NI FEATURE: THE EDITORIAL DEBATE II-- PROS AND CONS
|Year : 2017 | Volume
| Issue : 3 | Page : 475--476
Clinical and health policy-related challenges of pediatric spinal cord injuries
Mario Ganau, Michael G Fehlings
Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, Ontario, Canada
Michael G Fehlings
Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, Ontario
|How to cite this article:|
Ganau M, Fehlings MG. Clinical and health policy-related challenges of pediatric spinal cord injuries.Neurol India 2017;65:475-476
|How to cite this URL:|
Ganau M, Fehlings MG. Clinical and health policy-related challenges of pediatric spinal cord injuries. Neurol India [serial online] 2017 [cited 2021 Oct 18 ];65:475-476
Available from: https://www.neurologyindia.com/text.asp?2017/65/3/475/205915
Due to the different anatomy and physiology of their developing bodies, traumatic spinal cord injuries (SCI) occurring in children or adolescents represent a different challenge to that presented by SCI in adults. Although relatively rare, with an incidence accounting for 1-10% of all reported SCI, these injuries represent a substantial morbidity and mortality risk in the pediatric population. Another aspect of pediatric SCI that often remains unmentioned in the literature is that the etiology of SCI may differ not only between adults and children, but also between pediatric populations across different countries, due to peculiarities of their healthcare systems and differing lifestyles. Whilst most of the series reported in the literature are from western countries, some articles from large Chinese or Indian series are now being written. These demonstrate the careful attention being paid by doctors in these countries to SCI in children and their willingness to contribute to the international scientific discussion on this topic.,
The study from Babu et al., nicely points out those peculiarities and practical aspects. In their cohort from South India, the incidence of high-speed injuries appears much less common than in other series from North America and Europe. The reported percentage of SCI resulting from fall from height (>70% between 2002 and 2014) can certainly justify the lower occurrence of multilevel SCI, higher incidence of lumbar fractures and lower association with traumatic brain injuries than previously reported. The need to carefully allocate valuable resources can explain why only 20% of their patients underwent surgical intervention; certainly, this does not make more acceptable the fact that all Frankel Grade A patients were automatically deemed for conservative management. As such, the information provided in this study might be more useful in better understanding the specific needs of that region, and perhaps of the rest of India, with regard to SCI in the pediatric population.
Whereas, Babu et al., deserve praise for the epidemiological data provided in this work and their potential impact to foster better local health policies, it is worth noticing that the standard of clinical and surgical management of SCI has significantly evolved over the last two decades and this progress is not necessarily reflected in their work. Unfortunately, this series has several limitations: one is the lack of characterization of the thoraco-lumbar (TL) injuries reported. Apart from the description of anatomical level, radiological subgroups (fractures, subluxation and spinal cord injury without radiographic abnormality [SCIWORA]) and Frankel grade, no details are provided regarding the Denis and Magerl classifications. These latter details could have helped the readers to understand the technical challenges of the TL injuries included in this report. The diagnostic and therapeutic approach to SCI has evolved over the years, in part due to the introduction of tools which have helped spine surgeons to objectively define the characteristics of a wide range of different injuries, and tailor the most appropriate management options to each of those scenarios. An example of this is the most recent Thoracolumbar Injury Classification and Severity Score (TLICS) system, which was developed to streamline injury assessment and guide surgical decision making. Although created for adult SCI, some recent articles have confirmed the reliability of its criteria and related recommendations for children and adolescents.,
Furthermore, the loss of patients at follow up in the present series appears remarkably high; only 23% of patients were seen again, and among those lost to follow up are not only the non-surgical patients but also some of those treated with posterior instrumented fusion. This bias affects the analysis of the data as we do not know the real non-fusion rate, the number and type of complications, or to what extent permanent neurological deficits and, in those managed conservatively, spinal deformities are causing a burden in the life of those patients and their families.
Many aspects in the management of pediatric SCI are still evolving and should be kept in mind to better describe retrospective studies and design new prospective ones. These include the importance of pre-hospital management and transportation to tertiary care centers; the optimal timing for surgical intervention; the indications, and the pros and cons of anterior, posterior and lateral surgical approaches; the indications for fixation without fusion and possible removal of the implant later on; the importance of rehabilitation strategies, etc. Population-based surveillance data on SCI will still be the hallmark of the public health approach in the coming years; but a constant attention to the ongoing evolution of our field is nonetheless required for the development and application of up-to-date treatment and prevention guidelines for traumatic SCI all over the world. Indeed, the willingness of developing countries to meet the current standards of surgical practice is greatly needed if we are to expand the impact of international collaborations and benefit from their participation in randomized clinical trials (RCTs).
This, in fact, represents the greatest challenge with pediatric SCI as these patients are generally excluded from RCTs evaluating therapies that promote neuroprotection, neuroplasticity or neuroregeneration. Further studies could provide us with a better understanding of the peculiarities of SCI in children, from specific differences in the way secondary injury occurs (including timing of local ischemia, pathways for pro-apoptotic signaling and release of cytotoxic factors or inflammatory cell infiltration) to the safety of strategies that have proved to be promising in adults. Some of those experimental therapies have not been studied yet in children with SCI (i.e., riluzole, a sodium-channel blocker tested in adults with cervical level injuries, known to indirectly decrease glutamate release and enhance its reuptake, resulting in neuroprotection, has been tested in children only for obsessive compulsive disorders); others are not suitable (i.e., the anti-inflammatory minocycline, whose satisfactory preclinical results in decreasing lesion size and neuronal loss following SCI led to a currently ongoing Phase III study, is specifically contraindicated in children younger than 8 years because it can result in permanent change in the tooth coloring). On the other hand, some cell-based therapies (i.e. autologous bone marrow nucleated cells transplantation, that is able to facilitate direct axonal re-growth by producing extracellular matrix and promoting re-myelination) went beyond expectations set by previous RCTs conducted in adults, and showed encouraging results in children with SCI. Hence, the still unmet need is to design specific studies meant to identify therapies tailored for children and adolescents whose potential for functional improvement might be even better than in the adult population.
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