An arrow that missed the mark: a pediatric case report of remarkable neurologic improvement following penetrating spinal cord injury

Penetrating spinal cord injuries are rare in children but result in devastating impacts on long-term morbidity and mortality—with little known about the recovery capacity in this age group. We present the case of an eight-year-old child who sustained a penetrating injury through the right anterior thorax. Thoracic CT showed the arrow tip extending through the spinal canal at T6. Neurologic examination revealed no motor or sensory function below T6. The arrow was surgically removed without complications through an anterior-only approach. MRI on post-operative day (POD) 4 showed focal T2 hyperintensity at the T6 spinal cord. Patient was discharged on POD33 with an American Spinal Injury Association (ASIA)-D score and trace voluntary control over bowel and bladder function. Remarkably, four months later, he had near normal bowel and bladder function, with near-intact lower extremity strength and self-sustained ambulation. Follow-up imaging revealed hemicord formation at the level of injury. We review our case of penetrating spinal cord injury in a child and similar reports in the literature. Penetrating thoracic spinal cord trauma portends poor clinical outcomes, particularly when employing available adult prognostic spinal cord injury scoring metrics. Incomplete spinal cord injury, and often-associated spinal shock, can mimic a complete injury—as in our patient, which improved to near-complete motor and sensory restoration of function and resulted in the formation of a split hemicord. This case represents a unique penetrating spinal cord injury with remarkable neurologic recovery, which would advocate against definitive early prognostication in the pediatric population.