When treating patients with CSIs, emergency medicine physicians must remain focused on three goals. First, the emergency medicine physician must identify all significant injuries, including the CSI. The emergency physician, as the initial physician contact, must keep the complete patient clinical picture in mind to allow subspecialists to concentrate on specific injuries. Second, the emergency medicine physician must take steps to prevent worsening of any neurologic function associated with the spinal cord injury. Basic fundamentals must be addressed to complete this goal. Spinal immobilization of unstable injuries is imperative. Care must be taken during intubation to prevent further cord injury. Identification and treatment of shock is important to maintain adequate perfusion to the injured spinal cord. Finally, the emergency physician must expedite therapy for any CSI and associated spinal cord injury. Adult data suggest that urgent release of spinal cord compression may improve outcome. Urgent MRI may be necessary to identify cord compression. Intravenous steroids may be indicated for treatment of a spinal cord injury.
Steroids in Children. The use of steroids has been advocated for the treatment of patients with acute spinal cord injuries. (78,79) The indication for treatment in the quoted NASCIS trials was "having a spinal cord injury" as defined by study physicians. Approximately 8% of patients had normal neurologic function on enrollment in NASCIS 3. (79) No patient younger than age 14 was enrolled in this series. Patients with gunshot wounds were excluded, but patients with other forms of penetrating trauma were not excluded from study. Outcomes were not reported according to the type of cord injury sustained.
While steroid dosing in adults with acute spinal cord injuries may or may not provide benefit, the benefit and indications of this therapy in young children has not been proven. Centers should establish a consensus for the treatment of children after spinal trauma. Communication between emergency physicians and accepting subspecialists should be done so that all members of the treatment team will have a common understanding when a patient arrives in the ED. Controversy may arise about the treatment of a child with sensory deficits of an isolated Cervical level or the treatment of a very young child with an apparently normal neurological examination with an abnormal cervical spine radiograph.
Conclusion
Evaluation of the pediatric patient with a potential CSI is a complicated process. The emergency physician must exercise thoughtful clinical judgment in evaluating a pre-cooperative patient at a low risk of a potentially catastrophic injury. A complete understanding of the pertinent anatomy, radiographic features, and biomechanical tolerance of the pediatric spine is necessary to provide this care.
