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Updated: Sep 22 2024

Spinal Cord Injuries

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  • Epidemiology
    • Incidence
      • 11,000 new cases/year in US
        • 34% incomplete tetraplegia
          • central cord syndrome most common
        • 25% complete paraplegia
        • 22% complete tetraplegia
        • 17% incomplete paraplegia
    • Demographics
      • bimodal distribution
        • young individuals with significant trauma
        • older individuals that have minor trauma compounded by degenerative spinal canal narrowing
    • Anatomic location
      • 50% in cervical spine
  • Etiology
    • Mechanism
      • MVA causes 50%
      • falls
      • GSW
      • iatrogenic
        • it is estimated that 3-25% of all spinal cord injuries occur after initial traumatic episode due to improper immobilization and transport
    • Pathophysiology
      • primary injury
        • damage to neural tissue due to direct trauma
        • irreversible
      • secondary injury
        • injury to adjacent tissue due to
          • decreased perfusion
          • lipid peroxidation
          • free radical / cytokines
          • cell apoptosis
        • methylprednisolone used to prevent secondary injury by improving perfusion, inhibiting lipid peroxidation, and decreasing the release of free radicals
    • Associated conditions
      • acute phase conditions (see below)
        • spinal shock
        • neurogenic shock
      • associated injuries
        • closed head injuries
        • noncontiguous spinal fractures
        • vertebral artery injury
          • risk factors for vertebral artery injury include
            • atlas fractures
            • facet dislocations
          • most people with unilateral injury remain asymptomatic
          • imaging
            • magnetic resonance angiography is the least invasive method
          • treatment
            • stenting only if patient is symptomatic from basilar arterial insufficiency
  • Relevant Anatomy
    • See spinal cord anatomy
  • Classification
    • Descriptive
      • tetraplegia
        • injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs, and pelvic organs
      • paraplegia
        • injury to the thoracic, lumbar, or sacral segments leading to impairment of function in the trunk, legs, and pelvic organs depending on the level of injury
        • arm function is preserved
      • complete injury
        • an injury with no spared motor or sensory function below the affected level
        • patients must have recovered from spinal shock (bulbocavernosus reflex is intact) before an injury can be determined as complete
        • classified as ASIA A
      • incomplete injury
        • an injury with some preserved motor or sensory function below the injury level
        • incomplete spinal cord injuries include
          • anterior cord syndrome
          • Brown-Sequard syndrome
          • central cord syndrome
          • posterior cord syndrome
          • conus medullaris syndrome
          • cauda equina syndrome
  • ASIA Classification
      • ASIA Impairment Scale
      • Motor
      • Sensory
      • A
      • Complete
      • No motor function
      • Complete deficit
      • B
      • Incomplete
      • No motor function
      • Incomplete deficit
      • C
      • Incomplete
      • Motor function partially preserved; more than half of key muscles below the neurological level have a muscle grade less than 3
      • Incomplete deficit
      • D
      • Incomplete
      • Motor function is partially preserved; at least half of key muscles below the neurological level have a muscle grade of 3 or more
      • Incomplete deficit
      • E
      • Normal
      • Normal motor
      • Normal sensory
  • Acute Phase Conditions
    • Neurogenic shock
      • characterized by hypotension and relative bradycardia in a patient with an acute spinal cord injury
        • potentially fatal
      • mechanism
        • circulatory collapse from loss of sympathetic tone
          • disruption of autonomic pathway within the spinal cord leads to
            • lack of sympathetic tone
            • decreased systemic vascular resistance
            • pooling of blood in extremities
            • hypotension
      • treatment
        • Swan-Ganz monitoring for careful fluid management
        • pressors to treat hypotension
    • Spinal shock
      • defined as temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury
      • characterized by
        • flaccid areflexic paralysis
        • bradycardia and hypotension (due to loss of sympathetic tone)
        • absent bulbocavernosus reflex
          • reflex characterized by anal sphincter contraction in response to squeezing the glans penis or tugging on an indwelling Foley catheter
      • timing
        • variable but usually resolves within 48 hours
        • at its conclusion, spasticity, hyperreflexia, and clonus slowly progress over days to weeks
      • mechanism
        • neurophysiologic in nature
          • neurons become hyperpolarized and unresponsive to stimuli from brain
      • evaluation
        • important because one cannot evaluate neurologic deficit until spinal shock phase has resolved
          • end of spinal shock indicated by return of the bulbocavernosus reflex
          • conus or cauda equina injuries may lead to permanent loss of the bulbocavernosus reflex
      • ruled out when
        • bulbocavernosus reflex present
        • 48 hours has elapsed from time of injury
      • stages of spinal shock
        • Phase 1: hyporeflexic
          • 0-48 hours
          • areflexia/hyporeflexic
        • Phase 2: initial reflex return
          • 1-2 days
          • polysynaptic reflexes return (bulbocavernosus reflex)
          • monosynaptic (patellar) remain absent
        • Phase 3: initial hyperreflexia
          • 1-4 weeks
        • Phase 4: spasticity
          • 1-12 months
          • characterized by altered skeletal performance
      • Spinal vs. Neurogenic vs. Hypovolemic Shock
      • Spinal Shock
      • Neurogenic Shock
      • Hypovolemic Shock
      • BP
      • Hypotension
      • Hypotension
      • Hypotension
      • Pulse
      • Bradycardia
      • Bradycardia
      • Tachycardia
      • Reflexes / Bulbocavernosus Reflex
      • Absent
      • Variable/Independent
      • Variable/Independent
      • Motor
      • Flaccid paralysis
      • Variable/Independent
      • Variable/Independent
      • Time
      • ~48-72 hours immediately after spinal cord injury
      • ~48-72 hours immediately after spinal cord injury
      • Following excessive blood loss
      • Mechanism
      • Peripheral neurons become temporarily unresponsive to brain stimuli
      • Disruption of autonomic pathway leads to loss of sympathetic tone and decreased systemic vascular resistance
      • Decreased preload leads to decreased cardiac output
  • Evaluation
    • Field treatment
      • treatment of potential spinal cord injuries begins at the accident scene with proper spinal immobilization
      • immobilization
        • should include a rigid cervical collar and transport on a firm spine board with lateral support devices
        • patient should be rolled with standard log roll techniques with control of cervical spine
        • spine boards should be used for transport only and patients should be removed when clinically safe
          • decubitus ulcers can occur after only 30-60 minutes on a backboard
      • athletes
        • in the setting of sports-related injuries, helmets and shoulder pads should be left on until arrival at the hospital OR until experienced personnel can perform simultaneous removal of helmet and shoulder pads in a controlled situation
    • Initial evaluation
      • primary survey
        • airway
        • breathing
          • SCI above C5 likely to require intubation
        • circulation
        • initial survey to inspect for obvious injuries of head and spine
          • visual and manual inspection of entire spine should be performed
            • seat belt sign (abdominal ecchymoses) should raise suspicion for flexion distraction injuries of thoracolumbar spine
      • secondary survey
        • cervical spine exam
          • remove immobilization collar
          • examine face and scalp for evidence of direct trauma
          • inspect for angular or rotational deformities in the holding position of the patient's head
            • rotational deformity may indicate a unilateral facet dislocation
          • palpate posterior cervical spine looking for tenderness along the midline or paraspinal tissues
            • absence of posterior midline tenderness in the awake, alert patient predicts low probability of significant cervical injury
          • log roll patient to inspect and palpate entire spinal axis
          • perform careful neurologic exam
      • cervical spine clearance
  • Initial Medical Treatment
    • Medical / Prevention
      • DVT prophylaxis
        • indications
          • most patients
          • contraindications include
            • coagulopathy
            • hemorrhage
        • modalities
          • low-molecular weight heparin
          • rotating bed
          • pneumatic compression stocking
      • cardiopulmonary management
        • careful hemodynamic monitoring and stabilization is critical in early treatment
          • hypotension should be avoided
        • implement immediate aggressive pulmonary protocols
      • decubitus ulcer prevention
    • Steroids
      • high dose methylprednisolone
        • indications
          • current
            • current literature and available guidelines recommend against administration due to: 
              • lack of clear clinical benefit
              • risk of complications
          • historical
            • nonpenetrating SCI within 8 hours of injury recommended by NASCIS III
        • historical contraindications include
          • GSW
          • pregnancy
          • <13 y/o
          • >8 hours after injury
          • brachial plexus injuries (peripheral nerve injuries)
        • technique
          • load 30 mg/kg over 1st hour (2 grams for 70 kg man)
          • drip 5.4 mg/kg/hr drip
            • for 23 hours if started <3 hours after injury
            • for 47 hours if started 3-8 hours after injury
        • outcomes
          • may leads to improved root function at level of injury
          • associated with significant complications
      • monosialotetrahexosylganglioside (GM-1)
        • indications
          • remains controversial
            • large multicenter RCT did not show long term benefit
            • some evidence of faster recovery
    • Reduction
      • acute closed reduction with axial traction
        • indications
          • alert and oriented patient with neurologic deficits and compression due to fracture/dislocation
            • bilateral facet dislocation with spinal cord injury in alert and oriented patient is most common reason to perform acute reduction with axial traction
        • technique
          • reasons to abort
            • overdistraction
            • worsening neurologic exam
            • failure to obtain reduction
    • Hypothermia
      • systemic and local
        • evidence is weak and limited
        • currently not recommended due to increased complications
          • coagulopathy
          • sepsis
          • pneumonia
          • rebound hypertension
          • arrhythmias
  • Definitive Treatment
    • Nonoperative
      • bracing and observation
        • indications
          • most GSWs
            • exceptions listed below
    • Operative
      • surgical decompression and stabilization
        • indications
          • most incomplete SCI (except GSW)
            • decompress when patient hits neurologic plateau or if worsening neurologically
            • decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)
          • most complete SCI (except GSW)
            • stabilize spine to facilitate rehabilitation and minimize need for halo or orthosis
            • decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)
            • consider for tendon transfers
              • e.g. deltoid to triceps transfer for C5 or C6 SCI
          • GSW with
            • progressive neurological deterioration with retained bullet in the spinal canal
            • cauda equina syndrome (considered a peripheral nerve)
            • retained bullet fragment within the thecal sac
              • CSF leads to the breakdown of lead products that may lead to lead poisoning
  • Rehabilitation
    • Goals
      • assess and identify mechanisms for reintegration into community based on functional level and daily needs
      • patients learn transfer techniques, self care retraining, mobility skills
    • Restoring hand function
      • hand function is often limiting factor for many patients
      • tendon transfers can be used to restore function to paralyzed arms and hands by giving working muscles different jobs
    • Modalities
      • functional electrical stimulation is a technique that uses electrical currents to stimulate and activate muscles affected by paralysis
      • Spinal Cord Injury Level and Function
      • Level 
      • Patient Function
      • C1-3
      • Ventilator-dependent with limited talking
      • Electric wheelchair with head or chin control
      • C3-4
      • Initially ventilator-dependent, but can become independent
      • Electric wheelchair with head or chin control
      • C5
      • Ventilator independent
      • Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself
      • Independent ADL’s; electric wheelchair with hand control, minimal manual wheelchair function
      • C6
      • C6 has much better function than C5 due to ability to bring the hand to mouth and feed oneself (wrist extension and supination intact)
      • Independent living; manual wheelchair with sliding board transfers, can drive a car with manual controls
      • C7
      • Improved triceps strength
      • Daily use of a manual wheelchair with independent transfers
      • C8-T1
      • Improved hand and finger strength and dexterity
      • Fully independent transfers
      • T2-6
      • Normal UE function
      • Improved trunk control
      • Wheelchair-dependent
      • T7-12
      • Increased abdominal muscle control
      • Able to perform unsupported seated activities; with extensive bracing walking may be possible
      • L1-5
      • Variable LE and B/B function
      • Assist devices and bracing may be needed
      • S1-5
      • Various return of bowel/bladder and sexual function
      • Walking with minimal or no assistance
  • Prognosis
    • Complete Injuries
      • improvement of one nerve root level can be expected in 80% of patients
      • improvement of two nerve root levels can be expected in 20% of patients
      • only 1% have complete recovery at time of hospital diagnosis
      • ASIA A injuries have the least chance for marked recovery and the highest lifetime healthcare costs 
    • Incomplete Injuries
      • trends of improvement include
        • the greater the sparring, the greater the recovery
        • patients that show more rapid recovery have a better prognosis
        • when recovery plateaus, it rarely resumes improvement
    • Conus medullaris syndrome
      • has a better prognosis for recovery than more proximal lesions
  • Complications
    • Skin problems
      • treatment is prevention
      • start in ER
        • do not leave on back board
        • start log rolling early
        • proper bedding
    • Venous thromboembolism
      • prevent with immediate DVT prophylaxis
    • Urosepsis
      • common cause of death
      • strict aseptic technique when placing catheter
      • do not let bladder become overly distended
    • Sinus bradycardia
      • most common cardiac arrhythmia in acute stage following SCI
    • Orthostatic hypotension
      • occurs as a result of lack of sympathetic tone
    • Autonomic dysreflexia
      • potentially fatal
      • presents with headache, agitation, hypertension
      • caused by unchecked visceral stimulation
        • check foley
        • disimpact patient
        • radiographs of lower extremity if there is concern for undiagnosed fracture
    • Major depressive disorder
      • ~11% of patients with spinal cord injuries suffer from MDD
      • MDD in spinal cord injury patients is highly associated with suicidal ideation in both the acute and chronic phase
  • Prognosis
    • Only 1% have complete recovery at time of hospital diagnosis
      • conus medullaris syndrome has a better prognosis for recovery than more proximal lesions
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