Spinal cord injury (SCI) is a relatively rare, but potentially devastating diagnosis with life-long consequences. There are approximately 80-130 new cases of SCI in New Zealand per year.1 The majority of patients are males aged 24-45 with 40% of injuries resulting from motor vehicle accidents.
Brown Sequard Syndrome
In addition to the standard primary survey, the following are important considerations for patients with suspected SCI.
Patients with a suspect SCI should be treated with supplemental oxygen as required to treat hypoxia.
The degree of respiratory impairment correlates to the level of the SCI. Patients with high cervical cord injuries can rapidly develop respiratory failure (“C3,4,5 keeps the diaphragm alive”). Patients with lower cervical and upper thoracic SCIs can also have varying degrees of respiratory impairment depending on the level of the lesion.
Signs of impending respiratory failure include
These patients will require early intubation with special precautions
Hypotension in patients with SCI at or above T6 can be the result of “neurogenic shock” as the sympathetic outflow is interrupted causing decreased vascular resistance. This is usually associated with bradycardia.
However, hypotension in patients with SCI should be assumed to be from blood loss with a search for the source, until proven otherwise
Patients with concomitant neurogenic and hypovolaemic shock can have falsely reassuring findings – a relative bradycardia and warm peripheries.
Note also that patients with SCI can have an unreliable abdominal examination due to loss of motor tone and sensation. FAST +/- CT should be utilised to detect occult intraabdominal bleeding as the cause of shock.
Once haemorrhage is excluded, hypotension should be treated with IV fluid and vasopressors (eg: noradrenaline) if required. The BP aims are controversial with many guidelines recommending MAPs between 85-90, however this is level III evidence2 and has been questioned3,4
Note that neurogenic shock different from “spinal shock” – this is not a circulatory shock state, but a term for the loss of motor function and sensation with initial loss but gradual return of reflexes below the level of a SCI injury. This can last for hours to days (or even weeks). Note that patients with spinal shock above T6 can also develop neurogenic shock.
Once life threats have been addressed a full neurological assessment should be completed in order to assess the level and severity of the SCI. This can also guide treatment and prognosis.
The ASIA chart should be utilised to document neurological findings
This involves a detailed assessment of sensation and power (including anal tone and the sensation of deep anal pressure) resulting in a score from A to E
A – complete: no sensory or motor function in sacral segments 4-5
Prognosis – 80% remain the sam
B – sensory incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5
Prognosis – 80% improve (40% convert to ASIA C, 40% convert to ASIA D)
C – motor incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3
Prognosis – 60-80% convert to ASIA D
D = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade that is greater than or equal to 3
Prognosis – many can walk independently
E = Normal: Sensory and motor functions are normal
A log roll will need to be carefully performed with attend paid to
Other neurological findings that may be useful include
Arterial blood gas measurements are important in patients with higher level SCI as the development of hypercapnoea can indicate impending respiratory failure.
Plain films as part of an initial trauma assessment have a limited role in patients with neurological deficits from suspected SCI. CT is the imaging modality of choice. CT also has the advantage of detecting other injuries (eg: intraabdominal injuries).
10-15% of patients with a SCI will have a non-contiguous spinal fracture so the entire spine should be imaged if a significant # is found, preferably with CT.
MRI will usually be required to further characterise the cord itself and the surround soft tissues (ligaments, discs, paraspinal soft tissues) as well as detect epidural haematomas.
MRI is also invaluable in the workup of SCIWORA (spinal cord injury without radiological abnormality – ie: no boney abnormality on CT) as it will generally detect spinal cord injuries if present.
Decisions regarding definitive management (reduction of cervical dislocations or operative interventions) will be led by the spinal surgeons.
Patients with cervical spine fractures with subluxation will usually require reduction via traction techniques. Skull tongs or a halo are applied to the head with incrementally increasing weighted traction applied (note this is strictly led by the spinal surgeons)
Indications for operative management include
Judicious use of titrated opiates (eg: fentanyl) will be required to treat pain. Even though fentanyl is relatively cardiovascularly sparing, care should be taken to avoid worsening shock. Patients with the potential for respiratory failure will also need to be treated carefully with any opiates.
As the patient will be immobilised (from strict spinal cares and potentially paralysis) it is prudent to treat prophylactically with ondansetron.
Early placement of an NG tube is important as these patients are at high risk of ileus and aspiration
Patient with SCI can develop a polikotherm state due to vasodilation leading to increased heat loss. Keep the patient covered with blankets, avoid draughts/fans etc.
Pressure areas can develop remarkably rapidly in paralysed patients. Backboards should be removed on arrival to the ED if they have been placed prehospital. Hard cervical spine collars should be replaced with Aspen or other similar softer collars as soon as practical (though these still need to be watched carefully for pressure areas around especially around the pinna, chin, occiput and manubrium. Attention to the skin around the heels and buttocks is also essential. Patients should have spinal rolls q2h.
Steroids are NOT currently used in the treatment of acute SCI in New Zealand.
The use of steroids in patients with SCI has been an area of significant controversy.5 There is some evidence that administration within 8 hours might result in a modest improvement in motor function. However, this benefit is probably marginal at best, and is counterbalanced by the increased risk of infections/sepsis and GI bleeding associated with steroid use in trauma patients.
Patients with SCI and their families will likely be extremely anxious about the injury and their long term prognosis. The physical examination combined with imaging will give an indication regarding potential for recovery – early frank discussions regarding expectations should take place. Involvement of social work and cultural support is important.
Destination SCI with motor
Destination no motor