Spinal Cord Injury

ANDI IHWAN
Definition

Insult to spinal cord resulting in

a change, in the normal motor,
sensory or autonomic function.
This change is either temporary
or permanent.
Mechanisms:

i) Direct trauma
ii) Compression by bone
fragments / haematoma /
disc material
iii) Ischemia from damage /
impingement on the spinal
arteries
Suspected Spinal Injury

 High speed crash

 Unconscious
 Multiple injuries
 Neurological deficit
 Spinal pain/tenderness
Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
© 2007 Elsevier
Spinal Cord Injury
Classification
 Quadriplegia :
injury in cervical region
all 4 extremities affected
 Paraplegia :
injury in thoracic, lumbar or sacral
segments
2 extremities affected
Classification
Complete:
i) Loss of voluntary movement of parts innervated
by segment, this is irreversible
ii) Loss of sensation
iii) Spinal shock
Incomplete:
i) Some function is present below site of injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury, although
they are rarely pure and variations occur
Injury defined by ASIA
Impairment Scale
ASIA – American Spinal Injury Association :
A – Complete: no sensory or motor function preserved in
sacral segments S4 – S5

B – Incomplete: sensory, but no motor function in sacral

segments
C – Incomplete: motor function preserved below level and
power graded < 3

D – Incomplete: motor function preserved below level and

power graded 3 or more

E – Normal: sensory and motor function normal

Muscle Strength Grading:
 5 – Normal strength
 4 – Full range of motion, but less than
normal strength against resistance
 3 – Full range of motion against gravity
 2 – Movement with gravity eliminated
 1 – Flicker of movement
 0 – Total paralysis
Pre-hospital management
 Protect spine at all times during the management
of patients with multiple injuries
 Up to 15% of spinal injuries have a second
(possibly non adjacent) fracture elsewhere in the
spine
 Ideally, whole spine should be immobilized in
neutral position on a firm surface
 PROTECTION  PRIORITY
 Detection  Secondary

“Log-rolling”
Cervical spine
immobilization
 “Safe assumptions”
 Head injury and unconscious
 Multiple trauma
 Fall
 Severely injured worker
 Unstable spinal column

 Hard backboard, rigid cervical collar and

lateral support (sand bag)
 Neutral position
Philadelphia hard collar
Clinical assessment
 Advance Trauma Life Support (ATLS)
guidelines
 Primary and secondary surveys
 Adequate airway and ventilation are the
most important factors
 Supplemental oxygenation
 Early intubation is critical to limit
secondary injury from hypoxia
Physical examination
 Information
 Mechanism
 energy, energy
 Direction of Impact
 Associated Injuries
Physical examination
 Inspection and palpation
 Occiput to Coccyx
 Soft tissue swelling and bruising
 Point of spinal tenderness
 Gap or Step-off
 Spasm of associated muscles

 Neurological assessment
 Motor, sensation and reflexes
 PR

 Do not forget the cranial nerve (C0-C1 injury)

Comparison of neurogenic and hypovolemic shock
Neurogenic Hypovolemic
Etiology Loss of Loss of blood
sympathetic volume
outflow
Blood Hypotension Hypotension
pressure
Heart Bradycardia Tachycardia
rate
Skin Warm Cold
temperat
ure
Urine Normal Low
output 18
Cervical Spine Imaging
Options
 Plain films
 AP, lateral and open mouth view
 Optional: Oblique and Swimmer’s

 CT
 Better for occult fractures

 MRI
 Very good for spinal cord, soft tissue and ligamentous injuries

 Flexion-Extension Plain Films

 to determine stability
 Adequacy

 Must visualize entire C-spine

 A film that does not show the upper
border of T1 is inadequate
 Caudal traction on the arms may help
 If can not, get swimmer’s view or CT
Lateral Cervical Spine X-Ray

 Anterior subluxation of one vertebra on

another indicates facet dislocation
 < 50% of the width of a vertebral body 
unilateral facet dislocation
 > 50%  bilateral facet dislocation
 CT Scan
 Thin cut CT scan should be used
to evaluate abnormal,
suspicious or poorly visualized
areas on plain film

 The combination of plain film

and directed CT scan provides a
false negative rate of less than
0.1%
 MRI
 Ideally all patients with
abnormal neurological
examination should be
evaluated with MRI scan
Management of SCI
 Primary Goal
 Prevent secondary injury

 Immobilization of the spine begins in the initial

assessment
 Treat the spine as a long bone
 Secure joint above and below
 Caution with “partial” spine splinting
Management of SCI
 Spinal motion restriction: immobilization devices
 ABCs
 Increase FiO2
 Assist ventilations as needed with c-spine control
 Indications for intubation :
 Acute respiratory failure
 GCS <9
 Increased RR with hypoxia
 PCO2 > 50
 VC < 10 mL/kg
 IV Access & fluids titrated to BP ~ 90-100 mmHg
 Management of SCI
 Look for other injuries: “Life over Limb”
 Transport to appropriate SCI center once stabilized
 Consider high dose methylprednisolone
 Controversial as recent evidence questions benefit
 Must be started < 8 hours of injury
 Do not use for penetrating trauma
 30 mg/kg bolus over 15 minute
 After bolus: infusion 5.4mg/kg IV for 23 hours
Principle of treatment
 Spinal alignment
 deformity/subluxation/dislocation reduction
 Spinal column stability
 unstable  stabilization
 Neurological status
 neurological deficit  decompression
 Thank you
for your attention
Spinal Shock vs Neurogenic
Shock
Spinal Shock :

 Transient reflex depression of cord function

below level of injury
 Initially hypertension due to release of
catecholamines
 Followed by hypotension
 Flaccid paralysis
 Bowel and bladder involved
 Sometimes priaprism develops
 Symptoms last several hours to days
Neurogenic shock:
 Triad of i) hypotension
ii) bradycardia
iii) hypothermia
 More commonly in injuries above T6
 Secondary to disruption of sympathetic outflow
from T1 – L2
 Loss of vasomotor tone – pooling of
blood
 Loss of cardiac sympathetic tone –
bradycardia
 Blood pressure will not be restored by
fluid infusion alone
 Massive fluid administration may lead
to overload and pulmonary edema
 Vasopressors may be indicated
 Atropine used to treat bradycardia