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Questions and Answers
What percentage of spinal cord injuries (SCI) involve complete spinal damage?
What percentage of spinal cord injuries (SCI) involve complete spinal damage?
Which population has the highest incidence of spinal cord injuries?
Which population has the highest incidence of spinal cord injuries?
What is the most common mechanism of injury leading to traumatic spinal cord injury?
What is the most common mechanism of injury leading to traumatic spinal cord injury?
Which of the following is NOT a common sign or symptom of spinal cord injury?
Which of the following is NOT a common sign or symptom of spinal cord injury?
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What is required for an unstable spine to occur?
What is required for an unstable spine to occur?
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What distinguishes spinal cord injury (SCI) from spinal injuries?
What distinguishes spinal cord injury (SCI) from spinal injuries?
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What is the approximate percentage of individuals with SCI that suffer from limb fractures?
What is the approximate percentage of individuals with SCI that suffer from limb fractures?
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What should be avoided during the examination of a patient with suspected spinal injury?
What should be avoided during the examination of a patient with suspected spinal injury?
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In what type of fall might spinal cord injury commonly occur?
In what type of fall might spinal cord injury commonly occur?
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Which imaging modality is preferred for assessing intervertebral discs and neural structures?
Which imaging modality is preferred for assessing intervertebral discs and neural structures?
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What does the term 'SCIWORA' refer to in the context of spinal cord injuries?
What does the term 'SCIWORA' refer to in the context of spinal cord injuries?
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What is a common sign suggesting a spinal cord lesion in an unconscious patient?
What is a common sign suggesting a spinal cord lesion in an unconscious patient?
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What indicates the need for a CT scan in spinal injury assessment?
What indicates the need for a CT scan in spinal injury assessment?
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Which condition is characterized by a fracture of C1 due to severe load on the head?
Which condition is characterized by a fracture of C1 due to severe load on the head?
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Signs of possible spinal injury during the examination include all except:
Signs of possible spinal injury during the examination include all except:
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What movement pattern should be observed in a patient with a suspected spinal injury?
What movement pattern should be observed in a patient with a suspected spinal injury?
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What is the recommended treatment for stable, undisplaced fractures of the cervical spine?
What is the recommended treatment for stable, undisplaced fractures of the cervical spine?
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What type of injury is characterized by a fracture of the C2 pedicle with torn C1-C2 disc?
What type of injury is characterized by a fracture of the C2 pedicle with torn C1-C2 disc?
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Which of the following injuries is known to commonly occur during diving accidents?
Which of the following injuries is known to commonly occur during diving accidents?
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What kind of injury results in neurological injury being common?
What kind of injury results in neurological injury being common?
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In which situation should fractures involving the middle column and at least one other column be considered unstable?
In which situation should fractures involving the middle column and at least one other column be considered unstable?
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What type of spinal injury commonly requires the use of a comfortable collar for 6-8 weeks?
What type of spinal injury commonly requires the use of a comfortable collar for 6-8 weeks?
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Which of the following classifications describes a complete transection of the spinal cord?
Which of the following classifications describes a complete transection of the spinal cord?
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Which type of cervical fracture is associated with flexion injuries from high-velocity accidents?
Which type of cervical fracture is associated with flexion injuries from high-velocity accidents?
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What characterizes complete spinal cord injury (SCI)?
What characterizes complete spinal cord injury (SCI)?
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What is a characteristic feature of anterior cord syndrome?
What is a characteristic feature of anterior cord syndrome?
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Which statement is true regarding Brown-Sequard syndrome?
Which statement is true regarding Brown-Sequard syndrome?
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What does SCIWORA refer to?
What does SCIWORA refer to?
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What is a likely complication associated with secondary spinal cord injury?
What is a likely complication associated with secondary spinal cord injury?
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Which area of the spinal cord, if injured, will completely eliminate sympathetic outflow?
Which area of the spinal cord, if injured, will completely eliminate sympathetic outflow?
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What does spinal shock primarily refer to?
What does spinal shock primarily refer to?
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How long can spinal shock last in patients?
How long can spinal shock last in patients?
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What is a primary complication of cervical spinal cord lesions that affects management?
What is a primary complication of cervical spinal cord lesions that affects management?
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Which of the following is recommended for maintaining blood pressure in patients with spinal cord injuries?
Which of the following is recommended for maintaining blood pressure in patients with spinal cord injuries?
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What is the recommended bolus dose of methylprednisolone for spinal cord injury management?
What is the recommended bolus dose of methylprednisolone for spinal cord injury management?
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What condition is characterized by back pain, fever, and tenderness, particularly in patients with a history of diabetes or IV drug abuse?
What condition is characterized by back pain, fever, and tenderness, particularly in patients with a history of diabetes or IV drug abuse?
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Which clinical feature is NOT associated with lumbar disc issues?
Which clinical feature is NOT associated with lumbar disc issues?
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What does spinal perfusion pressure management aim to prevent?
What does spinal perfusion pressure management aim to prevent?
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Which clinical finding is a common feature in patients with spinal metastases?
Which clinical finding is a common feature in patients with spinal metastases?
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In the context of spinal cord injury, which of the following is a critical maneuver for airway management if intubation is indicated?
In the context of spinal cord injury, which of the following is a critical maneuver for airway management if intubation is indicated?
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Study Notes
Spinal Cord Injury
- A spinal cord injury (SCI) is damage to the spinal cord resulting in loss of function, such as mobility or feeling.
- SCI can be caused by traumatic or non-traumatic events.
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Epidemiology
- 450,000 people with SCI live in the USA.
- 10,000 new cases per year.
- 82% are males between 16-30 years.
- 45% are complete spinal damage.
- 50% involve the cervical spine (C5-C6).
- More than 50% result in quadriplegia.
- Common comorbidities: Limb fractures (67%), intrathoracic injuries (53%), and head injuries (33%).
Signs and Symptoms
- Weakness, numbness, tingling sensations, or loss of feeling.
- Painful movement of arms and legs.
- Pain or tenderness along the spine.
- Burning sensations along the spine or in an extremity.
- Deformity to the patient's head, neck, or spine.
- Injuries to the head.
- Loss of bladder or bowel control.
- Labored breathing with minimal or no chest rise.
Causes
- Traumatic SCI: Car accidents, gunshot, falls, etc.
- Non-traumatic SCI: Polio, spina bifida, Friedreich's Ataxia, etc.
Traumatic SCI Mechanisms
- Motor vehicle collisions (48%).
- Falls (21%).
- Assaults (15%).
- Sport-related injuries (14%), majority from diving.
Spinal vs. Spinal Cord Injury
- Spinal injury: With or without cord injury, includes fractures, dislocations, and facet locks.
- Spinal cord injury: With or without spinal injury, includes neuronal injury and SCIWORA.
- Treatment: Spinal injury: Reduction, fixation, and fusion. SCI: Decompression, then waiting for spinal cord repair, if needed.
Tracts vs. Nuclei
- Injury to a tract affects all levels below the injury level.
- Injury to a nucleus in the horns affects only the level of the injury.
- The white matter increases in the spinal cord as you go higher, as tracts gradually accumulate.
Spinal Injury & Bony Injury
- Stable fractures: Not displaced by normal movements.
- Unstable fractures: Significant risk of displacement and neural damage.
- Neurological injuries: May not be immediate and can worsen with movement or displacement of a vertebral fracture or dislocation (primary vs. secondary).
Principles of Diagnosis and Management
- Avoid inappropriate movements during examination, as this can worsen the outcome.
- Immobilization is only discontinued after serious spinal injuries have been excluded through clinical and radiological assessment.
- History: High index of suspicion; signs and symptoms may be minimal. Consider any patient with blunt injury above the clavicle, head injury, or loss of consciousness especially if it involves a fall from height, crushing accident, or high-speed deceleration accident.
- Examination (look, feel but not move!): Inspect the head and face for bruises, examine the neck for deformity, bruising, or penetrating injuries.
- Palpation: Palpate the bones and soft tissues of the neck. Investigate tenderness, bogginess, or abnormal space between adjacent spinous processes, which may suggest an unstable spine.
- Back: Roll the patient in a log position, inspect and palpate the back.
- Full Neurological Examination: Conduct a thorough neurological examination, repeating it several times during the first few days. Test each dermatome, myotome, and reflex.
The Unconscious Patient
- Features suggesting a spinal cord lesion: History of a fall or rapid deceleration, head injury, diaphragmatic breathing, flaccid anal sphincter, hypotension with bradycardia, and pain response above but not below the clavicles.
Imaging
- X-ray: Cervical spine: AP, lateral (C1 to T1), and open mouth.
- CT scan: For difficult areas (lower cervical and upper thoracic), damage to individual vertebrae, and displacement of bone fragments.
- MRI: Intervertebral disc, lig. flavum, and neural structures.
Cervical Spine Injuries
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History: Fall from height, diving accident, or motor vehicle accident involving forced neck movement.
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Examination: Abnormal neck position, tenderness, pain, and paraesthesia.
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Imaging:
- AP view: Lateral outline should be intact, spinous processes and tracheal shadow at the midline.
- Lateral view: C1 to T1.
- Open mouth: For odontoid fractures.
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Fracture of C1 (Jefferson's fracture): Caused by sudden severe load on the top of the head. Usually no neurological damage. Treatment: Stable, undisplaced fractures: Rigid collar until fracture unites. Unstable, sideway spreading of the lat. masses: Skull-traction, halo body orthosis followed by semi-rigid collar.
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Fractured pedicle of C2 (Hangman's fracture): Fracture of the C2 pedicle with a torn C1/C2 disc. Extension with Distraction. Results from a motor vehicle accident when the forehead strikes the dashboard. Treatment: Undisplaced fractures: Semi-rigid collar or halo-vest until united. Displaced fractures: Reduction, then halo-vest for 12 weeks.
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Fracture of the odontoid process: Flexion injury due to a high-velocity accident or falls. 1/4 have neurological involvement. Three types: 1. Evulsion of the tip, 2. Through the junction of the odontoid peg and body, 3. Through the body.
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Wedge-compression fractures: Pure flexion injury causes compression of the anterior part of the vertebral body. Stable injury, comfortable collar for 6-8 weeks.
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Burst fracture: Axial compression of the cervical spine. Frequent neurological injury. Treatment: Neurological deficit calls for urgent anterior decompression.
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Burst fracture, C7: Demonstrates a comminuted vertical fracture through the body of C7, with posterior displacement towards the spinal canal and anterior soft tissue swelling.
Thoracic Spine Injuries
- Hyperflexion injuries: Wedge-compression fractures are relatively common, stable, but may lead to progressive kyphosis.
- T11-T12: High risk of cord damage due to their transition zone between the fixed and mobile parts of the spine.
Thoracolumbar and Lumbar Injuries
- Transition zone: Between the fixed thoracic and mobile lumbar spine.
- Stable vs. unstable: Involves either the posterior osteoligaementous complex, middle column, or anterior column; at least one other column must be involved for an unstable spine to be present.
- Types: Wedge fractures, burst fractures, fracture dislocation.
Injuries with Spinal Cord Damage
- Burst fracture and fracture dislocation: Result in 1. Complete transection (paraplegia or quadriplegia) or 2. Incomplete transection (partial motor or sensory loss).
Complete SCI
- Loss of all function below the level of the lesion.
- Typically associated with spinal shock.
Incomplete SCI
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Types:
- Central cord syndrome.
- Anterior cord syndrome.
- Brown-Sequard syndrome.
- Spinal cord injury without objective radiologic abnormality (SCIWORA)
Anterior Cord Syndrome
- Flexion-compression injuries, damage to the anterior spinal artery, cutting off blood supply to the anterior 2/3 of the spinal cord.
- Also results from a herniated intervertebral disc.
- Characteristics: Loss of motor function, pain, and temperature sensation below the level of the lesion, but preservation of light touch and proprioception.
Central Cord Syndrome
- Hyperextension forces the cord to be pressed between the body anteriorly and the bulging lig. flavum posteriorly.
- Characteristics: Greater impairment of upper extremity function compared to lower extremity function, with varying degrees of sensory loss.
Brown-Sequard Syndrome
- Typically caused by penetrating trauma (e.g., gunshot, stab wound), or expanding tumors.
- Characteristics: Ipsilateral loss of motor function and proprioception below the level of the lesion, accompanied by contralateral loss of pain and temperature sensation below the level of the lesion.
Spinal Cord Injury Without Radiologic Abnormality (SCIWORA)
- No bony abnormalities on plain films or CT scans.
- MRI may show abnormalities.
- Typically in children, with transient symptoms initially.
- Requires immobilization to prevent potential further cord damage.
Secondary Spinal Cord Injury
- After the initial injury: Secondary injuries are a major cause of disability.
- Mechanisms: Movement of unstable spine, vascular insufficiency, and free radical induced damage.
Neural Control of Blood Pressure & Blood Flow
- Complete SCI above T1: Eliminates all sympathetic outflow.
- Complete SCI between T1 and T6: Preserves sympathetic tone in the head and upper extremities but denies it to the adrenals and lower extremities.
- Complete SCI between T6 and the lumbar cord: Preserves adrenal innervation but denervates the lower extremities.
‘Spinal’ Shock
- Acute loss of segmental tendon reflexes, muscle tone, and sensation below the level of a spinal cord lesion.
- Duration: Usually persists for 24 hours but can last up to 1-4 weeks.
- As shock diminishes: Neurons regain excitability, and the effects of upper motor neuron loss become evident.
- Hypotension in spinal shock: Typically accompanied by bradycardia due to loss of cardiac sympathetic efferents and unopposed vagal tone.
- Neurogenic pulmonary edema: Common in patients with cervical spinal cord lesions.
Management
- Volume resuscitation: Cannot solely be guided by physical findings, as hypotension and bradycardia persist regardless of the volume of saline or colloid administered.
- Replace missing adrenergic tone: Use α-agonists (phenylephrine or norepinephrine, depending on heart rate).
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Spinal Perfusion Pressure Management:
- Aims to prevent cord ischemia by raising blood pressure, based on the concept of cerebral perfusion pressure management and the assumption that similar secondary injury mechanisms worsen spinal cord injury outcome.
Early Management
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ABCs:
- If intubation is required, use in-line stabilization.
- Direct laryngoscopy vs. fiberoptic.
- Maintain blood pressure with volume, packed RBCs, and vasopressors as needed.
- Prevent secondary injury: Log-rolling.
- Concomitant head injury: Evaluate for potential head injury.
Pharmacologic Management
- Methylprednisolone: 30 mg/kg bolus, then 5.4 mg/kg/h for 23–47 hours depending on the time elapsed from injury.
- Debate about efficacy: It is the current ‘standard of care’ despite ongoing debate about its effectiveness.
Blood Pressure Management
- No standards or guidelines:
- Avoid or correct hypotension: Systolic BP < 90 mmHg.
- Maintaining MAP between 85 and 90 mmHg: Recommended for the first seven days.
Acute Non-Traumatic Spinal Cord Injuries
- **Causes: ** Disc herniation, tumor, infection, hemorrhage, and iatrogenic injury.
Cervical Disc with Myelopathy
- Clinical Features: Neck pain, hand numbness, weakness, unsteadiness, hyperreflexia.
- Generally not emergent: Can be treated with surgical decompression, but typically not emergent.
Lumbar Disc with Myelopathy
- Clinical Features: Low back pain, sphincter disturbance (retention, incontinence, rectal tone), saddle anesthesia, radicular symptoms (pain, weakness affecting multiple nerve roots).
Spinal Metastases
- Clinical Features: Back pain in patients known to have cancer.
- Prevalence: 10% of cancer patients.
- Common primary sites: Lung, breast, GI, prostate, melanoma, lymphoma, kidney.
Spinal Epidural Abscess
- Clinical Features: Back pain, fever, tenderness.
- Susceptible populations: Patients with diabetes, IV drug abuse, chronic renal failure, etc.
- WBC may be normal: Important to consider.
Iatrogenic Spinal Cord Injuries
- Causes: Surgical procedures, injections, and other treatments for different health conditions.
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Description
This quiz covers the essential aspects of spinal cord injuries (SCI), including their causes, epidemiology, and signs and symptoms. Gain insights into the impacts of SCI on function and associated comorbidities. Perfect for those studying health sciences or rehabilitation.
