SCIWORA Rozlyn McTeer BSN, RN, CEN Pediatric Trauma Coordinator Trauma Services Identify SCIWORA. OBJECTIVES Identify the population at risk. To identify anatomic and physiologic reasons for SCIWORA. To identify mechanisms associated with injury. To understand outcomes for patients with SCIWORA. DEFINITION SCIWORA refers to spinal injuries, typically located in the cervical region Defined as injury in the absence of identifiable bony or ligamentous injury in plain radiographs or CT. The majority of children with SCIWORA do have demonstrable injury of the spinal cord, spinal ligaments, or vertebral body end plate on MRI. 1
EPIDEMIOLOGY Mechanism 41% sports related 26% motor vehicle collision 14% falls 9% other Segment injury prevalence 46% Cervical Injury C1-C4 most common C5-C7 less common 14% Thoracic Equally distributed 7% Lumbar EPIDEMIOLOGY Accidental versus nonaccidental (1640) In the age 0-10 population, females are at greatest risk for upper segment SCIWORA (-54%) More injuries in this population are complete injuries. As children age, so does the incidence and prevalence. In the 11-17 age population, males are at most risk for lower segment SCIWORA (-72%). 2
EPIDEMIOLOGY 53% of kids with SCIWORA have associated injuries: In children 0-3: TBI in 64% In children 4-10: TBI in 47% In children 11-17: TBI in 28% Rib fractures more common in 0-3 age, 19% Orthopedic injuries in 0-3 age, 23% Facial bone fractures most common in 0-3 age, 23% CONSIDERATIONS Consider the associated injuries Consider compensatory mechanisms and physiologic differences with younger children. Consider the need for specialized pediatric service lines. Consider the difficulty with appropriate placement for rehabilitation. Higher hospital charges and longer lengths of stay are seen in younger kids 11-17: average 13 days, average cost $72K for acute stay. 0-10: average 20 days, average cost $210k for acute stay. ANATOMY WHY DOES SCIWORA OCCUR IN CHILDREN? Head versus body size Weak neck musculature Spinal ligaments and capsules are elastic Longitudinal expansion of the intervertebral disc and annulus due to a higher water content Facets are more horizontal and shallow Anterior wedging of the vertebral bodies Children lack uncinate processes on the vertebral bodies Growth zone of the vertebral body endplate is brittle 3
WHAT DOES THIS ALL MEAN? Children younger than 8 are at most risk. Blunt trauma, in kids under 8, is associated with upper cervical spine injury (segments C1-3). Older children and adolescents are more likely to have lower cervical spinal cord injuries (segments C4-8). Cervical spine maturation is not typically achieved until about 16 years of age. MECHANISMS HYPEREXTENSIONposterior interlaminar ligaments impinge upon the spinal canal causing up to 50% narrowing of the canal. Spinal cord shortening develops and leads to thickening in the cervical region. Further extension leads to transient bony displacement. MECHANISMS HYPERFLEXION- Similar impingement as with hyperextension. Anterior interlaminar ligaments impinge upon the cervical spinal canal causing narrowing at the point where the cord thickens. Flexion can leads to transient bony displacement 4
MECHANISMS DISTRACTION-Chance Fracture The spinal column is stretched well beyond normal limits. Failure of the posterior elements while anterior and middle columns are compressed Spinous processes widen Vertebral body is wedged anteriorally MECHANISMS Spinal Cord Infarction Vertebral artery occlusion with ischemia of the upper cervical spinal cord. This has been associated in neonates with failure of the atlanto-occipital articulation during delivery. Also associated in children who suffered high-energy thoraco-abdominal trauma and retroperitoneal injury and hypotension. CASE STUDY 18 month old female is the rear seat passenger of a two car MVC. She is in a forward facing 5 point harness car seat. Mother was driving northbound on I-44 when another vehicle crossed the median impacting the front end of the vehicle. Estimate speed: 70mph 5
CASE STUDY EMS report 18 month old rear seat passenger, restrained in a car seat. Child has remained unconscious since scene time. VS: 80/62, 143 bpm, 99% with bvm resp @ 18. GCS: 3 Mother and driver of other vehicle are J4 on scene. Child remains in car seat en route and has bruising to face. She remains flaccid and unresponsive. ETA 9 minutes by ground 6
CASE STUDY IV-fluids, sedation, pressure support Intubation CT H-CS-CAP Trauma Labs 7
IMAGING FLEXION-EXTENSION FILMS 8
FLEXION-EXTENSION FILMS X-RAY vs MRI SCIWORA Present with a spectrum of neurological deficits. Dependent on severity of injury and location Motor versus sensory or motor-sensory May have identified injuries on MRI. Injury patterns: extraneural versus neural Ligament injuries Muscle injury Intervetebral disc injury Neural injury 9
MRI FINDINGS Partial cord injury Complete cord injury Anterior cord syndrome Pain and temperature deficits; sphincter dysfunction Posterior cord syndrome Affects vibration and proprioception sense Central cord syndrome Intact sensation; Motor weakness in upper extremities greater than lower. Brown-Sequard syndrome Ipsilateral voluntary motor and proprioception deficits. Contralateral pain and temperature deficits below the lesion MRI FINDINGS Degrees of injury Complete cord injury from extreme flexion resulting in disc herniation into cord. Major cord hemorrhage-defined as more than 50% hemorrhage on axial image Minor cord hemorrhage-defined as less than 50% hemorrhage on MRI Edema of the cord-extent of edema is dependent on timing of MRI Acute neurological deficits without evidence Injury Patterns Hyperextension-Anterior longitudinal ligament with widening intervertebral space and anterior disc herniation Hyperflexion-posterior longitudinal ligament rupture with small posterior disc herniation CURRENT MANAGEMENT Immobilization Miami J Traction Medications Prevention of shock; high dose steroids. Imaging Radiographs CT MRI standard for SCIWORA Surgery vs Bracing (12 weeks) Ongoing research Prevention of further cellular death Ways to control inflammation Therapeutic hypothermia Rehabilitation and long term care 10
OUTCOMES Burden of Cost $1.7-4.7 lifetime cost. Mortality is very rare There could be delay in MRI findings. Consider additional injuries Prevent secondary injuries (hypotension and hypoxia) Stabilize instability-prevent further injury. Long term outcomes are varied due to difference in injury patterns ASIA American Spinal Injury Association CONSIDERATIONS Any a pediatric patient with neurological symptoms emergency department conditions should maintain a high level suspicion for injury. Considerations for clearance 11
HOW DO YOU CLEAR A CERVICAL SPINE? Clinical exam Radiographs and CT NEXUS Midline cervical tenderness Focal neurologic deficit Altered level of consciousness Evidence of intoxication Painful distracting injuries REFERENCES Caviness, A. C. (2016). Spinal cord injury without radiographic abnormality (SCIWORA) in children. Retrieved from https://www.uptodate.com/contents/spinal-cord-injury-without-radiographicabnormality-sciwora-in-children?source=search_result&search=sciwora&selectedtitle=1~11 Centers for Disease Controll and Prevention. (2014). Child maltreatment: Facts at a glance. Retrieved from https://www.cdc.gov/violenceprevention/pdf/childmaltreatment-facts-at-a-glance.pdf Farrell, C. A., Hannon, M., & Lee, L. K. (2017, June). Pediatric spinal cord injury without radiographic abnormality in the era of advanced imaging. Current Opinion Pediatrics, 29(3), 286-290. http://dx.doi.org/10.1097/mop.00000000000000481 Kirshblum, S.C., Biering-Sorensen, F., Betz, R. et. al. (2014, Spring). International Standards for Neurological Classification of Spinal Cord Injury: Cases with classification challenges. The Spinal Cord Injury Rehabilitation 20(2), 81-89. http://doi13.1310/sci2002-81 Knox, J. (2016, March 12). Epidemiology of spinal cord injury without radiographic abnormality in children: a nationwide perspective. Journal of Children s Orthopaedics, 10, 255-260. http://dx.doi.org/10.1007/s11832-016-0740-x Sunshine, J. E., Armangan, D., Barnes, S. P., et. Al. (2017, April). Methylprednisolone therapy in acute traumatic spinal cord injury: Analysis of a regional spinal cord model systems database. International Anesthesia Research Society, 124(3), 1200-1205. http://doi:10.1213/ane.0000000000001906 12