Delayed Onset Paraplegia from Improper Seat Belt Use.
A 3-year-old boy was wearing a lap belt when the vehicle he was in struck a tree. In the Emergency
Department 2 hours after the accident he could walk, but complained of his left foot hurting. The
patient had a diagonal ecchymosis in the left upper quadrant of the abdomen (the
Seat Belt Sign). The following day the child could no longer bear weight on either leg. He had a flaccid bilateral
weakness of both legs. The lumbar spine series was normal. In the next 24 hours the paraparesis
worsened, his legs became "floppy," and he developed urinary incontinence. Some leg abduction,
but no adduction was present. There was no demonstrable use of the thigh flexors or extensors. He
had an L1-2 sensory level with no lower extremity reflexes. Lumbar MRI demonstrated no bony
abnormality or evidence of spinal cord infarction, contusion, epidural hematoma or other soft tissue
injury. After 9 months of rehabilitation therapy, the patient could bear weight with only a mild gait
impairment and persistent foot drop. Ann Emerg Med
23:1123, 1994.
This is an example of a delayed onset SCIWORA Syndrome
, spinal cord injury without radiographic abnormality. The onset of neurologic symptoms is delayed in only a small percentage
of cases. The cause is unclear, but ischemia, direct compression from a spontaneously reducing
subluxation, traction, and a transient inward bulging of the ligamentum flavum during
hyperextension have been postulated. SCIWORA patients are highly susceptible to recurrent spinal
cord injury from even minor trauma. It is important to recognize occult spinal cord injuries quickly,
because the standard of care dictates consideration of high dose IV methylprednisolone sodium
succinate therapy. N Engl J Med 322:1405, 1990.