Pediatric emergency medicine trisk 2640 2640
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Evaluation should consist of contrast-enhanced MRI of the entire spine.
Imaging of the brain is also suggested to evaluate for lesions suggestive of
multiple sclerosis. CSF evaluation should be obtained, including cell count and
testing for oligoclonal bands. Serum testing for neuromyelitis optica IgG
antibodies is now recommended. Presence of these antibodies can aid in
determining the etiology as well as risk of recurrence.
Treatment of transverse myelitis is supportive, and some degree of recovery
occurs in approximately 80% of cases. All children with this syndrome should be
hospitalized. Although there are no controlled trials of their efficacy, there is a
consensus supporting the use of systemic corticosteroids. Currently, there is
moderate evidence to support the use of plasma exchange in patients who have
failed corticosteroid therapy; however, there is insufficient evidence to support
the use of IV immunoglobulin.
Acute spinal cord compression in children is usually caused by trauma,
infection, or cancer. Spinal trauma may lead to contusion or concussion of the
cord with hemorrhage, edema, and local mass effect, or may lead to development
of a spinal epidural hematoma. Mass lesions may cause damage by direct
compression of spinal cord tissues or, secondarily, by interference with the
tenuous arterial (or, less commonly, venous) blood flow to the spinal cord, with
resultant spinal cord infarction.
Parenchymal injury usually presents acutely, but an epidural hematoma may
develop over several days after the antecedent trauma. Epidural abscess is the
most common infectious cause of spinal cord compression. It is usually caused by
hematogenous spread of bacteria, with Staphylococcus aureus being the most
common pathogen. Neoplastic causes include both primary intraspinal tumors
(ependymoma and astrocytoma) and extrinsic lesions such as neuroblastoma or
lymphoma.
Traumatic and infectious spinal lesions are usually accompanied by relatively
acute onset of local back pain, which is exacerbated by direct percussion of the
area. Pain from an infectious cause occasionally may precede other symptoms for
days. With tumors, however, there may be weakness in the absence of pain.
Patients with epidural abscess often have systemic signs of infections such as
fever, headache, vomiting, and, perhaps, neck stiffness. Bony tenderness in such a
patient may indicate vertebral osteomyelitis or discitis, which can also present
with weakness, although usually less severe than is seen with actual spinal cord
involvement.
Diagnosis is confirmed by emergency neuroimaging, with precautions to
immobilize patients with potentially unstable lesions. Plain spine films are useful
