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Pulmonary complications contribute to morbidity and mortality in spinal cord injuries (SCIs). A retrospective review of 20 years of experience with tracheostomy- and ventilator-dependent SCI children is presented. The authors developed and analyzed a database of 47 children (average age = 11.4 years). Of the patients, 27% had concomitant brain injuries, 6% had prior histories of reactive airway disease, and 2% had thoracic fractures. Injuries were caused by motor vehicle accidents (53%); gunshot wounds (19%); sports-related accidents (19%); and vascular injuries, transverse myelitis, or spinal tumors (8%). Of the injuries, 52% were high level (C1 to C2) and 48% were mid- or low level (C3 to C5). Two groups were analyzed for demographic information. Complications included tracheitis, atelectasis, and pneumonia. Mean tidal volume was 14 cm2/kg (maximum = 22 cm2/kg). Bedside lung function parameters were attempted to assess readiness and the rapidity of weans. T-piece sprints were used to successfully wean 63% of patients. Successfully weaned patients were compared with those not weaned. No deaths or readmissions for late-onset respiratory failure postwean occurred. The authors' clinical impression favors higher tidal volumes and aggressive bronchial hygiene to minimize pulmonary complications and enhance weaning. Successfully weaned patients had fewer complications. A critical pathway for respiratory management of SCI children is presented.

Pediatric atlanto-occipital dislocation (AOD) most commonly occurs in victims of high-velocity motor vehicle collisions and usually results in death. The mechanical and anatomic predisposing factors for AOD in children have been well documented. With the introduction of passenger-side air bags in automobiles, reports have documented an increased incidence of pediatric cervical spine injuries, including AOD, in low-speed motor vehicle collisions. Although long-term survival in AOD is so unusual that there is no separate literature regarding its physiatric treatment, it is generally treated like any other high cervical spinal cord injury. Recent advances in adaptive technology have aided greatly in management. Despite benefits that adaptive technology affords, the best treatment for AOD is still prevention. For this reason, children under the age of 13 should be restrained backseat passengers in automobiles.

PURPOSE: A multi-institutional and multidisciplinary pediatric physical medicine rehabilitation healthcare system was developed to meet regional patient needs. METHODS: A ten-year experience meeting regional patient care needs in northeast Florida and southern Georgia is described. RESULTS: A collaborative effort of multiple institutions resulted in the recruitment of a pediatric physical medicine and rehabilitation physician in June 2009, followed by planning stages that included initiation, development, and structuring of the program. Phase I: selection of clinic spaces, training of existing staff, creating specialized programs. Phase II: recruitment of an additional physician and dedicated advanced practice registered nurse, hospital nursing and radiology personnel training, development of protocols for specific disease entities, formulating a team approach for patient care, development of dedicated clinics for disease processes. Phase III: incorporating care into existing multidisciplinary clinics, education of existing physical, occupational, and speech therapists in dedicated remote clinics on early detection and management of specialty issues. Phase IV: ongoing education provided by rehabilitation faculty. Quality improvement aspects included outcome studies, coordinating with the Cerebral Palsy Research Network databank, and others. All phases overlapped in time and are ongoing, adapting to new needs. CONCLUSION: A collaborative program can be created to provide comprehensive pediatric physical medicine and rehabilitation in regions lacking such a system.