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Review Article
Develop,Med. Child Neurl. 1975. 17. 103-110
Randolph K. Byers

Spinal-cord Injuries During Birth

Introduction
Intrapartum injury to the fetal spinal cord has been well described for over a century, Though in some instances its genesis is not understood. certain factors stand out as important: among these are longitudinal stretching of the vertebral column in breech presentation, torsional forces applied in rotating the head in cephalic deliveries, shoulder dystocia with traction on the cord via the brachial plexus, .,od hyperextension of the head in breech delivery.
Though cerebral and spinal apoplexy among neonates was commented on in the 1830's (Kennedy 1836, Billard 1839), Parrot (1869) was the first to describe intrapartum spinal-cord injury in full. His patient, seen at three days of age, was a full-term baby of a primipara, born by footling presentation. Delivery was difficult and considerable traction was used to Jeliver the head. During this process a loud snap was heard, so much so that a fracture of a major bone was suspected, but not found. When seen at three days the baby was limp, but sucked and swallowed well, and breathing was shallow. The arms were flaccid and motionless, and the legs were limp when unstimulated, but when the infant was picked up and suspended by the axillae the legs went into a semifiexion at hip and knee, and sharp flexion movements resulted from pinching the skin of the feet. The baby appeared to be anaesthetic over the lower trunk and legs, .autopsy showed a rupture of the spinal cord at the level of C6 and C7 vertebrae. the stumps of the cord being separated by a gap of 33mm. The salient features were traction on the infant's trunk, the loud snap (presumably due to rupture of the dura). anaesthesia and the establishment of spinal reflexes within a few days.
The mechanism of injury to the cord during breech delivery has been studied by a number of observers. Duncan (l874) demonstrated that the freshly dead human full-term fetus suspended by the head could tolerate weights up to 90 or 100 pounds attached to one foot for one minute. At this range of stress a loud snap was heard and the fetus increased in length by several inches. especially in the cervical region. Further increase in weight on the foot resulted in decapitation. usually between the 4th and 5th cervical vertebrae.
Injuries to the vertebral column and its joints have been repeatedly described among neonates (Stoltzenberg 1911. Foderl 1931, Muller and Lobker 1971), and hemorrhages into and about the cord and medulla have been recorded in some instances. Pierson (1923) noted a positive statistical relationship between internal podalic version and spinal injury.
The classical studies of Crothers (1922, 1923), Crothers and Putnam (1927) and Ford (1925) emphasised the importance of breech delivery in intrapartum spinal-cord injury. Crothers particularly discussed the elasticity of the largely cartilaginous vertebral column in relation to traction, the support given by the dura, and the vulnerability of the spinal cord to rupture once this support was compromised.
Reduction of fetal muscular tone as a factor in predisposing to spinal-cord injury during breech delivery was stressed by DeSouza and Davis (1974). In their report, prolapse of a non-pulsating umbilical cord during breech delivery was followed by increasing heart-rate and discharge of meconium, leading to rapid breech extraction. Transection of the cord in the mid-cervical region was found at autopsy.
Injury to the spinal cord during cephalic delivery is unusual. Schulman er 01. (1971) and Norman and Wedderburn (1973) report two cases bf spinal-cord transection following rotation of the head from occiput posterior to occiput anterior position by means of forceps. In Schulman's case, fracture of the odontoid and dislocation of C2 on CI, and of Cion the occiput were shown, with transection of the spinal cord at level of CI-C2. Norman and Wedderburn found hemorrhage into the substance of cord and medulla in their case. Neither baby breathed alone and both were anaesthetic below tbe face. The first baby had mass reflexes involving all four extremities, the only such instance known to me.
Schulman et 01. (1971) found in the literature 26 instances of spinal-cord injury associated with cephalic delivery. In 10 of these the lesion was demonstrated at autopsy, in the remainder the diagnosis was made clinically. Difficult forceps delivery with shoulder dystocia was common, but five had 'easy' cephalic deliveries (none of the autopsy cases), and only three had forceps rotation of the head. The level of injury varied from the medullary spinal junction down to T10.
Though hyperextension of the fetal head has been described in the literature since early this century, its relationship to spinalcord injury has been recognized only recently (Hellstrom and Sallmander 1968). Abroms et al. (1973) presented two cases of their own and reviewed the literature back to 1910. They found 77 breech presentations and 11 transverse lies with heads which remamed extended until the time of labor. Among these 88 infants, 31 were born by caesarean section, with no instance of spinal-cord injury. Of 57 born vaginally, 12 sustained cervical or thoracic cord injury, an incidence of 21 per cent. These authors urge x-ray examination in all breech presentations at the onset of labor in order that caesarean section may be done in cases where there is a hyp':r' extended head. Bhagwanani er 01. (1973.1 published a confirmatory report concerning four infants with hyperextended heads. Two delivered by easy breech deliveries had cervical spinal-cord injury, while two delivered by caesarean section were intact. It seems possible that spinal-cord injury may be secondary to vertebral dislocations which may become reduced by the time of delivery (Taylor 1948).
The mechanism of spinal-cord injury il: some instances remains unclear; thus Melchior and Tygstrup (1963) described a case at autopsy which was said to be the result of a spontaneous breech delivery, and at least two of the Crothers and Putnam (1927) clinically diagnosed cases were reported to be the results of easy cephalic deliveries.

Pathology
Pathological examination in most instances of spinal-cord transection has shown" fusio of meninges and spinal cord into a scar several millimetres in length, often thin enough to be translucent. Such damage isolates a segment of intact cord below the injury which is capable of ieveloping reflex activity. The common ievel of involvement is mid or lower cervical and upper thoracic (Byer 1932). Beevor (1902) reported an instance of almost complete destruction of the cord below C3 by hematomyelia, combined with right brachial plexus injury. Spencer (1891) reported the pathological findings in the spinal cord in 44 stillborn or neonatally dead infants and found hemorrhage outside the spinal meninges in 21, within the meninges in II. and into the substance of the spinal cord in six. of which four showed hemorrhage into the anterior cornua of the grey matter alone. Towbin (1964) has called attention to the frequency of spinal epidural hemorrhage in autopsies of newborns. Whether the are agonal or not is unclear. as has been discussed by Byers and Bresnan 119i41.
Yates (19591 and Jones (1970) studied frozen sections ot" the neck of stillborn and neonatally dead infants and called attention to damage to the vertebral arteries. Included were hemorrhages into the various coats of the arteries. often causing significant narrowing of the lumen. and occasionally thrombosis with organization. Both authors also nqted contusions and . emorrhages into the spinal cord in two Instances, sometimes quite localized-for instance to the grey matter of one side. They felt that impaired blood-flow to the cord might result from the described arterial obstruction.
Penry et al. (1970) reported an infant with cord transection following difficult breech delivery in whom the arms were held in strong abduction at the houlders, with flexion at the elbows and wrists (the so-called 'Thorburn posture'). Pathological study revealed a decrease in the neurones of the intermediate grey zone and also of Renshaw cells at C4 and C5. It was suggested that this unusual rigidity, rather than flaccidity, was due to the uninhibited discharge of remaining motor cells.

Clinical Manifestation Immediate Neonatal Period
A history of dystocia is usual, and frequently, if asked, the obstetrician will report a loud snap from within the birth canal while traction on the infant's trunk is being exerted during delivery of the aftercoming head. A state of shock and difficulty in initiating respiration are common. The motor manifestations vary with the site of injury. Those above C3-C4 are pre umably promptly fatal unless the infant is given constant respiratory support. Damage to lower cervical and upper thoracic cord, often associated with brachial plexus injury, produces flaccidity of the arms and hands (or, rarely, the 'Thorburn posture), respiratory embarrassment with paradoxical respiration, and occasionally Horner's syndrome. Thoracic injuries produce weakness of the intercostal and abdominal muscles. Flaccidity of the legs alone follows the rare injuries to the lumbosacral segments or plexi.
Although accurate sensory mapping is usually impossible early, lack of perceptible response to pin-prick can usually be demonstrated over a wide area. Bladder paralysis is usual, but in newborns this problem usually can be managed without catheterization. Gentle suprapubic pressure will usually empty the bladder and within a few days most babies develop automatic bladders, save in the rare case of lumbosacral injury.
X-rays of the spine are usually normal; however, they arc useful in excluding congenital anomalies, especially spina bifida, and they may occasionally demonstrate vertebral dislocations.
Except in the unusual case of destruction of the lumbosacral cord or its nerves, decubiti do not occur, but must be anticipated in this small group of patients and meticulous nursing care must be maintained.

Differential Diagnosis
Only a few conditions need be considered in the differential diagnosis. Myelodysplasia is probably the most common cause of motor and sensory paraplegia in infancy and should be excluded by physical and x-ray examination of the spine. Infantile muscular atrophy may be confused, but anaesthesia. rarely absent in spinal cord injury. is not pan of this disease. Later on. myelitis of various types can usually be identified by history, and neoplasia of the spinal cord usually have a progressive course.

Later Infancy
'Spinal shock' usually subsides within a few weeks, during which edema and hemorrhage at the site of injury are absorbed. It then becomes possible to establish a reasonably accurate and durable assessment of the patient's neurological status. At this point voluntary and reflex movement must not be confused. They can be separated after a period of observation of the spontaneous activity of the infant, followed by specific tests of response. When a sizeable isolated segment of intact spinal cord exists. reflex movements develop in response to noxious stimuli over a wide receptive area. These movements are quite stereotyped and often inappropriate; thus a pin-prick on the sole of the foot will produce withdrawal of the foot by flexion at hip. knee and ankle (appropriate), but the same response will occur after a pinprick on the dorsum of the foot (inappropriate). Rarely, the leg opposite that stimulated by the pin will go into extension, and according to the observation of Head (1917) and Riddoch (1917i) on men with war wounds, such a response should mean an incomplete transection. During such an examination the baby's face should bc closely watched for evidence of appreciation of pain, and the area of anaesthesia carefully estimated. Reflex movements should not be confused with voluntary ones. Hyperactive tendon reflexes may be present. Occasionally the Babinski sign persists after the age of 15 months. Ataxia, not previously appreciated, may also become evident on walking.
The musculature corresponding to tIlt area of cord injury is- usually flaccid. Because of the thick panniculus adiposus of infants, fasciculations are not seen: they can be demonstrated electromyographically. The occasional case of 'Thorburn posture' has been mentioned and may persist.
Spasticity leading to contractu res is unusual and is seen only of the hip and femoral muscles in babies with low spina! injury. Prevention of contractures by goou orthopedic care is then important.
In a few instances the clinical picture suggests that the anterior horn cells are the most involved spinal structures. Such injuries are usually lower cervical or upper thoracic, producing weakness of the hands and of intercostal muscles with little or no evidence of injury to the long tracts.
Regularly reproducible reflex emptying of the bladder as a result of pinching or pricking the inner aspects of the thighs may develop at this time, and may long postpone the nearly inevitable urinary tract infection.

Later Childhood
The history of persistent disability following dystocia and the absence of other congenital anomalies usually establishes the diagnosis in older children. Review of their neurological status should take place at intervals, especially if any suggestion of deterioration appears. Progressive functional changes suggest progressive disease, either neurological or orthopedic. Deterioration of gait and increased weakness of arms, hands or cranial nerves suggest either progressive cicatrization of the meninges about the cord, or the development of hydromyelia. The latter could conceivably be improved by surgery. (I have seen one such case with a well demonstrated hydromyelia which was not helped by attempts to drain the lesion.) Orthopedic handicaps such as scoliosis or flexion contracture of the hips may require surgical intervention. Retention of infected urine may require drainage and antibiotic treatment: after such therapy reflex func ions may occasionalIy return to the bladder.
Concomitant brain injury may complicate the diagnosis. Mental deficiency is not. of course. implicit in spinal cord injury. and when present it is evidence of more widespread involvement of the nervous system.

Prognosis
For an accurate statement of prognosis, systematic examinations of the spinal cord at autopsy would be required: obviously this is not possible. In the pre-antibiotic era. the majority died of infection of lungs or bladder in infancy. Random observations indicate that many children survive such injuries and that improvement in neurological function may continue in a few cases for a long period. Many of the cases reported in 1927 by Crothers and Putnam and in 1925 by Ford were older children. Among Crothers' patients was one whom I folIowed to the age of 31 years. She made her living as a telephone operator and supported her mother. She had a complete transection at Tl-T2, with lively mass reflexes in her legs, and an automatic bladder which she emptied by pinching the inner aspect of one thigh. She learned to walk on crutches without touching her feet to the ground because of the mass reflexes in her legs. She died of urinary tract infection.
Another girl recovered virtualIy completely from what appeared in the neonatal period to be a severe cord transection in the low cervical region. She now rides horseback, has mild weakness of extension in the third, fourth and fifth digits of her left hand, and minimal truncal ataxia on rapid turning. Of Leventhal's six patients reported in 1960, two died in early infancy (one a few weeks after laminectomy) and the remainder were alive at three to 12 years of age, one semi-ambulatory and the rest confined to wheelchairs. Two of the older children had bladder control adeq uate to allow them to attend school. and one wore a leg urinal.

Treatment
Surgical exploration has been employed sporadicalIy in many clinics, including our own. When spinal block has been demonstrated by myelography, exploration may be reasonable but, considering the pathology, not much is to be expected from it. Since a few infants with what appears to be spinal cord transection at birth recover astonishingly welI, conservatism seems to be justified.
If x-rays show vertebral dislocations. suitable treatment is needed, and support for the neck and spine should be provided during the early weeks by a light plaster shell or Bradford frame.
Treatment is largely supportive. Because of interference of sweating below the level of the lesion, wide fluctuations in temperature may occur in neonates, which can best be controlled by monitoring environmental temperature. In the newborn the bladder can usually be emptied by gentle use of the Crede maneuver, in the hope that automatic bladdet function will develop. Anticipation of contractu res or decubiti is only important in cases involving the lowest cord segments on the lumbosacral plexus.
The treatment of older children is mainly skilful, resourceful orthopedic rehabilitation, which must take into account the extent and severity of the neurological damage.

Obstetrical Consideradons
Compared with experience in the past when Crothers (19601 expected to see about 10 new cases of spinal-cord injury per year, there is evidence that such accidents have been greatly reduce':. largely because of his insistence on th elasticity of the largely cartilaginous vertebral bodies and the realization by obstetricians that in breech extraction no emergency exists after delivery of the umbilicus. In our own clinic, two clear-cut spinal transections of intrapartum origin were recognized in the 10 years from 1960 to 1969, with a third doubtful case. In 1970 two cases appeared, both as the result of breech deliveries of infants with hyperextended heads.

AUTHOR'S APPOINTMENTS
Randolph K. Byers. M.D., Clinical Professor of Pediatrics Emeritus. Harvard Medical Schoo!: Consultant in Neurology, The Children's Hospilal. Boston, Mass. 02115.

SUMMAR Y
The subject of perinatal injury to the spinal cord is briefly reviewed. Recognized causative factors are traction ('In the infant's trunk during breech delivery, rotational stresses applied to the spinal axis. traction on the cord via the brachial plexus in shoulder dystocia, and hyperextension (If the fetal head in breech delivery or transverse presentation. Recognition of these factors is the basis for prevention of this terrible accident.
Diagnostic criteria at various periods of life are mentioned and the importance of the recognition of ana thesia and reflex movements is emphasized. Treatment is mainly supportive. The development of an automatic reflex bladder evacuation is discussed.FolIowup examinations and resourceful orthopedic care are essential.
A few affected children learn to live with their disability and a very few who are apparently transected at birth recover surprisingly well.

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