Suggestions for preventing and diagnosing spinal cord injury in children after backbend dance

Abstract

Dear Editor The impact of spinal cord injury (SCI) on young children is devastating, particularly given their relatively long-life expectancy and immature physical development.1 In the past five years, Chinese physicians have reported over 200 cases of SCI related to backbend dance.2-4 Our review of these articles documented 144 cases of SCI among Chinese children following backbend dance, with ages ranging from 3 to 11 years; notably, 99% of these cases involved children under 10 years old, with an average age of 6±2 years. All cases exhibited hyperacute onset of SCI within the first four hours following the injury.2-4Many affected children displayed no symptoms immediately after the injury. However, during the incubation period-spanning from 15 minutes to four hours post injury- these patients did not receive timely treatment or management interventions, such as cessation of training, immobilization, or supine rest. Only MRI scans revealed a longitudinal diffuse intramedullary high-intensity signal with edema, although the extent of edema did not correspond with the neurological level of injury. Follow-up assessments indicated a poor prognosis for patients with complete SCI, with final MRI results taken one to four months later showing distal spinal cord atrophy. Furthermore, patients with complete SCI experienced serious complications during their last follow-up, including scoliosis, hip dysplasia or dislocation, pressure sores, urinary tract infections, neurogenic fractures in the lower limbs, and muscle atrophy.2-4In China, SCI resulting from backbend dance remains largely overlooked by the public, as well as by dance training institutions and sports centers.2-5 As more children globally engage in recreational activities such as yoga, gymnastics, ballet, cheerleading, acrobatics, Pilates, backbends, surfing, and swimming-many of which involve continuous spinal hyperextension movements-similar tragedies are likely occurring worldwide. Currently, there are no relevant textbooks or sports guidelines to assist in safe practices during children's dance training.4Wang et al., (2021) hypothesized that the mechanism behind this condition involves the effect of internal organs on the inferior vena cava, leading to impaired blood perfusion primarily at the T9-T10 levels, which ultimately results in ischemic SCI.4 While magnetic resonance angiography (MRA) is considered the gold standard for confirming the diagnosis and predicting prognosis following repetitive hyperextension SCI, diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) may also be beneficial in assessing prognosis and determining injury severity shortly after the incident.Based on the literature, our suggestions are as follows:Children aged 10 and under should not practice spinal hyperextension movements.Coaches and parents of children participating in hyperextension activities should be informed about the potential risk of SCI associated with these spinal movements. Additionally, measures should be taken to protect children from accidental injuries during such practices.In the event of an injury, training should be stopped immediately, and the child should be immobilized and placed in a supine position to prevent further aggravation. Medical assistance should be sought if any neurological symptoms arise.Reporting cases of SCI is essential to raise public awareness among guardians, sports institutions, and educational departments. Textbooks and guidelines should be developed to highlight potential hazards and provide warnings to training coaches and the public to prevent such injuries.If feasible, legislation should be considered to prohibit children under the age of 10 from participating in this type of sport.In conclusion, while MRI is the gold standard for diagnosing SCI, MRA is necessary following a backbend injury. SCI resulting from backbend dance differs from other types of SCI in terms of mechanism of injury (MOI), symptom onset, and imaging abnormalities. Preventing such injuries is the first step forward. Further research is required to deepen our understanding of SCI related to backbend dance.

Keywords

• spinal cord injury
• repetitive hyperextension
• backbend dance
• children
• china