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Traumatic Spinal Cord Injury

Disease/Disorder Definition Traumatic spinal cord injury (SCI) refers to a trauma to the spinal cord leading to impaired motor, sensory, and/or autonomic function. Etiology Common causes of pediatric traumatic SCI include the following: Motor vehicle accidents Violence such as gunshot or penetrating wounds Sports/recreational injuries Falls Motor vehicle accidents are the predominant etiology of traumatic SCI in children of all ages, whereas sports and recreation account for more injuries in adolescents.1 Unique etiologies of pediatric SCI include the following: Lap belt injuries Higher cervical injuries related to: Atlanto-axial instability, as seen in skeletal dysplasia (i.e., Down syndrome, Mucopolysaccharidosis IV Morquio syndrome) and rheumatoid arthritis. In rheumatoid arthritis, atlanto-axial instability results from synovitis of the facets and destruction of the dens. Achondroplasia, which results in myelopathy and central apnea due to a small foramen magnum. Osteogenesis imperfecta, with its complication of basilar invagination, though SCI due to this condition is rare. Birth injuries Child abuse Epidemiology including risk factors and primary prevention Annual incidence of pediatric traumatic SCI in the U.S. ranges from 14 to 25 cases per 1 million population, with approximately 6 times greater incidence in adolescents age 13-20 than in younger children.1 As in adults with SCI, traumatic SCI is more common in males than females during adolescence. However, the preponderance of males becomes less marked as age of injury decreases, such that incidence of traumatic SCI in females equals males in those 3 years of age or younger. Cervical SCIs are more common than thoracic and lumbar level injuries. The majority of pediatric traumatic SCI leads to incomplete injuries. Studies have shown a strong association between mechanism and severity of injury with race and socioeconomic factors. Most notably, there is a higher incidence of traumatic SCI sustained from gunshot wounds among black patients. Patho-anatomy/physiology Children have greater spinal mobility and less spinal stability than adults do. The cervical spine and its ligaments take 8 to 10 years to mature and achieve stability. The spinal ligaments are generally more elastic, and the facet joints have a shallow and horizontal orientation compared to the adult spine. The incompletely ossified vertebral bodies have relative anterior wedging. Moreover, a child’s head is relatively large compared with the strength of the neck muscles. The fulcrum of movement with flexion and extension is higher at the C2-3 level, and the increased mobility results in more frequent high cervical injuries.2 These features of the pediatric spine are responsible for the different pattern of injuries in children compared to adults. Spinal cord injury without radiographic abnormality (SCIWORA) is a relatively unique entity in children first termed and described in 1982 for traumatic myelopathy in the absence of findings on plain or flexion/extension radiographs or computed tomography (CT) studies. With the development of magnetic resonance imaging (MRI), findings such as spinal cord contusion, edema, or ligamentous injury are now shown in children who would have previously been diagnosed as SCIWORA.2 Due to the immature anatomy and greater laxity, the pediatric spinal column can stretch more than the spinal cord prior to disruption, leading to cord injury without local or adjacent spinal column injury. Traumatic injury to the vascular supply of the spinal cord results in cord ischemia. Injury to the spinal cord via force transmission through the intact spinal column can also occur. Disease progression including natural history, disease phases or stages, and disease trajectory – clinical features and presentation over time Most recovery from SCI occurs within the first 6 to 9 months. For individuals with traumatic SCI, neurologic recovery plateaus around 12 to 18 months. At 1 year post-injury, cases of incomplete SCI show a higher degree of motor recovery than those of complete SCI. Early ASIA impairment scale (AIS) scores, 72 hours after injury, have been determined to be good prognostic indicators of functional ambulation at 1 year post-injury. Functional recovery in SCI occurs by compensation and neural plasticity rather than by repair.3 Specific secondary or associated conditions and complications Spasticity, autonomic dysreflexia, pain, neurogenic bladder, urinary tract infections, neurogenic bowel, pressure injuries, depression, low bone mass and osteoporosis, sexual dysfunction, joint contractures, and heterotopic ossification are all seen in children. Immobilization hypercalcemia is more commonly seen in adolescent boys and occurs in the first 3 months after injury. Pathologic fractures of long bones, latex allergy, and syringomyelia are also common in children. Children with SCI are at unique risk for several orthopedic complications that do not occur in the skeletally mature adult, such as scoliosis. Almost every child who sustains an SCI before skeletal maturity develops scoliosis, and approximately two-thirds of these children require surgery.4 Early thoracolumbar-sacral orthotic bracing may slow the rate of curve progression, which could delay the need for surgery in children with SCI until they reach skeletal maturity. Close surveillance and referral to surgery when appropriate is essential to caring for pediatric SCI patients. General indications for spine fusion surgery in children with neurogenic scoliosis secondary to SCI include curves greater than 40° by Cobb angle, age greater than 10 years, rapid progression of the curve, and functional problems or pain in a mature patient. Another common orthopedic complication is hip dysplasia, with prevalence strongly associated with age. For patients who sustain SCI at a young age, especially less than 10 years, one study found 93% of those patients developed hip dislocation. The prevalence was significantly less, 9%, in patients greater than 10 years of age with SCI.5 This is likely related to joint instability from reduced weight-bearing time in young children. Since indications for surgical treatment for hip subluxation and dislocation is unclear, an aggressive prevention strategy is recommended.6 Rehabilitation management aims for stretching, spasticity management, prophylactic abduction bracing, and weight-bearing as possible. Essentials of Assessment History of new SCI Inquire about the nature of trauma, pain, new numbness/paresthesia, weakness, and function. Information as to the location, severity, and nature of symptoms, which may involve upper and lower limbs, should be included. Inquire as to whether the symptoms are transient, evolved over time, or permanent. Inquire about new-onset incontinence in a previously continent child. The presence of neck and back pain suggests the possibility of spinal injury, although back pain in children is rare. Physical examination Physical examination should include a general exam and an exam specific to SCI. A general physical exam for the respiratory tract (especially in patients with tetraplegia or high paraplegia), abdomen, skin to rule out pressure injury, and cranial nerves should be included. A physical exam specific to SCI is important in determining the level and extent of injury to the upper motor neurons. The exam involves testing all dermatomal levels from C2-S5 using both light touch and pinprick sensation, key muscle groups from C5-T1 and L2-S1, as defined by the American Spinal Injury Association (ASIA), and reflexes (bulbocavernosus, abdominal, deep tendon, and Babinski). Neurologic level of injury should be determined as outlined by the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) published by ASIA. Completion of the ASIA ISNCSCI exam requires enough cognitive maturity to follow motor commands and respond to sensory stimulation testing. Studies have demonstrated that this exam is less reliable in children less than 6 years of age, and hence may not be an appropriate method to determine neurological consequence of SCI in infants and toddlers. While examinations can be performed in children as young as 4 years of age, the interrater reliability is poor prior to age 6. Children injured at a young age and those who are not toilet trained prior to injury, with limited experience with volitional bowel movements, have difficulty with the anal motor exam. Clinicians may want to explain to parents how standardized testing for neurological classification is performed and, because of their child’s young age, classification as complete or incomplete may not be reliably determined and only an estimated neurological level can be provided from the examination.7,8 Currently, there is no validated alternative method of assessment of neurological impairment in infants with SCI. Monitoring physiological variables such as heart rate and blood pressure during sensory testing, or the use of electrodiagnostic testing may help assess the neurological consequence of SCI in very young children. Correlating the relationships between images of the injured spinal cord on MRI and/or CT combined with a careful neurologic exam may be useful for younger children or for older children who are unable to cognitively fully participate in the ASIA ISNCSCI examination.7,8 Functional assessment Functional assessment should include evaluation of mobility for transfers, potential for ambulation, and self-care. Bowel and bladder function and toileting skills should be assessed. A neuropsychological evaluation is essential if concomitant brain injury is suspected. The Functional Independence Measure (FIM) or WeeFIM II (in infants, children, and younger adolescents) and the Spinal Cord Independence Measure (SCIM) III may be used to measure progress.9 Laboratory studies Complete blood count, comprehensive metabolic profile, serum calcium, phosphate, parathyroid hormone, and urinalysis with culture are the minimum laboratory tests to be included during admission. Imaging Plain radiographs and CT images of the spine are essential to investigate for fractures, dislocations, bleeding, and other associated injuries. MRI, with or without contrast, is recommended in patients when SCI is suspected. It is useful for detecting both extraneural and intraneural damage to the cord and for determining prognosis. The contrast study would delineate ligamentous or soft tissue injury, scarring, or disk herniation. MRI of the brain is indicated if concomitant brain injury is suspected. Supplemental assessment tools The initial phase following acute SCI is spinal shock which may result in areflexia and an acontractile detrusor muscle. The duration of spinal shock varies widely, from several days to several months. Since SCI is often associated with severe concurrent head, thoracoabdominal, and skeletal injuries that require urgent management, the bladder is often initially managed with an indwelling urethral catheter. Early urologic care is important to maintain safe storage, minimize the risk of urologic complications, and maximize continence. The consensus for timing of initial assessment of urinary dysfunction is within 3 months of injury. Ultrasound is used to assess for hydronephrosis, renal stones, and bladder stone formation. Urodynamics study is the gold standard to evaluate lower urinary tract function in patients with SCI. Urine analysis, microscopy, and culture are important for the exclusion of urinary tract infection but should be reserved for the symptomatic SCI patient.  Early predictions of outcomes Younger patients tend to have more complete and severe injuries. At the time of initial injury, high-energy mechanisms, thoracic involvement, younger age, and complete injury portend a poor prognosis. In patients with complete injuries, significant neurologic recovery is rare. Patients with incomplete injuries tend to have a better prognosis in terms of motor and sensory function that can translate to ambulation and self-care.3 MRI showing intraneural hemorrhage is typically accompanied by a more severe injury resulting in permanent deficits. Environmental Environmental barriers need to be identified and addressed in terms of accessibility issues at home and in the community. Examples include the following: entrance/exit ramps and doorway clearance for wheelchair accessibility, grab bars in the bathroom for easier transfers and safety, and wheelchair transportation options for community and recreational activities. Social role and social support system Assess the support system and social roles to address functional needs and provide support at home, upon discharge from an inpatient setting, and for community reintegration. Inquire about the school setting, family roles, and necessary support systems, and ensure that they are available and that modifications are made. Professional issues Delayed onset of neurologic findings, normal radiographs of the spine, and unfamiliarity with SCIWORA may lead to the inappropriate discontinuation of spinal precautions and bracing. Such decisions could worsen the injury, leading to poor functional outcomes and medicolegal situations. One of the most challenging aspects of spinal cord injury rehabilitation medicine is discussing prognosis with patients and families. The available information for prognosis of recovery is often not great, and it can be difficult to explain and maintain a reasonable degree of hope for recovery. It is also important to distinguish the concepts of neurologic and functional recovery. Consider differences in approach based on clinical setting, patient/family background, education, culture, and age. When discussing prognosis, sit close to the patient, present information in small doses, use simple language, and convey support with open body language and eye contact. Rehabilitation Management and Treatments Available or current treatment guidelines No current specific treatment guidelines are available. A review of the current standard of medical and rehabilitation care has been previously described.10 Rehabilitation must be developmentally based.11 The challenge in caring for children and adolescents with SCI is to address the changing objectives of each developmental stage. Goals should address growing children’s needs regarding health maintenance and the restoration of function and participation to improve quality of life and life satisfaction throughout childhood and into adulthood. Interventions encompass training in mobility, activities of daily living, skin care, bladder and bowel programs, recreation, psychosocial counseling, education, vocational support, and community reintegration. Devices, which may assist with mobility, vary according to age, growth, and size. They may range from standing devices, strollers, and wheelchairs to gait orthoses, functional electric stimulation, modifications for sports, and driving. Long-term community ambulation is dependent on several factors including AIS score, total ASIA motor score, and age at injury.12 At different disease stages Acute Stage Treatment consists of Spine immobilization to prevent further neurologic injury Surgical spinal stabilization and decompression may be indicated Supportive care for neurogenic and vascular shock Thromboembolic and GI prophylaxis Autonomic nervous system management (blood pressure, heart rate, bowel and bladder) Pain control Skin protection Use of high dose methylprednisolone to improve neurologic recovery in the pediatric population is not currently recommended13 Subacute Stage/Rehabilitation phase Physical/occupational/speech therapy to learn mobility, self-care, and wheelchair management. Bowel program: Bowel programs are initiated at the developmentally appropriate age of 2 to 4 years, or earlier if they are experiencing diarrhea or constipation. Children who have hand function that is adequate to perform independent bowel care should begin their own bowel programs when they are 5 to 7 years old.11 Bladder program: Clean intermittent catheterization (IC) is the standard bladder management for children and adolescents with SCI. IC is initiated when the child is approximately 3 years old, or earlier if the child is having recurrent urinary tract infections or is starting to develop renal impairment. Children who have hand function that is adequate to perform self-catheterization should begin self-catheterization when they are 5 to 7 years old.11 Prophylaxis of venous thromboembolism (VTE): The literature available about thromboembolic complications in pediatric SCI is limited. The incidence of deep venous thrombosis (DVT) in children and adolescents with SCI has been reported to range from 2.5% to 17.5% with a 0% to 2.3% incidence of pulmonary emboli. Older (>13 years) and more severely injured patients are at higher VTE risk. Due to the low incidence of DVT in children who are injured before reaching adolescence, it may be reasonable to limit the use of anticoagulants […]

Spinal Cord Injury Without Radiological Abnormality

Disease/Disorder Definition Spinal cord injury without radiological abnormality (SCIWORA) involves symptoms of a traumatic myelopathy without evidence of fracture or ligamentous instability on radiograph or computed tomography (CT).1 The term was coined prior to the availability of magnetic resonance imaging (MRI) yet […]

Spinal Cord Injury – Related Pain

Disease/ Disorder Definition One of the most frequently occurring physical sequelae following spinal cord injury (SCI) is persistent pain. Taxonomies for pain after spinal cord injury are available.1,2 These taxonomies have commonality, defining pain by location with respect to the level of […]

Autonomic Dysreflexia in Spinal Cord Injury

Disease/Disorder Definition Autonomic dysreflexia (AD) in spinal cord injury (SCI) is a potentially life-threatening syndrome which results from a response to stimuli below the neurologic level of injury (NLI) resulting in a sympathetic nervous system response below the level of injury, leading […]

Pediatric Spinal Cord Tumors

Disease/ Disorder Definition Spinal cord tumors are rare central nervous system (CNS) tumors that involve the primary spinal cord, spinal meninges, or cauda equina. Unlike in adults, spinal cord tumors in children are usually primary tumors, not metastases. Etiology Multifactorial changes at the cellular level are just beginning to be described. In different anatomical locations, the same histopathological phenotype may have different tumor biology. Malignant transformation at the molecular level is much less understood in children. Epidemiology including risk factors and primary prevention Compared to adults, spinal cord tumors in pediatrics have lower incidences and have different histologic features, sites of origin, and responses to treatment. Although CNS tumors are the most common solid tumor in the United States, spinal cord tumors account for 1-2% of all childhood CNS tumors.1 Due to their rarity, comprehensive epidemiologic studies have been challenging in children. In children and adolescents (age 0-19), the overall incidence of primary tumors of the CNS is 6.14 per 100,000.2 Primary pediatric spinal cord tumors account for 1-10% of all CNS tumors in this age group, with an estimated incidence of 0.27 per 100,000 persons.3,4 Primary spinal cord tumors can be classified by anatomical sublocation5,6: Intradural intramedullary: Primarily glimoas, such as astrocytomas and ependymomas Intradural extramedullary: Primarily meningiomas and peripheral nerve sheath tumors Extramedullary: Primarily metastatic in origin Common pediatric spinal tumor histologic subtypes include2: Ependymal Tumors (19.6%) Tumors of the Meninges (17.8%) Nerve Sheath Tumors (17.2%) Other Neuroepithelial Tumors (16.6%) Pilocytic Astrocytoma (11.4%) Other Astrocytoma/Glioblastoma (8.3%) Metastatic tumors are very rare in children and may occur as drop metastases from brain tumors, unlike in adults, where most common spinal cord tumors are metastatic. In terms of location, extradural tumors account for approximately 30% of all pediatric spinal tumors.6 In the pediatric population, the 5- and 10-year survival rate after being diagnosed with a tumor of the spinal cord proper or cauda equina is 93.6% and 92.1%, respectively.2 The median age of diagnosis is 11 years and has higher incidence in caucasians.7 Patho-anatomy/physiology Pediatric spinal cord tumors are classified by the type of tissue involved, anatomical location, and growth/invasiveness. Tumor grade and histology directly affect prognosis, as some tumors are better resected than others. Malignant transformation of pediatric low-grade gliomas is very unusual compared to those in adults.8 Radiation therapy may generate malignant transformation by accelerating a tumor’s natural tendency towards dedifferentiation or by engendering a de novo high-grade tumor. Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) Children with low-grade spinal cord gliomas have a peak age of diagnosis between one and two years of age, with 41% diagnosed before age four.9 Pain of the bony segment directly over the tumor is the most common presenting complaint in children.10,11 The onset of back pain may be over months. Notably, back pain is generally uncommon in pediatrics, and therefore should always be thoroughly investigated. Other common presenting symptoms include abnormal gait or coordination difficulties, spinal deformity, focal motor weakness, and sphincter dysfunction.10 Older children may also note a history of progressive motor weakness. In infants, nonspecific crying episodes followed by motor weakness or torticollis may be seen. Long-term motor and sensory neuropathy deficits are often seen in children following intramedullary spinal cord tumor (IMSCT) resection. In a long-term assessment of 164 children who underwent IMSCT resection12: 1/3 experienced improvements in motor, sensory and urinary dysfunction years after resection. 2/3 experienced long-term dysesthetic symptoms that impacted their quality of life. Independent risk factors for long-term dysesthesia include increasing age, preoperative symptom duration >12 months, and worsening postoperative neurological symptoms. Survival depends on the histology and grade of the spinal cord tumor. High-grade intramedullary astrocytomas have poor prognoses; survival can be three to twelve months despite aggressive treatment.13,14 Specific secondary or associated conditions and complications Neurofibromatosis is associated with low-grade gliomas. Orthopedic complications, most often severe kyphoscoliosis, occurs in 35% of children treated for low-grade spinal gliomas.9 Early scoliosis is the most common sign of a thoracic astrocytoma. Significant syrinxes can also be found in many children with astrocytomas. Treatment related complications may also occur including radiation myelopathy from radiation over the spinal cord or the vertebral column.1 Essentials of Assessment History Ask about neurological deficits, both motor and sensory. Evaluate for dysphagia, neurogenic bowel and bladder, spasticity, scoliosis, and syrinx. Take a detailed pain history. Ask about the child’s or adolescent’s current schooling, academic progress, and family’s expectations on return to school post-rehabilitation. Take a detailed social history to determine family support, home setting, and need for ramps, doorway modifications, or other structural modifications. If environmental modifications or computer-aided environmental control systems are indicated, ask if the family has financial resources, as these items are generally not covered by insurance or Medicaid. Detail the child’s social role and social support system. Ask about members of child’s family, as well as details of the home, school, and recreational environment. Physical examination Check for palpable tenderness over the involved bony segment. Often it is most painful directly over the tumor. Perform a complete neuromuscular exam: evaluate for motor strength, coordination, reflexes, vibration, proprioception, light and sharp touch. Complete an American Spinal Injury Association (ASIA) assessment, keeping in mind the child’s developmental age and need for modesty (see the ISNCSCI Exam Pediatric Brochure at https://asia-spinalinjury.org/information/download/). Check for presence of scoliosis/kyphosis and their flexibility. Functional assessment Functional Independence Measure (FIM) and Functional Independence Measure for Children (WeeFIM) (available at https://www.udsmr.org/) Pediatric Evaluation of Disability Inventory (PEDI) (available at https://www.pearsonassessments.com/) Pediatric Balance Scale (PBS) (see ref. 15) Karnofsky Performance Scale (KPS): used by oncologists; standard measure of cancer patient’s ability to perform ordinary tasks (see http://www.npcrc.org/files/news/karnofsky_performance_scale.pdf). Pediatric Quality of Life Inventory (PedsQL) (available at http://www.pedsql.org). Modified McCormick Scale (mMS) – used by some neurosurgical studies to determine pre- and postoperative neurological function: (see https://www.nature.com/articles/sc200851/tables/1). Laboratory studies In addition to World Health Organization (WHO) grading, histological and molecular verification of the tumor is paramount to pathological diagnosis. Immunohistochemistry, such as SOX-10 staining, can help differentiate ependymomas from astrocytomas.16 Information on the underlying genetic abnormalities in pediatric diffuse gliomas allows better separation of these tumors from similar adult versions.11 Cerebral spinal fluid (CSF) studies are generally helpful to rule out other causes of spinal cord lesions, such as infection, but are not diagnostic for intramedullary tumors. See the section on treatment for further guidelines. Imaging MRI of the spinal cord and/or brain with and without gadolinium enhancement is the imaging modality of choice for the preoperative evaluation of spinal cord tumors. Intraoperative imaging may also decrease the need for further surgery. Imaging also plays a role in detecting tumor caused hydrocephalus, syringomyelia, scoliosis, and other complications. Early predictions of outcomes Early diagnosis of spinal cord tumors is most favorable.17,18,19 Tumor grade and the extent of surgical resection predict outcome.9 Most astrocytomas are low grade and surgically curable if they can be completely resected.3 Patients with astrocytomas and hemangioblastomas are more likely to undergo subtotal resection because of their indistinct borders. Ependymomas, schwannomas, and especially meningiomas are typically totally resected because of their well-defined borders. Ependymomas occurring in the lower half of the spinal cord have a worse prognosis; ependymomas occurring in the upper half of the spinal cord recur later and less frequently, with little or no mortality.20 Tumor recurrence usually indicates a very poor prognosis. Low FIM or WeeFIM scores correlate with severe neurological deficits at diagnosis, such as paraparesis, but not with tumor histology or localization, age at diagnosis, pre-diagnostic symptomatic interval, or the management of spinal cord compression. Environmental (see History section) Social role and social support system Ask about members of the child’s family and details of the home, school, and recreational environment. Peer mentorship, including a formalized parent-to-parent mentoring program, can be especially beneficial in supporting families by decreasing anxiety and social isolation.21 Rehabilitation Management and Treatments Available or current treatment guidelines The acute management of pediatric spinal cord tumors usually involves surgical resection plus chemotherapy and/or radiation therapy. Radiation and chemotherapy are generally added when a complete (>90%) resection is not possible. There are no standardized treatment guidelines. Inpatient versus outpatient rehabilitation may depend on the prognosis of the tumor (stage, types of treatment recommended), functional status change, goals of care and function and […]

Infectious Disorders of the Spinal Cord

[…] upper and lower extremities, assessment of major reflexes, gait assessment, and sensory examination.  An International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination should be performed if there is suspicion or clinical findings suggestive of spinal cord involvement.8 Tenderness to […]

Assessment/Determination of Spinal Column Stability

[…] M, Schnake K, Bellabarba C, Reinhold M, Aarabi B, Kandziora F, Chapman J, Shanmuganathan R, Fehlings M, Vialle L; AOSpine Spinal Cord Injury & Trauma Knowledge Forum. AOSpine thoracolumbar spine injury classification system: fracture description, neurological status, and key modifiers. Spine (Phila […]

Spinal Tumors

[…] Subacute: Pain and/or neurologic deficits will progressively worsen with continued tumor growth. Chronic/stable: If the tumor continues to grow, irreversible spinal cord injury, including paralysis, bowel and bladder incontinence, and loss of sensation below the level of the tumor could result. Pre-terminal: […]

Overuse Injuries in Disorders of the Central Nervous System

[…] is due to a combination of factors such as genetics, trauma history, age of injury, level of impairment after a spinal cord injury or severe weakness after a brain injury as well as environmental factors such as equipment and layout and design of home.2,4 For individuals with CNS disorders the most common cause for these injuries result from altered biomechanics of weight bearing through joints not designed to sustain repetitive motions or significant amounts of weight over time. Examples include upper limb activity with wheelchair propulsion and transferring the body between surfaces. Additionally, the individual in a wheelchair will be required to place joints in mechanically compromising positions, such as with overhead reaching, which over time, contributes shoulder injuries and adds to each other over time. Individuals with CNS disorders are more likely to have muscle weakness or mechanical disadvantages that causes an imbalance between muscle groups that can lead to injury.3 The majority of research in the area of overuse injuries in CNS disorders is with wheelchair users, but long-term reliance on walkers, crutches, and other assistive devices can also contribute to overuse injuries. There continues to be a lack of research regarding specific patterns that these assistive devices contribute to injuries. Studies have shown altered biomechanics in this specific population includes weakness, spasticity, lack of motor control and affected proprioception. This usually is followed by affected intraarticular pressure in affected joints that result in the overuse injury.5,6 Epidemiology including risk factors and primary prevention Most of the information on the epidemiology of overuse injuries comes from literature on persons with spinal cord injury (SCI). For patients with brain injuries., epidemiologic studies continue to be limited. Some of the most common injuries include, by region: Shoulder injuries: prevalence of pain symptoms range from up to 81% in spinal cord injury and 26% in patients with stroke.2,5 Shoulder pain in paraplegics versus tetraplegics is more likely to be orthopedic or musculoskeletal-related (80% versus 81%, respectively). Rotator cuff (RC) injuries: 20% unilateral, 29% bilateral for paraplegics, with full thickness tears more prevalent than partial thickness7 Prevalence of rotator cuff tears 4x higher in paraplegics vs. control with tear of supraspinatus most common.8 In brain injury patients with hemipleglic upper extremities, fatty infiltration of the RTC occurs and may affect functional recovery afterwards.9 Impingement syndrome: incidence as high as 75% in symptomatic shoulder pain patients with SCI10 Bicipital tendinitis: the incidence has yet to be described in literature, however, remains common cause for referred shoulder pain.2 Osteoarthritis (OA): glenohumeral OA 14-32%, AC joint 31-42% in spinal cord injury, incidence in brain injury yet to be described 5,8 Elbow injuries: prevalence of pain symptoms range from 6-15% with older studies reporting up to 32%.2,3 Lateral epicondylitis: 17% in wheelchair users that play sports11 Entrapment mononeuropathies have been found to be around 67% with ulnar neuropathy at the elbow (UNE)/cubital tunnel syndrome being around 10%.2 Wrist/hand injuries: prevalence of pain symptoms range from 9-63%.2 Median nerve entrapment 78%12 DeQuervain’s tenosynovitis Myofascial pain of the neck and low back with incidence over 50% of patients. Risk factors in both spinal cord injuries and brain injuries include age since initial injury, higher body mass index (BMI), wheelchair propulsion style or use of assistive devices and transfer techniques.2,5,7 Primary prevention includes early and comprehensive rehabilitation that teaches adequate and joint-sparing techniques in transfers and effective wheelchair propulsion. Identifying strength disproportion may help the rehabilitation group to target weak or affected muscles for proper rehabilitation. Decreased muscle strength especially in the shoulder adductors and low physical activity have been shown to be weak predictors of shoulder pain development over a 3-year period.13 Mulroy, et al. speculated that weaker shoulder adductors may be unable to unload the rotator cuff effectively leading to injury. Interestingly, higher UE weight-bearing activities were not found to be risk factors for development of shoulder pain whereas low activity was associated to the development of shoulder pain.14 Patho-anatomy/physiology Overuse injuries involve repetitive motions that most commonly affect the musculotendinous unit resulting in tendinopathy, tenosynovitis, and/or muscle soreness. Other tissues that can be involved include bursae (bursopathy), bone (stress fractures), nerve (compression neuropathies), and cartilage (OA). As a consequence of repetitive microtraumatic overuse, injuries eventually lead to an impairment in the tissue’s ability to self-repair. As a result, there occurs limited function associated to the involved structure.15 Physical stressors thought to be potentiating factors in overuse injury include level of force, posture, duration, contact stress, vibration and temperature.10 Examples of highly repetitive activities that require increase in intra-articular forces include transfers, pressure relief maneuvers, and wheelchair propulsion.5,6 Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) In general, overuse injuries develop over several months to years after the CNS injury or disorder but vary by individual and situation. Several conditions related to using a wheelchair and other assistive devices result in the development of overuse syndrome. Over time, these devices have progressed to be lighter and have had ergonomic adjustments that prevent poor postures that may contribute to injuries (posterior pelvic tilt, excessive neck flexion, prolonged shoulder abduction, internal rotation and extension). Overuse injuries pass through an acute and subacute phase in which ongoing microtrauma occurs and when it advances to chronic phases, maladaptive tissue forms and prevents further recovery. The prevalence of carpal tunnel syndrome has been noted to be higher in patients with longer periods since initial CNS insult which supports the scarring and tissue maladaptation associated with overuse.16 Three pain trajectories of self-reported musculoskeletal shoulder pain (0=No Pain, 1=very mild, 2=mild, 3=moderate, 4=severe, 5=very severe) over 5 years were identified in one prospective cohort study of 225 newly injured persons with SCI: “No or Low pain” (64%, n=148), “High Pain” (30%, n=63), and “Decrease of pain” (6%, n=14). The authors hypothesized that a fourth trajectory “Increase of pain” could be identified if a follow-up time of >5 years was used, which would hypothetically show pain problems in shoulders due to overuse. The trajectories were identified using […]

Pediatric Anoxic Brain Injury

[…] thalamocortical integrity. 32 SSEP is used as a neurophysiologic test for assessing integrity of neuronal pathways from the peripheral nerves, spinal cord, brainstem and cerebral cortex. Most reliable evoked potential waveform as median N20 component of SSEP Median N20 SSEP: first cortical response of SSEP with median nerve stimulation Bilateral absence of median N20 response on days 1 and 3 or later following CPR accurately predicts poor outcome (reflects widespread cortical necrosis) Bilateral absence of N20 potentials is a reliable/strong predictor of poor outcome after cardiac arrest yet may be impacted by hypothermia.32 Advantage: less susceptible to effects of sedative drugs, metabolic changes and artifact interference compared to EEG monitoring. Disadvantage: require advanced neurologic training, interpretation limited to specialized centers, low sensitivity Serum Biomarkers for ABI Prognostication Serum NSE (neuron-specific enolase) Isomer of intracytoplasmic glycolytic enzyme enolase found in neuronal bodies, axons, neuroendocrine cells and tumors NSE peaks in serum and CSF at ours after injury Serum NSE > 33 microgram/L at days 1 and 3 associated with poor outcome Use limited by lack of laboratory standardization, long turn-around […]