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Spinal Cord Injury

 

Synonyms: spinal cord injury, SCI,

Spinal Cord Injury Etiology / Epidemiology / Natural History

  • Caused by penetrating trauma / violence, MVA, falls, sports injury
  • Average age =32, 81% male.
  • Shortened life expectancy generally related to pulmonary complications.
  • Neurologic deficits are determined by primary and secondary (oxygen free radicals, calcium homeostasis disruption, opiate receptor abnormalities,, lipid peroxidation and excitatory neurotrasmitter acculumation [glutamate]) injurys.
  • Paralytic scoliosis will develops in nearly 100% of children with complete cervical cord injuries before age 10 (Dearolf WW III, LPO 1990;10:214).

Spinal Cord Injury Anatomy

  • Dorsal Column:ascending tract containing proprioception, vibratory sense, discriminative touch
  • Spinothalamic tract: ascending tract containing paiin, crude temperature, light touch
  • Spinocerebellar tract: ascending tract containing subconscious regulation of muscle position and tone
  • Corticospinl tract: descending tract containing voluntary motor function
  • Rubrospinal tract: descending tract containing felxor muscle tone control
  • Vestibulospinal tract:descending tract containing spinal cord relexes and muscle tone regulation
  • Reticulospinal tract: descending tract containing influences voluntary movement, head position and muscle tone

Spinal Cord Injury Clinical Evaluation

Spinal Cord Injury Xray / Diagnositc Tests

  • Lateral c-spine generally taken as part of ATLS. CT cervical spine: indicated for obtunded patients before c-spine clearance.
  • Plain films: xrays of entire spine due to high incidence of non-contiguous injuries (Keenen TL, J Trauma 1990;30:489).
  • CT +/- MRI generally indicated.
  • MRI: pre-reduction MRI remains controversial. Reduction should not be significantly delayed for MRI. (Darsaut TE, Spine 2006;31:2085).

Spinal Cord Injury Classification
Complete SCI: comlete loss of all motor and sensory function below the level of injury, poor prognosis.

  • C1-C3: ventilator dependent, limited talking ability. Head or chin control wheelchair. Needs assistance for transfers, ADL's.
  • C3-C4: Can become ventilator independent. Head or chin control wheelchair. Needs assistance for transfers, ADL's.
  • C5: ventilator independent, biceps/deltoid funtion, independent in ADLs. Head or chin control wheelchair. Limited mobility hand control wheelchair. Needs assistance with transfers/living.
  • C6: Wrist flexion/extension, independent ADL's/living. Hand control wheelchair, can drive hand control car. May need assistance with transfers.
  • C7: Triceps. Manual wheelchair capable, can drive hand control car, independent ADL's/living. May need assistance with transfers
  • C8-T1: Hand/finger dexterity. Independent transfers/ADL's/living, manual wheelchair, can drive hand control car.
  • T2-T6: Normal upper extremity function, some trunk control. Independent transfers/ADL's/Living, manual wheelchair, can drive hand control car.
  • T7-T12: Unsupported sitting ability. Independent transfers/ADL's/Living, manual wheelchair, can drive hand control car, walking possible with extensive bracing.
  • L1-L5: variable lower extremity/bowel/bladder funtion. Independent transfers/ADL's/Living, manual wheelchair, can drive hand control car, walking possible with bracing.
  • S1-S5: variable bowel/bladder/sexual function. Independent

Incomplete SCI: partial motor or sensory loss below the level of injury.

  • Central Cord Syndrome: most common; generally older patients with underlying spinal stenosis. Hyperextension injury. Greater weakness in the upper extremities and lower extremities. Favorable prognosis.
  • Anterior Cord Syndrome: generally from vascular insult, HNP, vertebral body fracture. Motor , light touch and pain sensation impaired. Deep pressure, proprioception and vibration intact. Poor prognosis for functional improvement.
  • Posterior-Cord Syndrome: proprioception, deep pressure and vibration impaired. Motor funtion normal. Rare
  • Brown-Sequard Sydrome: motor and proprioception on ipsilateral side of injury impaired; pain and temperature on contralateral side impaired. Generally from penetrating trauma. Favorable prognosis for functional recovery.
  • Conus medullaris syndrome: injury to the sacral cord and lumbar nerve roots leading to areflexic bladder, bowel, and lower limbs. Sacral segments occasionally show preserved reflexes (bulbocavernosus and micturition reflexes).
  • Cauda equina syndrome: injury to the lumbosacral nerve roots in the spinal canal leading to areflexic bladder, bowel, and lower limbs

Spinal Cord Injury Acute Treatment

  • ATLS Protocol.
  • Any trauma pt with suspected C-spine injury should be immobilized on a spine board with cervical collar and log-roll precautions until the c-spine has been cleared.
  • Maintain oxygen saturation >96%. 100% oxygen via nasal cannula, intubation may be required for upper cervical lesions.
  • Maintain systolic BP >90mmHg. Neurogenic shock: Heart rate typically 50-70 beats per minute; SBP 30-50 mm Hg below normal. Must be differentiated from hypovolemic shock(tachycardia/hyptotension). Treatment =initial fluid challenge,Trendelenburg positioning, central line placement, vasopressors (dopamine/phenylephrine hydrochloride), atropine for bradyarrhythmia.
  • Cervical tractionwith tongs or a halo ring indicated for neurologic deficit or evidence of cervical spine instability. Contraindications= cervical distraction injuries at any level, type IIA hangman's fractures.
  • Surgery indicated for neural compression and neruologic deterioration/deficit and spinal instability. Consider surgery for residual cord compression without deficit.
  • Methylprednisolone bolus dose 30 mg/kg followed by 5.4 mg/kg per hour for 23hours if given withing the first 3 hours of injury. If given 3 to 8 hrs after injury continue for 48 hours. Do not give if >8hrs from injury. (Bracken MB, JAMA 1997;277:1597). Steriod administration for spinal cord injury is currently controversial and is associated with higher risks for pneuonia, pulmonary embolism and wound infection/sepsis and has not been studied for penetrating injuries.
  • Future Considerations: Minocycline, erythropoietin, olfactor ensheathing cells (Baptiste DC, J Neurotrauma 2006;23:318).

Spinal Cord Injury Associated Injuries / Differential Diagnosis

  • Fractures
  • Pneumothorax/hemothorax
  • Head injury

Spinal Cord Injury Complications

  • Skin Breakdown
  • Autonomic dysreflexia
  • Osteoporosis / Fractures
  • Pneumonia, atelectasis, aspiration
  • Heterotopic ossification
  • Spasticity
  • DVT
  • Cardivascular disease
  • Syringomyelia
  • Neuropathic pain

Spinal Cord Injury Follow-up Care

  • 92% discharged to independent living or residential living with assistance.
  • Patient information: www.spinalinjury.net.

Spinal Cord Injury Review References

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