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18

Spinal Cord Injuries

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Topic updated on 03/09/16 3:17pm
Introduction
  • 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
    • location
      • 50% in cervical spine
  • 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
      • methylprednisone 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 least invasive method
        • treatment
          • stenting only if patient is symptomatic from basilar arterial insufficiency
  • Prognosis
    • only 1% have complete recovery at time of hospital diagnosis
      • conus medullaris syndrome has a better prognosis for recovery than more proximal lesions 
Relevant Anatomy
  • See Spinal Cord Anatomy topic
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 an 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 syndromes
        • cauda equina syndrome 
ASIA Classification
  1. Determine if patient is in spinal shock
    • check bulbocavernosus reflex
  2. Determine neurologic level of injury
    • lowest segment with intact sensation and antigravity (3 or more) muscle function strength
    • in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level.
  3. Determine whether the injury is COMPLETE or INCOMPLETE
    • COMPLETE defined as  (ASIA A)
      • no voluntary anal contraction (sacral sparing) AND
      • 0/5 distal motor AND
      • 0/2 distal sensory scores (no perianal sensation) AND
      • bulbocavernosus reflex present (patient not in spinal shock)
    • INCOMPLETE defined as
      • voluntary anal contraction (sacral sparing)
      • sacral sparing critical to determine complete vs. incomplete
      • OR palpable or visible muscle contraction below injury level OR
      • perianal sensation present
  4. Determine ASIA Impairment Scale (AIS) Grade:     
ASIA Impairment Scale
A Complete No motor or sensory function is preserved in the sacral segments S4-S5.
B Incomplete  Sensory function preserved but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
C Incomplete Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
D Incomplete Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.
E Normal Motor and sensory function are normal.
 
Acute Phase Conditions
  • Neurogenic shock
    • characterized by hypotension & relative bradycardia in 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 & 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 bulbocavernous reflex
        • conus or cauda equina injuries may lead to permanent loss of the bulbocavernous reflex
  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
      • immobilization should include rigid cervical collar and transport on firm spine board with lateral support devices
      • patient should be rolled with standard log roll techniques with control of cervical spine
    • athletes
      • in the setting of sports-related injuries helmets and shoulder pads should be left on until arrival at 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 injury7,
        • log roll patient to inspect and palpate entire spinal axis
        • perform careful neurologic exam
    • cervical spine clearance 
Acute Treatment
  • Nonoperative
    • high dose methylprednisone
      • indications
        • nonpenetrating SCI within 8 hours of injury
          • recommended by NASCIS III
      • contraindications include
        • GSW
        • pregnancy
        • under 13 years
        • > 8 hours after injury 
        • brachial plexus injuries
      • technique
        • load 30 mg/kg over 1st hour (2 grams for 70kg man)
        • drip 5.4 mg/kg/hr drip
          • for 23 hours if started < 3 hrs after injury 
          • for 47 hours if started 3-8 hours after injury
      • outcomes
        • leads to improved root function at level of injury
        • may or may not lead to spinal cord function improvement
    • monosialotetrahexosylganglioside (GM-1)
      • indications
        • remains controversial
          • large multicenter RCT did not show long term benefit
          • some evidence of faster recovery
    • 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
    • DVT prophlaxis
      • 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
  • Operative
    • rarely indicated in acute setting
Definitive Treatment
  • Nonoperative
    • bracing and observation
      • indications
        • most GSWs
          • exceptions listed below
        • metastatic CA patients with < 6 mos life expectancy
          • presence of six variables below correspond to short life expectancy
            1. multiple spinal mets
            2. multiple extraspinal mets
            3. unresectable lesions in major organs
            4. SCI (complete or incomplete)
            5. aggressive CA: lung, osteosarcoma, pancreas
            6. critically ill
  • 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 rehab 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 
        • metastatic CA patients with > 6 mos life expectancy
          • ~ no for six question above
        • GSW with
          • progressive neurological deterioration with retained bullet within 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
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
    • don't 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
  • 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.
Rehabilitation
  • Goals
    • goal is to 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

Level
Patient Function
C1-C3 - Ventilator dependent with limited talking.
- Electric wheelchair with head or chin control
C3-C4 - 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 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-T6 - Normal UE function
- Improved trunk control
- Wheelchair-dependent
T7-T12 - Increased abdominal muscle control
- Able to perform unsupported seated activities; with extensive bracing walking may be possible
L1-L5 - Variable LE and B/B function
- Assist devices and bracing may be needed
S1-S5

- Various return of B/B and sexual function
- Walking with minimal or no assistance

 


 

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Qbank (23 Questions)

TAG
(SBQ12.15) An 18-year-old male is evaluated for a suspected spinal cord injury. His neurological exam shows diminished sensation below the T7 level. His bulbocavernosus reflex is intact. Which physical finding of motor function, below the affected neurological level, would classify this injury as an ASIA B according to the American Spinal Injury Association impairment scale? Topic Review Topic

1. More than half of the major muscles demonstrate palpable or visible muscle contraction
2. At least half of key muscles have a muscle grade of 5.
3. More than half of key muscles have a muscle grade less than 3.
4. At least half of key muscles have a muscle grade of 3 or more.
5. No motor function preserved below affected neurological level

PREFERRED RESPONSE ▶
TAG
(OBQ14.45) A 32-year-old man is brought to the Emergency Department after cervical spine trauma. Physical examination has classified his injury as ASIA B at the C6 level. All of the following exam findings are expected in this patient EXCEPT? Topic Review Topic

1. Sensation intact in the long finger
2. Sensation intact over the medial aspect of the forearm
3. 5/5 strength in deltoid function
4. 2/5 strength in triceps function
5. 0/5 strength in the instrinic hand muscles

PREFERRED RESPONSE ▶
TAG
(OBQ12.55) An 17-year-old football player is brought to the emergency room following a tackling injury 90 minutes prior. On arrival to the emergency room he is alert and oriented. On physical exam he has tenderness in his posterior midline cervical spine. He reports intact sensation in his upper and lower extremities. He motor exam shows he has some motion in his arms and legs, but is unable to lift his legs or arms against gravity. His bulbocavernosus reflex is absent. The decision is made to initiate methylprednisolone. What is the most appropriate dosage and duration? Topic Review Topic

1. 30 mg/kg bolus followed by a 5.4 mg/kg/hr infusion x 8 hours
2. 30 mg/kg bolus followed by a 5.4 mg/kg/hr infusion x 24 hours
3. 60 mg/kg bolus followed by a 5.4 mg/kg/hr infusion x 8 hours
4. 60 mg/kg bolus followed by a 5.4 mg/kg/hr infusion x 24 hours
5. 60 mg/kg bolus followed by a 5.4 mg/kg/hr infusion x 28 hours

PREFERRED RESPONSE ▶
TAG
(OBQ12.184) A 36-year-old male involved in a high speed motor vehicle accident is found on exam to have Grade 2 of 5 motor strength in 80% of his key muscle groups in his lower extremity. His perianal sensation and rectal tone are intact. A bulbocavernosus reflex is present. His sensation is decreased from a point at the intersection of the mid-clavicular line and the 4th intercostal space at the level of the nipples distally. Based on the American Spinal Injury Association (ASIA) classification system, what ASIA grade is he? Topic Review Topic

1. ASIA A
2. ASIA B
3. ASIA C
4. ASIA D
5. ASIA E

PREFERRED RESPONSE ▶
TAG
(OBQ11.9) A 23-year-old man falls down a flight of stairs while intoxicated and is brought to the emergency room the following morning. On physical exam he has no motor function in his upper and lower extremities. Sensory exam shows diminished but present sensation in the perianal area and in the lower extremities. Reflex exam shows his bulbocavernosus reflex is intact. The inital CT and MRI are seen in Figures A and B. According to the American Spinal Injury Association (ASIA), how would this injury be classified? Topic Review Topic
FIGURES: A   B        

1. ASIA A
2. ASIA B
3. ASIA C
4. ASIA D
5. ASIA E

PREFERRED RESPONSE ▶
TAG
(OBQ11.225) A 49-year-old male fell from a height of 10 feet while cleaning his roof. He sustained the isolated injury shown in Figures A and B. Upon transfer from the outside hospital 10 hours later, he has 0/5 motor strength in bilateral lower extremities, no sensation distal to umbilicus, and an intact bulbocavernosous reflex. He has no perianal sensation or rectal tone. He received no medical management at the outside hospital. Which of the following is the most appropriate use of methylprednisolone in this patient.? Topic Review Topic
FIGURES: A   B        

1. Initiate high-dose methylprednisolone with a loading dose of 30mg/kg and a drip of 5.4 mg/kg/hr
2. Initiate high-dose methylprednisolone, without a loading dose, at 5.4 mg/kg/hr
3. Do not initiate treatment with methylprednisolone
4. Initiate high-dose methyprednisolone if his neurologic status does not improve over the next 14 hours
5. Administer a one-time dose of methylprednisolone at a dose of 30 mg/kg

PREFERRED RESPONSE ▶
TAG
(OBQ10.35) A 52-year-old male is involved in an altercation where his neck was twisted and extended with force. Upon presentation he complains of neck pain, and loss of ability to stand or ambulate. On physical exam, he has Grade 3 motor strength in the majority of his muscles groups in his upper and lower extremities. His sensory is intact in all four extremities, and his bulbocavernosus reflex is intact. Sagittal and coronal computed tomography are shown in Figure A and B respectively. The patient's neurologic condition is best classified as? Topic Review Topic
FIGURES: A   B        

1. ASIA E
2. ASIA D
3. ASIA C
4. ASIA B
5. ASIA A

PREFERRED RESPONSE ▶
TAG
(OBQ10.44) What percentage of patients with a spinal cord injury suffer from Major Depressive Disorder? Topic Review Topic

1. Less than 5%
2. 5 to 20%
3. 20 to 50%
4. 50 to 75%
5. Greater than 75%

PREFERRED RESPONSE ▶
TAG
(OBQ09.43) All of the following are attributed to the loss of supraspinal control of the sympathetic nervous system that commonly occurs in patients with spinal cord lesions at T-6 or higher EXCEPT Topic Review Topic

1. Supine hypotension
2. Orthostatic hypotension
3. Spasticity
4. Autonomic dysreflexia
5. Cardiac arrhythmias

PREFERRED RESPONSE ▶
TAG
(OBQ09.154) Functional electrical stimulation is used in the rehabilitation of patients with spinal cord injuries. This rehabiliation method has the greatest functional effect on which of the following? Topic Review Topic

1. Sensory nerves
2. Motor nerves
3. Skeletal muscle
4. Motor cortex
5. Dorsal root ganglion

PREFERRED RESPONSE ▶
TAG
(OBQ09.170) A 30-year-old male is involved in a motor vehicle accident and sustains a fracture-dislocation of the cervical spine. On physical exam he has absent distal motor function, absent sensation, absent rectal tone, and an intact bulbocavernosus reflex. Which term best describes this spinal cord injury pattern? Topic Review Topic

1. Central cord syndrome
2. Incomplete spinal cord injury
3. Complete spinal cord injury
4. Neurogenic shock
5. Spinal shock

PREFERRED RESPONSE ▶
TAG
(OBQ08.17) A 16-year-old male is involved in a diving accident six months ago that leads to a spinal cord injury. On physical exam he has 5 out of 5 deltoid and biceps strength. He has good brachioradialis muscle tone and 5 out of 5 bilateral wrist extension. He has 0 out of 5 wrist flexion and triceps strength. He has no anal sphincter tone, absent perianal sensation, absent lower extremity sensation, and an intact bulbocavernosus reflex. He has no motor tone in his lower extremities. How would you define this patients neurologic deficit. Topic Review Topic

1. Incomplete C5 spinal cord injury (ASIA A)
2. Complete C5 spinal cord injury (ASIA E)
3. Complete C6 spinal cord injury (ASIA A)
4. Complete C7 spinal cord injury (ASIA A)
5. Incomplete C7 spinal cord injury (ASIA B)

PREFERRED RESPONSE ▶
TAG
(OBQ08.82) Which of the following best describes a patient's functional level with a complete C5 spinal cord injury? Topic Review Topic

1. Electric wheelchair with only head or chin control
2. Electric wheelchair with hand control
3. Limited use of manual wheelchair, can drive car with manual controls
4. Long-distance use of a manual wheelchair
5. Fully independent transfers

PREFERRED RESPONSE ▶
TAG
(OBQ08.87) Following an acute spinal cord injury a patient presents with systemic hypotension and relative bradycardia. His bulbocavernosus reflex is present. This is characteristic of what type of response in acute spinal cord injuries? Topic Review Topic

1. Spinal shock
2. Cardiac shock
3. Neurogenic shock
4. Septic shock
5. Hypovolemic shock

PREFERRED RESPONSE ▶
TAG
(OBQ05.12) A 2-year-old child falls down a flight of stairs and is found to have spinal cord injury without radiographic abnormality (SCIWORA). What is the most important predictor of her neurologic outcome? Topic Review Topic

1. Mechanism of injury
2. Severity of initial neurologic injury
3. Injury pattern of fracture or dislocation
4. Location of spinal cord injury
5. Age of patient

PREFERRED RESPONSE ▶
TAG
(OBQ04.154) Which of the following scenarios would be most appropriate for posterior deltoid-to-triceps transfers? Topic Review Topic

1. Axillary nerve injury
2. C6 ASIA A Spinal Cord Injury with 5/5 biceps and 4/5 brachioradialis
3. Erb's palsy with waiters tip deformity
4. C5 ASIA C Spinal Cord Injury with 3/5 deltoid and 2/5 biceps
5. C5 ASIA D Spinal Cord Injury with 4/5 deltoid and 4/5 biceps

PREFERRED RESPONSE ▶
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