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Spinal Cord Injury

Overview

Spinal cord injury (SCI) may result directly from injury to the cord (e.g., birth injury, falls, motor vehicle accidents, non-accidental shaking, diving and trampoline accidents) or indirectly from disease of the surrounding bones, tissues, or blood vessels. SCI can also occur in the setting of autoimmune demyelination (e.g., transverse myelitis, neuromyelitis optica, other autoimmune myelopathies). [Cree: 2014] Cervical injuries in children younger than 8 years occur because they have more elastic intervertebral ligaments and their more horizontally aligned facet joints predispose them to subluxation of the cervical spine without bony injury. Immature neck muscles and a proportionately large head further compound this effect.

Multi-system trauma, such as head injury, fractures of the pelvis and long bones, and visceral injuries, often accompanies SCI. The acute period of spinal shock, manifested by hypotonia, flaccid muscles, and decreased or absent deep tendon reflexes below the level of injury, is followed by the return of reflexes and, in upper motor neuron injury, development of spasticity over the next 1-12 weeks. Overlaid on this process is the possibility of some recovery, depending on the completeness of the spinal cord injury. [Wang: 2004] The manifestations of SCI evolve over time and affect every body system, requiring the medical home and collaborating specialists, particularly physiatrists and the rehabilitation team, to adjust their approaches periodically to optimize function and outcome.

Acute flaccid myelitis (AFM) is a rare but serious condition resulting in spinal cord injury. It affects the nervous system, especially the area of the spinal cord called gray matter, which causes the muscles and reflexes in the body to become weak. New awareness has resulted from increases in AFM cases every 2 years since 2014, mostly in young children. Still, CDC estimates that fewer than 1-2 in a million children in the United States will get AFM yearly. Viruses likely play a role in AFM. [CDC: 2020]

Other Names & Coding

Acute Flaccid Myelitis
Cervical/Thoracic/Lumbar/Sacral spine cord injury
Spina Bifida
Transverse Myelitis
ICD-10 coding

S14.xxxy, Injury of nerves and spinal cord at neck level

S24.xxxy, Injury of nerves and spinal cord at thorax level

S34.xxxy, Injury of lumbar and sacral spinal cord and nerves at abdomen, lower back and pelvis level

Additional digits (x) and letter (y) specify nature and level of injury and encounter. See Injury, Poisoning and Other Consequences of External Causes (icd10data.com) for more detail.

Prevalence

Approximately 20% of SCIs occur in children and adolescents. [ASIA: 2020] The incidence of new SCI in children in the United States is 1.99 per 100,000 per year. [Vitale: 2006] As estimated from the above data, 1,455 children are admitted to US hospitals annually for SCI treatment. [ASIA: 2020]

Genetics

There is no genetic component to traumatic SCI. Although suspected, the genetic aspects of autoimmune-related SCI have not yet been determined.

Prognosis

Prognosis depends on the injury level within the spinal cord, mechanism and severity of injury, and associated complications. Children are more likely than adults to show some neurological improvement. [Wang: 2004]

Practice Guidelines

Rozzelle CJ, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Ryken TC, Theodore N, Walters BC, Hadley MN.
Management of pediatric cervical spine and spinal cord injuries. In: Guidelines for the management of acute cervical spine and spinal cord injuries.
Neurosurgery. 2013;72 Suppl 2:205-26. PubMed abstract

Calhoun CL, Schottler J, Vogel LC.
Recommendations for mobility in children with spinal cord injury.
Top Spinal Cord Inj Rehabil. 2013;19(2):142-51. PubMed abstract / Full Text

Roles of the Medical Home

The medical home can:
  • Schedule frequent health maintenance and/or chronic condition management visits to monitor for complications, build a partnership with the family, and be aware of arising issues.
  • Ensure that the family has access to reliable, family-focused information about SCI and relevant community services and resources.
  • Facilitate access to other health professionals, coordinate the care that they provide, and interpret the information and advice they offer.
  • Guide the family in working with pre-school and school systems to ensure appropriate accommodations. This assumes even greater importance if a brain injury accompanies the SCI. Please see Traumatic Brain Injury.
  • Facilitate access to private providers if the child needs services, such as PT and OT, and is not getting adequate services within the school system.
  • Assess parental stress and social supports during each visit to the medical home.
  • Help the child and family to accept and adapt to the injury, optimize remaining function, and allow for the best future life.
  • Evaluate for depression or other mental health issues.
  • Facilitate any needed admissions for related or unrelated health problems allowing the family to contribute their knowledge to management of the patient in a hospital setting. [Gall: 2008]
The Medical Home Questionnaire for SCI (MHP) (PDF Document 51 KB) may be helpful in assessing patients with SCI.

Clinical Assessment

Overview

Understanding the nature of the SCI, its impact on function, and the potential complications and sequelae are important. The immediate focus after traumatic injuries is stabilization and recovery; a rehabilitation team is usually consulted early in the process while the child is still in the intensive care unit. The manifestations of SCI evolve over time. Initially, there is a period of spinal shock when the child is hypotonic, with flaccid muscles and decreased or absent deep tendon reflexes below the level of injury.

The second phase evolves over the next 1-12 weeks as reflexes return and spasticity results. New bowel and bladder problems may occur during this latter stage. Overlaid on this process is the possibility of some recovery, depending on the extent of the injury, after edema decreases and contusions resolve. [Wang: 2004] This evolution of the SCI will continue after the child leaves rehabilitation for care in a medical home. Ongoing programs for the major care areas (respiratory, muscle/bone/joint care, decubitus prevention, bowel and bladder management) will be needed.

Pearls & Alerts for Assessment

Autonomic dysreflexia = medical emergency

Autonomic dysreflexia can occur with SCI above T6 (but can occur if injury is above T10). The increase in blood pressure can be life-threatening, as it may lead to seizures or other cerebral manifestations. Recognition of the symptoms followed by quickly identifying and removing the trigger can resolve the escalating blood pressure. The blood pressure may need to be managed with medications.

Inquire about chronic pain

Chronic pain is described in up to 65% of children with SCI; inquire about pain at visits. [Jan: 2004]

Heterotopic ossification

Heterotopic ossification involves abnormal deposition of bone into muscles and tendons or into joints. It usually occurs within the first year after an SCI. It is uncommon in children, but frequency increases in adolescents. Symptoms of heterotopic ossification include erythema, pain, swelling over a joint, and restricted range of motion. Failure to detect and treat this process can lead to permanent loss of joint motion.

Screening

For the Condition

Traumatic SCI should be highly suspected in the presence of abnormal neck or neurological exam, a high-risk mechanism of injury, or a distracting injury even in the absence of radiological anomaly. [Parent: 2011] Consider screening special populations at risk, which include patients with trisomy 21, JRA, skeletal dysplasias, and those with tumors, infection, or arteriovenous malformation (AVM).

Presentations

The most common mechanism for SCI in younger children is a motor vehicle accident, while sports injury is the most common for teenagers. SCI prior to the age of 15 makes up <4% of the SCI population. In the pediatric population, about 80% of the injuries occur in the cervical spine and less commonly in the thoracic and lumbar spinal cord.

The spinal cord injury may present with midline tenderness to palpation of the vertebrae on examination as well as neurologic deficits. The presentation can be variable, depending on the pattern of injury (where the injury is and to what extent). Cervical spinal cord injuries can potentially affect the respiratory system, all four limbs and the trunk resulting in decreased or absent motor, sensory, and autonomic function below the level of the injury.

Central Cord and Brown-Sequard Syndromes are both incomplete SCI’s which are common in the cervical area. Central Cord Syndrome can present with loss of motor function that is worse in the upper extremities versus the lower extremities, bladder and bowel dysfunction, as well as variable sensory losses. Brown-Sequard Syndrome is characterized by one-sided loss of motor function, vibratory sensation, proprioception and temperature below the level of the injury.

Children can present with a spinal cord injury without radiological anomaly (SCIWORA) in up to 43% of the injuries, typically blunt injuries. It was first described in 1982 as ‘children with objective signs of myelopathy as a result of trauma, whose plain films of the spine, tomography carried out at the time of admission showed no evidence of skeletal injury or subluxation.’ In these settings, the patient should be followed up with an MRI. However, the physical examination is extremely important in the diagnostic process. [Parent: 2011] It is felt that children are more susceptible to SCIWORA because of higher elasticity of ligaments allowing for more movement without fracture or dislocation of vertebrae.

Clinical Classification

The ASIA Impairment Scale (AIS) is used to categorize the degrees of injury: [Kirshblum: 2011]

A. Complete: no motor or sensory function is preserved below the level of injury, including the sacral segments S4-S5
B. Incomplete: sensory, but not motor function is preserved below the neurologic level and some sensation in the sacral segments S4-S5
C. Incomplete: motor function is preserved below the neurologic level; however, more than half of key muscles below the neurologic level have a muscle grade less than 3 (i.e., not strong enough to move against gravity)
D. Incomplete: motor function is preserved below the neurologic level, and at least half of key muscles below the neurologic level have a muscle grade of 3 or more (i.e., joints can be moved against gravity)
E. Normal: motor and sensory functions are normal

Medical Conditions Causing Condition

SCI can occur in the setting of transverse myelitis due to para-infectious or autoimmune-mediated spinal cord inflammation, secondary to tumor-related mass effect and following disruption of its vascular supply (i.e., cord ischemia or infarction). Primary pediatric spinal cord tumors account for 0.5-10% of all pediatric CNS tumors (see PM&R Knowledge NOW). Is this what I'm supposed to link to here? See Evidence-based guideline: clinical evaluation and treatment of transverse myelitis (American Academy of Neurology) [Scott: 2011] for an abstract with recommendations.

Comorbid & Secondary Conditions

Autonomic dysreflexia can be a true medical emergency. It is caused by an exaggerated response of the autonomic nervous system when there is a noxious source of stimulation below the level of injury, which triggers sympathetic reflexes (T5-T12), causing hypertension and usually bradycardia (can cause tachycardia in young children). The most common trigger is a full bladder or stool in the rectum; however, other sources to consider are irritation of the skin (tight clothing bands, sunburn, ingrown toenail, pressure sores, fractures, urologic/gynecologic procedures, deep venous thromboses, etc.).

The child or adolescent may notice the following symptoms: sudden, pounding headache, red face, blurry vision, runny nose, diaphoresis, red blotchy skin above the level of injury, cold, clammy skin below the area of injury, or an overall feeling of anxiety or impending doom.

Recognition of the symptoms of autonomic dysreflexia, followed by quickly identifying and removing the trigger, can resolve the escalating blood pressure. However, if unable to find the trigger, or if the trigger is related to a chronic condition, the blood pressure may need to be managed with medications.

Other issues and complications to be watched for include:
  • Traumatic Brain Injury (depending on method of injury)
  • Orthopedic, abdominal and/or dermatologic issues
  • Chronic pain Urinary Tract Infection and Kidney Disease
  • Hypercalcemia
  • Pressure wounds (decubitus ulcers)
  • Muscle atrophy and joint contractures, spasticity
  • Neurogenic bowel and bladder
  • Pulmonary complications
  • Adjustment problems, behavior problems
  • Heterotopic ossification
  • Sexuality and reproduction issues
  • Depression
  • Scoliosis
  • Hip instability
  • DVT/PE
  • Urinary tract infection and kidney disease

History & Examination

Current & Past Medical History

Review details of the child's treatment program and assess for any needed changes. The plan will likely address pulmonary problems, bladder program, bowel program, therapy schedule, dietary issues, pain management, bone/joint/muscle health (spasticity, contractures), and decubitus ulcers. Determine the level of injury of the spinal cord and major problems experienced during the hospitalization. Ask about:
  • Changes in breathing, mobility, bladder and bowel, skin, intercurrent illnesses
  • Medications, such as baclofen for spasticity or antibiotics for infection, and any side effects
  • Neuropathic and other pain
  • Difficulty adjusting, symptoms of depression
  • Frequency of autonomic dysreflexia episodes and what triggers them for this particular patient. Autonomic dysreflexia is a complication of SCI where environmental stimuli below the level of the injury elicit a massive sympathetic discharge leading to possibly life-threatening hypertension.

Pregnancy/Perinatal History

Ask child's mother about pregnancy and perinatal history to identify any premorbid problems that might affect recovery.

Developmental & Educational Progress

Developmental/educational history should be explored to identify any premorbid problems, such as developmental delay or learning and attention problems, which might interfere with recovery and/or require additional treatment.

Social & Family Functioning

Identify family functioning problems and strengths, including financial resources for dealing with medical expenses. Ask about the layout of the patient’s home (e.g., how many stairs) and places often visited.

Physical Exam

Vital Signs

RR | HR | BP Monitor temperature, especially, for autonomic dysreflexia. Repeat vitals frequently if there are concerns of autonomic dysreflexia.

Growth Parameters

Ht | Wt | BMI to monitor for obesity

Skin

Look for areas of redness, warmth, tenderness, and ulceration. If there is a history of autonomic dysreflexia, look for ingrown toenails (a potential pain trigger). Check for incipient decubitus ulcers.

Chest

Listen for decreased breath sounds, wheezing, and breathing difficulties. Auscultate for pneumonia, access depth of breathing, check ventilator settings if applicable.

Abdomen

Check for mobile, non-tender masses that may represent stool and distended bladder, particularly if autonomic dysreflexia is a problem.

Extremities/Musculoskeletal

Assess mobility, strength, and coordination. Look for contractures and decreased range of motion of joints. Evaluate as appropriate for scoliosis and hip instability. See Musculoskeletal Exam for Common Orthopedic Complications (PDF Document 579 KB) for a form for assessing functional abilities, joint mobility, and muscle strength.

Neurologic Exam

Confirm level of injury as a baseline for future evaluations, include sensory, motor, and reflexes. Look for spasticity.

Testing

Laboratory Testing

Consider checking post-void bladder residual, UA, and culture if symptoms of infection or autonomic dysreflexia are occurring.

Imaging

An acute decrease in function may trigger re-imaging of brain and/or spine.

Other Testing

In a non-traumatic setting, electromyography and/or nerve conduction studies might be used to either rule in/out nerve muscle involvement (i.e., to rule out/support possibility of cord injury).

Consider screening for depression. See Center for Epidemiological Studies Depression Scale for Children (CES-DC) (PDF Document 37 KB) for a 20-item self-report inventory.

Specialty Collaborations & Other Services

Pediatric Physical Medicine & Rehabilitation (see ID providers [1])

Provides ongoing care to prevent complications, promote recovery, and optimize remaining function. Often works with the physiatrist who was involved during the acute inpatient stay to address a broad set of issues, including spasticity, sexuality, toileting, recreation, transportation, and psychological well-being.

Nursing Services (see ID providers [1])

Provides education for the patient and parents about how to manage and prevent complications following SCI. The nurse collaborates with the interdisciplinary team to provide opportunities for the patient and parents to practice what was learned in therapy. The rehabilitation nurse works with the PM&R provider to manage the bowel and bladder, prevent complications, and promote continence of urine and stool.

Physical Therapy (see ID providers [34])

Provides outpatient and home programming while broadly concentrating on gross motor movements and positioning. Follow-up appointments should be considered if status is worsening.

Occupational Therapy (see ID providers [27])

Provides outpatient/home programming, broadly concentrating on activities of daily living. Follow-up appointments should be part of the discharge plan. Reassessment should be considered if status changes.

Pediatric Pulmonology (see ID providers [1])

Assists with pulmonary toilet and/or ventilation management when the injury is in the cervical cord.

Pediatric Gastroenterology (see ID providers [3])

Consider for evaluation and treatment of neurogenic bowel issues and associated GI complaints.

Pediatric Urology (see ID providers [1])

Consider for evaluation and management of a neurogenic bladder and when making changes in the bladder program.

Treatment & Management

Overview

Treatment of the acute SCI occurs in the hospital and may include surgical stabilization of the vertebral column, high-dose intravenous steroids, and airway management. After the acute phase, the primary risks to life are from associated complications, usually infection of the lungs or kidneys or septicemia from decubitus ulcers. The role of the medical home in monitoring for and responding to illness in these children is critical; however, the focus of management should be optimizing function and developmental/educational outcomes. Avoidance and management of complications are directly related to perceived quality of life in patients with SCI. [Vogel: 2002] Collaboration with subspecialists, particularly physiatry and a rehabilitation team, is key in achieving best outcomes.

Pearls & Alerts for Treatment & Management

Depression after SCI

Children sustaining SCI have an increased risk for depression as children and into adulthood. [Craig: 2008] [Anderson: 2007] Depressive symptoms are associated with increased mortality after SCI. [Krause: 2008]

Chronic pain

Similar to other types of chronic pain (e.g., headache), chronic pain in children following SCI may respond to tri-cyclic antidepressants, SSRIs, and SNRIs. A referral to a pain clinic in refractory cases may be helpful (see all (Pain Management (see ID providers [5]) in our database).

Systems

Musculoskeletal

Spasticity and Contractures: Muscles contract slightly at rest (tone) and are dependent on inhibitory input from the brain, which is interrupted by SCI. Muscles innervated from below the level of the injury may develop high tone or spasticity. Spasticity can take weeks to months to develop after the spinal shock that follows injury.

Often the spasticity will hold a joint in a bent posture, which over time, leads to permanent contractures due to tendon remodeling. In addition to pain, loss of function, and positioning problems with the involved joints, inner surfaces of contracted joints, such as the palm or armpit, can develop skin breakdown that is very difficult to treat.

During the initial hospital visit, physical therapy should have been arranged and caregivers taught to perform range of motion exercises to prevent or limit contracture development. Ask about range of motion exercises and physical therapy visits if spasticity and decreasing range of motion are observed, consider referral to a physiatrist for botulinum toxin and/or phenol injections.

Oral medications, such as baclofen or valium, may be used to prevent spasticity, although their efficacy is limited by sleepiness at the doses often required. Baclofen is usually tolerated at higher doses if titrated gradually. [Montane: 2004]

An implantable baclofen pump may be used in children with severe spasticity.

If contractures occur, surgery to release the tight tendon or to move it to another site to decrease its pull on the affected joint may be necessary. Selective dorsal rhizotomy (SDR) has been used in the management of spasticity in selected children with cerebral palsy and may have a role in the management of SCI-induced spasticity. [Reynolds: 2014]

Scoliosis: Paralysis and spasticity may lead to scoliosis in children with spinal cord injuries, particularly if the injury occurred prior to puberty. [Dearolf: 1990] Scoliosis may take months to years to develop. Bracing may be used for positioning to facilitate seating and buy time before surgery.

Heterotopic Ossification: Symptoms of heterotopic ossification include erythema, pain, swelling over a joint, and restricted range of motion. Failure to detect and treat this process can lead to permanent loss of joint motion. Treatment is somewhat controversial and will probably require a visit to a rehabilitation specialist to consider pharmacologic treatment with etidronate or indomethacin, and enhancement of the physical therapy regimen. Because joints with decreased range of motion may present as spasticity or dystonia, a visit with a neurologist to rule out some other evolving neurological process may be necessary. Sometimes orthopedic surgery is required to release the joint contracture or remove the ossification after it has matured. See Heterotopic Ossification (eMedicine) for more information.

Specialty Collaborations & Other Services

Pediatric Physical Medicine & Rehabilitation (see ID providers [1])

Helps manage spasticity and contractures, evaluates for scoliosis and heterotopic ossification, and coordinates physical and occupational therapies. A physiatrist generally is involved on a regular basis.

Pediatric Orthopedics (see ID providers [4])

Patient mobility is highly correlated with patient independence. Fitting for appropriate orthoses to prevent contractures and improve function is vital. Use of mobility devices, adaptive equipment, and other modalities such as electrical stimulation units should be encouraged.

Pediatric Nephrology (see ID providers [1])

Facilitates the restoration of muscle strength and flexibility; improves mobility and coordination; and, maintains body functions through exercise. Gait training may be taught to patients with difficulty walking and could include teaching use of assistive devices (e.g., walker, crutches, or cane).

Occupational Therapy (see ID providers [27])

Encourages independence by helping the patient with daily tasks, such as dressing, bathing, food preparation, going to the toilet, and other activities of daily living.

Skin & Appearance

Decubitus ulcers are most likely to occur at the hips, heels, and buttocks. They are first seen as an area of erythema that persists following release of pressure on the affected body part. Before discharge from the initial hospitalization, the patient and caregivers should have been taught to move the child with SCI frequently to prevent this complication; severe decubitus ulcers can become infected and cause of mortality if not treated. If there are no signs of pressure ulcers, children should be moved every 2 hours and more frequently if redness is present. The medical home should reinforce this teaching during visits. Special wheelchair cushions and mattresses may be used to prevent pressure sores. See Decubitus Ulcer Description (Merck Manuals) for more details.

Genito-Urinary

Bladder problems, if not identified early and treated, can be severe and lead to autonomic dysreflexia, chronic infection, high bladder pressures, vesicoureteral reflux, and kidney failure. Continence and avoidance of urinary complications improve quality of life in people with SCI. Evolution of the bladder management program that was begun during the initial hospitalization should be managed by the medical home in collaboration with specialists when necessary. Ideally, the child's bladder will have low pressure, no detrusor muscle contractions against a closed bladder sphincter, and complete emptying with each void. Occasionally, medication and/or surgery are required to achieve this. Patients may also need to take antibiotic prophylaxis to prevent UTI and/or stool softeners to avoid constipation.

Complete emptying, leaving minimal residual after voiding, is important to prevent reflux. Residual urine volumes should be checked periodically by the patient/caregiver. Good fluid intake is important to prevent complications of both bladder and bowel and should be stressed with patients and their families. Generally, a cystometrogram and a renal ultrasound should be done within the first few months after injury and every 1-2 years thereafter to measure bladder pressure and assess kidney size. Signs and symptoms of infection, including smelly, bloody, or discolored urine, abdominal pain, and increased temperatures or rigors, should be watched for. Suprapubic or chronic urethral catheterization or a continent urinary diversion may be initiated by the urologist in some situations. [Chulamorkodt: 2004]

For a helpful article on the evaluation and treatment of the neurogenic bladder in children, from many causes, see [Bauer: 2008]. The Portal's Constipation module contains information for managing constipation.

Specialty Collaborations & Other Services

Pediatric Physical Medicine & Rehabilitation (see ID providers [1])

Helps manage genitourinary complications and attempts to prevent dysfunction. Help to optimize independence with bowel and bladder programs. A physiatrist generally is involved on a regular basis.

Pediatric Urology (see ID providers [1])

Periodic visits with a urologist may be helpful for a child with bladder management problems.

Maturation/Sexual/Reproductive

Families often ask whether their child will be able to be a biological parent. Adolescents with spinal cord injuries also have questions about their sexuality and might have feelings of not being attractive or worries about bladder and bowel accidents. Issues of sexuality and parenthood, including sexual activity and parenting, should be raised by the medical home and/or the rehabilitation physician. Females are still able to get pregnant following SCI. Practical advice, such as talking about planning sexual activity after bowel and bladder care to avoid accidents, can be very helpful and lead to more discussion. Psychological counseling might also be necessary at some point to help adolescents deal with emotional issues regarding poor body image, intimacy, and sexuality issues.

Males: Sexual responsiveness in males will depend on the level and completeness of their injury. Almost all men with complete and/or higher levels of SCI will be able to have reflex erections, but may not have psychogenic erections. The erection may not be sustained enough or complete enough for sexual activity; however, a variety of treatments may be helpful. The patient should be referred to urology for more information. Though condom use may be difficult in men with impaired upper extremity function, use should be advised for the same reasons as for other patients. Even though impaired ejaculation and/or decreased sperm motility may make biologic impregnation difficult, fertility specialists may be able to obtain semen for artificial insemination. See Sexuality and Sexual Function After SCI (UAB) for patient information.

Females: If the level of injury is high or complete, psychogenic stimulation leading to vaginal lubrication may not occur, but local stimulation may lead to reflex lubrication. Water-based lubricants can be used to avoid vaginal dryness and irritation. About half of women with spinal cord injuries are able to have orgasms. The majority of women after SCI are able to get pregnant and have normal vaginal deliveries. Therefore, adolescent females with SCI should have the usual counseling regarding sexually transmitted disease and pregnancy. SCI-related care is more complicated during pregnancy, due to the use of chronic medications, pressure sores, autonomic dysreflexia, and bladder and bowel care. See Pregnancy after SCI (UAB) and Sexuality and Sexual Function After SCI (UAB) for patient information.

Cardiology

Autonomic dysreflexia is usually initiated by pain/discomfort from an overfull bladder, fecal impaction, or skin irritation due to tight clothing bands, sunburn, ingrown toenail, etc. Episodes of autonomic dysreflexia should be monitored in the medical home. Causes and what the patient and/or family found effective in managing the episode should be identified. Families should be equipped with a blood pressure cuff, education about the individual's baseline blood pressure, and what would constitute an elevated BP. Individuals with SCI often have lower baseline blood pressures – systolic BP in those with quadriparesis may be less than 100. A blood pressure of 120 systolic or above 70-80 mm Hg diastolic may be abnormally high for these individuals. [Hickey: 2004]

Although anti-hypertensive medications can be used when necessary, the best treatment consists of good bowel and bladder care and prompt removal of irritants. Education of patients and caregivers can help prevent episodes or allow for early recognition. [Hickey: 2004] Patients may want to visit Autonomic Dysreflexia (SCI-Info-Pages) for more information; Autonomic Dysreflexia (UAB) (PDF Document 277 KB) provides a 5-page pdf with information for patients and families about warning signs, symptoms, importance of blood pressure measurements, triggers, and treatments.

Swelling of the extremities and orthostatic hypotension (low blood pressure when rising) can also occur. Orthostatic hypotension can be helped by abdominal binders, increased salt intake, TED hose, Florinef, etc. There is a small risk that circulation changes may increase risk of developing blood clots, such as deep vein thrombosis or a pulmonary embolus.

Other

Pain Management: Ideally, patients and providers should aim to prevent acute pain through avoidance of pressure ulcers and fall-related injuries. Chronic pain prevention is achieved via various therapies, range of motion exercises, and safety measures relating to mobility and transitions.

Specialty Collaborations & Other Services

Pediatric Physical Medicine & Rehabilitation (see ID providers [1])

Helps manage pain complications. A physiatrist generally is involved on a regular basis.

Pain Management (see ID providers [5])

Referral may be helpful for acute or chronic pain management.

Issues Related to Spinal Cord Injury

Constipation
Depression
Childhood Obesity Screening & Prevention

Funding & Access to Care

Appealing Funding Denials
Writing Letters of Medical Necessity

Mobility/Function/ADLs/Adaptive

Mobility

Ask the Specialist

What can I do if a child with an SCI in my practice is denied physical therapy because they are not making any progress?

Physical therapy is very important for children with spinal cord injuries even if progress is slow and hard to define. Maintaining range of motion is very important and will possibly prevent the need for future expensive procedures, such as botulinum toxin injections and surgeries. That being said, sometimes the child and family may benefit from short breaks in a rigorous physical therapy schedule. Please see Writing Letters of Medical Necessity (general)and Appealing Funding Denials (general).

There is a child with an SCI in my practice that hates wearing diapers now that he is getting older. Are there any alternatives?

Children with SCIs may benefit from a visit to a rehabilitation specialist to discuss this. Self-cathing may be a possibility but will need support from staff that are familiar with this as it has associated possible complications, such as urinary tract infections. Although SCI is obviously not the same as spina bifida, experts in spina bifida may also be able to provide this education and support.

Resources for Clinicians

On the Web

Spinal Cord Injury Information Network (UAB-SCIMS)
A wealth of information about SCI for health care professionals, including patient education materials; University of Alabama at Birmingham Spinal Cord Injury Model System.

PM&R Knowledge NOW
A list of search results on spinal cord injury highlighting the breadth and depth of clinical topics in the specialty of PM&R.

Primary Care Resources for Spinal Cord Injury Care (ASIA)
Resource list that includes Caring for Persons with Spinal Cord Injury, a SCI Primary Care Flowsheet, Health Promotion Maintenance Checklist, and more; American Spinal Injury Association.

Helpful Articles

PubMed search for articles published within the last 5 years about pediatric spinal cord injuries

Bauer SB.
Neurogenic bladder: etiology and assessment.
Pediatr Nephrol. 2008;23(4):541-51. PubMed abstract / Full Text

Buldini B, Amigoni A, Faggin R, Laverda AM.
Spinal cord injury without radiographic abnormalities.
Eur J Pediatr. 2006;165(2):108-11. PubMed abstract

Chulamorkodt NN, Estrada CR, Chaviano AH.
Continent urinary diversion: 10-year experience of Shriners Hospitals for Children in Chicago.
J Spinal Cord Med. 2004;27 Suppl 1:S84-7. PubMed abstract

Klaas SJ, Kelly EH, Anderson CJ, Vogel LC.
Depression and anxiety in adolescents with pediatric-onset spinal cord injury.
Top Spinal Cord Inj Rehabil. 2014;20(1):13-22. PubMed abstract / Full Text

Parent S, Mac-Thiong JM, Roy-Beaudry M, Sosa JF, Labelle H.
Spinal cord injury in the pediatric population: a systematic review of the literature.
J Neurotrauma. 2011;28(8):1515-24. PubMed abstract / Full Text

Sayama C, Chen T, Trost G, Jea A.
A review of pediatric lumbar spine trauma.
Neurosurg Focus. 2014;37(1):E6. PubMed abstract / Full Text

Clinical Tools

Assessment Tools/Scales

Medical Home Questionnaire for SCI (MHP) (PDF Document 51 KB)
Historical questions and physical exam items that may be helpful in assessing patients with SCI; Medical Home Portal.

International Standards for Neurological Classification of Spinal Cord Injury Worksheet (ASIA) (PDF Document 637 KB)
Two-page assessment sheet updated in 2019; American Spinal Injury Association.

Center for Epidemiological Studies Depression Scale for Children (CES-DC) (PDF Document 37 KB)
Ages 12 to 18; 6th grade reading level; Spanish version available; 20 items, 5 to 10 minutes to complete. No fee required.

Clinical Checklists & Visit Tools

Musculoskeletal Exam for Common Orthopedic Complications (PDF Document 579 KB)
A concise, easy-to-use tool to document the limitations of a child's musculoskeletal abilities and exam; Medical Home Portal.

Patient Education & Instructions

Autonomic Dysreflexia (UAB) (PDF Document 277 KB)
A 5-page pdf with information for patients and families about warning signs, symptoms, importance of blood pressure measurements, triggers, and treatments; University of Alabama at Birmingham.

Resources for Patients & Families

Information on the Web

Spinal Cord Injuries (MedlinePlus)
Basic information and links to additional reliable sources; National Library of Medicine.

American Spinal Injury Association (ASIA)
Promotes standards of excellence, educates professionals and families, and facilitates research. Includes conference announcements, publications, and research information.

SCI-INFO-PAGES
A "best of the web" site for SCI health and caregiver information. Includes information about spinal cord injury, rehabilitation sites, clinical trials, related problems, and resources for patients with SCI and their caregivers; created by an individual with a spinal cord injury.

Reeve Foundation
Dedicated to curing spinal cord injury by funding innovative research; provides grants, information, advocacy, and referral service.

EP Magazine (Exceptional Parent)
A monthly publication that provides practical advice, emotional support, and up-to-date educational information for people with disabilities.

United Spinal Association
A products & services directory with reviews.

National & Local Support

Challenged Athlete Foundation
Provides opportunities and support to people with physical challenges, so they can pursue active lifestyles through physical fitness and competitive athletics. Challenged Athletes Foundation believes that involvement in sports at any level increases self-esteem, encourages independence and enhance his quality of life.

Studies/Registries

Spinal Cord Injuries Clinical Trials (CenterWatch)
Lists trials by state.

Services for Patients & Families in Idaho (ID)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: December 2008; last update/revision: June 2020
Current Authors and Reviewers:
Author: Lynne M. Kerr, MD, PhD
Reviewer: Michael Green, DO
Authoring history
2014: update: Meghan Candee, MDR
2008: first version: Teresa Such-Neibar, DOA; Lynne M. Kerr, MD, PhDR
AAuthor; CAContributing Author; SASenior Author; RReviewer

Bibliography

ASIA.
Facts on Pediatric Spinal Cord Injury.
American Spinal Injury Association; (2020) https://asia-spinalinjury.org/committees/pediatric/pediatric-committee....

Anderson CJ, Vogel LC, Chlan KM, Betz RR, McDonald CM.
Depression in adults who sustained spinal cord injuries as children or adolescents.
J Spinal Cord Med. 2007;30 Suppl 1:S76-82. PubMed abstract / Full Text

Bauer SB.
Neurogenic bladder: etiology and assessment.
Pediatr Nephrol. 2008;23(4):541-51. PubMed abstract / Full Text

Buldini B, Amigoni A, Faggin R, Laverda AM.
Spinal cord injury without radiographic abnormalities.
Eur J Pediatr. 2006;165(2):108-11. PubMed abstract

CDC.
Acute Flaccid Myelitis.
Centers for Disease Control and Prevention; (2020) https://www.cdc.gov/acute-flaccid-myelitis/index.html. Accessed on May 2020.

Calhoun CL, Schottler J, Vogel LC.
Recommendations for mobility in children with spinal cord injury.
Top Spinal Cord Inj Rehabil. 2013;19(2):142-51. PubMed abstract / Full Text

Chulamorkodt NN, Estrada CR, Chaviano AH.
Continent urinary diversion: 10-year experience of Shriners Hospitals for Children in Chicago.
J Spinal Cord Med. 2004;27 Suppl 1:S84-7. PubMed abstract

Craig A, Tran Y, Middleton J.
Psychological morbidity and spinal cord injury: a systematic review.
Spinal Cord. 2008. PubMed abstract

Cree BA.
Acute inflammatory myelopathies.
Handb Clin Neurol. 2014;122:613-67. PubMed abstract

Dearolf WW 3rd, Betz RR, Vogel LC, Levin J, Clancy M, Steel HH.
Scoliosis in pediatric spinal cord-injured patients.
J Pediatr Orthop. 1990;10(2):214-8. PubMed abstract

Gall A, Turner-Stokes L.
Chronic spinal cord injury: management of patients in acute hospital settings.
Clin Med (Lond). 2008;8(1):70-4. PubMed abstract / Full Text

Hickey KJ, Vogel LC, Willis KM, Anderson CJ.
Prevalence and etiology of autonomic dysreflexia in children with spinal cord injuries.
J Spinal Cord Med. 2004;27 Suppl 1:S54-60. PubMed abstract

Jan FK, Wilson PE.
A survey of chronic pain in the pediatric spinal cord injury population.
J Spinal Cord Med. 2004;27 Suppl 1:S50-3. PubMed abstract

Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey MJ, Schmidt-Read M, Waring W.
International standards for neurological classification of spinal cord injury (revised 2011).
J Spinal Cord Med. 2011;34(6):535-46. PubMed abstract / Full Text

Klaas SJ, Kelly EH, Anderson CJ, Vogel LC.
Depression and anxiety in adolescents with pediatric-onset spinal cord injury.
Top Spinal Cord Inj Rehabil. 2014;20(1):13-22. PubMed abstract / Full Text

Krause JS, Carter RE, Pickelsimer EE, Wilson D.
A prospective study of health and risk of mortality after spinal cord injury.
Arch Phys Med Rehabil. 2008;89(8):1482-91. PubMed abstract

Montane E, Vallano A, Laporte JR.
Oral antispastic drugs in nonprogressive neurologic diseases: a systematic review.
Neurology. 2004;63(8):1357-63. PubMed abstract

Parent S, Mac-Thiong JM, Roy-Beaudry M, Sosa JF, Labelle H.
Spinal cord injury in the pediatric population: a systematic review of the literature.
J Neurotrauma. 2011;28(8):1515-24. PubMed abstract / Full Text

Reynolds RM, Morton RP, Walker ML, Massagli TL, Browd SR.
Role of dorsal rhizotomy in spinal cord injury-induced spasticity.
J Neurosurg Pediatr. 2014:1-5. PubMed abstract

Rozzelle CJ, Aarabi B, Dhall SS, Gelb DE, Hurlbert RJ, Ryken TC, Theodore N, Walters BC, Hadley MN.
Management of pediatric cervical spine and spinal cord injuries. In: Guidelines for the management of acute cervical spine and spinal cord injuries.
Neurosurgery. 2013;72 Suppl 2:205-26. PubMed abstract

Sayama C, Chen T, Trost G, Jea A.
A review of pediatric lumbar spine trauma.
Neurosurg Focus. 2014;37(1):E6. PubMed abstract / Full Text

Scott TF, Frohman EM, De Seze J, Gronseth GS, Weinshenker BG.
Evidence-based guideline: clinical evaluation and treatment of transverse myelitis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.
Neurology. 2011;77(24):2128-34. PubMed abstract

Vitale MG, Goss JM, Matsumoto H, Roye DP Jr.
Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000.
J Pediatr Orthop. 2006;26(6):745-9. PubMed abstract

Vogel LC, Krajci KA, Anderson CJ.
Adults with pediatric-onset spinal cord injury: part 2: musculoskeletal and neurological complications.
J Spinal Cord Med. 2002;25(2):117-23. PubMed abstract
This article discusses long term follow up of adults that had sustained spinal cord injury as children in regard to musculoskeletal and neurological complications.

Wang MY, Hoh DJ, Leary SP, Griffith P, McComb JG.
High rates of neurological improvement following severe traumatic pediatric spinal cord injury.
Spine. 2004;29(13):1493-7; discussion E266. PubMed abstract