Diving, Spinal Cord Injury, Methylprednisolone

Numbness in the hands and feet, paralysis, and absent patellar reflexes suggest that the child described in the vignette has suffered an acute spinal cord injury (SCI). Motor vehicle crashes and sports injuries are the leading causes of SCIs in the adolescent population, the age group in which most of these injuries occur. Two thirds of sports-related injuries are a result of diving accidents. Most of these diving accidents occur in natural bodies of water, but up to one third occur in swimming pools. A water depth of 9 ft (2.74 m) has been suggested as the minimum for safe recreational diving.

Axial loading or hyperflexion of the vertebral column is the usual mechanism of diving injuries, and generally there is no associated head trauma. Neurologic injury occurs in 70% of those who have diving-related SCIs, with 50% experiencing complete loss of neurologic function below the level of the injury.

The current edition of the Advanced Trauma Life Support (ATLS) Manual recommends that pediatric spinal trauma be treated similarly to spinal trauma in adults, including the use of high-dose methylprednisolone.  The National Acute SpinalCord Injury Studies assessed the role of  methylprednisolone in preventing secondary neuronal damage after acute SCI. Although the investigators concluded that high-dose methylprednisolone is helpful and recommended its use, this issue remains somewhat controversial. However, the studies have documented a good safety profile for this treatment.

There is no role for prophylactic antibiotics or anticonvulsants in a patient who suffers SCI because neither infection nor head trauma with associated seizures is expected. The use of ranitidine for treatment  f spinal shock may be appropriate for the prevention of stress ulcers, as may a saline infusion, but they are not as immediately important as the administration of high- dose methylprednisolone. 

References:
American College of Surgeons Committee on Trauma. Pediatric trauma.
In: Advanced Trauma Life Support for Doctors: Student Course Manual.
6th ed. Chicago, Ill: American College of Surgeons; 1997:289-311
Bracken MB, Aldrich EF, Herr DL, et al. Clinical measurement,
statistical analysis, and risk-benefit: controversies from trials of
spinal injury. J Trauma. 2000;48:558-561
Delamarter RB, Coyle J. Acute management of spinal cord injury. J Am
Acad Orthop Surg. 1999;7:166-175
Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS 2
and NASCIS 3 trials. J Trauma. 1998;45:1088-1093