Spinal cord injury without radiographic abnormality in a 4-year-old child: hypoperfusion injury or direct trauma?

Spinal cord injury without radiographic abnormality is uncommon even in major paediatric trauma. A case is described of a 4-year-old girl sustaining multiple injuries from blunt trauma including spinal cord injury without radiographic abnormality. She was profoundly shocked with extensive thoracic, abdominal and pelvic injuries. An MRI performed 8 days after injury showed an ischaemic area from T8 to L2 consistent with hypoperfusion. Various possible aetiologies exist, including distraction, hyperflexion, hyperextension and ischaemic spinal cord damage. In this case the likely cause was spinal ischaemia. The anterior spinal and two posterior spinal arteries supply the spinal cord. The aorta feeds these superiorly via the subclavian and vertebral arteries, and inferiorly via the radicular arteries. Injury may tear these conduit arteries from the aorta causing cord ischaemia. This is important in the thoracolumbar area where the radicular artery of Adamkewicz supplies a large area of the spinal cord. The artery of Adamkewicz may have been interrupted directly by blunt trauma. The other cause of ischaemia is the systemic hypoperfusion sustained owing to profound hypovolaemia, which could also correlate with the child's reported transient blindness. Treatment and prognosis of spinal cord injury without radiographic abnormality are considered.