Spinal Cord Injury

Talha Nazir (1), Awais Khan (2)
1 King Edward Medical University, Lahore, Pakistan
2 Assistant Professor, Department of Neurology, University of Arizona
Special thanks to Hafiz Muhammad Junaid mjunaid2611@gmail.com for graphic design work


Introduction

  • The annual incidence of spinal cord injury in United States is 54 per million and almost 17,730 new cases of SCI are being reported annually.
  • The traumatic spinal cord injury often results from a gunshot wound (10.4%), accidental trauma to head, neck and back region (31.5%), falling (25.3%) and spinal sports injuries (4.3%).
  • Non-traumatic spinal cord injuries can have a range of etiologies like degenerative changes, infections (Staph. Aureus and Mycobacterium tuberculosis), malignancy of spine (Primary: multiple myelomas, Metastasis: prostate in male and breast in females are common etiologies), inflammation or congenital abnormalities

Acute traumatic spinal cord injury

Pathophysiology

  • Primary injury (immediate) is due to trauma or and hemorrhage in the spinal cord that lead to ischemia, necrosis, and neuronal damage.
  • Secondary injury (days to weeks), followed by primary injury, is due to inflammatory cascade that leads to edema, free radical formation, apoptosis, and release of neurotransmitters

Complete spinal cord transection

  • Common causes include fracture of vertebrae, penetrating injury and expanding tumor.
  • Bilateral at level of the lesion: Flaccid paralysis and atrophy
  • Bilateral below the level of lesion:
    • Spastic paralysis and absent superficial reflexes (corticospinal tract)
    • Loss of the pain and temperature sensations (Lateral spinothalamic tract)
    • Loss of light touch and pressure sensations two to three levels below due to different levels of decussations (anterior spinothalamic tract)
    • Loss of the vibration, two-points discrimination and proprioception (posterior column).

Incomplete spinal cord syndromes

  • Central Cord syndrome
    • Involvement of cervical spines is the most common presentation. Elderly people are the high-risk population (hyperextension injury and fall)
    • Associated with cervical spondylosis, syringomyelia and neuromyelitis optica.
    • Symptoms are due to compression of spinothalamic and corticospinal tracts.
    • Upper extremities are affected more than lower extremities due to the central location of nerves.
    • Bladder dysfunction and some sensory loss.
    • Cruciate paralysis: Rare condition involving cervico-medullary junction. Commonly due to trauma to C1 and C2 vertebrae with the involvement of upper limbs only.
    • Syringomyelia: Formation of cyst within the spinal cord (syrinx) that can expand and destroy the spinal cord. Lower cervical and upper thoracic spine are commonly locations.
    • Symptoms include bilateral loss of pain and temperature sensations in specific dermatomes (Cape like distribution).
    • Associated with Chiari malformation.
  • Brown Sequard syndrome (hemisection of spinal cord)
    • Common etiologies include penetrating injury and expanding tumor of cervical spine (most common).
    • Ipsilateral at the level of lesion: Hypotonic paralysis (anterior grey horn) and anesthesia (posterior grey horn)
    • Ipsilateral below the level of lesion:
      • Spastic paralysis and loss of superficial reflexes (corticospinal tract)
      • Loss of vibration, two-point discrimination and proprioception (Posterior column)
    • Contralateral below the level of lesion:
      • Loss of pain and temperature sensations (Lateral spinothalamic tract)
      • Loss of fine touch and pressure sensations two to three levels below due to different levels of decussations (anterior spinothalamic tract)
  • Anterior cord syndrome:
    • Anterior 2/3rd of spinal cord is affected due to a range of etiologies like ischemia (anterior spinal artery occlusion and severe hypotension), trauma, disc herniation and multiple sclerosis.
    • Bilateral at level of lesion: Flaccid paralysis (Anterior grey horn)
    • Bilateral below the level of injury:
      • Spastic paralysis (corticospinal tracts)
      • Loss of pain, temperature, light touch and pressure sensation (anterior and lateral spinothalamic tracts)
    • Dorsal column: Sensations of two-point discrimination, vibration and proprioception are preserved bilaterally.
  • Posterior cord syndrome:
    • Posterior 1/3rd of spinal cord is affected
    • Common causes include MS, trauma, and hyperextension injury.
    • Ipsilateral loss of vibration, two points’ discrimination and proprioception.
    • Pain, temperature, fine touch and pressure sensations (anterior and lateral spinothalamic tract) and motor functions (corticospinal tract) are intact.

Cauda equina syndrome

  • Injury at the level of L2 or below due to various etiologies like disc herniation or compression due to tumor or abscess.
  • LMN, sensory and autonomic nerves are involved.
  • Common symptoms include pain radiating to legs, bladder and anal dysfunction, saddle anesthesia, impotence (male) and loss of ankle and knee reflexes.
  • Conus medullaris syndrome: Injury between T12 to L2. Spontaneous pain is not common and loss of motor function and saddle anesthesia is symmetrical. Conus medullaris syndrome may be associated with cauda equina syndrome.
  • Treatment: Surgical

Spinal shock syndrome

  • Transient depression or loss of entire functions below level of the lesion.
  • Anal sphincter reflex testing is used for diagnosis except in patient with lower spinal cord injury(S2-S4).
  • Reflexes are absent
  • Many patients recover in 24 hours, while others may take one to four weeks

Figure 2: Spinal Cord Transection Syndromes

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Table 1: Upper Motor Neuron Lesion vs Lower Motor Neuron Lesion

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Table 2: Localization of lesions (Cervical Region)

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Table 3: Localization of lesions (Thoracic and Lumbosacral Region

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Table 4: ASIA Impairment Scale

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Physical examination

Motor system

  • Bulk
    • Compare both sides. Atrophy in LMN lesions.
  • Tone
    • Spastic paralysis (UMN lesion)
    • Cog-wheel rigidity (Lesion of basal ganglia)
    • Flaccid paralysis (LMN and sensory pathway lesions, cerebellar dysfunction and spinal shock)
  • Power
    • Common terminologies are Monoplegia (one limb involvement), Paraplegia (both lower limbs involvement), Diplegia (both upper limbs involvement), Quadriplegia (Both upper and lower limbs involvement).
  • Reflexes
    • Reflex arc is made up of afferent (sensory) and efferent (motor) limbs. Each reflex arc represents specific spinal nerve roots.

Sensory system

  • Pain and temperature (lateral spinothalamic tract)
  • Light touch and pressure (anterior spinothalamic tract)
  • Sense of position and localization (spinocerebellar tract)
  • Vibration and two-point discrimination (posterior column)
 

Table 5: Grading of Muscle Power

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Table 6: Nerve Root values for reflexes

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Table 7: Important points to consider during examination

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Table 8: Acute Spinal Injury Management Steps

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Workup

  • Blood: CBC, Serum electrolytes, ABGs, LFTs, Serum amylase and lipase, Coagulation studies, blood typing and screening for alcohol
  • Complete Urine and toxicology
  • Chest X-ray
  • ECG
  • PFTs
  • Imaging: CT/MRI spine

Management

ABCs

Airway

Airway can be maintained by the suction of secretions and by Chin Lift or Jaw thrust maneuver. Airway Support can also be given via endotracheal intubation, cervical stabilization as well as cricothyroidotomy.
  • Goals
    • Prevention of atelectasis
    • Removal of respiratory secretions
    • Prevention of respiratory infections.
    • Increased oxygen delivery to the spinal cord
  • Monitor
    • Respiratory rate, use of accessory muscles and paradoxical chest movements.
    • Respiratory mechanics (NIF, FVC and TV)
    • Oxygen saturation
    • Changes in secretions
    • Temperature
    • Breathing adequately (15L/min oxygen) is required to maximize patient oxygenation and carbon dioxide elimination
    • Monitor respiratory rate and effort.
    • Atelectasis can be prevented by using higher tidal volume (10-15ml.kg).
    • Use diaphragmatic pacer in quadriplegics during the weaning process.
  • Ventilated patients:
    • Pneumonia can be prevented by following VAP (Ventilator-associated pneumonia) protocol.
    • Assist coughing every 4 hours
    • Nebulized with 2.5mg Albuterol every 4 hours
  • Non-ventilated patients:
    • Spirometry every 1-2 hours
    • Assist coughing
    • EZ-PAP every 4 hours
    • Nebulized with 2.5mg Albuterol every 4 hours

Circulatory collapse

Circulatory collapse requires to be quickly recognized and managed. A high bore of (14- or 16-gauge) IV line must be maintained. Fluid bolus using crystalloid must be administered as per confined protocols in shocks.
  • Goals
    • Prevention of bradycardia
    • Prevention of hypotension (MAP > 85mmHg and MAP > 65mmHg in incomplete and complete SCI, respectively.
    • Stabilize hemodynamic parameters
  • Hypotension
    • Fluid challenge: 2L normal saline
    • 0.05mcg/kg/min norepinephrine if BP doesn’t improve
    • Check for serum cortisol if BP is still low. Start 100mg IV hydrocortisone every 8 hours.
  • Bradycardia
    • Assess airway blockage
    • 0.5mg IV atropine if HR<40
    • Consider albuterol, caffeine or external pacemaker for refractory bradycardia
  • DVT prophylaxis
    • LMW heparin (5000 units SQ)
    • IV filter in high-risk patients.

Neurological management

  • Evaluate both motor and sensory system.
  • Localize the level of the lesion.
  • Use rotorest bed for patients who need immobilization and log roll method to transfer the patients.
  • Neurosurgery should be done within 72 hours for immediate support (bilateral locked facet for incomplete SCI)
  • Gastrointestinal management:
    • Goals:
      • Prevention of paralytic ileus
      • Diet management
      • NPO until bowel sounds return
      • Clear NG tube every 4 hours
      • Peptic ulcers prophylaxis: Proton pump inhibitors (20mg omeprazole)
    • Constipation:
      • Irritant suppository
      • Digital stimulation
      • Abdominal massage
      • Use of assistive devices to improve bowel evacuation.
  • Continence:
    • Catheterization due to neurogenic bladder
    • Prevent catheter-associated infections
    • Measure total fluid intake and urine volume per day
  • Skincare:
    • Apply the appropriate collar (cervical).
    • Initiate protocol to prevent pressure ulcers

Rehabilitation

  • In the cervical spine, reduction can be achieved and maintained with traction, whereas in the thoracolumbar spine recumbency and appropriately positioned bolsters are used.
  • Emphasize on respiratory management such as deep breathing, assisted cough, chest physiotherapy, and abdominal support should be given.
  • Patient education, functional independence training including bed mobility, transfer and wheelchair mobility.
  • Preservation plus strengthening of the existing function of muscle by a range of motion exercises.
  • Restoration of fine motor abilities and the learning of adaptive methods for mobility.
  • Stretching of muscles with spasm plus pelvic exercise for bowel and bladder control.
  • Strollers, crutches and orthoses training is considered essential for providing ambulation in later phases

Further Reading

  • Zhang Y, Al Mamun A, Yuan Y, Lu Q, Xiong J, Yang S, Wu C, Wu Y, Wang J. Acute spinal cord injury: Pathophysiology and pharmacological intervention (Review). Mol Med Rep. 2021 Jun;23(6):417. doi: 10.3892/mmr.2021.12056. Epub 2021 Apr 13. PMID: 33846780; PMCID: PMC8025476.

Bibliography

  • Kristine H. O’Phelan, B. B., JW Kuluz (2017). Emergency Neurologic Life Support: Spinal Cord Compression. Neurocritical Care, 23(Suppl 2), 129-135. doi: 10.1007/s12028-015-0166-1
  • Walker, J. (2009). Spinal cord injuries: acute care management and rehabilitation. Nursing Standard, 23(42), 47-56. doi: 10.7748/ns2009.06.23.42.47.c7055
 
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