Spinal Cord Injury Presentation and Treatment | Bone and Spine

Spinal cord injury is term used for spectrum of insults to the spinal cord which results in either temporary or permanent loss of function of the affected area of the cord.

Spinal cord works to relay motor and sensory signals to the peripheral organs. Therefore the function affected are sensation, proprioreception, activity of smooth and striated muscles.

The profile of the injury and region affected would determine the functions affected. This motor and sensory loss pattern in fact guides the clinicians to reach at the diagnosis of the levels of injury.

At any level, the injury to spinal cord could be complete[ a total loss of sensation and muscle function at and below the level of injury] incomplete [sparing of some functions distal to level of injury indicating the signal transmission]

The prognosis of the spinal cord injury depends on the severity of the injury and may range from complete recovery to permanent quadriplegia [cervical injuries] and complete paraplegia in lower injuries.

Physical trauma like motor vehicle injury, gunshots, falls, or sports injuries are most common causes of injury to spinal cord. But the cord injury can also occur due to non-traumatic causes like infection, insufficient blood flow, and tumors.

In every trauma patient, unless confirmed otherwise, spinal injury is presumed and patient is handled accordingly. That means following spinal precautions in the field and transit.

Males suffer from spinal cord injuries about 4 times more than females. Most of these injuries occur in men under 30 years of age.

The general perception of a cure for spinal cord injury is the loss of motor function. But injury to the spinal cord affects many systems and functions of the body including neural control of motor, sensory, autonomic, bowel and bladder.

The goal of treatment of spinal cord injuries is

Spine consists of many vertebrae stacked and articulating with one another to form a vertebral column. Spinal canal occupies the vertebral or spinal canal.

At each level of the spinal column, spinal nerves branch off from either side and exit through intervertebral foramina to supply different regions of body.

The area of skin innervated by a specific spinal nerve is called a dermatome, and the group of muscles innervated by a single spinal nerve is called a myotome. [see the table below for motor functions of different segments].

[ Read more about spinal nerves]

Following are links to detailed anatomy of the spine and spinal cord.

Spinal injuries could be classified according to causation which broadly could be traumatic or non-traumatic.

Another way to classify is complete or incomplete injuries.

A complete injury results in loss of all functions below the injured area whereas incomplete spinal injury preserves some motor or sensory function. American spinal injury association (ASIA) suggests that if the person does not have motor and sensory function in the anal and perineal region representing the lowest sacral cord (S4-S5), it should be classified as complete spinal injury. These segments represent the last spinal nerves of the cord and if the injury has occurred to the lowest segments, it is a complete injury.

Spinal cord injury can also be classified by the degree of impairment. ASIA score is used for measuring degree of impairment.

More on ASIA score.

Physical injuries include hyperflexion, hyperextension , lateral stress, rotation (twisting of the head) and compression or distraction.

Traumatic spinal cord injury can result in contusion, compression, or stretch injury.

Nontraumatic injury can occur due to mechanical pressure, toxicity or ischemia.

[Read Flexion Distraction Injuries of Spine]

In this scenario there could be primary and secondary injury. [primary injury is the cell death that occurs immediately in the original injury, and secondary injury occurs due to biochemical cascades that are initiated by the original insult and cause further tissue damage.

Motor vehicle injury is most common cause of spinal cord injury followed by falls. Gunshot wounds and sports injuries are other important causes.

Nontraumatic causes include tumors, degenerative diseases and infections like tuberculosis.

Intervertebral disc prolapse, compromise of blood supply due to arteriovenous malformation or intervertebral disks can herniate. Diseases of spinal cord such as multiple sclerosis can also cause the injury.

Non-traumatic orthopedic causes are discussed elsewhere. From here on we would concentrate on traumatic injuries and their management.

[Read about tuberculosis of spine]

After an injury, every patient is deemed to have a spinal injury and is treated like one unless spinal injury has been ruled out. That means right from initial contact with patient in the field the patients is handled with a protocol that protects the spine as well.

Because the spinal cord has got sensory and motor function, the injury to spinal cord would present with loss of sensation, motor weakness or paresthesiae.

The specific parts of the body affected by loss of function are determined by the level of injury.

Sometimes, there may not be signs of spinal cord injury. But patient may have injured spinal cord and not considering protection of the spine is fraught with risk of injury to spinal cord during handling of patient in extrication, transport and shifting. Therefore, it becomes important to protect spine in all cases.

Following are gross region wise affection of spinal cord injury. The severity of loss of function is dictated by the severity of injury. As a rule higher level of injury affects more functions than lower.

Depending upon level of injury, the functions affected are motor and sensory functions of all the four limbs, abdominal and trunk muscles, visceral muscles [loss of bladder and bowel functions], respiratory muscles and neck muscles.

Upper cervical muscles are more severe and require ventilator support.

Low heart rate, low blood pressure, problems regulating body temperature can also be present.

Thoracic spinal injuries result in paraplegia, but function of the hands, arms, and neck are not affected. Higher injuries [T1 to T8] affects function of the abdominal muscles and trunk muscles in addition. Injuries to the level T9 to T12 result in partial loss of trunk and abdominal muscle control.

Autonomic dysreflexia, neurogenic shock and temperature regulation may be affected.

Loss of control of the legs and hips, bladder, bowel and genital function system, and anus. Different levels may spare different functions.

It may be reiterated again that a higher complete lesion would include all the deficits of lower level in addition to addition of other neural deficits.

It must be kept into the mind that all trauma patients are at risk for spinal cord injury. The principle of spinal care in all trauma patient is based on the possibility that all trauma patients may have an unstable spine injury definitively excluded.

In any trauma setting the treatment priorities are preserving life, limb, and function. The spine must be protected as these priorities are addressed.

Proper extrication of the patient and immobilization of the cervical spine at the accident scene are critical to avoid further neurologic injury. The neck movements are to be avoided when taking out the person out of the car or shifting the person. For this, the head and neck need to be aligned with the long axis of the trunk and immobilized in this position.

The cervical spine needs to be immobilized to prevent further movements that can cause damage to the spinal cord. Immobilization with cervical collar, sandbags, tape, and spine board. The spine is usually kept in neutral position irrespective of type of injury.

Neutral flexion-extension head and neck alignment is optimal during prehospital transport of cervical spine injury patients .

Helmet and shoulder gear should be left in position until personnel trained in safe removal techniques are available.

Determination of gross neurologic status in the field helps prioritize subsequent treatment interventions.

Suspicion of neurologic injury should be conveyed to the hospital to prepare for subsequent evaluation and management.

When the patient arrives in hospital a brief over must be taken from the prehospital care team. This helps to get an idea about the scene of injury and circumstances in which patient had been. Also relevant information about treatment along the way must be sought.

There are lot of possibilities in this scenario. In some countries, the prehospital care is excellent and by the time patient arrives in hospital, all the relevant information had been passed by prehospital care team over radio or phone and the hospital is ready to receive the patients.

On the other extreme patient might be brought to the hospital by police van or some good Samaritan and the physician is first person to look at the patient.

Sometimes there is no information available about the circumstances of the injury as the patient was found roadside and brought to the hospital.

In either case, initial evaluation of the patient must include spinal injury evaluation which might go concurrent with resuscitative measures.

Initial evaluation at the hospital arrival must include

Any condition which needs immediate treatment should be part of the side by side ongoing resuscitation.

Hypotension, bradycardia, warm extremities in presence of normal urine output must raise the suspicion of neurogenic shock and it needs to be differentiated from hemorrhagic shock shock as the treatment is different. Treatment of neurogenic shock is pharmacologic intervention to augment peripheral vascular tone and may be essential for effective resuscitation. Fluid overload from excessive fluid volume administration, as appropriate for hemorrhagic shock, can result in pulmonary edema in the setting of neurogenic shock.

Spinal cord injury also increases the risk of multiple organ system failure in polytrauma patients. The presence of severe hemodynamic parameter abnormalities in the initial phases of resuscitation is associated with a poor prognosis for neurologic recovery but normal hemodynamics, however, do not predict neurologic recovery.

After the patient has been resuscitated, a detailed examination of the patient follows.

This detail examination follows a different sequence in unresponsive and awake (cooperative) patients and awake sequence of evaluation and intervention steps differs in both the cases.

If patient is responsive, a detailed history is obtained regarding acute symptoms and past history.

For unresponsive patients, a past history is obtained from family members or available previous medical records.

The patient must be rolled on his or her side using a log-rolling maneuver. For this, The patients head and neck are supported by one person and the trunk by two to three other assistants. The head and trunk are then rolled in unison to facilitate the examination of spine by physician.

Following things are noted

Trunk and abdomen are also examined for injury.

After local examination of the spine neurological examination is performed.

The neurological examination would vary in awake-cooperatibve and unresponsive patients.Awake and cooperative patients require a complete neurological examination. There are many methods and gradings to assess the neurological deficit whose basic purposes are following

Initial care in the hospital, as in the prehospital setting, aims to ensure adequate airway, breathing, cardiovascular function, and spinal immobilization. Acute spinal cord injury should be treated in intensive care unit, especially injuries to the cervical spinal cord

This is achieved by detailed motor and sensory examination.

Following reflexes must be seen in patients of spinal injury

Reflexes of Spinal Cord and Conus Medullaris

In case of unresponsive patient, radiographic studies are the primary modalities for identifying a spine injury. Spine injury precautions must be observed until the spine is cleared. If a spinal column injury is identified, the neurological deficit should be assessed. This can be done by serial neurological examinations, magnetic resonance imaging and sensory- or motor-evoked potentials.

[More on cervical spine clearance]

Spinal column injury is trauma that causes fracture of the bone or instability of the ligaments in the spinal column. this can coexist with or cause injury to the spinal cord, but each injury can occur without the other.

Spinal cord injury without radiographic abnormality (SCIWORA) exists when spinal cord injury is present but there is no evidence of spinal column injury on radiograph.

Abnormalities might show up on MRI, but the term was coined before MRI was in common use.

A radiographic evaluation using an X-ray, CT scan, or MRI can determine if there is damage to the spinal column and where it is located.

Following xrays are essential in a patient who has multiple injuries

Rest of the imaging for spine is done after patient has been stabilized.

After patient is stabilized, a complete imaging of cervical spine views should be obtained. Following views are generally ordered.

Flexion-extension views may be done in case there is doubt of instability.

To avoid further injury the patient is not moved to position for the various views. Instead, the x-ray beam and film position is adjusted.

Lateral radiograph allows visualization of the spine from the occiput to C6 vertebra and C7 if shoulders are pulled during the xray. A swimmers lateral view or a CT scan may be needed if lower cervical spine cannot be visualized. Following things are noted in a cervical spine x-ray.

Lateral View

Anteroposterior View

Shows the C3 to T4 segments. A change in alignment of the uncovertebral joints (Small synovial joints between adjacent lateral lips of the bodies of the lower cervical vertebrae) and spinous processes can indicate an acute injury.

Open mouth view

It is essential for excluding a C1 arch or odontoid process fracture.

Oblique views

To identify injuries of the facet joints, pedicles, and lateral masses.

Flexion-extension views

To identify any occult cervical ligamentous injury if the patient has pain and tenderness but other xrays are normalThese are dangerous in settings of injury and should be performed in alert patients, under supervision, and with voluntary unassisted positioning by the patient.

Anteroposterior and lateral thoracic and lumbar radiographs and a pelvis AP view are standard xrays. Alignment, destruction of vertebrae or reduction in height of vertebra, vertebral fractures are signs of injury.

CT scans are done for

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Spinal Cord Injury Presentation and Treatment | Bone and Spine