Spinal cord injuries in young children: a review of children injured at 5 years of age and younger

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1 DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE Spinal cord injuries in young children: a review of children injured at 5 years of age and younger JENNIFER SCHOTTLER 1 LAWRENCE C VOGEL 1,2 PETER STURM 1 1 Shriners Hospitals for Children, Chicago, IL. 2 Rush Medical College, Chicago, IL, USA. Correspondence to Jennifer Schottler at Shriners Hospitals for Children, 2211 North Oak Park Avenue, Chicago, IL 60707, USA. jschottler@shrinenet.org This article is commented on by Behrman and Trimble on pages 1078 of this issue. PUBLICATION DATA Accepted for publication 15th June Published online 23rd September ABBREVIATIONS AIS ASIA Impairment Scale DVT Deep venous thrombosis SCI Spinal cord injury SCIWORA Spinal cord injury without radiological abnormalities AIM To determine the epidemiology and complications of spinal cord injuries (SCIs) in children injured at 5 years of age and younger who were seen between 1981 and 2008 at a children s hospital in the USA. METHOD Complications studied were scoliosis, hip dysplasia, latex allergies, autonomic dysreflexia, pressure ulcers, spasticity, deep venous thrombosis, and kidney stones. Demographic and injury-related factors included age at injury, etiology, level of injury, American Spinal Injury Association Impairment Scale (AIS), and SCIs without radiological abnormalities (SCIWORA). RESULTS Of the 159 individuals seen (92 males, 67 females) median age at injury was 2 years (range 0y 5y 11mo). Forty-nine percent were injured in vehicular accidents, 60% had complete injuries, 66% had paraplegia, and 72% had SCIWORA. Ninety-six percent developed scoliosis, 57% had hip dysplasia, and 7% had latex allergy. Thirty-four percent with injuries at or above T6 experienced autonomic dysreflexia, 41% developed pressure ulcers, and 61% experienced spasticity. Of those without bowel or bladder control, 82% were on intermittent catheterization and 69% were on a bowel program. Median age of initiating wheelchair use was 3 years 4 months (range 1y 2mo 12y 5mo). Twenty-four were community ambulators, and they were more likely to have AIS D lesions (half the key muscle functions below the level of injury have a muscle grade 3 or greater) and less likely to have skeletal complications. INTERPRETATION The epidemiology, complications, and manifestations of SCIs in children injured at a young age are unique and differ distinctively from adolescent and adult-onset SCIs. Spinal cord injuries (SCIs) are an uncommon occurrence in children aged 5 years and younger but can have a devastating effect on the children and their families. The impact of an SCI in all spheres of life in such young children is immense in view of their relatively long life span and the mutual interaction of SCIs and growth and development. Younger children have relatively unique etiologies for their SCI, such as lap belt or birth injuries, and unique pathophysiology of their injuries, including SCIs without radiographic abnormalities (SCIWORA). Compared with adults and adolescents, younger children who sustain SCIs are more likely to have paraplegia or complete injuries. 1,2 Children who sustain an SCI at a young age are at high risk of a variety of complications such as scoliosis and hip dysplasia. 2 In addition, because of their young age at injury and relatively long lifespan, they will most likely be at risk for a variety of aging-related complications throughout their life, including overuse syndromes and cardiovascular disease. 3,4 The purpose of this study is to describe injury-related factors, demographic information, and the incidence of secondary complications that develop in children who sustained an SCI at 5 years of age and younger. This information may be used to compare outcomes for future surgical, medical, or therapeutic approaches with the goal of altering the course or decreasing the incidence of secondary complications in children. Other goals of this study include delineation of the modes of wheelchair mobility, potential for community ambulation, and information about bladder and bowel programs for persons injured in this very young age group. METHOD This project was approved by the institutional review board for the Shriners Hospitals for Children, Chicago; all institutional regulations about the ethical use of human volunteers were followed during the course of this research. All 159 children who were injured between the ages of 0 and 5 years from the Midwestern and South Central USA seen at the Shriners Hospitals for Children, Chicago, from 1981 to 2008 were identified, and medical records reviewed to obtain information about demography, injuries, and secondary medical complications. Medical and surgical causes of injury included transverse myelitis, vascular insults, tumors, spinal cord anomalies, spinal and cardiac surgery complications, and delivery complications. One participant was injured by a flying foreign object; she was included in the falls flying objects category. Patients for whom 1138 DOI: /j x ª The Authors. Developmental Medicine & Child Neurology ª 2012 Mac Keith Press

2 What this paper adds The epidemiology SCIs in children injured at 5 years and younger is described. Complications and manifestations in young children differ distinctively from adolescent and adult-onset SCIs. The study provides information for identifying and targeting clinical care for this population to reduce the incidence of secondary complications. imaging studies were available from the acute injury were considered to have SCIWORA if no abnormalities were noted on plain radiographs or computerized tomography. Only SCIs with traumatic etiologies were included. Neurological level and injury severity (American Spinal Injury Association Impairment Scale [AIS]) was determined using the International Standards for the Neurological Classification of Spinal Cord Injury. 5 A complete injury (AIS A) is defined as the absence of sacral sparing (sensory and motor function in the lowest sacral segments, S4 5), whereas an incomplete injury is defined as the presence of sacral sparing (some preservation of sensory and or motor function at S4 5). In a sensory incomplete SCI (AIS B), sensory but not motor function is preserved below the neurological level. When motor function is preserved below the neurological level (motor incomplete SCI) the SCI is classified as AIS C when greater than half of key muscle functions below the level of injury have a muscle grade less than 3, or AIS D when at least half of key muscle functions below the level of injury have a muscle grade 3 or greater. If sensation and motor function as tested with the International Standards for the Neurological Classification of Spinal Cord Injury are graded as normal in all segments in a patient who had previous deficits, then the AIS is E. Recent findings indicate that there are limitations in using these standards in young children. 6 However, despite the young age at injury for the participants in this study, the data were collected throughout the follow-up visits, and AIS was often determined at a later age. For those who sustained their SCI in motor vehicle accidents, information about car seat use and positioning in the car at the time of the accident was collected. Complications assessed on an annual basis included scoliosis, hip dysplasia, latex allergies, hyperhidrosis, autonomic dysreflexia, pressure ulcers, spasticity, deep venous thromboses (DVTs), and kidney stones. To determine the incidence of scoliosis accurately, only participantswhowerefollowedtoatleast15yearsofage,who would have been post-pubertal, were included in this analysis. Young people with a Cobb angle of 20 or more were considered to have scoliosis. To determine the incidence of hip dysplasia accurately, only participants who were followed for at least 1 year after injury were included in this analysis. Spasticity was noted to be present or absent as a function of having an upper motor neuron or lower motor neuron lesion by the treating physician during the clinical evaluation. Bowel and bladder information was reviewed with information about initiation of wheelchair use including age at initiation, type of wheelchair used, and amount of assistance required for propulsion. Finally, we examined ambulatory ability in this population with spinal cord injuries. Community ambulation was defined as the ability to ambulate more than 150 feet (approx. 45.7m). The Statistical Package for the Social Sciences (SPSS, version 15.0, SPSS Inc., Chicago, IL, USA) was used to analyze the data. Descriptive statistics were used to describe epidemiology, skeletal and medical complications, bowel and bladder function, wheelchair use, and ambulation. v 2 analyses were used to examine differences between subgroups including paraplegia and tetraplegia, complete and incomplete SCIs, etiology of injury, presence of SCIWORA, medical complications, bowel and bladder programs, wheelchair use, and ambulation. For analyses of wheelchair use and ambulation, participants were categorized into three groups: paraplegia AIS A, B, and C; tetraplegia categories A, B, and C; and those with AIS D injuries. RESULTS Epidemiology Of the 159 children in this study (92 males, 67 females), the median age at injury was 2 years with a median age at follow-up of 10 years 9 months and a median duration of injury of 8 years 10 months. Of these 159 children, 42 (26.4%) were injured before 1 year, with 16 having SCI present at birth; 58% were male, 66% had paraplegia, 60% of participants had complete injuries, and the most common cause of injury was vehicular-related incidents (49%; Table I). There were no significant changes noted for demographic or epidemiological information throughout the observation period. Those with tetraplegia were significantly more likely to have AIS D lesions; whereas those with paraplegia were more likely to have complete injuries (v 2 =8.147, p=0.043) (Table I). SCIs caused by motor vehicle accidents and violence were more likely to result in paraplegia and complete lesions; in Table I: Demographic and injury characteristics of participants Participants, n All (n=159) (n=60) (n=99) Sex, n (%) Male 92 (58) 33 (55) 59 (59) Female 67 (42) 27 (45) 40 (41) Level of injury, n (%) Tetraplegia, n (%) 52(34) 17(31) 35(36) Complete 24 (51) 6 (43) 18 (55) Incomplete 23 (49) 8 (57) 15 (45) Paraplegia, n (%) 100 (66) 38 (69) 62 (64) Complete 64 (66) 25 (69) 39 (64) Incomplete 33 (34) 11 (31) 22 (36) Etiology of injury, n (%) Vehicular 77(49) 31(52) 46(47) Medical surgical 64 (40) 22 (37) 42 (42) Falls flying objects 10 (6) 5 (8) 5 (5) Violence 6 (4) 2 (3) 4 (4) Sports 2 (1) 0 (0) 2 (2) Age at injury, n (%) Median, y 2y 2y 1mo 2y 4mo (26) 17(28) 25(25) (20) 12(20) 19(19) (18) 10(17) 18(18) (18) 12(20) 17(17) (14) 6 (10) 17 (17) (4) 3 (5) 3 (3) Spinal Cord Injuries in Young Children Jennifer Schottler et al. 1139

3 contrast, falls more commonly resulted in tetraplegia and incomplete lesions. SCIs due to medical or surgical causes were more likely to be paraplegia and incomplete (Table II). Of the children injured in motor vehicle accidents and for whom adequate information was available, most (77%, 30 39) did not have a car or booster seat in use at the time of the accident, and 83% (29 35) were seated in the rear of the car at the time of the crash. Of the 30 children who were not in a car or booster seat, 11 sustained lap belt injuries with a median age at injury of 3 years (range 1 5y). Of the 72 participants for whom imaging studies were available from the acute injury, 52 (72%) had SCIWORA. Those without SCIWORA were significantly more likely to have complete lesions than those with SCIWORA (90% vs 67%; v 2 =3.95, p=0.047). Forty percent of those without SCIWORA had tetraplegic injuries compared with 25% of those with SCIWORA (v 2 =1.57, p=0.210). Medical complications Of the 88 participants with injury levels at or above T6, 29 (34%) experienced autonomic dysreflexia. Those with complete lesions were significantly more likely to experience autonomic dysreflexia than those with incomplete lesions (v 2 =8.10, p=0.004; Table III). In addition, three of the 63 participantswithinjurylevelsatt7andbelowhadahistoryof autonomic dysreflexia: two of these participants with injuries at T10 AIS A and T8 AIS A experienced autonomic dysreflexia with a full bladder and another with a T7 AIS A injury Table II: Injury severity and level of injury as a function of etiology Complete Incomplete Paraplegia Tetraplegia Etiology of injury, n (%) MVA 55 (78) 16 (22) a 57 (75) 19 (25) b Medical surgical 25 (42) 35 (58) 35 (60) 23 (40) Violence 4 (67) 2 (33) 4 (67) 2 (33) Falls flying objects 3 (33) 6 (67) 3 (30) 7 (70) Sports 1 (50) 1 (50) 1 (50) 1 (50) a p<0.001 (v 2 =20.18). b p<0.05 (v 2 =9.54). MVA, motor vehicle accident. experienced autonomic dysreflexia in relationship to the bowel program. Skeletal complications Of the 51 participants who met the criteria for inclusion in the scoliosis analyses, almost all (96%) had scoliosis and most had acurveof40 or more (63%) and had undergone surgery for correction of their scoliosis (58%). For those with scoliosis, no significant differences were found for sex or for level of injury between those with curves of <40 or those with curves >40. However, participants were more likely to have a scoliosis of more than 40 if they had a complete injury as opposed to an incomplete injury (v 2 =12.85, p<0.001; Table III). Of the 146 participants who had follow-up more than 1 year after injury, 57% had hip dysplasia although only a few (8%) had undergone surgery for it. No difference was found for sex, but participants were significantly more likely to develop hip dysplasia if they had paraplegia (v 2 =4.67, p=0.031) and if they had a complete injury (v 2 =9.53, p=0.002; Table III). Sixty-three (41%) of the participants had a history of pressure ulcers. Development of pressure ulcers was more common in those with complete lesions (v 2 =4.22, p=0.040) and in those with paraplegia (v 2 =3.74, p=0.053; Table III). Of the participants with a positive history of pressure ulcers, 36% required hospitalizations and 29% required surgery for treatment of the pressure ulcers. There were 116 pressure ulcers, with some participants having ulcers in more than one area. The most common sites for ulcers were the foot and ankle (45), sacrum (16), knees (16), ischium (10), and hips (8). Spasticity affected 84 (61%) of the participants, and was more common in those with incomplete lesions (v 2 =6.17, p=0.013) and in those with tetraplegia although the difference did not reach statistical significance for the latter (v 2 =3.17, p=0.075; Table III). Other complications included latex allergy in 7% (10 146), hyperhidrosis in 3% (4 131), DVT in 2% (3 138), and kidney stones in 1% (1 137). Of the three children who experienced a DVT, all experienced DVTs many years after injury (6y, 14y, and 18y). Table III: Medical and skeletal complications as a function of sex, injury level, and severity Pressure ulcers Autonomic dysreflexia Spasticity Scoliosis 40 Presence of hip dysplasia Normal bladder and bowel control Sex, n (%) Male a (42) (33) (57) (75) (56) (14) Female (40) (36) (66) (50) (59) (22) Severity of injury, n (%) Complete (49) b (45) b (52) b (91) c (69) b 1 88 (1) c Incomplete (32) 4 29 (14) (74) 9 22 (41) (41) (42) Level of injury, n (%) Paraplegia (48) 9 34 (27) (56) (70) (64) b (12) b Tetraplegia (31) (39) (72) 7 12 (58) (44) (17) a Number of participants with condition number of participants in that category. b p<0.05. c p< Developmental Medicine & Child Neurology 2012, 54:

4 Bladder and bowel Overall, 82% ( ) of participants did not have normal bladder or bowel control. Of those with normal bladder and bowel control (28 158), those with tetraplegia were more likely to have bladder and bowel control than those with paraplegia (52% vs 48%, v 2 =4.09, p=0.043). In addition, bladder and bowel control was more common in those with incomplete versus complete lesions (96% vs 4%, v 2 =40.47, p<0.001). Of the participants without bowel or bladder control, 82% ( ) were on an intermittent catheterization program and 69% (90 130) were on a bowel program. Of participants older than 3 years of age who did not have normal bowel or bladder control, 90% (45 50) were on an intermittent catheterization program and 76% (38 50) were on a bowel program. Participants became independent with intermittent catheterization program at a median age of 8 years 4 months (range 5y 4mo 13y 2mo) and with bowel programs at a median age of 11 years 9 months (range 6y 6mo 17y 1mo). Mobility The median age that wheelchair use was initiated was 3 years 4 months (range 1y 2mo 12y 5mo). Manual wheelchair use was initiated at a median age of 3 years 5 months (range 1y 6mo 12y 5mo) and power wheelchair use was initiated at a median age of 2 years 11 months (range 1y 2mo 5y 8mo). Among the 131 participants who used a wheelchair, 98% were independent in propulsion. Overall, 3% exclusively used power wheelchairs, 85% exclusively used manual wheelchairs, and 12% used both power and manual wheelchairs. Most of those with AIS D used a manual wheelchair (33%) or no wheelchair at all (52%). Not surprisingly, most of those with paraplegia, AIS A, B and C, used a manual wheelchair (97%); only one person in this group used a power wheelchair. Of those with tetraplegia, AIS A, B and C, 62% used a manual wheelchair; the remainder used both power and manual wheelchairs. Twenty-four participants in our group were capable of community ambulation at some point during follow-up. Table IV compares those who were and were not community ambulators for neurological impairment, level of injury, sex, and skeletal complications. Those with AIS D lesions were more likely to be community ambulators than those with either paraplegia or tetraplegia with AIS A, B, or C injuries. Community ambulators were also less likely to have hip dysplasia or more severe scoliosis curves. There was no significant difference between community ambulators and non-community ambulators in sex. DISCUSSION Motor vehicle accidents are the leading cause of SCI in all age groups; 1,2,7 most of the participants in the current study were injured in vehicular-related accidents. As the age of injury increases towards adolescence and adulthood, males are far more likely than females to suffer an SCI. However, when injuries occur in younger children, sex plays a less significant role. For those injured at 3 years of age and younger, females tend to equal or may even outnumber Table IV: Ambulation ability based on injury level and severity, sex, and orthopaedic complications Community ambulators, n (%) Non-community ambulators, n (%) Statistics (v 2 ; p-value) Injury level severity, AIS Paraplegia, 6 (7.1) 78 (92.9) 19.80; <0.001 A, B, C vs paraplegia D Tetraplegia, 1 (2.9) 33 (97.1) 20.95; <0.001 A, B, C vs tetraplegia, D DvsA,B,C 15 (60) 10 (40) 46.3; <0.001 (all) Sex Male 17 (18.9) 73 (81.1) 2.01; Female 7 (10.6) 59 (89.4) Presence of hip 7 (8.8) 73 (91.3) 8.12; <0.05 dysplasia Presence of scoliosis 40 0 (0) 46 (100) 10.83; AIS, American Spinal Injury Association Impairment Scale. males. 1,8 In 1996, Vogel and DeVivo 7 found a 61% male contingent of those injured between the ages of 0 and 8 years. Our findings were relatively similar with males constituting 58% of the group. Most of the participants in this study had both paraplegia and complete injuries, which have been documented in previous studies as well. 1,2 In a series of 97 children who were injured between the ages of 1 year and 15 years, Kewalramani and Tori 9 reported that 69% of the injuries were complete. Similarly, DeVivo and Vogel 1 reported that 69% of children injured between the ages of 0 and 5 had complete lesions. The somewhatlowerrateofcompletelesionsinthecurrentstudy of 60% may reflect improvement in performance of the International Standards for the Neurological Classification of Spinal Cord Injury in children or the trend of decreasing complete lesions noted in all age groups over the past several decades. 10 Seventy-two percent of our participants were positive for SCIWORA. Pang and Wilberger 11 found that 67% of all children with non-penetrating SCI who were seen and evaluated during a 20-year period had SCIWORA. Of those with SCIWORA, they found most of them to have complete injuries. Although the SCIWORA group in the current study was also more likely to have complete than incomplete injuries, it is interesting to note that the group that did not have SCIW- ORA had a significantly higher percentage of complete injuries than those with SCIWORA (90% vs 67%). There is an incredibly high rate of developing scoliosis if a person sustains an SCI before puberty. 2,3,12 Ninety-six percent of the children in the current report did indeed have a scoliosis, with 63% of the participants eventually developing a curve of 40 or greater. The current finding that 57% of children injured between 0 and 5 years of age developed hip instability is consistent with previous reports. In one study, hip subluxation was associated Spinal Cord Injuries in Young Children Jennifer Schottler et al. 1141

5 with age at injury and showed 43% of participants injured at or before 5 years developed hip subluxation. 3 The presence of latex allergy in 7% of our participants is consistent with previous findings from our institution, where 18% of 67 participants had latex allergy, although based on criteria for diagnosis the rate ranged from 6 to 18%. 13 The lower rate of latex allergy in the current participants may be related to the fact that the diagnosis of latex allergy in this study population was based on a positive history. In contrast, latex history in the previous study was based on either a positive history of latex allergy or a positive laboratory test. The incidence of autonomic dysreflexia in adults with tetraplegia or high thoracic injuries has been reported to range from 48 to 85%. 14 In a previous study from our institution, autonomic dysreflexia was identified in 51% of 121 children with T6 or higher lesions who had sustained their SCI before their 14th birthday and who had been followed for a minimum of 1 year. 15 Our finding of a 34% prevalence of autonomic dysreflexia in children injured at 5 years of age and younger may reflect the fact that diagnosis of autonomic dysreflexia may be more difficult to establish in younger children because of their limited ability to communicate symptoms consistent with autonomic dysreflexia. In the current study, it was found that those with complete injuries were significantly more likely to experience autonomic dysreflexia, which is similar to the findingsofhickeyetal. 15 except that their difference did not reach statistical significance. One other significant finding worth noting in the current study is the occurrence of autonomic dysreflexia in three participants who had neurological levels below T6; these three participants with T7, T8, and T10 lesions all had complete injuries. Although it is possible that these children truly experienced autonomic dysreflexia symptoms at their level of injury, another potential explanation is that the identified neurological level was incorrect because of the difficulty performing an accurate neurological examination on children. 6 In previous studies of adults, it has been shown that 50 to 80% of those with SCI will develop a pressure ulcer at some point after their injury. 14 In a previous retrospective review of pediatric SCI from our institution, 55% of participants injured at age 12 years and younger had experienced at least one pressure ulcer; it was also found that those with paraplegia were more likely to develop pressure ulcers than those with tetraplegia. 16 This is similar to our findings of 41% of participants overall with a history of pressure ulcers. Additionally, we too found that those with paraplegia were more likely to experience pressure ulcers than those with tetraplegia, although the difference did not reach statistical significance (p=0.053). Because more children with paraplegia have complete injuries and thus less sensation than their counterparts with tetraplegia, it is intuitive that they would be more likely to develop pressure ulcers. Additionally, it is possible that young children with tetraplegia may have more frequent skin inspections from caregivers than the more active children with paraplegia. Of adults with acute SCI, studies have found that 14 to 16% will develop DVT. 14 In a previous report from our institution, no DVTs were identified in children 5 years of age and younger and in only 1.9% of those 6 to 12 years of age compared with a 7.9% to 9.1% incidence in adolescents. 17 Similarly, a study by Jones et al. 18 identified venous thromboembolism within 91 days of their hospital admission in 1.1% (2 181) of children 13 years and younger. The DVT finding of 2.2% in the current study is consistent with these previous reports; however, as noted earlier, none of the participants in the current study experienced DVTs during their initial rehabilitation stay or even soon thereafter. Using manual or powered mobility, 98% of participants in this study were capable of independent wheelchair propulsion. Of the two participants who were unable to propel, one had cognitive delay and the second had central cord syndrome and an inability to use his upper extremities. The median age for beginning wheelchair use was 2 years 8 months, 2 years 3 months, and 3 years 6 months for those injuredbetween0and1,1and2,and2and5yearsofage respectively. For all groups combined, we found the median age for beginning wheelchair use to be 3 years 4 months. Despite the median age found in this study, it is our recommendation that children with SCIs have early initiation of wheelchair use, including the use of power wheelchairs, beginning at 12 to 18 months of age. Studies have shown that independent mobility can impact on a child s ability to learn, participate with peers, improve confidence, and decrease depression. 19,20 Children typically begin to walk at 12 to 13 months of age, and use of power wheelchairs should begin at a similar age to enable them to explore their environment, increase independence, and improve their cognitive skills. 21 Previous studies from this institution have looked at both autonomic dysreflexia and pressure ulcers in the pediatric population. The study on autonomic dysreflexia in persons injured as children included 60 participants, and all of the information was collected before The study on pressure ulcers included children aged 12 years and younger, and all information for that study was collected before The current study included follow-up data and collection periods from 1981 through The current study is also unique in that it includes a much larger number of participants and is limited only to those children who were injured at 5 years of age and younger. Although the catchment area for this particular project is a significant area of the USA, this study is further limited by its applicability to other countries. The findings of this study are limited by the retrospective nature of this project, which in turn is limited by patient and parent reports during clinical visits, and the accuracy of clinical documentation. Additionally, the current review did not include other secondary complications that may arise from SCIs such as decreased bone density and thus increased risk of fracture, muscle atrophy, and possible cardiovascular impairments. Future work could include studying the development of scoliosis as a function of age and use of orthoses. CONCLUSION Caring for a young child with a SCI brings with it many unique challenges for caregivers as well as for clinicians. It is 1142 Developmental Medicine & Child Neurology 2012, 54:

6 important to remember the long life expectancy of these children and therefore the secondary medical complications they may face along the way. The growth and developmental changes these children will go through deserve consideration, and care will need to be adapted as the child grows and matures. Our findings highlight the importance of regular follow-up visits, every 6 to 12 months, by an interdisciplinary SCI team. This comprehensive description may provide an informative foundation for identifying and targeting directions in clinical care and research to reduce the incidence of secondary complications across the lifespan in children injured at age 5 years and younger. ACKNOWLEDGEMENTS This study was funded by Shriners Hospitals for Children Chicago. REFERENCES 1. DeVivo MJ, Vogel LC. Epidemiology of spinal cord injury in children and adolescents. J Spinal Cord Med 2004; 27:(Suppl. 1) S Massagli T. Medical and rehabilitation issues in the care of children with spinal cord injury. Phys Med Rehabil Clin N Am 2000; 11: Vogel LC, Krajci K, Anderson CJ. Adults with pediatriconset spinal cord injury. Part 1. Prevalence of medical complications. J Spinal Cord Med 2002; 25: Massagli T, Jaffe K. Pediatric spinal cord injury: treatment and outcome. Pediatrician 1990; 17: American Spinal Injury Association. Standards for Classification of Spinal Injured Patients. Chicago, IL: American Spinal Injury Association, Mulcahey MJ, Gaughan J, Betz RR, et al. The International standards for neurological classification of spinal cord injury: reliability of data when applied to children and youth. Spinal Cord 2007; 45: Vogel LC, DeVivo MJ. Etiology and demographics. In: Betz RR, Mulcahey MJ, editors. The Child with a Spinal Cord Injury. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1996: Ruge J, Sinson G, McLone D, Cerullo L. Pediatric spinal injury: the very young. J Neurosurg 1988; 68: Kewalramani L, Tori J. Spinal cord trauma in children: neurologic patterns, radiologic features and pathomechanics of injury. Spine 1980; 5: DeVivio MJ. Epidemiology of Spinal Cord Injury. In: Lin VW, editor. Spinal Cord Medicine Principles and Practice. New York, NY: Demos Medical Publishing, 2010: Pang D, Wilberger J. Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982; 57: Dearolf W, Betz R, Vogel L, Levin J, Clancy M, Steel H. Scoliosis in pediatric spinal cord-injured patients. J Pediatr Orthop 1990; 10: Vogel L, Schrader T, Lubicky M. Latex allergy in children and adolescents with spinal cord injuries. J Pediatr Orthop 1995; 15: Kirshblum S, Campagnolo D. Spinal Cord Medicine. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins, Hickey K, Vogel L, Willis K, Anderson C. Prevalence and etiology of autonomic dysreflexia in children with spinal cord injuries. J Spinal Cord Med 2004; 27:(Suppl. 1) S Hickey K, Anderson C, Vogel L. Pressure ulcers in pediatric spinal cord injury. Top Spinal Cord Inj Rehabil 2000; 6:(Suppl.) Vogel LC, Betz RR, Mulcahey MJ. Pediatric spinal cord disorders. In: Kirshblum S, Campagnolo DI, editors. Spinal Cord Medicine. 2nd edn. New York: Wolters Kluwer Lippincott Williams & Wilkins, 2011: Jones T, Ugalde V, Franks P, Zhou H, White R. Venous thromboembolism after spinal cord injury: time course, and associated risk factors in adults and children. Arch Phys Med Rehabil 2005; 86: Biringen Z, Emde R, Campos J, Appelbaum M. Affective reorganization in the infant, the mother and the dyad: the role of upright locomotion and its timing. Child Dev 1995; 66: Butler C. Augmentive mobility: why do it? Phys Med Rehabil Clin N Am 1991; 2: Rosen L, Arva J, Furumasu J, et al. RESNA position on the application of power wheelchairs for pediatric users. Assist Technol 2009; 4: Spinal Cord Injuries in Young Children Jennifer Schottler et al. 1143