Available online 19 March 2024, 101122

Author links open overlay panel, ABSTRACT

Management of pediatric spinal cord injury (SCI) is an essential skill for all pediatric neurocritical care physicians. In this review, we focus on the evaluation and management of pediatric SCI, highlight a novel framework for the monitoring of such patients in the intensive care unit (ICU), and introduce advancements in critical care techniques in monitoring and management. The initial evaluation and characterization of SCI is crucial for improving outcomes as well as prognostication. While physical examination and imaging are the main stays of the work-up, we propose the use of somatosensory evoked potentials (SSEPs) and transcranial magnetic stimulation (TMS) for challenging clinical scenarios. SSEPs allow for functional evaluation of the dorsal columns consisting of tracts associated with hand function, ambulation, and bladder function. Meanwhile, TMS has the potential for informing prognostication as well as response to rehabilitation. Spine stabilization, and in some cases surgical decompression, along with respiratory and hemodynamic management are essential. Emerging research suggests that targeted spinal cerebral perfusion pressure may provide potential benefits. This review aims to increase the pediatric neurocritical care physician's comfort with SCI while providing a novel algorithm for monitoring spinal cord function in the ICU.

Section snippetsINTRODUCTION

Management of patients with spinal cord pathology is an essential skill for all pediatric neurocritical care physicians and pediatric spinal cord injury (SCI) is considered a primary pediatric neurocritical care (PNCC) diagnosis1. Annually, there are approximately 54 new traumatic SCIs (tSCI) per one million people in the United States, nearly 18,000 new cases per year based on 2022 estimates2 with 12.42% in patients ≤18 years of age3. Recent evaluation from the Kids Inpatient Database found

Examination

Initial evaluation of a patient with SCI includes assessment and stabilization of the airway, breathing, and circulation (ABCs); and spinal immobilization if traumatic etiology is suspected to avoid further injury during transport, evaluation, and management5. When trauma is suspected, an expedited Advanced Trauma Life Support (ATLS) primary and secondary survey should be performed. Important components of the examination include pupil size and reactivity, Glasgow Coma Scale, and extremity

Immediate Spine Stabilization and Surgical Intervention

External immobilization is indicated for initial management of suspected spine injury in the pre-hospital setting, consisting of a rigid external cervical orthosis and spinal precautions (limiting movement of the spine) are used to prevent further injury. In infants with large heads, thoracic padding or a backboard with occipital recess is needed to prevent neck flexion while supine21. Timing of surgical management tSCI is an area of active investigation22. Earlier studies suggested that

PROGNOSTICATION

Early neurological examination is crucial for prognostication of spinal cord function especially ambulation, bowel/bladder function, and other self-care activities. The AIS described above has been studied extensively and is a valid and reliable tool for assessing and communicating SCI severity with high intrarater and interrater reproducibility in children as young as six years of age84,85. Unfortunately, there is a paucity of data on pediatric outcomes and the following studies primarily

DISCUSSION

With limited data specifically related to pediatric patients, caring for children with acute SCI requires close collaboration with a multidisciplinary team consisting of emergency medicine, trauma, neurology, neurosurgery, critical care, and rehabilitation specialists with specific expertise in pediatric SCI. Expert consensus suggests that after the initial trauma resuscitation, children with SCI should be admitted to the intensive care unit for close monitoring and prompt intervention.

CONCLUSION

Pediatric SCI remains a challenging diagnosis. Innovative new techniques for imaging, neuromonitoring, and intervention are currently undergoing investigation and novel approaches are emerging. The creation of comprehensive multidisciplinary clinical programs in the ICU to support these new strategies will be important with the goal to improve functional outcomes and quality of life for these children and their families.

DECLARATIONS

The authors did not receive support from any organization for the submitted work. The authors have no relevant financial or non-financial interests to disclose.

AUTHOR CONTRIBUTIONS

AXT and JCE performed the literature search, analysis, drafted, and critically revised the work.

CRediT authorship contribution statement

Ajay X. Thomas: Writing – review & editing, Writing – original draft, Methodology, Investigation, Formal analysis, Conceptualization. Jennifer C. Erklauer: Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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