Definition
A.Spinal cord injury (SCI) is any damage to the spinal cord that causes temporary or permanent changes that disrupt normal function. This includes changes to motor, sensory, or autonomic function in the body below the level of the SCI.
B.It is a challenging medical condition due to the limited therapeutic options available to treating physicians. There is a significant economic and social burden of SCI patients as well as society.
Incidence
A.Can affect up to 750 per million annually.
B.In the United States, there are approximately 10,000 to 12,000 new traumatic SCIs per year.
C.Approximately 280,000 people are presently living with SCI in North America.
D.Up to 60% of injuries include the cervical spine.
E.For the geriatric population, a majority of injuries are incomplete.
F.For the geriatric patient, mortality and morbidity are significantly higher.
G.Higher incidence of central cord injuries occurs in the geriatric population.
Pathogenesis
A.Spinal cord injuries are considered high impact injuries, often resulting from high speed motor vehicle crashes or falls from significant height.
B.Other mechanisms may include:
1.Hyperextension injury with or without longitudinal ligament tear.
2.Vertical column loading (axial load) compression.
3.Distraction injuries (seen with hangings).
4.Penetrating injuries.
5.Pathological fractures (seen more commonly in the elderly).
Predisposing Factors
A.Male.
B.Persons between 15 and 24 years of age.
C.Increasing occurrence in elderly.
Subjective Data
A.Common complaints/symptoms.
1.Neck or back pain.
2.Numbness.
3.Loss of limb function.
4.Paresthesia.
B.Common/typical scenario.
1.Other signs and symptoms.
a.Bowel and bladder dysfunction.
b.Priapism.
c.Hyperparesthesia/pain.
C.Family and social history.
1.Emergency medical support (EMS) report may give you significant information regarding the scene and how the patient was found.
2.If possible, ask the patient about the history of events: Mechanism? Motor vehicle collisions (MVC)? Location in car? Restrained? Ejected? Mechanical fall or syncope? Fall from height? How far?
3.Blunt versus penetrating.
4.Distraction injury to spine? Hyperextension, hyperflexion, hyperrotation?
5.Ask the patient about pain and the ability to move extremities after injury (see Figure 17.1).
6.Assess for drug or alcohol use as this may impact your examination.
FIGURE 17.1 Dermatome map.
Physical Examination
A.Primary survey (advanced trauma life support [ATLS]) to assess for life-threatening injuries.
B.Pay particular attention to respiratory status as level of injury can impact spontaneous breathing.
1.Injuries above C3 result in respiratory arrest.
2.Injuries at C5 to C6 spare the diaphragm and diaphragm breathing is seen.
3.Injuries below T1 to the level of L2 can affect the intercostals.
C.Motor and sensory assessment to assess level of injury.
D.Cardiovascular changes seen with SCI: SCI can impact the sympathetic pathways leading to alterations in blood pressure, heart rate, and temperature regulation.
E.Gastrointestinal changes associated with SCI may include loss of bowel function, development of an ileus, or obstruction.
F.GU: urinary incontinence and retention.
G.Always have a heightened suspicion for other injuries.
Diagnostic Tests
A.CT.
B.MRI.
C.Plain films (x-rays) can help identify fractures.
Differential Diagnosis
A.Central cord syndrome.
B.Anterior cord syndrome.
C.Posterior cord syndrome.
D.Brown-Sequard syndrome (often seen with penetrating trauma).
Evaluation and Management Plan
A.General plan.
1.Interventions in SCI are aimed at preventing secondary injury.
2.Earlier surgical intervention, when indicated, has been shown to improve neurological recovery.
3.Maintain adequate airway and respirations.
4.Cervical spine immobilization.
5.Thoracic and lumbar bracing if necessary.
6.Maintain adequate circulation.
7.Ongoing neurological assessment.
8.Assess for signs of neurogenic shock and support hemodynamics.
9.Aggressive bowel regimen to prevent constipation.
10.Monitor urine with either a Foley catheter or self-catheterization as needed.
B.Patient/family teaching points.
1.Patients need to be taught how to monitor and assess their skin for any breakdown.
2.Depending on the level of the ACI, patients may have bowel, bladder, and sexual dysfunction.
3.Teach patients and caregivers to recognize a life-threatening condition called autonomic dysreflexia, which can be caused by bladder spasms, urinary tract infections, or even external factors such as too tight clothing, belts, or shoes.
4.Physical and occupational therapy will be necessary for reducing muscle contractures and atrophy.
C.Pharmacotherapy.
1.Use of glucocorticoids, specifically methylprednisone, after acute traumatic SCI has been a controversial concept. The recommendations were to use methylprednisone for either 24 or 48 hours, depending on whether it was started 3 or 8 hours after injury, respectively.
a.Many studies are showing early surgical intervention with decompression is preferable to steroid use.
2.Other pharmacological agents used in human clinical trials include: Tirilazad, naloxone, GM ganglioside, and riluzole. Recent neuroprotection agents involved in clinical trial include BA-120 (Cethrin) and minocycline.
3.Antibiotics for penetrating injuries.
4.Gastrointestinal (GI) prophylaxis and bowel regimen.
Follow-Up
A.SCI patients have a long course of physical medicine and rehabilitation.
B.Neurosurgery, orthopedics, and any other specialty group needed is involved in care.
Consultation/Referral
A.Neurosurgery/orthopedics (bony injuries) for management and possible fixation/fusion.
B.Prompt transfer to a Level I trauma center needs to be prioritized.
Special/Geriatric Considerations
A.SCI is an ever-increasing challenge with annual incidence of 750 per million in the developed world and even higher incidence in the developing world.
B.Pathophysiology of SCI involves primary and secondary injury mechanisms with future treatment strategies and emphasis on preventing or reversing secondary injury.
C.Medical management of SCI patients is in accordance with Advanced Trauma Life Support guidelines. Surgery for acute SCI within 24 hours of injury as a treatment option is not associated with any increased risk of complications and may provide a neurological benefit.
D.Patients with an unstable spinal column with incomplete SCI should be considered for acute stabilization as soon as possible after obtaining necessary imaging studies.
Bibliography
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