When a patient presents with the symptoms and signs of spinal cord injury but boney injury cannot be found, the patient is said to have a spinal cord injury without radiological abnormalities (SCIWORA). SCIWORA injuries occur nearly exclusively in children because pediatric patients have elastic spinal columns with immature ligaments and muscles that permit cord injury without obvious column injury from hyperextension and hyperflexion. While prehospital providers will be able to detect motor/sensory deficit suggesting spinal cord injury, do not plan on being able to differentiate patients with boney injury from those with SCIWORA. However, providers who perform interfacility transports may be asked to transport these patients to trauma centers. Management of these patients is identical to any other spinal cord-injured patient.
SCIWORA is most common in children under 8; in fact, one study found it only occurred in patients younger than 8.9 The authors of this study, led by physician Patrick Platzer, do believe SCIWORA is possible in older children. Mechanisms associated with SCIWORA are typically high-energy impacts with hinging forces that produce extreme stretching and whipping of the child’s head and neck. There are no defining symptoms for SCIWORA other than that the patient will have some type of motor or sensory deficit but x-rays and CT scans will fail to show spinal column injury.
Central cord syndrome is an incomplete spinal cord injury that occurs from hyperextension of the cervical spine. When cervical spinal cord hyperextension occurs, one of two injuries may result, both of which present as central cord syndrome. The more common comes from tearing and/or stretching of the central portion of the cervical spinal cord. Alternatively, central cord syndrome can result if the spinal artery is injured and inadequate blood flow to the central portion of the spinal cord leads to ischemia and then central cord necrosis. Distinguishing these two injuries in the field is impossible.
The symptoms of central cord syndrome are hallmarked by a disproportionately greater loss of motor strength in the upper extremities compared to the lower extremities. Additionally some degree of sensory loss is common. The upper extremities experience greater symptoms because the nerves that affect them are concentrated in the central column of the cervical cord.
Brown-Séquard syndrome is observed following hemisection of the spinal cord by penetrating trauma. It is fortunately quite rare.5 This syndrome manifests with ipsilateral (same side as the injury) motor loss, the generalized loss of sense of position, and contralateral (opposite side from the injury) sensation loss for pain and temperature.
Spinal cord contusions are bruises to the spinal cord, and their presentation is determined on the location of the contusion. Typically cord contusions present with some varying degree of sensory or motor deficit in the extremities. Completely flaccid extremities are not consistent with spinal cord contusions.
When a patient has a mechanism suggesting a potential spine injury and is not reliable for a spine assessment, immobilization is indicated. The threshold for identifying a mechanism as able to cause a spine injury needs to be lower in children than in adults, particularly since no studies have focused on prehospital pediatric spine clearance.10
There are two goals during immobilization: Limit current damage and prevent secondary injury. Immobilization with a cervical collar does not effectively stabilize the entire spine. Spine stabilization is achieved with the patient’s spine and the weight centers (head, shoulders, pelvis) and legs all in an inline neutral position.10
Pediatric cervical collars are designed for children, and their use is essential as a part of proper immobilization. Be sure to apply the properly sized cervical collar, as using one that’s too small will provide no stabilization and may obstruct the airway, while one that’s too large may allow the cervical spine to flex.
The principles of immobilizing children are simple:
1. Maintain the spine in a neutral and inline position;
2. Control the weight centers: head, shoulders and pelvis;
3. Controlled spine movement toward the inline position is safe;
4. Provide padding to maintain a neutral spine position;