The Acute Pediatric Spine and Spinal Cord

Abstract

Acute conditions involving the spine and spinal cord in the pediatric age group are rare but potentially devastating and result from several etiopathogenetic mechanisms. Patients may present with a combination of back pain and acute neurological deterioration. Neuroimaging studies, especially magnetic resonance imaging (MRI), play a pivotal role in the management of affected patients, while computerized tomography (CT) plays a secondary role in some conditions.

Trauma to the pediatric spine has different pathomechanisms than in adults due to the peculiar state of incomplete ossification of the spine; thus, ligamentous injuries and involvement of the cervical spine prevail. Normal variants such as C2–C3 pseudosubluxation render radiographic evaluation more challenging in children, and radiologists must be familiar with them. Spinal cord injury without radiographic abnormality (SCIWORA) is associated with more complete neurologic injuries than in cases where the injuries can be seen on X-rays. Musculoskeletal causes other than trauma may present with acute back pain that prompts clinical evaluation, including spondylolysis/spondylolisthesis, muscle strain, and disc herniation. Infectious/inflammatory conditions involving the pediatric spine are manifold; in general terms, inflammation is more frequent than infection. Acute transverse myelitis (ATM) presents with an acute onset of motor, sensory, and autonomic dysfunction and can be idiopathic or occur in the context of autoimmune conditions such as acute disseminated encephalomyelitis (ADEM), multiple sclerosis, and neuromyelitis optica (NMO). MRI shows normal or slightly expanded spinal cord with diffuse or patchy hyperintensity on T2-weighted images involving more than three to four vertebral levels in length and more than 2/3 of the cross-sectional area of the spinal cord. Spinal cord ischemia enters the differential diagnosis with ATM and may be indistinguishable on MRI; however, its clinical presentation is typically hyperacute and stroke-like. The Guillain-Barré syndrome is an acute inflammatory disorder involving the spinal and peripheral nerves; patients experience acute onset of lower extremity weakness, progressing to flaccid paralysis and possibly ascending to involve the upper limbs, diaphragm, and cranial nerves. MRI shows contrast enhancement of the affected nerve roots, typically at the level of the cauda equina. Spinal infection is rare in the absence of predisposing conditions, such as immune suppression; spinal cord abscess can be seen in patients harboring dermal sinus tracts, which allow skin bacteria to colonize the central nervous system.

Spinal cord tumors may present acutely, either because they compress the spinal cord (extradural/intradural extramedullary tumors) or because they primarily infiltrate the spinal cord, causing neurological deterioration and pain. Acute pain is a characteristic of several spinal tumors, prominently including osteoid osteomas which tend to give nocturnal pain that recedes with salicylates.

In conclusion, the differences between children and adults with acute spinal conditions are significant; thus, children with acute spinal presentation require tailored neuroimaging studies and management.