cross-sectional. METHODS: In May 1999, surveys were mailed to every trauma facility medical director and emergency medical system physician advisor in the state. Physicians were asked to provide information about their facilities' or agencies' current practice(s) for administering steroids to patients with spinal cord injuries. They were also asked about their opinion on whether the data on corticosteroid treatment for spinal cord injury support its use. RESULTS: Ninety-eight percent (39 out of 41) of the medical directors who responded and treat patients with spinal cord injuries said that their facilities do administer steroids to those patients. Fourteen percent reported following the NASCIS 3 protocol; 75%, the NASCIS 2 protocol. About half of the medical directors were either uncertain or did not believe that the data regarding the corticosteroid treatment for spinal cord injury supported its use. The majority of physician advisors responded that they do not authorize the administration of corticosteroids to patients with spinal cord injuries in the field, primarily because of short transport times. CONCLUSIONS: Our study demonstrated relatively poor compliance with the NASCIS 3 protocol, but good compliance with the NASCIS 2 protocol. There was skepticism about the efficacy of corticosteroid treatment among some Colorado physicians that treat patients with spinal cord injuries acutely; however, this does not completely explain the findings. Emergency Department, St. Anthony Central Hospital, Denver, CO 80204, USA.
    30. Pang D (2004). Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery 55: 1325-42; discussion 1342-3. OBJECTIVE: Much new research has emerged since 1982, when the original description of spinal cord injury without radiographic abnormality (SCIWORA) as a self-contained syndrome was reported. This article reviews new and old data on SCIWORA, from the past 2 decades. METHODS: This article reviews what we have learned since 1982 about the unique biomechanical properties of the juvenile spine, the mechanisms of injuries, the profound influence of age on injury pattern and outcome, the magnetic resonance imaging (MRI) features, and management algorithms of SCIWORA. RESULTS: The increasing use of MRI in SCIWORA has yielded ample evidence of damage in virtually all nonbony supporting tissues of the juvenile vertebral column, including rupture of the anterior and posterior longitudinal ligaments, intervertebral disc disruption, muscular and interspinal ligament tears, tectorial membrane rupture, and shearing of the subepiphyseal growth zone of the vertebral endplates. These findings provide the structural basis for the postulated "occult instability" in the spine of a patient after SCIWORA. MRI also demonstrated five classes of post-SCIWORA cord findings: complete transection, major hemorrhage, minor hemorrhage, edema only, and normal. These "neural" findings are highly predictive of outcome: patients with transection and major hemorrhage had profoundly poor outcome, but 40% with minor hemorrhage improved to mild grades, whereas 75% with "edema only" attained mild grades and 25% became normal. All patients with normal cord signals made complete recovery. The large pool of clinical data from our own and other centers also lends statistical power to uphold most of our original assertions regarding incidence, causes of injury, pathophysiology, age-related changes in the malleability of the spine, vectors of deformation, and the extreme vulnerability of young children to severe cord injury, particularly high cervical cord injury. Thoracic SCIWORA has been identified as an important subset, comprising three subtypes involving high-speed direct impact, distraction from lap belts, and crush injury by slow moving vehicles. Computation of the sensitivities of MRI and somatosensory evoked potentials in detecting SCIWORA shows that both tests were normal in 12 to 15% of children with definite, persistent myelopathy; all of these children were nevertheless braced for 3 months because of their clinical syndrome. Children with transient deficits but abnormal MRI and/or somatosensory evoked potentials were also braced, but the 60% with transient deficits and normal MRI and somatosensory evoked potentials were not braced. This is a change from our original policy in 1982 of bracing all children with persistent or transient deficits, brought on by our new MRI and electrophysiology data. CONCLUSION: Injury prevention, prompt recognition, use of MRI and electrophysiological verification, and timely bracing of SCIWORA patients remain the chief measures to improve outcome. Department of Pediatric Neurosurgery, University of California at Davis, California, USA.
    31. Partrick DA, Bensard DD, Moore EE, Calkins CM and Karrer FM (2000). Cervical spine trauma in the injured child: a tragic injury with potential for salvageable functional outcome. J Pediatr Surg 35: 1571-5. BACKGROUND/PURPOSE: Cervical spine injuries are uncommon in children, and, therefore, presumptive immobilization and diagnosis remain controversial. The purpose of this study was to review the author's experience with cervical spine injuries in children to determine the incidence, injury mechanism, pattern of injury, and subsequent functional outcome. METHODS: Fifty-two children over a 6-year period (1994 to 1999) with a cervical spine injury secondary to blunt trauma were identified (1.3% incidence). The functional independent measure (FIM) was assessed at the time of discharge in each of 3 categories: communication, feeding, and locomotion. RESULTS: Mean age of the study children was 10.7 +/- 0.7 years. Eight children (15%) were less than 5 years old, and 4 (8%) were less than 2 years old. The mechanism of injury included motor vehicle crash (52%), falls (15%), bicycle accidents (11%), sports-related injuries (10%), pedestrian accidents (8%), and motorcycle crashes (4%). Seven patients died yielding an overall mortality rate of 13%. Injuries were distributed along the cervical spinal cord as follows: 5 atlanto-occipital dislocations, 28 C1 to C3 injuries, 17 C4 to C7 injuries, and 2 ligamentous injuries. FIM scores were recorded for 18 patients. Seventeen communicated independently, 14 fed themselves independently, and 12 had independent locomotive function. CONCLUSIONS: Cervical spine injuries occur in children across a spectrum of ages. Although atlanto-occipital dislocation is a highly lethal event, children with C1 to C7 injuries have a high likelihood of reasonable independent functioning. Division of Pediatric Surgery, The Children's Hospital, 80218, USA.
    32. Peter Vellman W, Hawkes AP and Lammertse DP (2003). Administration of corticosteroids for acute spinal cord injury: the current practice of trauma medical directors and emergency medical system physician advisors. Spine 28: 941-7; discussion 947. OBJECTIVE: In 1997, the results from the Third National Acute Spinal Cord Injury Study (NASCIS 3) were published. We undertook the present study to determine the treatment protocols for patients with spinal cord injuries in Colorado and assess whether there were any barriers to the administration of corticosteroids. STUDY DESIGN: Cross-sectional. METHODS: In May 1999, surveys were mailed to every trauma facility medical director and emergency medical system physician advisor in the state. Physicians were asked to provide information about their facilities' or agencies' current practice(s) for administering steroids to patients with spinal cord injuries. They were also asked about their opinion on whether the data on corticosteroid treatment for spinal cord injury support its use. RESULTS: Ninety-eight percent (39 out of 41) of the medical directors who responded and treat patients with spinal cord injuries said that their facilities do administer steroids to those patients. Fourteen percent reported following the NASCIS 3 protocol; 75%, the NASCIS 2 protocol. About half of the medical directors were either uncertain or did not believe that the data regarding the corticosteroid treatment for spinal cord injury supported its use. The majority of physician advisors responded that they do not authorize the administration of corticosteroids to patients with spinal cord injuries in the field, primarily because of short transport times. CONCLUSIONS: Our study demonstrated relatively poor compliance with the NASCIS 3 protocol, but good compliance with the NASCIS 2 protocol. There was skepticism about the efficacy of corticosteroid treatment among some Colorado physicians that treat patients with spinal cord injuries acutely; however, this does not completely explain the findings. Emergency Department, St. Anthony Central Hospital, Denver, CO 80204, USA.
    33. Polinder S, Meerding WJ, Toet H, Mulder S, Essink-Bot ML and van Beeck EF (2005). Prevalence and prognostic factors of disability after childhood injury. Pediatrics 116: e810-7. OBJECTIVE: To assess the prevalence and the prognostic factors of disabilities after minor and major childhood injuries and to analyze which sociodemographic and injury-related factors are predictive for suboptimal functioning in the long term. METHOD: We conducted a patient follow-up study in a stratified sample of 1221 injured children who were aged 5 to 14 years and had visited an emergency department in The Netherlands. Our study sample was stratified so that severe, less common injuries were overrepresented. Postal questionnaires were sent 2.5, 5, and 9 months after the injury. We gathered injury and external cause data, sociodemographic information, and data on functional outcome with a generic health status measure EuroQol (EQ-5D) with an additional cognitive dimension. A nonresponse analysis was performed by multivariate logistic regression, and the data were adjusted for nonresponse and the sample stratification. We performed bootstrap analysis to estimate the prevalence of disability in terms of the EQ-5D summary score and the occurrence of limitations in separate health domains: mobility, self-care, usual activities, pain/discomfort, anxiety/depression, and cognition. Respondents also rated their own health state on a visual analog scale, between 0 (worst imaginable health state) and 100 (best imaginable health state). We analyzed the relationship between functional outcome and sociodemographic (age and gender) and injury-related determinants (type of injury, external cause, multiple injury, admission to hospital, and length of stay) by logistic regression analysis. RESULTS: Response rates with respect to the original sample were 43%, 31%, and 30%, respectively. A total of 37% of the children were admitted to the hospital. The mean age of the children was 9.6 years. In two thirds (65%) of the cases, the injury was attributed to a home and/or leisure injury. The health status of injured children improved from 0.92 (EQ-5D summary score) at 2.5 months to 0.96 at 5 months and 0.98 at 9 months. Of all injured children, 26% had at least 1 functional limitation after 2.5 months, 18% after 5 months, and 8% still experienced functional limitations after 9 months. After 2.5 months, lower extremity fractures and other injuries (eg, spinal cord injury, injury of the nerves) demonstrated the worst functional outcome. Independent of the type of injury, our sample of injured children generally showed good recovery between 2.5 and 9 months. The highest prevalence of dysfunction after 9 months existed for pain/discomfort (7%) and usual activities (5%). Hospital admission (odds ratio: 3.6-5.8) and female gender (odds ratio: 3.0) were predictive for long-term disability. Girls reported more problems for all health domains (except self-care) compared with boys after 9 months, which was also confirmed by the visual analog scale score for self-related health (89 for girls vs 95 for boys). Almost one fifth of injured children with a hospital stay of >3 days still had pain and problems with usual activities 9 months after the injury. Three quarters of all residual problems were caused by nonhospitalized injuries. CONCLUSION: Most children show quick and full recovery after injury, but a small subgroup of patients (8%) have residual disabilities after 9 months. Girls have a 3-fold risk compared with boys for long-term disability after childhood injury. Prognosis in the long-term is also negatively influenced by hospitalization, but in absolute terms, residual disabilities are frequently caused by injuries that are treated fully in the emergency department. The group of injured children with persistent health problems as identified in this study indicates the importance of health monitoring over a longer period in trauma care, whereas trauma care should be targeted at early identification and management of the particular needs of these patients. Department of Public Health, Erasmus MC/University Medical Centre Rotterdam, Rotterdam, The Netherlands.
    34. Scivoletto G, Morganti B and Molinari M (2004). Neurologic recovery of spinal cord injury patients in Italy. Arch Phys Med Rehabil 85: 485-9. OBJECTIVE: To evaluate neurologic recovery of spinal cord lesion patients and its relationship to some lesion and patient features. DESIGN: Retrospective review of the charts. SETTING: Rehabilitation hospital in Italy. PARTICIPANTS: A total of 284 consecutive, newly injured patients were included with evaluation of lesion to admission time, etiology, lesion level, associated injury, medical complications and surgical intervention, length of stay, and American Spinal Injury Association (ASIA) impairment grade and motor scores. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: ASIA impairment grade and motor scores. RESULTS: Neurologic recovery was present in 27% of the patients. Most patients who improved and reached a functional status (ASIA class D) had an ASIA class C impairment at admission (71/129), versus ASIA class A (2/84) and ASIA class B (5/19). The lesion-to-admission interval was significantly longer in patients who did not improve (73+/-51.2d vs 47.2+/-38.4d, P=.006). CONCLUSIONS: ASIA impairment designations have prognostic value. Recovery from complete lesions was limited. Patients with ASIA class B impairment at admission had a better prognosis than those with ASIA class A. Patients with ASIA class C at admission had the best neurologic improvement. Finally, ASIA class D patients had lower ASIA grade improvement. Neurologic recovery was negatively associated with patients' age and delayed rehabilitation, but not by other lesion features. Spinal Cord Unit, IRCCS Fondazione S. Lucia, Rome, Italy.
    35. Sipski ML, Jackson AB, Gomez-Marin O, Estores I and Stein A (2004). Effects of gender on neurologic and functional recovery after spinal cord injury. Arch Phys Med Rehabil 85: 1826-36. OBJECTIVE: To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI). DESIGN: Case series. SETTINGS: Model Spinal Cord Injury Systems (MSCIS) throughout the United States. PARTICIPANTS: People (N=14,433) admitted to an MSCIS within 30 days of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI. RESULTS: When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI. CONCLUSIONS: Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended. Center for Excellence in Functional Recovery in Chronic SCI, Veterans Administration Rehabilitation Research and Development, Miami, FL, USA.
    36. Tanaka ST, Stone AR and Kurzrock EA (2006). Transverse myelitis in children: long-term urological outcomes. J Urol 175: 1865-8; discussion 1868. PURPOSE: Urological complications are well documented in patients with traumatic spinal cord injury. We examined the long-term urological outcomes in a large population of children affected by transverse myelitis. MATERIALS AND METHODS: We retrospectively reviewed the medical history, imaging studies and urodynamic findings in 22 children with transverse myelitis. Age at disease onset ranged from 3 months to 18 years (average 8.8 years). RESULTS: At a mean followup of 7.1 years 19 patients (86%) had persistent bladder dysfunction and 17 (77%) had persistent bowel dysfunction. Initial evaluation at least 1 month after disease onset revealed detrusor overactivity in 59% of patients, detrusor external sphincter dyssynergia in 41%, low compliance in 47% and detrusor leak point pressure greater than 40 cm water in 12%. Functional motor recovery and absence of lower extremity spasticity did not reflect normal urodynamic findings. Of the 19 patients with imaging available for review 5 (26%) had upper tract changes. One patient had development of chronic renal insufficiency. Low compliance (p = 0.02) and upper tract changes (p = 0.1) were more frequent in patients who started clean intermittent catheterization more than 2 years after disease onset. CONCLUSIONS: Persistent bowel and bladder dysfunction is common in transverse myelitis. Urodynamic abnormalities may be present despite normal neurological examination and absence of urinary symptoms. All pediatric patients with transverse myelitis require baseline renal ultrasound and urodynamic evaluation to guide treatment. Early institution of clean intermittent catheterization appears to preserve bladder compliance and decrease upper tract disease, and should be instituted at disease onset. Department of Urology, University of California Davis Children's Hospital, Sacramento, California, USA.
    37. Wang MY, Hoh DJ, Leary SP, Griffith P and McComb JG (2004). High rates of neurological improvement following severe traumatic pediatric spinal cord injury. Spine 29: 1493-7; discussion E266. STUDY DESIGN: Retrospective single-center study OBJECTIVES: To determine the long-term outcome of pediatric spinal cord injuries SUMMARY OF BACKGROUND DATA: Spinal cord injuries are uncommon events in the pediatric population. In the few large series reported in the literature, recovery of neurologic function was demonstrated after mild injuries but was rare after severe injuries. METHODS: A total of 4,876 cases of pediatric trauma treated at the Children's Hospital of Los Angeles over a 9-year period (1993-2001) were reviewed. During the study period, 91 cases of spinal cord or spinal column injury were identified, and 30 cases involving a spinal cord injury were identified. Cauda equina injuries were excluded. Seven craniocervical, 12 cervical, 5 thoracic, and 6 thoracolumbar cases were identified. There were 6 cases of spinal cord injury without radiographic abnormality. Eight of the 30 patients received methylprednisolone at the time of admission. Follow-up ranged from 2 to 54 (mean = 19) months. RESULTS: Twenty patients presented with complete injuries (ASIA grade A). Of these, 7 died, 7 had no neurologic recovery, and 6 experienced neurologic improvement. Five of these six eventually became ambulatory with functional gains occurring over a 4- to 50-week period. None of these 5 patients was found to have spinal cord injury without radiographic abnormality. Of the remaining 10 patients (grades B-D), 8 experienced improvements in neurologic function. Cervical dislocation injuries were associated with a low likelihood of neurologic improvement and atlanto-occipital injuries were associated with early death. CONCLUSIONS: Recovery of neurologic function following severe traumatic spinal cord injury occurs with a significantly greater incidence in children than adults, and these improvements can occur over a prolonged postinjury period. Department of Neurological Surgery, Keck School of Medicine, University of Southern California, USA.
    Last edited by Wise Young; 11 Dec 2006, 8:35 PM.


      Rattle that one off on your coffee break, Professor? What's it like to be a genius?
      Last edited by Ozymandias; 12 Dec 2006, 7:35 PM.


        Thank you. That was informative! Scott.


          thanks a lot dr. Young you are one of a kind. i printed it and will be studying it for a while.