Spinal cord injury at birth

How does this happen?

The spinal cord runs inside the bony spine and carries every signal between the brain and the body below the neck. It has very little slack.

A newborn spine is unusually flexible. The bones and ligaments can stretch a long way. The cord cannot. That mismatch is the whole mechanism: the spine stretches, the cord inside it does not, and the cord is injured while the bones return to normal and look intact on an X-ray. ¹

That is why MRI is the test and why a normal X-ray does not rule this out.

The situations where this happens involve the head and body being pulled in different directions, or the neck being over-extended or twisted.

• A breech delivery where the body is delivered and the head is difficult, which stretches the neck. ³
• A difficult instrument-assisted delivery with rotation. ⁵
• A baby whose head is hyperextended, sometimes described as a star-gazing position, entering labor.
• A severe shoulder dystocia with strong traction. ⁶

Where the injury sits decides what is affected. High in the neck affects breathing and everything below. Lower in the neck affects the arms partly and the legs fully. In the chest region the arms are normal and the legs are not.

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

• A difficult breech delivery, where the head does not deliver easily after the body. This can occur despite correct technique. ³
• A hyperextended fetal head entering labor, which is a position that carries risk and is not always identified beforehand.
• A severe shoulder dystocia managed correctly, where the maneuvers themselves involve force. ⁶
• An emergency delivery where speed was necessary for the baby's survival.
• Underlying conditions affecting the spine or its ligaments, which are rare.

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• A breech birth managed outside recommended practice, including decisions about mode of delivery and technique. Guidance addresses term singleton breech delivery specifically. ³
• Excessive or wrongly directed traction, including during a shoulder dystocia. ⁶
• Rotational instrument delivery outside recommended limits. ⁵
• A hyperextended head not identified before a vaginal breech delivery was undertaken.
• The injury not recognized, with a floppy newborn worked up for brain or muscle causes and the spine never imaged. This is the most common way the diagnosis is delayed. ¹
• X-ray relied on and treated as ruling out injury, when a newborn spinal cord can be injured with normal bones. ¹
• Breathing not assessed where a high injury was possible. ⁴

Whether any of this amounts to a departure from the standard of care takes a physician expert reading the whole record.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

• A floppy newborn with little or no movement below a certain point.
• Poor or absent breathing effort, in a high injury, requiring resuscitation. ⁴
• Absent reflexes below the level.
• A baby who is alert and responsive in the face while the body does not move, which is the pattern that should raise the question.
• Low Apgar score scores. ⁷

The first week

• Persistent flaccid weakness below a level.
• Retention of urine, or a bladder that has to be emptied.
• Constipation.
• Absent sensation below the level, which is hard to assess but can show as no response to a heel prick below the level and a normal response above it.
• Breathing support needs.

Around 3 months

• Weakness that has a clear level.
• Development of stiffness below the injury in some babies, replacing the initial floppiness.
• Recurrent urine infections from incomplete bladder emptying.
• Poor growth of the affected limbs.

Around 6 months

• Motor delay below the level. ⁸
• Normal development of anything above the level, including social and language development, which is often normal.
• Skin problems over pressure areas.

Around 12 months

• Head and arm control depending on the level.
• Not sitting or standing where the level is high.
• Continued bladder and bowel management needs.

Toddler years

• Mobility using equipment.
• Scoliosis, a curve of the spine, which develops commonly after spinal cord injury and needs monitoring.
• Bladder and bowel programs.
• Normal cognitive development in most children, since the brain is not affected.

School age

• Full participation with equipment and access.
• Scoliosis management.
• Skin care and pressure area awareness.
• Independence in bladder and bowel care, taught in stages.

How is it diagnosed?

The diagnosis rests on recognizing a level.

A newborn who is alert, who responds normally with the face, and who has no movement below a certain point does not fit a brain problem or a general muscle condition. That pattern should prompt spinal imaging. ¹

MRI of the spine is the test. It shows the cord itself, including swelling, bleeding and disruption.

X-ray and CT scan show the bones and are often normal, because a newborn spine can stretch enough to injure the cord without visible bone injury. A normal X-ray does not rule this out. ¹

Assessment of breathing, including whether the diaphragm is working, in any injury that could be high in the neck. ⁴

Bladder assessment, because retention is common and unrecognized retention damages the kidneys over time.

Differential diagnosis. The conditions most often considered instead are severe hypoxic-ischemic encephalopathy, hypotonia from a neuromuscular condition, and a severe brachial plexus injury. What separates spinal cord injury is the level, the preserved facial and cognitive function, and the bladder involvement. ^{1 9}

What is the treatment?

Immediate care is about breathing, circulation and preventing further injury, in a neonatal intensive care unit. ⁴

Careful handling and positioning to protect the spine.

Breathing support, which may be short term or long term depending on the level.

Bladder management, usually with a program of emptying the bladder on a schedule, which protects the kidneys.

Bowel management.

Skin protection, because skin without sensation is injured by pressure without the child noticing.

Therapy, early and ongoing. physical therapy and occupational therapy for whatever movement is present, for positioning, and for equipment. Referral to early intervention is free to evaluate for a child under 3. ¹⁰

Equipment, including seating, standers and wheeled mobility. Powered mobility can be introduced early and transforms independence. ¹¹

Monitoring for scoliosis and for hip problems, both of which are common after spinal cord injury in a growing child.

A specialist center. This is a rare injury and it benefits from a team that manages spinal cord injury regularly.

What is the long-term outlook?

Outcome depends almost entirely on the level of the injury and on whether it is complete or incomplete.

An incomplete injury, where some signals still cross the injured area, has meaningfully better prospects than a complete one, and some recovery can occur in the first months as swelling settles. ¹

A high injury affecting breathing carries the most serious outlook.

Cognitive development is usually normal, because the brain is not affected. Children with spinal cord injury go to school, learn, work and live full lives with equipment and access. That is worth stating clearly, because the first conversation about this diagnosis is frightening and the long-term picture is one of adaptation rather than absence.

Lifelong issues to manage are bladder and kidney health, skin, scoliosis, and hip position.

What does daily life look like?

Bladder and bowel programs, done on a schedule, every day. Families learn these and later teach them to the child.

Skin checks, every day, in areas without sensation.

Equipment: seating, standing frames, wheeled mobility, and eventually vehicle and home modification.

Therapy, and school access planning.

Practically, families describe the routines as the biggest adjustment and, once established, as manageable. What takes longer is the housing and transport side, which is expensive and slow, and which is worth starting early. See equipment and home modifications.

What does care cost over a lifetime?

No agency publishes a lifetime cost estimate for spinal cord injury sustained at birth, and this site does not invent one.

The cost drivers are equipment, home and vehicle modification, personal care, and lifelong medical management of bladder, skin and spine.

If a legal case is filed, the relevant figure is a life care plan written for your child. See what a birth injury case looks like.

What can you do this week?

1. Ask whether an MRI of the spine has been done. A normal X-ray does not rule this out.
2. Ask what level the injury is at, and whether it is complete or incomplete.
3. Ask whether the diaphragm is working.
4. Ask whether the bladder is emptying, and what the plan is.
5. Ask for referral to a center that manages spinal cord injury.
6. Request the complete delivery records, including the mode of delivery and any breech or shoulder dystocia notes.
7. Refer to early intervention.

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the neonatologist or neurologist

• Has an MRI of the spine been done, and what did it show?
• What level is the injury, and is it complete or incomplete?
• Is the diaphragm working on both sides?
• Is the bladder emptying, and how are we managing that?
• What recovery, if any, would you expect over the first months?

For the rehabilitation team

• What equipment will we need in the first year?
• When can we start powered mobility?
• How do we do the bladder and bowel program?
• What skin checks should we do, and how often?
• When does scoliosis monitoring start?

For the obstetric team

• What was the mode of delivery, and was it breech?
• Was the head hyperextended before delivery?
• Were instruments used, and was there rotation?
• Is all of this in the delivery note?

You can also build a printable list with the question generator.