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20A. Traumatic spinal cord injuries

Traumatic spinal cord injuries (TSCI) are often caused by motor vehicle accidents, falls, violence, or sport injuries. The extent of the damage depends on the level of the injury.

Spinal shock refers to transient loss of spinal cord function below the level of the injury. It may take weeks for function to return. Haemodynamic monitoring is important as it’s accompanied by hypotension, etc.

Intubation is indicated with GCS < 9 or if the injury is above C4. General supportive therapy otherwise.

Classification

As with traumatic brain injury, we can distinguish primary and secondary injuries. Primary injuries occur at the time of the injury and may be due to spinal cord compression, direct spinal cord injury, or interruption of cord blood supply. Secondary injuries occur after the initial injury, and may be due to oedema, inflammation, ischaemia, moved body fragments, etc.

We may classify them according to the pathomorphology:

  • Spinal cord concussion/contusion – temporary loss of function
  • Spinal cord compression – decompression required to reduce permanent injury
  • Spinal cord laceration – permanent injury unavoidable

We may also classify according to the severity of the spinal cord injury. These are the so-called cord syndromes:

  • Complete cord injury/transection
    • Complete paralysis and anaesthesia below the level of the injury
    • Urinary retention
    • Bulbocavernosus reflex absent
  • Incomplete cord injury
    • Variable degree of motor and sensory function below the level of the injury
    • Motor function is usually more affected because the motor tracts are located in the more vulnerable areas of the cord
    • Bulbocavernosus reflex present
    • Anterior cord syndrome
      • Due to compression of anterior spinal artery, by bone fragment, AAA, etc.
      • Dissociated sensory loss below the level of the lesion
      • Loss of motor and spinothalamic tract modalities
      • Dorsal column sensory modalities intact
    • Central cord syndrome
      • Due to hyperextension of cervical spine
      • Weakness of upper extremities
      • Normal strength in lower extremities
    • Hemisection syndrome (Brown-Sequard syndrome)
      • Ipsilateral paralysis
      • Ipsilateral loss of dorsal column sensory modalities
      • Contralateral loss of spinothalamic modalities

The deficits occur below the level of the injury. If the injury is at the cervical level, tetraparesis can occur. If above C4, respiratory arrest may occur. If at the thoracic or lumbar level, paraparesis can occur.

Spinal shock may occur, which is the reversible loss of all spinal cord function below the level of the injury. It may last hours or weeks, and it may not completely resolve.

Diagnosis and evaluation

CT is the initial imaging modality, as it shows the bony structures and any fractures. If damage to the spinal cord is suspected, MRi is performed.

Treatment

Initially, stabilisation by ABCDE is performed. It’s important to immobilise patients with suspected spinal injury, to prevent further injury. The bladder should be catheterised to prevent rupture.

Steroids can decrease the oedema of the spinal cord. In severe cases, surgery is necessary.