In this review, we discuss the available evidence-based recommendations in the management of pediatric traumatic brain injury and spinal cord injury. We also discuss the relevant unique spinal and cranial anatomy and physiology of children versus adults and how this impacts the management of these cases. Lastly, we discuss outcomes as it relates to children following these complex injuries.
Key points
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Traumatic brain injury (TBI) and spinal cord injury (SCI) are significant causes of morbidity and mortality in children on a global scale.
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Children, especially neonates and infants, have distinctive pathophysiologic responses to TBI and SCI compared to older children and adults.
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These differences may be explained by the rapid postnatal neurodevelopment that occurs in the first 2 years of life.
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Children aged under 8 years are prone to upper cervical injuries.
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Infants with significant brain injuries may make unexpectedly good recoveries, presumably as new pathways develop in the noninjured area.
| ASIA | American Spinal Injury Association |
| CSF | cerebrospinal fluid |
| CT | computed tomography |
| EEG | electroencephalography |
| EVD | external ventricular drain |
| GCS | Glasgow Coma Scale |
| GFAP | glial fibrillary astrocytic protein |
| ICP | intracranial pressure |
| ISNCSCI | International Standards for Neurological Classification of Spinal Cord Injury |
| MAP | mean arterial pressure |
| mTBI | mild traumatic brain injury |
| SCI | spinal cord injury |
| sTBI | severe traumatic brain injury |
| TBI | traumatic brain injury |
Introduction
Traumatic brain injury (TBI) and spinal cord injury (SCI) are significant causes of morbidity and mortality in pediatric populations. These injuries can lead to long-term physical, cognitive, and emotional impairments affecting the quality of life of children and their families. Given the rapid postnatal cerebral and spinal development that occurs in children, pediatric neurotrauma presents unique challenges in diagnosis and management compared to adults.
TBI and SCI are considered acute conditions immediately following injury. These conditions evolve into chronic diseases among survivors. As acute conditions, urgent assessment and treatment are essential and impact recovery, quality of life, and mortality. As chronic conditions, follow-up care and rehabilitation are integral for positive outcomes.
In this review, we discuss the available evidence-based recommendations in the management of pediatric TBI and SCI. We also discuss the relevant unique spinal and cranial anatomy and physiology of children versus adults and how this impacts the management of these cases. Lastly, we discuss outcomes as they relate to children following these complex injuries.
Epidemiology
Traumatic Brain Injury
In the United States, TBI is a leading cause of death and disability in children and adolescents. It accounts for about 80% to 90% of pediatric trauma-related deaths annually with incidence rates ranging between 200 and 300 per 100,000 in high-income countries. , Although no age group is immune from TBI, the extremes of age are most vulnerable. The highest frequency of emergency department visits, hospital admissions, and death occur among the elderly (aged ≥75 years), closely followed by the pediatric age group (0–4 and 15–24 years). While children and adolescents have an overall lower mortality than adults (approximately 4% of all TBI-related deaths), the true burden of the disease in the young is significantly more substantial when measured in terms of years of lost life and years lived with disability.
Spinal Cord Injury
While less common than TBI, SCI can also lead to significant morbidity with outcomes including death or spastic quadriplegia/paraplegia. The global incidence of SCI ranges from 1.99 to 5.36 per million children annually, with significant regional variations due to differences in trauma-related risk factors and healthcare systems. Various sources estimate the prevalence of pediatric SCI in the United States and Canada at between 8 and 13 per million population annually (3000–5000 cases). ,
Definitions, grading, and nomenclature
Both TBI and SCI are categorized based on their severity, mechanism, and clinical presentation. Initial evaluation and grading of severity of injury is paramount in guiding the management of pediatric neurotrauma.
Traumatic Brain Injury
The Glasgow Coma Scale (GCS) is the most widely used assessment system to quantify initial severity of brain trauma globally. Historically, this grading system has been used to characterize mild (GCS 13–15), moderate (GCS 9–12), and severe (GCS 3–8) injury. However, both clinical observation and longstanding research have shown us that this “bucket” system may need refining. Within each GCS category, there is variability to treatment response and heterogeneity of outcome. Despite this challenge, the GCS itself remains the predominant assessment tool and has been shown to be, in general, predictive of outcomes particularly at its extremes. Because of age differences in motor and speech development, a modified pediatric GCS has been developed. Although useful in tertiary pediatric centers, it has not yet achieved the same widespread use as the adult scoring system. This system has altered criteria for verbal and motor skills for patients that are aged less than 5 years ( Table 1 ).
| Area Assessed | Infants | Young Children | Older Children/Adults | Score |
|---|---|---|---|---|
| Eye opening | Open spontaneously | Open spontaneously | Open spontaneously | 4 |
| Open in response to verbal stimuli | Open in response to verbal stimuli | Open in response to verbal stimuli | 3 | |
| Open in response to pain only | Open in response to pain only | Open in response to pain only | 2 | |
| No response | No response | No response | 1 | |
| Verbal response | Coos and babbles | Appropriate words | Oriented, appropriate | 5 |
| Irritable cries | Inappropriate words | Confused | 4 | |
| Cries in response to pain | Screams | Inappropriate words | 3 | |
| Moans in response to pain | Grunts | Incomprehensible words or nonspecific sounds | 2 | |
| No response | No response | No response | 1 | |
| Motor response | Moves spontaneously and purposefully | Normal spontaneous movement | Obeys commands | 6 |
| Withdraws to touch | Withdraws to touch | Localizes painful stimulus | 5 | |
| Withdraws in response to pain | Withdraws in response to pain | Withdraws in response to pain | 4 | |
| Responds to pain with decorticate posturing (abnormal flexion) | Responds to pain with decorticate posturing (abnormal flexion) | Responds to pain with decorticate posturing (abnormal flexion) | 3 | |
| Responds to pain with decerebrate posturing (abnormal extension) | Responds to pain with decerebrate posturing (abnormal extension) | Responds to pain with decerebrate posturing (abnormal extension) | 2 | |
| No response | No response | No response | 1 |
The mild TBI or concussion category presents its own unique challenges from a clinical management and research perspective. The literature is replete with differing terms for this spectrum of TBI and includes mild TBI, mild head injury, minor head injury, concussion, sports-related concussion, complicated mild TBI, and mild closed head injury, among others. Within the last several decades, clinical criteria for classifying mild TBI and related constructs have been developed by many authors and professional groups with limited consensus. These definitions vary in their length of loss of consciousness, posttraumatic amnesia, inclusion of neuroimaging findings, and level of alertness. The definition of concussion by the International Conference on Concussion in Sports is the most widely used and describes concussion as a “complex pathophysiological process affecting the brain, induced by biochemical forces.”
Spinal Cord Injury
The severity and prognosis of adult SCI is typically graded through the use of the American Spinal Injury Association (ASIA) scale ( Table 2 ). The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) scale is commonly used in pediatrics. It should be noted that the use of both classification systems in children aged below 4 years is limited as reliable participation of the patient is needed for an accurate assessment.
| AIS Score | Classification |
|---|---|
| A = Complete | No sensory or motor function is preserved in the sacral segments S4–S5 |
| B = Sensory incomplete | Sensory but not motor function is preserved at the most caudal sacral segments S4–S5 and no motor function is preserved more than 3 levels below the motor level on either side of the body |
| C = Motor incomplete | Motor function is preserved at the most caudal sacral segments on voluntary anal contraction or the patient meets the criteria for sensory incomplete status (sensory function preserved at the most caudal sacral segments (S4–S5) by LT, PP, or DAP), with sparing of motor function more than 3 levels below the motor level on either side of the body. This includes key or nonkey muscle functions more than 3 levels below the motor level to determine motor incomplete status. For AIS C, less than half of key muscle functions below the single NLI have a muscle grade of 3 or greater |
| D = Motor incomplete | Motor incomplete status as defined earlier, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade of 3 or greater |
| E = Normal | If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments and the patient had prior deficits, then the AIS grade is E. Someone without an SCI does not receive an AIS grade |
Similar to adult SCI, complete loss of neurologic function (motor, sensory, and urinary function) below the level of a traumatic injury to the spinal cord, especially in the setting of a present bulbocavernosus reflex, portends a very poor prognosis for neurologic recovery. This is termed ASIA A, whereas partial loss of function, as delineated by grades ASIA B to D, is associated with increasing likelihood of neurologic recovery.
Pathophysiology
Pediatric cranial and spinal anatomy and physiology are not analogous to the adult anatomy. Children have differing and unique pathophysiologic responses to trauma compared with adults. The biomechanical, anatomic, and physiologic differences in children include a thinner and more pliable calvarium, less myelination and more compliant brain matter (especially in the first 2 years of life), and a greater proportion of cerebrospinal fluid (CSF). Following TBI, the pathophysiologic consequences of these features are impaired autoregulation and more widespread cerebral edema. , ,
Biomechanical differences intrinsic to the pediatric spine contribute to a greater incidence of upper than lower cervical spinal injuries. The reasons include a relatively larger cranial size that places a stress fulcrum rostrally at C1 and C2, poor occipital-cervical muscular support, spinal ligamentous laxity, and shallow horizontal facets. Children aged under 8 years are more prone to atlantooccipital and C1 and C2 injuries than older children and adults.
Management
The management of TBI and SCI in children requires a multidisciplinary approach, given the complexity of these conditions and the unique aspects of pediatric care. Advancements have been made in both TBI and SCI management thanks to the development and introduction of evidence-based, resource-based, and expert consensus guidelines. Studies have consistently shown that the systematic use of these TBI guidelines leads to improved management and care of children following trauma.
Traumatic Brain Injury
In the most recent pediatric severe traumatic brain injury (sTBI) guidelines published by the Brain Trauma Foundation in 2019, 22 recommendations were made; all were Level II or Level III, indicating, respectively, moderate or weak evidence in support of the recommendation ( Table 3 ). The only recommendations that achieved Level II status were those for the use of 3% hypertonic saline bolus in patients with elevated intracranial pressure (ICP) and against the use of either prophylactic hypothermia or use of an immune-modulating diet (diet enriched with certain amino acids and vitamins showed no benefit over a normal diet ). Level III recommendations included obtaining a computed tomography (CT) scan at presentation, with emergent surgery if a surgical lesion is present; otherwise, the placement of an ICP monitor is advised, with escalating measures for ICP management followed by consideration of craniectomy if the ICP elevation is refractory to medical therapies. Early enteral nutrition and rehabilitation were also recommended to aid in reducing complications and accelerating recovery. Frequent follow-up care is recommended to further monitor and improve recovery (see Table 3 ).
Related posts:
Fundamentals of Acute Care for Patients with Traumatic Spinal Cord Injury
Multimodality Monitoring for the Management of Severe Traumatic Brain Injury
Challenges in Pulmonary Management after Traumatic Brain and Spinal Cord Injury
Fever in the Neurocritically Ill Patient
Thrombosis and Coagulopathy
Psychosocial Characteristics of Acquired Brain Injury
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