Spinal Cord Injury

Spinal cord injury, insult to the spinal cord resulting in a

change, either traumatic or non-traumatic in aetiology, leads
to temporary or permanent damage to the spinal cord function
 Pathophysiology
Primary Injury
● Primary mechanism of acute SCI is generally considered to be irreversible
● Caused by rapid and violent spinal cord compression and distortion from displacement of normally
protective structures due to traumatic fracture or dislocation

Secondary Injury
● Secondary mechanisms involve a cascade of events occurs within minutes of the primary injury
leading to subsequent cell death via hypoxia, ischaemia, ionic shifts, lipid peroxidation, free radical
formation, protease activation, and prostaglandin-causing apoptosis
● Biochemical cascade is result of haemorrhage, oedema and ischaemia.
● Management of spinal cord injury must focus on minimising secondary injury.
Acute Management
 Patient assessment
● Advanced trauma life support: control ABCDE
● The spine should initially be immobilised using full spinal precautions, on the assumption that
every trauma patient has a spinal injury until proven otherwise
● finding of a spinal injury makes it more likely that there will be a second injury at another level
● Spinal boards lead to skin breakdown in insensate patients, and are very uncomfortable for those
with normal sensation, should only be used in transferring patient
● For unconscious patient:
○ Spinal immobilisation should be maintained until Imaging done to rule out unstable spinal injury
 History and Physical Examination
History
● Mechanism and velocity of injury
● Presence of spinal pain
● Onset and duration of neurological symptoms
● Underlying cardiopulmonary comorbidity etc COPD & heart failure

Physical Examination
Start with initial assessment, followed by systemic examination:
● Chest - respiratory dysfunction
● Abdomen - spinal cord injury may mask signs of intra-abdominal injury;
seat belt sign suggest high-energy trauma

Spinal Examination
● Inspection of underlying skin for wound, swelling, bruising
● Log rolling the patient and palpate the entire spine
○ Significant swelling, tenderness, palpable steps or gaps suggestive
of spine injury
 Identification of Shock
3 categories of shock may present in spinal trauma:

1. Hypovolemic shock:
a. Hypotension with tachycardia and cold clammy peripheries
b. Common cause is haemorrhage
c. Treat with appropriate resuscitation
2. Neurogenic shock:
a. Hypotension with normal heart rate/bradycardia and warm peripheries
b. Cause: unopposed vagal tone resulting from cervical spinal cord injury at or
above the level of sympathetic outflow (T1/T5)
c. Treat with inotropic support, avoid fluid overload
3. Spinal Shock
a. Temporary physiological disorganisation of spinal cord function, start within
minutes after injury
b. Duration of effect varies, may last 6 weeks or more
c. Presented as paralysis, decreased tone and hyporeflexia
d. Bulbocavernosus reflex returns when resolved
 Neurological Examination
The American Spinal Injury Association (ASIA) neurological evaluation system is an internationally accepted
method of neurological evaluation.

This standardised physical examination consist of :

● Myotomal-based motor examination
● Dermatomal-based sensory examination
● Anorectal examination

Aim of this scale:

● Standardised and detailed documentation of the SCI neurological level of injury
● Guidance for radiographic assessment and treatment
● Determine complete and incomplete SCI
Diagnostic Imaging
 Plain Radiography
● A full cervical spine series includes anteroposterior and lateral
radiographs of the whole cervical spine, and open mouth views
○ This view focuses on the odontoid process of C2, useful in
visualizing odontoid and Jefferson fractures
● Clear visualisation of the cervicothoracic junction
○ common site for injury, often not seen on plain radiography
● If spinal fracture identified, further imaging of the whole spine is
required

A system for evaluation of the lateral cervical spine x-ray:

● Assessment of prevertebral soft tissue swelling
● Assess sagittal alignment using three imaginary lines (anterior,
posterior, spinolaminar)
● Assess for instability:
○ 3.5 mm of sagittal translation;
○ Sagittal angulation of >11° (compared to adjacent level).
 Computed Tomography
● CT scanning with two-dimensional reconstruction remains gold standard in spinal trauma
● Indicated when for patients with suspected or visible injuries on plain radiographs
● If a CT scan of the head is required, then it is usually simpler and faster to obtain a CT of the cervical
spine at the same time
● CT scans of the chest and abdomen are performed as part of the assessment of polytrauma patients and
will usually include the spine.
● Perform also when plain radiography is inadequate or fails to visualize segments of the axial skeleton

Axial computed tomography scan demonstrating a

thoracolumbar fracture dislocation
 Magnetic Resonance Imaging
● MRI is indicated in cases with neurological deficit and
where assessment of ligamentous structures is important

Sagittal T2-weighted magnetic resonance imaging scan

demonstrating a cervical spine subluxation and spinal cord contusion
Basic Management
Principle
Spinal Realignment
● Cervical spine subluxation or dislocation, anatomical realignment
is achieve with skeletal traction using skull tongs
● Formal open reduction and stabilisation using internal fixation is
required in many spinal trauma cases
● A halo brace can be used to perform a closed realignment and
immobilisation of cervical fractures
Decompression of the neural elements
● Direct decompression indicated when there are bone fragments causing residual compression
or a significant haematoma
● Indirect decompression is achieved with realignment of the spine and correction of the spinal
deformity

a. Sagittal T2-weighted
magnetic resonance imaging
scan showing an L1 burst
fracture and neural
compression
b. Treated with combined
anterior and posterior
surgery.
Specific spine
injuries
Upper cervical spine (skull C2)
Occipital condyle fracture

stable injury often associated with head injuries

best treated in a hard collar for 6–8 weeks.

Occipitoatlantal dislocation

caused by high energy trauma and is often fatal.

The dislocation may be anterior, posterior or vertical

Power’s ratio is used to assess skull translation.

Treatment is with a halo brace or occipitocervical fixation.

Atlas fracture (jefferson fracture)

Fracture of the C1 ring is associated with axial loading of the cervical

spine

Stable or unstable

Associated transverse ligament rupture may occur

Treated non-operatively in a cervical collar or halo brace

Atlantoaxial instability

This is defined as non-physiological movement between C1 and C2.

It can be translational or rotatory

resolves either spontaneously or with traction followed by a cervical

collar.
Odotonoid fractures

There are three types of odontoid peg fracture.

Neurological injury is rare.

The majority of acute injuries are treated non-operatively in a hard collar or halo
jacket for 3 months.

Internal fixation with an anterior compression screw is indicated for displaced

fractures

Traumatic spondylolisthesis of the axis (hangman’s fracture)

This is a traumatic spondylolisthesis of C2 on C3.

There a four types with varying degrees of instability

Those with significant displacement or associated facet dislocation are treated

operatively, usually with posterior stabilisation
Thoracic spine and thoracolumbar fractures
Classification

● AO spine thoracolumbar classification system

● Consists of 3 classes of injuries
○ A: Compression injuries (A0- A4) involving vertebral body except A0
○ B: Distraction injuries (B1- B3) involving anterior or posterior tension band
○ C: Translation injuries involving displacement in any direction
● Multiple injury types can present at the same time
● Increasing instability and neurological injury
● Majority of type B and C injury require surgical stabilization
Thoracic
T1-T10
● Osteoporotic wedge
compression fracture is
commonest in older adults
● Most of these heal but
symptomatic fractures can be
treated with percutaneous
bone cement augmentation/
vertebroplasty/ kyphoplasty
T1-T10

● In trauma cases, high-energy fractures

especially those involving multiple posterior
ribs can be associated with major internal
injuries such as pulmonary contusion
● Combination of thoracic spine and sternal
fracture can lead to aortic rupture
● Multimodality diagnostic imaging is
recommended
Thoracolumbar spinal fractures (T11-L2)
● Prone to injury which can vary form minor wedge fracture to spinal
dislocation
● Burst fractures are comminuted fractures of vertebral bodies that
are characterized by widening of the interpedicular distance
● Chance fractures are flexion-distraction injuries of thoracolumbar
junction and are associated with duodenal, pancreatic, and aortic
ruptures
Lumbar spinal fractures
●Mostly treated non-surgically due to lower incidence of
neurological injury as neural canal is more capacious at this
level
●Owing to lumbar lordosis, kyphotic deformity like those seen
in thoracolumbar junction injuries rarely occur
 Complete Spinal Cord Injury

Types of Spinal
Incomplete Spinal Cord Injury
Cord Injuries
- Central cord syndrome
- Brown-Sequard syndrome
- Anterior spinal syndrome
- Posterior spinal syndrome
- Cauda equina syndrome
 Complete Spinal Cord Syndrome
Damage to the spinal cord resulting in complete bilateral loss of communication
between the nerve fibers above and below the lesion

Etiology:
● Traumatic (complete spinal cord transection)
● Non-traumatic → Spinal tumors, Multiple Sclerosis, Myelitis, Infarction, Compression

Clinical Features:
● Impaired sensation
● Muscle hypertonia with spastic paresis (Hyper-reflexia, ankle and patellar clonus,
absent anal reflex, Bilateral diaphragm paralysis)
● Positive Hoffman’s Sign Symptoms classically occur
6–8 weeks after
● Positive Babinski Sign
spinal shock has worn off
● Urinary incontinence
● Neurogenic bowel
● Erectile dysfunction
● Autonomic dysreflexia (injury at T6 or above)
Incomplete Spinal Cord Syndrome
- Lesions of the ascending or descending spinal tracts
- A spinal cord injury is incomplete when there is preservation of perianal sensation

Central Cord Syndrome Affected Spinal Tract

- Central corticospinal tracts
Etiology - Decussating fibers of the lateral spinothalamic tract
- Degenerative spine disease
- Cervical Spondylosis
- Hyperextension injury (MVA)
- Syringomyelia

Clinical Features
- Bilateral motor paresis
- Variable sensory impairment (burning pain in the arms,
loss of pain and temperature in the arm
- Sacral sparing (deep anal pressure sensation,
voluntary anal contraction, light touch and pinprick
sensation)
Anterior Cord Syndrome Damage to anterior ⅔ of the spinal cord
→ Usually as a result of reduced blood flow or occlusion to the anterior spinal
artery
Affected Spinal Tract
- Dorsal Corticospinal tracts
- Lateral Spinothalamic tracts

Etiology
- Trauma ( penetrating, vertebral burst fracture)
- Occlusion of anterior spinal artery
- Arteriosclerosis, vasculitis, Thrombosis- embolus
- Aortic Dissection, Aneurysm
- Systemic Hypoperfusion
Anterior Cord Syndrome : Clinical Features

● Acute (within hours)

○ Back or chest pain
○ Bilateral loss of temperature and pain sensation
○ Lower motor neuron deficits (flaccid paralysis) at the level of
and below the lesion
○ Autonomic dysfunction (bladder, bowel, and
sexual dysfunction, orthostatic hypotension)
○ Absent bulbocavernosus reflex

● Late (after days or weeks)

○ Continued sensory and autonomic dysfunction
○ Upper motor dysfunction (spastic paraparesis or
quadriparesis)
Proprioception and vibration sense (posterior column)
○ Lower motor neuron deficits at the level of the lesion due spared
to damage to the anterior horn
○ Hyperreflexia
Posterior Cord Syndrome

Affected Spinal Tract

- Posterior Column

Etiology
- Trauma eg. penetrating
- Occlusion of posterior spinal artery
- Multiple sclerosis
- Tabes dorsalis
- Subacute combined degeneration

Clinical Features (Below level of lesion)

- Bilateral loss of proprioception→ sensory ataxia,
loss of vibration, fine touch sensation
 Bowel Sequard Syndrome (Hemisection syndrome)
Clinical Features
Affected Spinal Tract Ipsilateral
- Hemisection of the spinal cord - Loss of all sensations at the level of the injury
- Loss of proprioception, vibration, and tactile discrimination
Etiology below level of lesion
- Trauma eg. penetrating → Spinal cord - Segmental flaccid paresis at level of lesion
compression - Spastic paralysis below level of lesion
Less common - Positive Babinski’s Sign
- Disk herniation - Ipsilateral sympathetic fibers → Horner’s Syndrome above
- Spinal epidural hematoma T1
- Spinal epidural abscess
- Multiple sclerosis Contralateral : Interrupted spinothalamic tract
- Loss of pain and temperature sensation and Crude touch
sensation one or two levels below lesion
Bowel Sequard Syndrome (Hemisection syndrome)
 Cauda Equina Syndrome
- Damage or compression of the Cauda Equina located
below L2
- Common causes: large posteromedial disk herniation,
trauma, tumors
Clinical Features
○ Lower back pain, severe radicular pain
○ Motor symptoms: asymmetric, areflexic, flaccid
paresis of the legs, muscle atrophy
○ Sensory Symptoms: saddle anesthesia (lack of
sensitivity in the dermatomes S3 - S5), asymmetric
unilateral numbness or paresthesia in lower limb
dermatomes.
 Management

Complete Spinal cord syndrome

Definitive management
○ Bracing (e.g., in gunshot wounds) or surgical repair (e.g., decompression and stabilization
of spine fracture)
○ C1–C4 tetraplegia
■ Phrenic nerve pacemakers may be indicated
■ Tracheostomy and/or ventilator may be needed
 Management
Followed by acute management Surgery should be considered in patients who are likely to benefit from
decompression, mechanical stabilization, fracture reduction, and deformity correction

DECOMPRESSION/ FIXATION (restore neurological function)

Timing: depends on cause
Acute cord injury due to herniated disc causing ischemia secondary to anterior spinal artery
compression → urgent surgery (24 hours))

Open reduction and

internal fixation of high
cervical fracture
Endoscopic microdiscectomy and
laminectomy (lumbar disc prolapse)
 Surgical Management

Kyphoplasty is indicated in stable vertebral

compression fractures with progressive pain or
Vertebroplasty for lumbar fracture
kyphosis despite conservative treatment.
 Further Management
Nutrition
- Early nasogastric tube insertion to limit risk of vomiting and aspiration as
patient will often have paralytic ileus initially
- Early feeding within 72 hrs is safe
- Involve a nutritionist early to ensure adequate nutrition, fluid & fibre in the
feeds
- Consider gastric ulcer prophylaxis (Proton pump inhibitors)
- Re-introduce oral feeding after ensuring ability to swallow and protect airway
Stool softeners to achieve at least one bowel movement per day
- In patients with complete cord injury, rectal stimulation should be performed
daily, with adjustments by frequency of bowel movements
Placement of urinary catheter due to bladder decompression
- The aim of bladder care is to prevent infections, minimise and contain
incontinence and find an appropriate way to empty the bladder
 Further Management
Pressure sore prophylaxis
- patient with SCI > risk of damage to skin integrity
- Reposition 2 hourly from the time of admission, pad all extensor surfaces
- Remove spine board as soon as possible ; check skin underneath

Thromboprophylaxis
- LMWH thromboprophylaxis with pneumatic compression device should be started within
72 h of injury for a duration of at least 8 weeks.

Anti embolic stockings, Abdominal binders, slow increase in bed angle to sitting position to
prevent Postural Hypotension
 Further Management
High Risk Of Pulmonary Complications (aspiration pneumonitis)
- Vaccination against influenza and pneumococcus for all patients
- Aggressive daily chest physiotherapy with bed percussion, deep suctioning.
- Antiemetics used aggressively.

Steroids (improve neurological outcomes in patients with acute, non-penetrating TSCI)

- Methylprednisolone 30 mg/kg bolus over 15 minutes and an infusion of methylprednisolone
at 5.4 mg/kg/h for 23 hours beginning 45 minutes after the bolus.
Rehabilitation and Patient Outcome
- The goal of spinal cord injury rehabilitation is based on a multidisciplinary approach.
- The level of neurological impairment determines the functional outcome

Spinal cord injury rehabilitation objectives :

1. Prevention of secondary complications
2. Promoting neurorecovery
3. Maximizing function following injury
4. Improve a patient’s independence in activities of daily living
5. To facilitate community reintegration
 Rehabilitation
1. Upright position tolerance (sitting exercises, raising the head of the bed, and utilizing a tilt table or
standing frame)
2. Staff also initiates a passive range of motion stretching program in which family can actively
participate
3. Bed mobility, endurance training, and transfer training (bed to chair and chair to commode)
4. Helping patients to understand the need for weight-shifting maneuvers, learning to self-catheterise
and insert suppositories (due to high risk of pressure sores and likelihood of bowel and bladder
incontinence) → promote bowel and bladder care independence
5. Occupational therapists (OT) focus on ADLs (transferring from one surface to another, dressing,
bathing, grooming, eating, and preparing food)
6. Wheelchair training - improves sense of wellbeing
 Rehabilitation
7. Speech and language therapists and respiratory therapists - The goals of these therapies are voice
production, secretion clearance, ventilator weaning, resistive expiratory muscle training, and utilization of
assisted communication devices
8. Gait training - includes Body Weight Supported Treadmill Training (BWSTT), assisted devices
(canes, crutches, walking frames), functional electrical stimulation.
individuals with complete paraplegia to partially
paralysed lower extremities by using orthoses and
walking aids such as; knee-ankle-foot and hip-knee-
ankle-foot orthoses.
 Prognosis
- Despite continuing improvements in patient care, life expectancy remains below normal
following SCI. The median life expectancy is 33 years, but varies considerably

- The prognosis for neurological recovery is strongly influ­enced by factors such as the
level and completeness of the injury, ventilator dependence and the age at presentation.
Complications Associated with Spinal Cord Injury
- Pressure ulcers
- Pain and spasticity
- Autonomic dysreflexia (This is a paroxysmal syndrome of hypertension, hyperhydrosis
(above level of injury), bradycardia, flushing and headache in response to noxious
visceral and other stimuli )
- Neurological deterioration
- Deep Vein Thrombosis
- Osteoporosis, heterotopic ossification and contractures
References:
1. Freeman, B. J. C. & Lavy, C., 2018. The spine. In: N. Williams, P. R. O'Connell & A. W. McCaskie, eds. Bailey &
Love's Short Practice of Surgery 27th Edition. Boca Raton, FL: CRC Press, pp. 338-354,

2. Spinal Cord Injury @ AMBOSS : https://www.amboss.com/us/knowledge/complete-spinal-cord-injury/

3. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Spinal_Cord_Injury_Acute_Management/#compl
eteincomplete-injury