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 to those who have other risk factors for DVT.^11,14
• Hypercalcemia: This most commonly occurs in adolescents and young adult males during the first 3 months after injury. Patients with hypercalcemia typically present with abdominal pain, nausea, vomiting, lethargy, malaise, polydipsia, polyuria, and dehydration. Serum calcium and ionized calcium are elevated above age-appropriate normal values. Complications may include nephrolithiasis, urolithiasis, and renal failure. Treatment may include pamidronate and hydration.¹¹
• Pressure injuries are one of the most common complications for youth with SCI. Preventive interventions should be developmentally based, with responsibility gradually shifting from parents to the youth. Prevention of tissue damage employing relief techniques may include wristwatches with automatic resetting timers to remind children about pressure relief. Properly fitting wheelchairs and adequate cushions must be prescribed and modified as the child grows; pressure mapping utilization to reduce the risk of pressure injury should be employed.¹⁵
• Pulmonary complications: Similar to the adult SCI population, pulmonary dysfunction is a major complication during both the acute and chronic phases of SCI. Children with high cervical injuries require aggressive and early ventilatory support and will generally require lifelong ventilatory support, phrenic nerve, or diaphragmatic pacing.¹¹
• Pain control: Chronic pain is a significant co-morbidity in children and adolescents with SCI and can be very disabling and negatively affect school, work, and social interactions. Evaluation of pain in infants and younger children may be complicated by their variable communication abilities.¹¹
• Spasticity management: Compared with adults, a smaller percentage of children with SCI experience spasticity. The general principles of managing spasticity are similar to the adult SCI population. Namely, to improve function, prevent complications, alleviate pain, and reduce incontinence.¹¹
• Autonomic dysreflexia: Noxious stimuli must be identified and minimized. The degree of hypertension can be variable depending upon the child’s age, with elevation of the systolic BP of at least 15 mm Hg in children and 20 mm Hg in adolescents. As BP varies with age and gender as well as level of SCI, it is important to establish baseline BP and adjust as the child grows. In view of the varying cognitive and verbal communication abilities of children, symptoms of AD may not be expressed or may be communicated less clearly.¹⁵
• Hyperhidrosis: Hyperhidrosis is seen primarily in individuals with tetraplegia or upper thoracic paraplegia. Stimuli that may incite hyperhidrosis include noxious stimuli like UTI, urolithiasis, posttraumatic syringomyelia, and tethering of the spinal cord, or it may be unexplained. Treatment should be initiated if it is distressing to the child, impairs function, or increases risk of developing pressure injuries. Management should begin with avoidance and alleviation of precipitating factors. Medications that inhibit sympathetic overactivity, such as propantheline or transdermal scopolamine, can be used.¹⁵
• Rehabilitation: Goals of (re)habilitation should be to maintain health and restore participation, with the ultimate goal of the patient feeling satisfaction in their life. The challenge in caring for children and adolescents with SCI is to address the changing objectives of each developmental stage, such that the child becomes an adult with a high quality of life.¹¹
• Provide family/caretaker training and education for necessary modifications for discharge along with community resources.

Chronic/Stable phase

Health maintenance and prevention of secondary complications associated with neurogenic bowel and bladder, management of spasticity and pain, prevention of pressure injury, screening for low bone mass with a dual-energy x-ray absorptiometry (DXA) scan, and immunizations are all critical during the chronic phase.

Other aspects include the following

• Annual assessments with the ISNCSCI exam to evaluate for changes/recovery.
• Screening and monitoring for scoliosis and hip deformities.
• Evaluation for candidacy to undergo tendon or nerve transfers to improve function.
• Continued education for the identification and management of autonomic dysreflexia.
• Assessing and prescribing assisted technology, wheelchair, and power mobility.
• Ongoing family/caretaker training as needs change.
• Identification and utilization of available community resources for school, educational, vocational, and leisure activities.

Coordination of care

A multidisciplinary team consisting of the patient, family, physiatrist, nursing, physical, occupational and speech therapists, rehabilitation psychologist, social worker, child-life support/recreation therapist, discharge coordinator, and other medical/surgical specialties must work together to achieve successful rehabilitation and reintegration to the community. An education consultant is recommended to assist with school reentry.

Young people with SCI face many barriers and facilitators in their transition to adulthood with regard to both health care services and normative life milestones such as education, employment, social participation, and independent living. Children with SCI and caregivers would benefit from organizations providing flexible and progressive care options, including social reintegration opportunities, peer-mentoring activities, and programs to educate individuals with SCI and families on ways to develop motivation, resilience, and independent living skills.¹⁶

Patient & family education

Education of the patient and family is vital for medical management, as well as activity and participation. Within this context, it becomes imperative to equip families with comprehensive instruction in areas such as mobility, self-care, and tailored bowel and bladder regimens. The specific focus should be attuned to the child’s individual deficits, developmental stage, preparedness for training, and the extent of accessible community resources. The concept of anticipatory guidance, denoting the education provided to both children and parents regarding the potential future impacts of a disability, emerges as a crucial factor in facilitating smooth transitions throughout each phase of development and ultimately into adulthood.

Emerging/unique interventions

Tracking includes the following:

• Neurologic recovery via the ISNCSCI exam.
• Functional changes in WeeFIM II and SCIM III scores.
• Success in community reintegration.
• Participation in academic, athletic, and recreational activities.
• Participation in community activities.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

A unique opportunity arises to educate primary care pediatricians regarding the identification and management of the conditions that tend to afflict the SCI population. These include obesity, hyperlipidemia, metabolic syndrome, and low bone mass/osteoporosis. The promotion of wellness programs with accessibility and advocacy is critical.

Cutting Edge/Emerging and Unique Concepts and Practice

The field of pediatric SCI has been rapidly evolving, with several cutting-edge advancements and research areas.

Neuroregeneration and Neural Repair: Researchers are exploring innovative techniques to promote neural regeneration and repair after SCI. This includes stem cell therapies, neurotrophic factors, and tissue engineering approaches to encourage regrowth and reconnection of damaged neural pathways.¹⁷

Neuroplasticity and Rehabilitation: Advances in neuroplasticity research have led to novel rehabilitation strategies that aim to rewire the nervous system and enhance functional recovery in pediatric SCI patients. Technologies such as virtual reality, brain-computer interfaces, and robotic-assisted therapies are being explored.¹⁸

Neuromodulation: Techniques like spinal cord stimulation and transcranial magnetic stimulation are being investigated for their potential to modulate neural circuits and enhance functional recovery after SCI.¹⁹

Exoskeletons and Assistive Devices: Exoskeletons and wearable robotic devices are being designed to help children with SCI regain mobility and independence. These devices are becoming more lightweight, user-friendly, and tailored to the specific needs of pediatric patients.

Multi-Disciplinary Care: The treatment of pediatric SCI involves a multidisciplinary approach. Collaboration between these disciplines is crucial for providing comprehensive care and achieving better outcomes.

Gaps in the Evidence-Based Knowledge

Limited Pediatric-Specific Data: Much of the research on SCI is conducted in adults, and there is a scarcity of pediatric-specific data. Children’s physiology, developmental stages, and responses to treatment can differ significantly from adults, making it crucial to gather data specific to the pediatric population.

Ethical Considerations: Ethical challenges in pediatric SCI research, such as informed consent, involving minors in experimental treatments, and the balance between potential benefits and risks, need careful examination.

Long-Term Outcomes: Long-term outcomes of pediatric SCI, including the effects on growth, bone health, neurological function, and quality of life as children transition into adulthood, require more comprehensive study.

Healthcare Transitions: Research on the successful transition of children with SCI from pediatric to adult healthcare systems is lacking. Ensuring continuity of care and addressing the unique challenges of this transition is crucial.

References

1. Crispo J, Liu L, Noonan V, Thorogood N, Kwon B, et al. Pediatric traumatic spinal cord injury in the United States: a national inpatient analysis. Top Spinal Cord Inj Rehabil. 2022;28(1):1-12. https://doi: 10.46292/sci21-00047.
2. Yadav A, Singh A, Verma R, Singh V, Ojha B, Chandra A, Srivastava C. Pediatric cervical spine injuries. Asian J Neurosurg. 2022;17:557-562. https://doi.org/ 10.1055/s-0042-1757728.
3. Chay W, Kirshblum S. Predicting outcomes after spinal cord injury. Phys Med Rehabil Clin N Am. 2020;31(3);331-343. https://doi: 10.1016/j.pmr.2020.03.003.
4. Mulcahey M, Gaughan J, Betz R, Samdani A, Barakat N, Hunter L. Neuromuscular scoliosis in children with spinal cord injury.  Top Spinal Cord Inj Rehabil. 2013;19(2):96-103. https://doi: 10.1310/sci1902-96.
5. McCarthy J, Chafetz R, Betz R, Gaughan J. Incidence and degree of hip subluxation/dislocation in children with spinal cord injury. J Spinal Cord Med. 2004;27:S80-83. https://doi: 10.1080/10790268.2004.11753423.
6. McCarthy J, Betz R. Hip disorders in children who have spinal cord injury. Orthop Clin N Am. 2006;37(2):197-202. https://doi: 10.1016/j.ocl.2005.09.004.
7. Mulcahey M, Gaughan J, Betz R, Johansen K. The international standards for neurological classification of spinal cord injury: reliability of data when applied to children and youths. Spinal Cord. 2007;45:452–459. https://doi.org/10.1038/sj.sc.3101987.
8. Mulcahey M, Gaughan J, Chafetz R, Vogel L, Samdani A, Betz R. Interrater reliability of the international standards for neurological classification of spinal cord injury in youths with chronic spinal cord injury. Arch Phys Med Rehabil. 2011;92(8):1264-1269. https://doi: 10.1016/j.apmr.2011.03.003.
9. Mulcahey M, Thielen C, Sadowsky C, Silvestri J, Martin R, et al. Despite limitations in content range, the SCIM-III is reproducible and a valid indicator of physical function in youths with spinal cord injury and dysfunction. Spinal Cord. 2018;56(4):332-340. https:// doi: 10.1038/s41393-017-0036-0.
10. Greenberg J, Ruutiainen A, Kim H. Rehabilitation of pediatric spinal cord injury: From acute medical care to rehabilitation and beyond. J Pediatr Rehabil Med. 2009;2(1):13-27. https://doi: 10.3233/PRM-2009-0059.
11. Kirshblum S, Lin V (Eds.). (2018). Spinal cord medicine. Springer Publishing Company.
12. Vogel L, Mendoza M, Schottler J, Chlan K, Anderson C. Ambulation in children and youth with spinal cord injuries. J Spinal Cord Med. 2007;30(1):S158–S164.
13. Pettiford J, Bikhchandani J, Ostlie D, St Peter S, Sharp R, Juang D. A review: The role of high dose methylprednisolone in spinal cord trauma in children. Pediatr Surg Int. 2012;28(3):287-294. https://doi: 10.1007/s00383-011-3012-3.
14. Thompson A, McSwain S, Webb S, Stroud M, Streck C. Venous thromboembolism prophylaxis in the pediatric trauma population. J Pediatr Surg. 2013;48(6):1413–1421.
15. Zebracki K, Melicosta M, Unser C, Vogel L. A primary care provider’s guide to pediatric spinal cord injuries. Top Spinal Cord Inj Rehabil. 2020;26(2):91–99. https://doi.org/10.46292/sci2602-91.
16. Porto A, Anderson L, Kalinich T, Deane K, Vogel L, Zebracki K. Understanding transition for youth with spinal cord injury: Youth and caregiver perceptions. J Spinal Cord Med. 2020;43(4):505–511. https://doi.org/10.1080/10790268.2019.1574437.
17. Shinozaki M, Nagoshi N, Nakamura M, Okano H. Mechanisms of stem cell therapy in spinal cord injuries. Cells. 2021;10(10):2676. https://doi.org/10.3390/cells10102676.
18. Lorach H, Galvez A, Spagnolo V, Martel F, Karakas S, et al. Walking naturally after spinal cord injury using a brain-spine interface. Nature. 2023;618(7963):126–133. https://doi.org/10.1038/s41586-023-06094-5.
19. James N, McMahon S, Field-Fote E, Bradbury E. Neuromodulation in the restoration of function after spinal cord injury. Lancet Neurol. 2018;17(10):905–917. https://doi.org/10.1016/S1474-4422(18)30287-4.

Original Version of the Topic

K. Rao Poduri, MD, Colin D Canham, MD, Woojoong Lee, MD. Traumatic spinal cord injury. Published 5/12/2013.

Previous Revision(s) of the Topic

Heather Asthagiri, MD and Justin Weppner, DO. Traumatic spinal cord injury. Published 8/1/2017.

Cristina Sadowsky, MD, Kavita Nadendla, MD. Traumatic Spinal Cord Injury. 2/23/2021

Author Disclosures

Kavita Nadendla, MD
Nothing to Disclose

Jing Chen, MD
Nothing to Disclose

Cristina Sadowsky, MD
Nothing to Disclose