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Pediatric spinal cord injury with radiographic abnormality: the Beijing experience

  • Author Footnotes
    # Equal contribution first authors.
    Zhewei Zou
    Footnotes
    # Equal contribution first authors.
    Affiliations
    Department of Neurology, Beijing Children's Hospital, 56 Nanlishi Road, Xicheng, Beijing, 100045, China
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  • Author Footnotes
    # Equal contribution first authors.
    Shaoyang Kang
    Footnotes
    # Equal contribution first authors.
    Affiliations
    Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Yifu Science Hall, 37 Xueyuan Road, Haidian, Beijing, 100191, China
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  • Author Footnotes
    # Equal contribution first authors.
    Yuxin Hou
    Footnotes
    # Equal contribution first authors.
    Affiliations
    Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Yifu Science Hall, 37 Xueyuan Road, Haidian, Beijing, 100191, China
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  • Kinon Chen
    Correspondence
    Corresponding author: Department of Neurology, Beijing Children's Hospital, 56 Nanlishi Road, Xicheng, Beijing, 100045, China. Tel.: +86-(0)10-82316427.
    Affiliations
    Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Yifu Science Hall, 37 Xueyuan Road, Haidian, Beijing, 100191, China
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  • Author Footnotes
    # Equal contribution first authors.
Published:September 01, 2022DOI:https://doi.org/10.1016/j.spinee.2022.08.023

      Abstract

      BACKGROUND CONTEXT

      Spinal cord injury (SCI) without radiographic abnormality (SCIWORA) is a syndrome that usually occurs in children primarily because of the unique biomechanics of the pediatric spine. We recently found that the histopathological and behavioral effects of SCI with radiographic abnormality (SCIWRA) and SCIWORA are very different from each other in animal models. Although numerous studies were conducted to understand the epidemiological and clinical characteristics of the overall pediatric SCI population and the pediatric SCIWORA population, the characteristics of the pediatric SCIWRA population and their differences from those of the SCIWORA population are poorly understood.

      PURPOSE

      To describe the epidemiology and clinical outcomes of pediatric patients with SCIWRA and their differences from those with SCIWORA.

      STUDY DESIGN/SETTING

      Retrospective study.

      PATIENT SAMPLE

      47 pediatric SCIWRA patients.

      OUTCOME MEASURES

      Epidemiological characteristics, Injury severities, functional deficits, and management and recovery outcomes.

      METHODS

      Review of all cases with SCIWRA at Beijing Children's Hospital between July 2007 and December 2019 and comparison between the present data and our previous SCIWORA data.

      RESULTS

      47 of the 187 pediatric SCI patients had SCIWRA (age: 7.06 ± 3.75 years, male-to-female ratio: 3:2). Main causes of SCIWRA were fall (38%) and traffic accidents (38%). Lesions were often located at multiple levels (62%). Incubation period was 3 ± 18 hours. According to the American Spinal Injury Association impairment scale (AIS), many SCIWRA patients had incomplete impairment (AIS B, 9%; AIS C, 9%; AIS D, 32%). Specifically, many of them had abnormal upper and lower limb muscle powers (55% and 60%), upper and lower limb muscle tones (34% and 49%), sensation (38%), and knee, ankle, and abdominal reflexes (47%, 34%, and 36%). 72% of SCIWRA patients were treated with methylprednisolone, dexamethasone, or both. 81% of them showed neurological improvement before discharge. There was no association between corticosteroid therapy and neurological improvement. Moreover, functional outcomes of their upper and lower limb muscle powers were significantly associated with functional outcomes of their upper and lower limb muscle tones (p < 0.01), respectively. In comparison to the SCIWRA population, the SCIWORA population had a higher ratio of younger and female patients of sports-related thoracic injuries with long incubation period leading to lower-body deficits and complete impairment (p<0.05 or p<0.01). Despite all the differences, their neurological improvement was similar (p>0.05).

      CONCLUSIONS

      Demographic differences exist in the SCIWRA population. Corticosteroids do not appear to be effective in the different types of pediatric SCI. Limb muscle tone may be used to evaluate the functional status of limb muscle power. The epidemiological and clinical characteristics of SCIWRA and SCIWORA are very different from each other. It is important to formulate tailor-made prevention, evaluation, and management strategies for the pediatric population to optimize the SCI outcomes.

      Keywords

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      References

        • DeVivo MJ
        • Vogel LC.
        Epidemiology of spinal cord injury in children and adolescents.
        J Spinal Cord Med. 2004; 27: S4-10
        • Jackson AB
        • Dijkers M
        • Devivo MJ
        • Poczatek RB.
        A demographic profile of new traumatic spinal cord injuries: change and stability over 30 years.
        Arch Phys Med Rehabil. 2004; 85: 1740-1748
        • Kewalramani LS
        • Kraus JF
        • Sterling HM.
        Acute spinal-cord lesions in a pediatric population: epidemiological and clinical features.
        Paraplegia. 1980; 18: 206-219
        • Lee JH
        • Sung IY
        • Kang JY
        • Park SR.
        Characteristics of pediatric-onset spinal cord injury.
        Pediatr Int. 2009; 51: 254-257
      1. Complete public version of the 2017 annual statistical report for the spinal cord injury model systems.
        National Spinal Cord Injury Statistical Center, Birmingham, Alabama2017
        • Nobunaga AI
        • Go BK
        • Karunas RB.
        Recent demographic and injury trends in people served by the Model Spinal Cord Injury Care Systems.
        Arch Phys Med Rehabil. 1999; 80: 1372-1382
        • Wyndaele M
        • Incidence Wyndaele JJ.
        prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey?.
        Spinal Cord. 2006; 44: 523-529
        • Alexander MS
        • Alexander CJ.
        Recommendations for discussing sexuality after spinal cord injury/dysfunction in children, adolescents, and adults.
        J Spinal Cord Med. 2007; 30: S65-S70
        • Anderson CJ
        • Vogel LC
        • Chlan KM
        • Betz RR
        • McDonald CM.
        Depression in adults who sustained spinal cord injuries as children or adolescents.
        J Spinal Cord Med. 2007; 30: S76-S82
        • Argetsinger LC
        • Trimble SA
        • Roberts MT
        • Thompson JE
        • Ugiliweneza B
        • Behrman AL.
        Sensitivity to change and responsiveness of the Segmental Assessment of Trunk Control (SATCo) in children with spinal cord injury.
        Dev Neurorehabil. 2019; 22: 260-271
        • Behrman AL
        • Trimble SA
        • Argetsinger LC
        • et al.
        Interrater Reliability of the Pediatric Neuromuscular Recovery Scale for Spinal Cord Injury.
        Top Spinal Cord Inj Rehabil. 2019; 25: 121-131
        • Betz RR
        • Mulcahey MJ
        • D'Andrea LP
        • Clements DH
        Acute evaluation and management of pediatric spinal cord injury.
        J Spinal Cord Med. 2004; 27: S11-S15
        • Chafetz RS
        • Gaughan JP
        • Calhoun C
        • et al.
        Relationship between neurological injury and patterns of upright mobility in children with spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2013; 19: 31-41
        • Calhoun CL
        • Haley SM
        • Riley A
        • Vogel LC
        • McDonald CM
        • Mulcahey MJ.
        Development of items designed to evaluate activity performance and participation in children and adolescents with spinal cord injury.
        Int J Pediatr. 2009; 2009854904
        • Calhoun Thielen C
        • Slavin MD
        • Ni P
        • Mulcahey MJ.
        Development and initial validation of ability levels to interpret pediatric spinal cord injury activity measure and pediatric measure of participation scores.
        J Pediatr Rehabil Med. 2021; 14: 463-476
        • Eswara JR
        • Castellan M
        • Gonzalez R
        • Mendieta N
        • Cendron M.
        The urological management of children with spinal cord injury.
        World J Urol. 2018; 36: 1593-1601
        • Flett PJ.
        The rehabilitation of children with spinal cord injury.
        J Paediatr Child Health. 1992; 28: 141-146
        • Goetz LL
        • Hurvitz EA
        • Nelson VS
        • Waring 3rd, W
        Bowel management in children and adolescents with spinal cord injury.
        J Spinal Cord Med. 1998; 21: 335-341
        • Gorski K
        • Harbold K
        • Haverstick K
        • Schultz E
        • Shealy SE
        • Krisa L.
        Locomotor Training in the Pediatric Spinal Cord Injury Population: A Systematic Review of the Literature.
        Top Spinal Cord Inj Rehabil. 2016; 22: 135-148
        • Hwang M
        • Chlan KM
        • Vogel LC
        • Zebracki K.
        Substance use in young adults with pediatric-onset spinal cord injury.
        Spinal Cord. 2012; 50: 497-501
        • Hwang M
        • Zebracki K
        • Betz RR
        • Mulcahey MJ
        • Vogel LC.
        Normative blood pressure and heart rate in pediatric spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2013; 19: 87-95
        • Hwang M
        • Zebracki K
        • Vogel LC
        • Mulcahey MJ
        • Varni JW.
        Development of the Pediatric Quality of Life Inventory™ Spinal Cord Injury (PedsQL™ SCI) module: qualitative methods.
        Spinal Cord. 2020; 58: 1134-1142
        • Jan FK
        • Wilson PE.
        A survey of chronic pain in the pediatric spinal cord injury population.
        J Spinal Cord Med. 2004; 27: S50-S53
        • January AM
        • Zebracki K
        • Chlan KM
        • Vogel LC.
        Understanding post-traumatic growth following pediatric-onset spinal cord injury: the critical role of coping strategies for facilitating positive psychological outcomes.
        Dev Med Child Neurol. 2015; 57: 1143-1149
        • Johnson KA
        • Klaas SJ.
        Recreation involvement and play in pediatric spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2000; 6: 105-109
        • Johnston TE
        • McDonald CM.
        Health and fitness in pediatric spinal cord injury: medical issues and the role of exercise.
        J Pediatr Rehabil Med. 2013; 6: 35-44
        • Krisa L
        • Mulcahey MJ
        • Gaughan JP
        • Smith B
        • Vogel LC.
        Using a limited number of dermatomes as a predictor of the 56-dermatome test of the international standards for neurological classification of spinal cord injury in the pediatric population.
        Top Spinal Cord Inj Rehabil. 2013; 19: 114-120
        • Liu AJ
        • Briody JN
        • Munns CF
        • Waugh MC.
        Regional changes in bone mineral density following spinal cord injury in children.
        Dev Neurorehabil. 2008; 11: 51-59
        • Massagli TL.
        Medical and rehabilitation issues in the care of children with spinal cord injury.
        Phys Med Rehabil Clin N Am. 2000; 11: 169-182
        • McGinnis KB
        • Vogel LC
        • McDonald CM
        • et al.
        Recognition and management of autonomic dysreflexia in pediatric spinal cord injury.
        J Spinal Cord Med. 2004; 27: S61-S74
        • Mulcahey MJ
        • Gaughan J
        • Betz RR
        • Johansen KJ.
        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
        • Mulcahey MJ
        • Gaughan JP
        • Betz RR
        • Samdani AF
        • Barakat N
        • Hunter LN.
        Neuromuscular scoliosis in children with spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2013; 19: 96-103
        • Peljovich A.
        Hand Reconstruction in Children with Spinal Cord Injury.
        Phys Med Rehabil Clin N Am. 2020; 31: 471-498
        • Singh G
        • Ugiliweneza B
        • Bickel S
        • Behrman AL.
        Single and sequential voluntary cough in children with chronic spinal cord injury.
        Respir Physiol Neurobiol. 2021; 285103604
        • Tian F
        • Ni P
        • Mulcahey MJ
        • et al.
        Tracking functional status across the spinal cord injury lifespan: linking pediatric and adult patient-reported outcome scores.
        Arch Phys Med Rehabil. 2014; 95 (e2015): 2078-2085
        • Tori JA
        • Kewalramani LS.
        Urolithiasis in children with spinal cord injury.
        Paraplegia. 1979; 16: 357-365
        • Zebracki K
        • Hwang M
        • Patt PL
        • Vogel LC.
        Autonomic cardiovascular dysfunction and vitamin D deficiency in pediatric spinal cord injury.
        J Pediatr Rehabil Med. 2013; 6: 45-52
        • Kriss VM
        • Kriss TC.
        SCIWORA (spinal cord injury without radiographic abnormality) in infants and children.
        Clin Pediatr (Phila). 1996; 35: 119-124
        • Pang D
        • Eibach S.
        Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) in Children.
        Textbook of Pediatric Neurosurgery. 2017; : 1-39
        • Chen K
        • Liu J
        • Assinck P
        • et al.
        Differential Histopathological and Behavioral Outcomes Eight Weeks after Rat Spinal Cord Injury by Contusion, Dislocation, and Distraction Mechanisms.
        J Neurotrauma. 2016; 33: 1667-1684
        • Guo Y
        • Hu H
        • Wang J
        • Zhang M
        • Chen K.
        Walking Function After Cervical Contusion and Distraction Spinal Cord Injuries in Rats.
        J Exp Neurosci. 2019; 131179069519869615
        • Wang J
        • Zhang M
        • Guo Y
        • Hu H
        • Chen K.
        Quantification of surviving neurons after contusion, dislocation, and distraction spinal cord injuries using automated methods.
        J Exp Neurosci. 2019; 131179069519869617
        • Allen DD
        • Mulcahey MJ
        • Haley SM
        • et al.
        Motor scores on the functional independence measure after pediatric spinal cord injury.
        Spinal Cord. 2009; 47: 213-217
        • Anderson CJ
        • Mulcahey MJ
        • Vogel LC.
        Menstruation and pediatric spinal cord injury.
        J Spinal Cord Med. 1997; 20: 56-59
        • Apple Jr., DF
        • Anson CA
        • Hunter JD
        • Bell RB
        Spinal cord injury in youth.
        Clin Pediatr (Phila). 1995; 34: 90-95
        • Augutis M
        • Levi R.
        Pediatric spinal cord injury in Sweden: incidence, etiology and outcome.
        Spinal Cord. 2003; 41: 328-336
        • Augutis M
        • Abel R
        • Levi R.
        Pediatric spinal cord injury in a subset of European countries.
        Spinal Cord. 2006; 44: 106-112
        • Bosch PP
        • Vogt MT
        • Ward WT.
        Pediatric spinal cord injury without radiographic abnormality (SCIWORA): the absence of occult instability and lack of indication for bracing.
        Spine (Phila Pa 1976). 2002; 27: 2788-2800
        • Brauge D
        • Plas B
        • Vinchon M
        • et al.
        Multicenter study of 37 pediatric patients with SCIWORA or other spinal cord injury without associated bone lesion.
        Orthop Traumatol Surg Res. 2020; 106: 167-171
        • Burke DC.
        Traumatic spinal paralysis in children.
        Paraplegia. 1974; 11: 268-276
        • Cage JM
        • Knox JB
        • Wimberly RL
        • Shaha S
        • Jo C
        • Riccio AI.
        Complications Associated With High-dose Corticosteroid Administration in Children With Spinal Cord Injury.
        J Pediatr Orthop. 2015; 35: 687-692
        • Choi JU
        • Hoffman HJ
        • Hendrick EB
        • Humphreys RP
        • Keith WS.
        Traumatic infarction of the spinal cord in children.
        J Neurosurg. 1986; 65: 608-610
        • Chien LC
        • Wu JC
        • Chen YC
        • et al.
        Age, sex, and socio-economic status affect the incidence of pediatric spinal cord injury: an eleven-year national cohort study.
        PLoS One. 2012; 7: e39264
        • Darain H
        • Arsh A
        • Zeb A
        • Ilyas SM
        • Muhammad D
        • Epidemiology Khan MN.
        Clinical Features and Consequences of Spinal Cord Injury in Children.
        J Coll Physicians Surg Pak. 2018; 28: 532-535
        • Dare AO
        • Dias MS
        • Li V.
        Magnetic resonance imaging correlation in pediatric spinal cord injury without radiographic abnormality.
        J Neurosurg. 2002; 97: 33-39
        • Davis PC
        • Reisner A
        • Hudgins PA
        • Davis WE
        • O'Brien MS.
        Spinal injuries in children: role of MR.
        AJNR Am J Neuroradiol. 1993; 14: 607-617
        • Dhillon JK
        • Shi J
        • Janezic A
        • Wheeler KK
        • Xiang H
        • Leonard JC.U.S.
        Estimates of Pediatric Spinal Cord Injury: Implications for Clinical Care and Research Planning.
        J Neurotrauma. 2017; 34: 2019-2026
        • Dickman CA
        • Zabramski JM
        • Hadley MN
        • Rekate HL
        • Sonntag VK.
        Pediatric spinal cord injury without radiographic abnormalities: report of 26 cases and review of the literature.
        J Spinal Disord. 1991; 4: 296-305
        • Eleraky MA
        • Theodore N
        • Adams M
        • Rekate HL
        • Sonntag VK.
        Pediatric cervical spine injuries: report of 102 cases and review of the literature.
        J Neurosurg. 2000; 92: 12-17
        • Erhan B
        • Ulu MO
        • Gunduz B
        • Tanriverdi T.
        Pediatric spine and spinal cord injury in Istanbul: a retrospective analysis of 106 patients.
        Neurosurg Q. 2005; 15: 21-24
        • Farley FA
        • Hensinger RN
        • Herzenberg JE.
        Cervical spinal cord injury in children.
        J Spinal Disord. 1992; 5: 410-416
        • Galvin J
        • Scheinberg A
        • New PW.
        A retrospective case series of pediatric spinal cord injury and disease in Victoria, Australia.
        Spine (Phila Pa 1976). 2013; 38: E878-E882
        • Gilgoff RL
        • Gilgoff IS.
        Long-term follow-up of home mechanical ventilation in young children with spinal cord injury and neuromuscular conditions.
        J Pediatr. 2003; 142: 476-480
        • Grabb PA
        • Pang D.
        Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children.
        Neurosurgery. 1994; 35 (discussion 414): 406-414
        • Hadley MN
        • Zabramski JM
        • Browner CM
        • Rekate H
        • Sonntag VK.
        Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries.
        J Neurosurg. 1988; 68: 18-24
        • Hagen EM
        • Eide GE
        • Elgen I.
        Traumatic spinal cord injury among children and adolescents; a cohort study in western Norway.
        Spinal Cord. 2011; 49: 981-985
        • Hamilton MG
        • Myles ST.
        Pediatric spinal injury: review of 174 hospital admissions.
        J Neurosurg. 1992; 77: 700-704
        • Jain A
        • Brooks JT
        • Rao SS
        • Ain MC
        • Sponseller PD.
        Cervical fractures with associated spinal cord injury in children and adolescents: epidemiology, costs, and in-hospital mortality rates in 4418 patients.
        J Child Orthop. 2015; 9: 171-175
        • Johnston TE
        • Greco MN
        • Gaughan JP
        • Smith BT
        • Betz RR.
        Patterns of lower extremity innervation in pediatric spinal cord injury.
        Spinal Cord. 2005; 43: 476-482
        • Kewalramani LS
        • Tori JA.
        Spinal cord trauma in children. Neurologic patterns, radiologic features, and pathomechanics of injury.
        Spine (Phila Pa 1976). 1980; 5: 11-18
        • Knox J.
        Epidemiology of spinal cord injury without radiographic abnormality in children: a nationwide perspective.
        J Child Orthop. 2016; 10: 255-260
        • Li Y
        • Ge P
        • Huang Y
        • Wang Y
        • Li J.
        Treatment characteristics and outcomes in 58 children with spinal cord injury.
        Research Square. 2019; : 1-10
        • Liao CC
        • Lui TN
        • Chen LR
        • Chuang CC
        • Huang YC.
        Spinal cord injury without radiological abnormality in preschool-aged children: correlation of magnetic resonance imaging findings with neurological outcomes.
        J Neurosurg. 2005; 103: 17-23
        • Mahajan P
        • Jaffe DM
        • Olsen CS
        • et al.
        Spinal cord injury without radiologic abnormality in children imaged with magnetic resonance imaging.
        J Trauma Acute Care Surg. 2013; 75: 843-847
        • McLean DE
        • Kearney J
        • Cawley MF.
        Environmentally responsive temperature instability in pediatric spinal cord injury.
        Spinal Cord. 1999; 37: 705-709
        • Odetola FO
        • Gebremariam A.
        Variation in patterns of hospitalization and associated resource use among children with spinal cord injury in the US.
        Injury. 2016; 47: 1123-1127
        • Osenbach RK
        • Menezes AH.
        Spinal cord injury without radiographic abnormality in children.
        Pediatr Neurosci. 1989; 15 (discussion 175): 168-174
        • Osenbach RK
        • Menezes AH.
        Pediatric spinal cord and vertebral column injury.
        Neurosurgery. 1992; 30: 385-390
        • Pang D
        • Wilberger Jr., JE
        Spinal cord injury without radiographic abnormalities in children.
        J Neurosurg. 1982; 57: 114-129
        • Pang D
        • Pollack IF.
        Spinal cord injury without radiographic abnormality in children–the SCIWORA syndrome.
        J Trauma. 1989; 29: 654-664
        • Perez-de la Cruz S
        • Cimolin V
        • Gil-Agudo A.
        Spinal cord injury in pediatric age in Spain. Reality of a national reference center.
        Childs Nerv Syst. 2015; 31: 917-921
        • Pollack IF
        • Pang D
        • Sclabassi R.
        Recurrent spinal cord injury without radiographic abnormalities in children.
        J Neurosurg. 1988; 69: 177-182
        • Ruge JR
        • Sinson GP
        • McLone DG
        • Cerullo LJ.
        Pediatric spinal injury: the very young.
        J Neurosurg. 1988; 68: 25-30
        • Scher AT.
        Trauma of the spinal cord in children.
        S Afr Med J. 1976; 50: 2023-2025
        • Smith E
        • Finn S
        • Fitzpatrick P.
        Epidemiology of Pediatric Traumatic and Acquired Nontraumatic Spinal Cord Injury in Ireland.
        Top Spinal Cord Inj Rehabil. 2017; 23: 279-284
        • Shin JI
        • Lee NJ
        • Cho SK.
        Pediatric Cervical Spine and Spinal Cord Injury: A National Database Study.
        Spine (Phila Pa 1976). 2016; 41: 283-292
        • Sidram V
        • Tripathy P
        • Ghorai SP
        • Ghosh SN.
        Spinal cord injury without radiographic abnormality (SCIWORA) in children: a Kolkata experience.
        Indian Journal of Neurotrauma. 2009; 6: 133-136
        • Turgut M
        • Akpinar G
        • Akalan N
        • Ozcan OE.
        Spinal injuries in the pediatric age group: a review of 82 cases of spinal cord and vertebral column injuries.
        Eur Spine J. 1996; 5: 148-152
        • Vitale MG
        • Goss JM
        • Matsumoto H
        • Roye Jr., DP
        Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000.
        J Pediatr Orthop. 2006; 26: 745-749
        • Vogel LC
        • Lubicky JP.
        Ambulation with parapodia and reciprocating gait orthoses in pediatric spinal cord injury.
        Dev Med Child Neurol. 1995; 37: 957-964
        • Walsh JW
        • Stevens DB
        • Young AB.
        Traumatic paraplegia in children without contiguous spinal fracture or dislocation.
        Neurosurgery. 1983; 12: 439-445
        • Wang MY
        • Hoh DJ
        • Leary SP
        • Griffith P
        • McComb JG.
        High rates of neurological improvement following severe traumatic pediatric spinal cord injury.
        Spine (Phila Pa 1976). 2004; 29 (discussion E1266): 1493-1497
        • Wang YJ
        • Zhou HJ
        • Liu PJ
        • et al.
        Risks of undernutrition and malnutrition in hospitalized pediatric patients with spinal cord injury.
        Spinal Cord. 2017; 55: 247-254
        • Yngve DA
        • Harris WP
        • Herndon WA
        • Sullivan JA
        • Gross RH.
        Spinal cord injury without osseous spine fracture.
        J Pediatr Orthop. 1988; 8: 153-159
        • Zou Z
        • Teng A
        • Huang L
        • et al.
        Pediatric Spinal Cord Injury without Radiographic Abnormality: The Beijing Experience.
        Spine (Phila Pa 1976). 2021; 46: E1083-E1088
        • Kirshblum SC
        • Burns SP
        • Biering-Sorensen F
        • et al.
        International standards for neurological classification of spinal cord injury (revised 2011).
        J Spinal Cord Med. 2011; 34: 535-546
        • Ren J
        • Zeng G
        • Ma YJ
        • et al.
        Pediatric thoracic SCIWORA after back bend during dance practice: a retrospective case series and analysis of trauma mechanisms.
        Childs Nerv Syst. 2017; 33: 1191-1198
        • Burns AS
        • Ditunno JF.
        Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future directions in rehabilitation management.
        Spine (Phila Pa 1976). 2001; 26: S137-S145
        • Kirshblum SC
        • O'Connor KC
        Predicting neurologic recovery in traumatic cervical spinal cord injury.
        Arch Phys Med Rehabil. 1998; 79: 1456-1466
        • Marino RJ
        • Ditunno Jr., JF
        • Donovan WH
        • Maynard Jr., F
        Neurologic recovery after traumatic spinal cord injury: data from the Model Spinal Cord Injury Systems.
        Arch Phys Med Rehabil. 1999; 80: 1391-1396
        • Carlson GD
        • Gorden C.
        Current developments in spinal cord injury research.
        Spine J. 2002; 2: 116-128
        • Dumont RJ
        • Verma S
        • Okonkwo DO
        • et al.
        Acute spinal cord injury, part II: contemporary pharmacotherapy.
        Clin Neuropharmacol. 2001; 24: 265-279
        • Fehlings MG
        • Sekhon LH
        • Tator C.
        The role and timing of decompression in acute spinal cord injury: what do we know? What should we do?.
        Spine (Phila Pa 1976). 2001; 26: S101-S110
        • Fouad K
        • Tetzlaff W.
        Rehabilitative training and plasticity following spinal cord injury.
        Exp Neurol. 2012; 235: 91-99
        • Jalan D
        • Saini N
        • Zaidi M
        • Pallottie A
        • Elkabes S
        • Heary RF.
        Effects of early surgical decompression on functional and histological outcomes after severe experimental thoracic spinal cord injury.
        J Neurosurg Spine. 2017; 26: 62-75
        • Jones CF
        • Cripton PA
        • Kwon BK.
        Gross morphological changes of the spinal cord immediately after surgical decompression in a large animal model of traumatic spinal cord injury.
        Spine (Phila Pa 1976). 2012; 37: E890-E899
        • Karsy M
        • Hawryluk G.
        Modern Medical Management of Spinal Cord Injury.
        Curr Neurol Neurosci Rep. 2019; 19: 65
        • Kwon BK
        • Tetzlaff W
        • Grauer JN
        • Beiner J
        • Vaccaro AR.
        Pathophysiology and pharmacologic treatment of acute spinal cord injury.
        Spine J. 2004; 4: 451-464
        • Lee DY
        • Park YJ
        • Song SY
        • Hwang SC
        • Kim KT
        • Kim DH.
        The Importance of Early Surgical Decompression for Acute Traumatic Spinal Cord Injury.
        Clin Orthop Surg. 2018; 10: 448-454
        • Li Y
        • Walker CL
        • Zhang YP
        • Shields CB
        • Xu XM.
        Surgical decompression in acute spinal cord injury: A review of clinical evidence, animal model studies, and potential future directions of investigation.
        Front Biol (Beijing). 2014; 9: 127-136
        • Thuret S
        • Moon LD
        • Gage FH.
        Therapeutic interventions after spinal cord injury.
        Nat Rev Neurosci. 2006; 7: 628-643
        • van Hedel HJ
        • Dietz V.
        Rehabilitation of locomotion after spinal cord injury.
        Restor Neurol Neurosci. 2010; 28: 123-134
        • Choo AM
        • Liu J
        • Lam CK
        • Dvorak M
        • Tetzlaff W
        • Oxland TR.
        Contusion, dislocation, and distraction: primary hemorrhage and membrane permeability in distinct mechanisms of spinal cord injury.
        J Neurosurg Spine. 2007; 6: 255-266
        • Choo AM
        • Liu J
        • Dvorak M
        • Tetzlaff W
        • Oxland TR.
        Secondary pathology following contusion, dislocation, and distraction spinal cord injuries.
        Exp Neurol. 2008; 212: 490-506
        • Choo AM
        • Liu J
        • Liu Z
        • Dvorak M
        • Tetzlaff W
        • Oxland TR.
        Modeling spinal cord contusion, dislocation, and distraction: characterization of vertebral clamps, injury severities, and node of Ranvier deformations.
        J Neurosci Methods. 2009; 181: 6-17
        • Tator CH.
        Review of treatment trials in human spinal cord injury: issues, difficulties, and recommendations.
        Neurosurgery. 2006; 59 (discussion 982-957): 957-982
        • Zhang N
        • Fang M
        • Chen H
        • Gou F
        • Ding M.
        Evaluation of spinal cord injury animal models.
        Neural regeneration research. 2014; 9: 2008-2012