Asian Journal of Orthopaedic Research

Introduction: Delayed complete paraplegia in children following minor trauma is rare and is typically associated with poor neurological recovery, particularly when treatment is initiated beyond the conventional therapeutic window. Diagnostic uncertainty arises when profound neurological deficits occur despite the absence of abnormalities on initial radiographic evaluation. Spinal cord injury without radiographic abnormality (SCIWORA) is a distinctive entity observed predominantly in the paediatric population and accounts for approximately 13–42% of spinal cord injuries in children. Management of paediatric SCIWORA remains challenging, particularly regarding the role of high-dose corticosteroid therapy. The National Acute Spinal Cord Injury Study (NASCIS) protocol recommends methylprednisolone for acute spinal cord injury; however, its application in children remains controversial because the original studies were conducted primarily in adults, and concerns persist regarding potential complications. In addition, the therapeutic value of corticosteroid therapy administered beyond the traditional eight-hour treatment window remains uncertain. We report a case of post-traumatic delayed paraplegia in a paediatric patient initially suspected of having SCIWORA who demonstrated rapid neurological recovery following delayed corticosteroid administration.

Case Presentation: A previously healthy five-year-old boy presented with progressive bilateral lower-extremity weakness and urinary retention five days after falling approximately two metres from playground equipment and landing in a seated position. Initial symptoms were mild but gradually progressed to a severe motor deficit. Neurological examination revealed complete flaccid paraplegia (Medical Research Council grade 0/5), with hypoesthesia below the Th5 level, preserved upper-extremity strength, and brisk lower-extremity reflexes. Plain radiographs of the thoracolumbar spine and pelvis demonstrated no evidence of fracture, dislocation, or spinal malalignment, raising suspicion of SCIWORA. Despite the delayed presentation, intravenous methylprednisolone therapy following a modified NASCIS III protocol was initiated. Magnetic resonance imaging performed on the second hospital day revealed longitudinally extensive T2 hyperintensity extending from C5 to Th10, consistent with spinal cord oedema manifesting with SCIWORA-like symptoms. Neurological improvement was observed within 48 hours after steroid administration. By the fourth day of treatment, the patient was able to lift both lower extremities against minimal resistance, and by day six, complete motor recovery and restoration of bowel and bladder function were achieved. No steroid-related complications occurred.

Discussion: Although SCIWORA was initially suspected on the basis of the clinical presentation and normal radiographs, magnetic resonance imaging demonstrated spinal cord oedema. This imaging pattern explained the neurological manifestations and emphasises the importance of advanced imaging in children with severe neurological deficits after trauma. The rapid neurological recovery observed following corticosteroid therapy suggests that reversible spinal cord oedema, rather than irreversible axonal injury, may have been the predominant mechanism of neurological dysfunction. Notably, improvement occurred despite initiation of therapy five days after symptom onset, raising the possibility that the therapeutic window for corticosteroid treatment in selected cases may extend beyond the traditionally described eight-hour window for traumatic spinal cord injury.

Conclusion: This case demonstrates that delayed administration of methylprednisolone may still be associated with rapid neurological recovery in paediatric spinal cord syndromes that initially resemble SCIWORA but may involve reversible spinal cord oedema manifesting with SCIWORA-like symptoms. Early MRI evaluation is essential to clarify the underlying pathology and guide treatment strategies. Given the absence of consensus guidelines for paediatric spinal cord injury with delayed neurological presentation, individualised clinical decision-making remains necessary. Further investigation is warranted to clarify the potential role of the NASCIS protocol in paediatric spinal cord injury and to better define the optimal timing of corticosteroid therapy.