Article Text

Clinical and radiological diagnosis of spinal cord birth injury
  1. L SIMON,
  2. F PERREAUX,
  3. D DEVICTOR,
  4. B MILLOTTE
  1. Réanimation pédiatrique et néonatale
  2. CHU du Kremlin Bicêtre
  3. 78 rue du Général Leclerc
  4. 94275 LE KREMLIN BICETRE Cedex
  5. France
  6. Department of Paediatric Radiology and Medical Imaging
    1. B HUSSON,
    2. J WAGUET
    1. Réanimation pédiatrique et néonatale
    2. CHU du Kremlin Bicêtre
    3. 78 rue du Général Leclerc
    4. 94275 LE KREMLIN BICETRE Cedex
    5. France
    6. Department of Paediatric Radiology and Medical Imaging

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      Editor—The diagnosis of spinal cord injury is often delayed and/or missed in neonates.1 Non-invasive imaging, such as ultrasonography and magnetic resonance imaging, is important to confirm the diagnosis.

      From 1990 to 1997, we observed four spinal cord injuries in neonates. Three of these infants had a cephalic presentation and needed instrumental delivery using forceps. The other infant was a breech presentation and was born vaginally without instrumentation. The infants were depressed at birth, with no spontaneous breathing, and they all needed tracheal intubation. Two infants remained totally unreactive throughout their course, whereas a suck reflex and opening of the eyes were noted 24 hours after birth in the two other infants. All the infants developed bladder distension. The four infants had spinal sonographic (transducer of 10 or 7.5 MHz; HDI 3000 TM, ATL or Hitachi EUB 415) and magnetic resonance imaging (MRI) (1,5 Tesla, Magneton vision TM, Siemens or Signa General Electric) evaluation in the first week of life. In two infants ultrasonography showed an hyperechogenic well delimited mass (haematomyelia) within a normal hypoechogenic cervical spinal cord. Another patient had a thoracic vertebral dislocation, confirmed on plain films, with an hyperechogenic area in the underlying thoracic cord. The fourth infant had increased echogenicity of cerebrospinal fluid space surrounding the cervical cord which itself was hyperechoic at the level C1–C2 spreading into the inferior brain stem (fig 1).

      Figure 1

      Midline sagittal T1 weighted magnetic resonance image showing an enlarged cervical cord but with a normal signal (A). Spinal sonogram showing an hyperechogenic mass (haematomyelia) (arrow) into the cervical cord (B).

      One of the infants with cervical haematomyelia on ultrasonography had an enlarged cervical cord on T1 images with heterogeneous signal in T2 studies (fig 1). The other patient with a haematomyelia on ultrasonography had a normal MRI scan. The infant with a thoracic vertebral dislocation had surgical fixation of the vertebrae T3 to T5 two days after birth. This infant is still alive, at the time of writing, with a persistent paraplegia and long term oxygen dependency. The others did not improve their neurological status at any time and died between 10 and 15 days after birth.

      Infants with spinal cord injury usually present at birth with apnoea and flaccid paralysis.1 Many have other traumatic lesions such as skin haematomas or fractures.2 Despite the history of a difficult delivery, the diagnosis of spinal cord injury is often delayed for several days or weeks. Ultrasonography is performed at the bedside, with a high frequency transducer, and the patient in a lateral decubitus position. Ultrasonography using a high frequency transducer shows the intra- and extra spinal lesions observed in this condition, such as haematomyelia, spinal disruption, extraspinal haematoma, and malalignment. MRI is helpful for tissue characterisation and facilitates differential diagnosis between oedema, ischaemia, or haemorrhage, factors that influence prognosis. In two of our infants, however, MRI showed non-specific enlargement of the cervical cord in one case and in the other a normal spinal cord. In the second infant MRI was performed on day 4, when haemorrhage can still appear isoechoic to spinal tissue. McKinnon et al have already reported a false negative result using MRI.1Ultrasonography is the recommended diagnostic method in neonates at the acute stage of the injury.2

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