Severe Cervical Spinal Cord Injury Research Articles

The use of classification tree analysis to assess the influence of surgical timing on neurological recovery following severe cervical traumatic spinal cord injury.

Post hoc analysis of prospectively collected data. Assess the influence of surgical timing on neurological recovery using classification tree analysis in patients sustaining cervical traumatic spinal cord injury. Hôpital du Sacré-Coeur de Montreal METHODS: 42 patients sustaining cervical SCI were followed for at least 6 months post injury. Neurological status was assessed from the American Spinal Injury Association impairment scale (AIS) and neurological level of injury (NLI) at admission and at follow-up. Age, surgical timing, AIS grade at admission and energy of injury were the four input parameters. Neurological recovery was quantified by the occurrence of improvement by at least one AIS grade, at least 2 AIS grades and at least 2 NLI. Proportion of patients that improved at least one ASIA grade was higher in the group that received early surgery (75 vs. 41 %). The proportion of patients that improved two AIS grades was also higher in the group that received early surgery (67 vs. 38 %). Finally, 30 % of the patients that received early decompression improved two NLI as compared with 0% in the other group. Early surgery was also associated with a non-statistically significant improvement in functional recovery. Neurological recovery of patients sustaining cervical traumatic spinal cord injury can be improved by early decompression surgery performed within 19 h post trauma. U.S. Army Medical Research and Material Command, Rick Hansen Institute.

The Need for Early Tracheostomy in Patients with Traumatic Cervical Cord Injury.

BackgroundIn patients who need sustained endotracheal intubation and mechanical ventilation due to respiratory failure after traumatic cervical spinal cord injury, tracheostomy can be performed to reduce the duration of mechanical ventilation and respiratory complications. The purpose of this study was to determine criteria and timing of tracheostomy in patients with severe traumatic cervical spinal cord injury accompanied by motor weakness.MethodsWe reviewed 22 patients who underwent tracheostomy (study group) and 27 patients who did not (control group) from January 2005 to March 2016. We assessed the American Spinal Injury Association (ASIA) impairment scale score and investigated accompanying thoracic injury, paradoxical respiration, postoperative endotracheal intubation and other clinical parameters. The study group was also subdivided into the early tracheostomy group and late tracheostomy group depending on whether the tracheostomy was performed within or later than 7 days after surgery.ResultsTwenty-two patients in the study group had a mean ASIA impairment scale score of 14.1 points, which was lower than the control group's 23.4 points. Paradoxical respiration was observed in 77% of the patients in the study group compared to 18% in the control group. Postoperative intubation was maintained in 68% in the study group; 32% underwent endotracheal intubation due to respiratory failure within 4 days after surgery and had a tracheostomy. In the control group, postoperative intubation was maintained in 22%, and all of them were weaned off intubation within 4 days after surgery. The duration of intensive care unit hospitalization was 11.4 days for the early tracheostomy group, which was shorter than the late tracheostomy group's 19.7 days.ConclusionsIn patients with severe traumatic cervical spinal cord injury, tracheostomy may be needed when the motor grade of the ASIA scale is low, above the C4 segment is injured, or paradoxical respiration occurs after injuries. In addition, if endotracheal extubation is not feasible within 4 days after surgery, an early tracheostomy should be considered.

Lysophospholipids in retinal axon guidance: roles and cell signaling.

Nerve regeneration in the central nervous system (CNS) has become a holy grail of biomedical research. To understand nerve growth that would be required for efficient regeneration, many scientists have turned to developing systems where nerve growth is abundant and normal neural connections are established. One aspect of this neural development, which would also be important in nerve regeneration, is axon guidance – the process by which a growing axon, through its growth cone, is guided to the correct target for synaptic connections.

The diagnostic value of magnetic resonance imaging measurements for assessing cervical spinal canal stenosis.

The authors investigated the relevance of 2D MRI measurements for the diagnosis of critical cervical spinal canal stenosis. Among patients who had sustained a minor cervical spine trauma, they compared MRI measurements of the cervical spine between those with acute cervical spinal cord injury (CSCI) and those without. They also investigated the correlation between the MRI measurements and the severity of CSCI as well as classification accuracy concerning the diagnosis of critical spinal canal stenosis for acute CSCI after a minor trauma. The authors conducted a single-center retrospective radiological case-control study of patients who had sustained CSCI after a minor trauma to the cervical spine from January 2000 to August 2010. The controls were patients who had sustained a cervical trauma without clinical or radiological signs of cervical spinal cord pathology. On axial T2-weighted MR images, the following were measured: the transverse spinal canal and cord area, the transverse and sagittal cord diameter, and the sagittal canal diameter of the cervical spine (C3-7). Using these measurements, the authors calculated the cord-canal-area ratio by dividing the transverse cord area by the transverse canal area, the space available for the cord by subtracting the sagittal canal diameter from the sagittal cord diameter, and the compression ratio by dividing the transverse cord diameter by its sagittal diameter. The severity of CSCI was assessed by using the motor index scores of 10 key muscles at different time points (initially, 1, 3, and 12 months after injury) obtained from the clinical records. The intra- and interobserver reliability of the MRI measurements, intra- and intergroup differences, and correlations between variables were also investigated. Receiver operating characteristic curves were calculated for evaluating the classification accuracy of the imaging variables for CSCI. Data for 52 CSCI patients and 77 control patients were analyzed. The intra- and interobserver reliability regarding the MRI measurements ranged from good (0.72) to perfect (0.99). Differences between the CSCI group and the control group were significant (p < 0.001) for all parameters, except for the cord area. The most prominent differences between the groups existed for the spinal canal area, cord-canal-area ratio, and space available for the cord. The classification accuracy was best for the cord-canal-area ratio and the space available for the cord; areas under the curve were 0.99 (95% CI 0.97-1.0) and 0.98 (95% CI 0.95-0.99), respectively. There was no significant (p > 0.05) correlation between any of the imaging parameters and the motor index score at any time point. The cord-canal-area ratio (> 0.8) or the space available for the cord (< 1.2 mm) measured on MR images can be used to reliably identify patients at risk for acute CSCI after a minor trauma to the cervical spine. However, there does not seem to be any association between spinal canal imaging characteristics and the severity of or recovery from CSCI after a minor trauma.

Influence of spinal cord compression and traumatic force on the severity of cervical spinal cord injury associated with ossification of the posterior longitudinal ligament.

Retrospective review. To evaluate the influence of static compression factors and dynamic factors based on the various degrees of traumatic force on the cervical spinal cord injury (SCI) in patients with ossification of the posterior longitudinal ligament. Spinal cord disorder occurs as a result of various factors, including static factors and traumatic force. Discussions about the severity of paralysis resulting from SCI must therefore focus on dynamic factors based on the traumatic force as well as on static compression factors. However, the past reports did not describe the influence of traumatic force in detail. Fifty patients presenting with cervical SCI associated with ossification of the posterior longitudinal ligament were included in this study. The American Spinal Injury Association motor score 3 days after injury, the degree of the traumatic force, and the spinal cord compression rate were investigated, and the relationships among these factors were investigated. Paralysis at the time of injury was not determined by static factors alone or by traumatic force alone. The severity of paralysis at the time of injury was determined on the basis of a combination of both the static factors and the degree of traumatic force. Both the degree of spinal cord compression and the degree of traumatic force were found to be important factors associated with the severity of cervical SCI in patients with ossification of the posterior longitudinal ligament. 4.

Respiratory nursing interventions following tracheostomy in acute traumatic cervical spinal cord injury.

Tracheostomy is frequently performed in severe cervical spinal cord injury (SCI) patients with the pulmonary dysfunction. A series of respiratory nursing interventions are required to plan tracheostomy removal. Tracheostomy was performed in 29 patients after acute traumatic cervical SCI. A series of respiratory nursing interventions were introduced in these patients after closed tracheostomy and decannulation, including closed tracheostomy tube training, manually assisted cough. Chacheostomy was successfully removed in 21 patients after the respiratory nursing interventions. In contrast, eight patients died from associated injuries. The average time from tracheostomy to decannulation was 40 days (14-104 days), the average time from closed tracheostomy to decannulation was 18.80 ± 13.50 days. Second tracheostomy was performed in one patient after 29 days' removal due to pulmonary infection. One patient presented with delayed incision healing for 29 days. Closed tracheostomy tube training and manually assisted cough are key factors for tracheostomy removal, although intensive nursing are also needed. The time from tracheostomy to decannulation and from closed tracheostomy to decannulation is increased in case of "late" (>24 h) tracheostomy and longer mechanical ventilation.

Strengthened respiratory management for lower tracheostomy risks in patients with complete cervical spinal cord injury

To access the feasibility of reducing tracheostomy rates in patients with complete cervical spinal cord injury through a systemic respiratory management mode. A retrospective review was performed for 239 patients on a systemic respiratory management mode after complete cervical spinal cord injury in Shanghai Changzheng Hospital from 2006 to 2012. Their demographic and clinical data, including age, gender, cause of injury, level of cervical spinal cord injuries, surgical approaches, tracheostomy rates and mortality rates, were collected and analyzed. Tracheostomy rates were compared with those of patients with complete cervical spinal cord injury. Tracheostomy rates were compared with those patients with complete cervical spinal cord injury from 1991 to 2005. The new respiratory management mode for patients with severe cervical spinal cord injury included maintaining adequate energy and water for patients, relieving bronchospasm, loosening phlegm, strengthening body-turning and backslapping, sputum aspiration with suction tube through nasal cavity or bronchofibroscope, strengthening deep breath and cough training, strict control of tracheostomy indications and short-term postoperative intubation reserving if necessary. 32 patients were implemented tracheostomy. The tracheostomy rate was 13.4%. 10 patients died, the mortality rate was 4.18%. However, the tracheostomy rate was 19.1% and mortality rate 21.4% from 1991 to 2005. The tracheostomy rate was significantly lower than before and survival rate improved significantly. The systemic respiratory management mode can effectively reduce tracheostomy rate of patients with complete cervical spinal cord injury and improve their survival rate.

Problématique de la prise en charge des traumatismes graves du rachis cervical en pays sous-développé

Background and purposeThe management of cervical spine injuries requires a multidisciplinary approach based on emergency management and rehabilitation. In our context this chain fails, especially on the post-hospital care. Our goal is to explain the difficulties we had in the management of these patients in Dakar. MethodsThis retrospective cohort study (2005–2009) included 99 patients admitted for severe cervical spinal cord injury in two hospitals in Dakar. The clinical signs, treatment and outcome were studied. The follow up was between 3 and 54 months. ResultsThe average age of patients was 36.1 years and the traffic accidents were the main etiology (73.7%). Medical transport of patients was done in 65.7% with an admission average time of 64.86hours. On admission, 57.6% of patients had Frankel score A or B. Dislocations (59.6%) and Tear drop fractures (16.2%) were the main lesions. The surgery was performed in 83.8% with a mean interval of 128.84hours after the trauma. Outpatient rehabilitation was offered whatever the patient's neurological status. Recovery was complete in 20.2% and partial in 31.3% with a mortality rate of 37.4%. Most deaths occurred between 1 and 6 months (59.5%) mainly due to decubitus complications (56.8%). ConclusionThe efficacy of the management of severe spinal cord injuries is based on reducing the preoperative time and rehabilitation.

Analysis of the risk factors for early death in acute severe traumatic cervical spinal cord injury

To survey the risk factors for early death of patients with acute severe traumatic cervical spinal cord injury. A retrospective analysis of data of consecutive patients with acute severe traumatic cervical spinal cord injury admitted from January 1st 1994 to October 1st 2012 were made. The patients died within 30 days or not were allocated for death group or survival group. The risk factors for early death were analyzed through univariate analysis and logistic analysis. Among 1093 patients with acute traumatic cervical spinal cord injury, 352 patients with severe injury were included, and the early death rate was 14.49% (51/352). The leading causes of spinal cord injury were vehicle accidents (153 cases) and falls (117 cases). The main causes of early death were respiratory failure (16 cases), multiple organ failure (MOF, 14 cases) and gastrointestinal bleeding (11 cases). Combining the results of univariate and logistic analysis, it was found that high acute physiology and chronic health evaluation II(APACHEII) score [>15, odds ratio (OR)=11.595, P=0.000], high damage level (OR=3.519, P=0.032), hyponatremia (OR=6.316, P=0.000), neurogenic shock (OR=6.209, P=0.000), pulmonary infection (OR=14.627, P=0.000) and tracheostomy (OR=8.983, P=0.000) were risk factors for early death of patients with acute severe traumatic cervical spinal cord injury, however, the impact of gender, age, surgery, fracture and dislocation, high central fever, and administration of steroids on early death of patients with acute severe traumatic cervical spinal cord injury were uncertain. The factors reflecting disease severity and occurrence of related complications were more important in predicting the early death among patients with acute severe traumatic cervical spinal cord injury, while the influence of age, surgical manipulation etc. were minor factors.

Identification of risk factors for respiratory complications in upper cervical spinal injured patients with neurological impairment

Clinical features of respiratory complications in patients with upper cervical spine injuries (CSI) are unique due to the complex regional anatomy in the region. The objective of this study was to identify the risk factors for respiratory complications in the patients with upper CSI and cervical spinal cord injuries (C-SCI). Ninety-two patients (out of 1593 spine injured patients) who met the inclusion criteria of upper CSI were admitted to our hospital from 1992 to 2010. Their records were retrospectively reviewed. Respiratory complications occurred in 16 patients (17.4%). In addition, ventilator-associated pneumonia played an important role in the respiratory complications, however, no pulmonary thromboembolism was found. Death rate in respiratory complication group (RCG, 31.3%) was significantly higher than that in non-respiratory complication group (NCG, 1.3%). In RCG, severe C-SCI (American Spinal Cord Injury Association Grades A and B, OR=34.401; 95% CI, 2.609-5.525) and hypoalbuminemia (OR=24.616; 95% CI, 1.492-6.182) were identified by logistic regression analysis as main risk factors for respiratory complications; whereas levels of neurological injury, quadriplegia, atlanto-axial fractures, smoking history, and electrolyte disturbances were not identified as risk factors (although statistically relevant to respiratory complications). Severe C-SCI and hypoalbuminemia played important roles in predicting respiratory complications among the patients with upper CSI and neurological impairment. In addition, levels of neurological injury, quadriplegia, atlanto-axial fractures, smoking history, and electrolyte disturbances are also valuable indicators for these complications. Moreover, prevention of ventilator-associated pneumonia was crucial in the treatment of these patients. However, a screening for deep venous thrombosis was seemingly unnecessary in our patients.

Comparative effects of glibenclamide and riluzole in a rat model of severe cervical spinal cord injury

Both glibenclamide and riluzole reduce necrosis and improve outcome in rat models of spinal cord injury (SCI). In SCI, gene suppression experiments show that newly upregulated sulfonylurea receptor 1 (Sur1)-regulated NCCa-ATP channels in microvascular endothelial cells are responsible for “persistent sodium currents” that cause capillary fragmentation and “progressive hemorrhagic necrosis”. Glibenclamide is a potent blocker of Sur1-regulated NCCa-ATP channels (IC50, 6–48nM). Riluzole is a pleotropic drug that blocks “persistent sodium currents” in neurons, but in SCI, its molecular mechanism of action is uncertain. We hypothesized that riluzole might block the putative pore-forming subunits of Sur1-regulated NCCa-ATP channels, Trpm4. In patch clamp experiments, riluzole blocked Sur1-regulated NCCa-ATP channels in endothelial cells and heterologously expressed Trpm4 (IC50, 31μM). Using a rat model of cervical SCI associated with high mortality, we compared the effects of glibenclamide and riluzole administered beginning at 3h and continuing for 7days after impact. During the acute phase, both drugs reduced capillary fragmentation and progressive hemorrhagic necrosis, and both prevented death. At 6weeks, modified (unilateral) Basso, Beattie, Bresnahan locomotor scores were similar, but measures of complex function (grip strength, rearing, accelerating rotarod) and tissue sparing were significantly better with glibenclamide than with riluzole. We conclude that both drugs act similarly, glibenclamide on the regulatory subunit, and riluzole on the putative pore-forming subunit of the Sur1-regulated NCCa-ATP channel. Differences in specificity, dose-limiting potency, or in spectrum of action may account for the apparent superiority of glibenclamide over riluzole in this model of severe SCI.

Hypothermic treatment for acute spinal cord injury.

Spinal cord injury (SCI) is a devastating condition that affects approximately 11,000 patients each year in the United States. Although a significant amount of research has been conducted to clarify the pathophysiology of SCI, there are limited therapeutic interventions that are currently available in the clinic. Moderate hypothermia has been used in a variety of experimental and clinical situations to target several neurological disorders, including traumatic brain and SCI. Recent studies using clinically relevant animal models of SCI have reported the efficacy of therapeutic hypothermia (TH) in terms of promoting long-term behavioral improvement and reducing histopathological damage. In addition, several clinical studies have demonstrated encouraging evidence for the use of TH in patients with a severe cervical spinal cord injury. Moderate hypothermia (33°C) introduced systemically by intravascular cooling strategies appears to be safe and provides some improvement of long-term recovery of function. TH remains an experimental clinical approach and randomized multicenter trials are needed to critically evaluate this potentially exciting therapeutic intervention targeting this patient population.

Systemic Hypothermia for the Treatment of Acute Cervical Spinal Cord Injury in Sports

Spinal cord injury is a devastating condition that affects approximately 12,000 patients each year in the United States. Major causes for spinal cord injury include motor vehicle accidents, sports-related injuries, and direct trauma. Moderate hypothermia has gained attention as a potential therapy due to recent experimental and clinical studies and the use of modest systemic hypothermia (MSH) in high profile case of spinal cord injury in a National Football League (NFL) player. In experimental models of spinal cord injury, moderate hypothermia has been shown to improve functional recovery and reduce overall structural damage. In a recent Phase I clinical trial, systemic hypothermia has been shown to be safe and provide some encouraging results in terms of functional recovery. This review will summarize recent preclinical data, as well as clinical findings that support the continued investigations for the use of hypothermia in severe cervical spinal cord injury.

Endothelial sulfonylurea receptor 1–regulated NCCa-ATP channels mediate progressive hemorrhagic necrosis following spinal cord injury

Acute spinal cord injury (SCI) causes progressive hemorrhagic necrosis (PHN), a poorly understood pathological process characterized by hemorrhage and necrosis that leads to devastating loss of spinal cord tissue, cystic cavitation of the cord, and debilitating neurological dysfunction. Using a rodent model of severe cervical SCI, we tested the hypothesis that sulfonylurea receptor 1-regulated (SUR1-regulated) Ca(2+)-activated, [ATP](i)-sensitive nonspecific cation (NC(Ca-ATP)) channels are involved in PHN. In control rats, SCI caused a progressively expansive lesion with fragmentation of capillaries, hemorrhage that doubled in volume over 12 hours, tissue necrosis, and severe neurological dysfunction. SUR1 expression was upregulated in capillaries and neurons surrounding necrotic lesions. Patch clamp of cultured endothelial cells exposed to hypoxia showed that upregulation of SUR1 was associated with expression of functional SUR1-regulated NC(Ca-ATP) channels. Following SCI, block of SUR1 by glibenclamide or repaglinide or suppression of Abcc8, which encodes for SUR1 by phosphorothioated antisense oligodeoxynucleotide essentially eliminated capillary fragmentation and progressive accumulation of blood, was associated with significant sparing of white matter tracts and a 3-fold reduction in lesion volume, and resulted in marked neurobehavioral functional improvement compared with controls. We conclude that SUR1-regulated NC(Ca-ATP) channels in capillary endothelium are critical to development of PHN and constitute a major target for therapy in SCI.

Sexual function in females with severe cervical spinal cord injuries: a controlled study with the Female Sexual Function Index

The objective of this study was to identify the sexual adjustment of females with severe cervical spinal cord injuries (SCI) using the Female Sexual Function Index (FSFI). The 19-item questionnaire of the FSFI concerns sexual function and satisfaction in sex life. This study, conducted by the Orthopaedic and Psychiatry Departments of Patras University, used a sample of a series of 39 consecutive female patients with severe traumatic SCI. We compared these female patients with an age-economic-educational level- and marital status-matched control group of the general population. Sexual activity was lower among females with SCI, but the desire, the emotional quality of sex life and overall sexual satisfaction did not differ from the controls. These results demonstrate that sexual life in females with SCI remains almost unaffected.

Severe high cervical spinal cord injury.

Severe high cervical spinal cord injury.

Autonomic dysreflexia in acute spinal cord injury: an under-recognized clinical entity.

While autonomic dysreflexia (AD) is well recognized in the chronic stage of spinal cord injury (SCI) this potentially life-threatening complication has been only rarely documented in the acute phase (1 month) after SCI. Based on our clinical experience we hypothesized that AD is under-recognized in the acute phase of SCI. This study was undertaken to determine the incidence and clinical associations of early AD in our center. We reviewed the charts of patients with acute traumatic SCI admitted to the Toronto Western Hospital Spinal Program between 1998 and 2000. Among 58 patients with acute traumatic SCI (15F, 43M; ages 17-89 years, mean of 55.4), all three individuals who developed evidence of early AD had complete cervical tetraplegia (1F, 2M; ages 31-42 years, mean of 38.3). The incidence of early AD was 5.2% (3 of 58), whereas the adjusted incidence for the population at risk (SCI at T6 or above) was 5.7% (3 of 53). A significant number of patients in this series (87.9%, or 51 of 58) had a cervical SCI. While the mean resting systolic arterial blood pressure among these three individuals was 105.7+/-3 mm Hg, the mean systolic blood pressure at the time of early AD was 173.3+/-14.8 mm Hg (increase in systolic blood pressure over baseline ranged from 35.5% to 95%). The earliest episode of AD occurred on the 4(th) post-injury day. The trigger mechanisms for AD were somatic pain, fecal impaction, and abdominal distention. Although numerous reports emphasize AD as a potential complication of chronic SCI, our study demonstrates that AD occurs in 5.7% of patients with acute SCI above T6. Patients with severe cervical SCI are particularly susceptible to the early onset of AD. Clinicians need to be aware and highly vigilant of the potential development of AD in the acute phase of SCI.

Early versus delayed stabilization of pediatric femur fractures: analysis of 387 patients.

To assess the effect of timing of femur fracture stabilization on pulmonary complication rates in pediatric trauma patients. Retrospective review. Level I trauma center. Three hundred eighty-seven previously healthy patients from zero to fifteen years of age with traumatic diaphyseal femur fractures. Femur fracture stabilization: early (less than twenty-four hours after injury) in 213 patients and late in 174 patients. Age, sex, GCS (Glasgow Coma Score), AIS/ISS (Abbreviated Injury Score/Injury Severity Score), timing of fracture stabilization, duration of mechanical ventilation, intensive care unit stay, and hospital stay were recorded. Pulmonary complications, including pneumonia, respiratory distress syndrome, and pulmonary embolus, were recorded. Thirteen patients developed pulmonary complications. Twelve of these had severe head injuries (GCS < or = 8). One had sustained an upper cervical spine fracture that resulted in quadriplegia. Statistical analysis revealed GCS, GCS < or = 8, ISS, and head and neck AIS to be significant predictors of pulmonary complications. Early stabilization of femur fractures had no apparent effect on the pulmonary complication rate. Pulmonary complications are rare in pediatric femur fracture patients. Patients with severe head injuries (GCS < or = 8) or cervical spinal cord injuries are at high risk for pulmonary complications. The timing of femur fracture stabilization does not appear to affect the prevalence of pulmonary complications in these patients.

Severe cervical spinal cord injuries related to rugby union and league football in New South Wales, 1984-1996.

To determine the frequency and circumstances of serious cervical cord injuries associated with rugby union and league football in New South Wales. Retrospective review of patients with rugby football-related cervical spinal cord injuries. The two central spinal units in NSW, from January 1984 to July 1996. Admission to spinal units; injury resulting in permanent tetraplegia. During the review period, 115 rugby football players (56 union and 59 league) were admitted to the spinal units because of cervical spinal cord injuries. 49 patients had resultant permanent neurological deficits (complete tetraplegia [quadriplegia])--26 associated with rugby union and 23 with rugby league. Two patients died of injury sequelae within two weeks of admission. There was no significant change in the rate of football-related admissions to spinal units for either code. There was a small decline in the number (from 15 in 1984 to 1987 to 7 in 1992 to 1996) and incidence (from 1.2 to 0.5 per 10,000 participants) of patients with tetraplegia associated with rugby union. When this decline was tested as a trend over the years, it was found to be statistically significant (P = 0.06). No significant trend was found in the tetraplegia data associated with rugby league. Cervical spinal cord injuries leading to complete tetraplegia were most commonly associated with scrum-like plays in union and with tackles in league. Serious cervical spinal injuries associated with both codes of rugby continue to occur in NSW. Rugby football in its various forms is still an inherently dangerous game.

Radiologic imaging of severe cervical spinal cord birth trauma

The radiological approach of a child with severe cervical spinal cord injury after a difficult breech delivery is presented. This diagnosis is often missed due to concurrent asphyxia. Ultrasound studies clearly showed the localisation and the extent of the injury. These findings were later confirmed by MRI. Ultrasonography is recommended as the initial imaging technique to evaluate possible spinal cord lesions in the neonate.