Management of

spinal cord injury

(SCI)

Dr FUAD HANIF SpS M Kes

 Outline
 Overview  Diagnosis
 Causes  Neurological
 Type assessment and
classification
 Pathophysiology
 Management
 Key terms
 Clinical  References
syndromes

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 Overview
 SCI is damage to the spinal cord
that results in loss of functions
such as mobility or feeling.
 The fourth leading cause of
death in the US.
 Most common vertebrae
involved are C5, C6, C7, T12,
and L1 because they have the
greatest ROM
 Epidemiology
Spinal Cord Injury
• Incidence: 10000-12000/ yr
• 80-85% males (usually 16-30 y/o), 15-
20% female
• 50% of SCI’s are complete
• 50-60% of SCI’s are cervical
• Immediate mortality for complete
cervical SCI ~ 50%
 Mechanism of Injury
• High energy trauma such as an MVA or fall from a
height or a horse.
MVC : Motor vehicular crashes
GSW : Gunshot wound

– MVA: 40-55%
– Falls: 20-30%
– Sports: 6-12%
– Others: 12-21%

• Low energy trauma in a high risk patient (ie a patient

with known spinal canal compromise such as ankylosing
spondylitis, Osteoporosis or metatstatic vertebral lesions)
• Penetrating trauma from gunshot or knives.
 Spinal Cord Injury
epidemiology
– Cause
• MVC 42% – Level of Education
• Fall 20% • To 8th Grade: 10%
• GSW 16% • 9th to 11th: 26%
– Gender • High School: 48%
• Male 81% • College: 16%
• Female 19%

MVC : Motor vehicular crashes

GSW : Gunshot wound
 Etiology of SCI by Age

Vehicular kendaraan lalu lintas

Violence kekerasan
Fall jatuh

Source: National Spinal Cord Injury Statistical Center,

University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
 Employment Status

Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004 employed karyawan
 Percent Employed

Source: National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, 2004
Annual Statistical Report, June, 2004
 Pathophysiology
• Hemorrhage: Blood flows into the extradural, subdural,
or subarachnoid spaces of the spinal cord
 Injury to spinal cord vasculature causes nerve fibers to
swell and disintegrate

 Blood circulation to the gray matter of the spinal cord is

impaired

 Secondary chain of events: Ischemia, hypoxia, edema,

and hemorrhagic lesions

 These secondary events result in destruction of myelin

and axons.
 Pathophysiology
 These secondary reactions, are
believed to be the principal
causes of spinal cord
degeneration .
 The damage may be reversible
within the first 4 to 6 hours
after the injury.
 Key terms used in SCI
• Dermatome The area sensory nerve
root.
• Myotome muscles motor nerve root.
 Neurological Level of Injury segment
of the spinal cord with normal motor
and sensory function on both sides.
 Skeletal Level The radiographic level
 Key terms used in SCI
Sacral sparing
• motor function (voluntary
external anal sphincter
contraction)
• sensory function (light touch,
pinprick at S4/5 dermatome, or
anal sensation on rectal
examination)
 Definitions
Spinal shock:
• transient flaccid paralysis
• areflexia (including bulbocavernosus reflex)
• while present (usually <48 h), unable to predict
potential for neurological recovery.
Neurogenic Shock:
• Loss of sympathetic tone, vasomotor and
cardiac regulation.
• Hypotension with relative bradycardia.
 Classification
Complete
• absence of sensory & motor function in lowest
sacral segment after resolution of spinal shock

Incomplete
• presence of sensory & motor function in lowest
sacral segment (indicates preserved function
below the defined neurological level)
 Classification
Incomplete SCI syndromes

Central Cord Syndrome

• Motor loss UE>LE
• Hands affected
• Common in elderly w/
pre-existing spondylosis
and cervical stenosis.
• Substantial recovery can
be expected.
 Classification
Incomplete SCI syndromes

Brown Sequard
• Ipsilateral motor,
proprioception loss.
• Contralateral pain,
temperature loss.
• Penetrating injuries.
• Good prognosis for
ambulation.
 Classification
Incomplete SCI syndromes

Anterior Cord Syndrome

• Motor loss
• Vibration/position
spared
• Flexion injuries
• Poor prognosis for
recovery
 Classification
Incomplete SCI syndromes

Posterior Cord
Syndrome
• Profound sensory
loss.
• Pain/temperature less
affected.
• Rare.
 Classification
Other SCI syndromes

Conus Medullaris Syndrome

• Loss of bowel or bladder function
• Saddle anaesthesia
• Looks like cauda equina
• Skeletal injuries T11-L2
 Level of Cord Injury
determines level of function

Prognosis for Recovery

of spinal Cord Injury:
Poor prognosis for recovery if:

-pt arrives in shock

-pt cannot breath
-pt has a complete injury
 Neurologic Examination
• American Spinal Injury Association (ASIA)
– A = Complete – No Sacral Motor / Sensory
– B = Incomplete – Sacral sensory sparing
– C = Incomplete – Motor Sparing (<3)
– D = Incomplete – Motor Sparing (>3)
– E = Normal Motor & Sensory
 ASIA Sensory Exam
– 28 sensory “points” (within dermatomes)
– Test light touch & pin-prick pain

**Importance of sacral pin testing**

– 3 point scale (0,1,2)
– “optional”: proprioception & deep pressure to
index and great toe (“present vs absent”)
– deep anal sensation recorded “present vs absent”
 Motor Examination
• 10 “key” muscles (5 upper & 5 lower extremity)

C5-elbow flexion L2-hip flexion

C6-wrist extension L3-knee extension
C7-elbow extension L4-ankle dorsiflexion
C8-finger flexion L5-toe extension
T1-finger abduction S1-ankle PF

– Sacral exam: voluntary anal contraction (present/absent)

 Motor Grading Scale
• 6 point scale (0-5) …..(avoid +/-’s)
– 0 = no active movement
– 1 = muscle contraction
– 2 = active movement without gravity
– 3 = movement thru ROM against gravity
– 4 = movement against some resistance
– 5 = movement against full resistance
 Diagnosis
 X-rays of cervical spine to establish level
and extent of vertebral injury
 CT scan and MRI: changes in vertebrae,
spinal cord, tissues around cord
 Arterial blood gases to establish baseline

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9
 Management
 Always assume
there is a spinal
cord injury until it
is ruled out
 Immobilize
 Prevent flexion,
rotation or
extension of neck
 Avoid twisting
patient

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 Management
 Management consists of
emergency treatment following an
A-B-C-D-E sequence.
 Airway
 Breathing
 Circulation
 Disability
 Expose
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 Medical management
 High dose corticosteroids
(Methylprednisolone) - improves the
prognosis and decreases disability if
initiated within 8 hours of injury.
Patient receives a loading dose and then
a continuous drip.
 Neurological/orthopedic management
includes methods a surgeon may use to
treat unstable spinal cord injuries:
 Reduction
 Fixation
 Fusion

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 Reduction
 With reduction, the spine is
realigned through the application
of a skeletal traction devise (such
as Gardner-Wells tongs, Minerva
vest, Halo traction) or Soft and
hard collars.

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 Gardner-Wells tongs

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 Minerva vest and halo-vest

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 Soft and hard collars

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 National Acute Spinal Cord
Injury Studies
NASCIS II NASCIS III
• 10 hospitals, 487 patients • 16 hospitals, 499 patients
• Compared: • 3 treatment arms (all got MPSS
MPSS (30 mg/kg bolus + 5.4 mg/kg x bolus)
23°) MPSS 5.4 mg/kg 24 hrs
Naloxone (5.4 mg/kg bolus + MPSS 5.4 mg/kg 48 hrs
4.5mg/kg x 23°) Tirilazad 2.5 mg/kg Q6 hr for 48 hrs
Placebo • 48 hr protocol better than 24 hr
•  8 hours, steroids neurologic protocol (if treated between 3 and 8
improvement hours)
• Infections, PE  but not • 2x incidence of pneumonia, sepsis in
48 hr group (NS)
significant

Bracken, N Engl J Med, 1990 Bracken, JAMA, 1997

Bracken, N Engl J Med, 1992 Bracken, J Neurosurg, 1998
…….THANK YOU