This document discusses the clinical manifestations and management of acute spinal cord injury. It begins with an introduction that defines spinal cord injury and discusses epidemiology and common causes. It then covers the clinical manifestations of complete and incomplete spinal cord injuries at different levels. The management section addresses pre-hospital care, hospital evaluation including history, exam, and imaging, as well as treatment approaches like surgical decompression and rehabilitation. Complications of spinal cord injury are also briefly mentioned.

1. DISCUSS THE CLINICAL
MANIFESTATIONS AND
MANAGEMENT OF ACUTE
SPINAL CORD INJURY
Dr. Arojuraye S.A
National Orthopaedic Hospital
Dala - Kano
23/04/2015

2. Outline
 Introduction
 Clinical Manifestations
 Management
 History
 Physical Examination
 Investigations
 Treatment
 Non-operative
 Operative
 Complications
 Conclusion
 References

3. Introduction
 Definition:
SCI is defined as damage to the spinal cord, resulting in
transient or permanent loss of usual sensory, motor &
autonomic functions.
 SCI is a medically complex and life-disrupting & frustrating
clinical condition.
 SCI rarely occurs in isolation:
 80% have concurrent multiple system injuries
 41% have associated head injury

4. Introduction…
 Epidemiology:
 10,000 cases per year in the United States
 M:F = 4:1
 Traumatic SCI is common < 40yrs
 5% of SCI occur in children
SCIWORA is common in children (immature skeleton)

5. Introduction…
 Management is multidisciplinary
 ∆ morbidity & mortality
 Functional, medical & social burdens
 Improved rehabilitation & spinal stabilization
 Regain mobility
 Improve quality of life
 Achieve prolonged survival
NO cure for complete paralysis!

6. Introduction…
 Aetiology:
 MVA
 Fall
 Violence
 Blast injuries
 Sports e.g diving
 Mechanisms:
 Direct trauma
 Bone fragments
 Hematoma
 Disc prolapse
 Spinal arteries damage

7. Introduction…
 Common site of SCI
 Cervical (50% to 64%)
 Lumbar (20% to 24%)
 Thoracic cord (17% to 19%)
 Most common vertebrae involved are C5, C6, C7, T12, and L1
Cervical injuries are more often incomplete neurologic
deficits, whereas thoracic injuries are more often complete

8. Anatomy
Spinal cord:
 Foramen magnum  L1/L2.
 Gray matter: central
 White matter: peripheral
 Dorsal (sensory) & ventral (motor) roots
 spinal nerves
 31 pairs of spinal nerves:
8 cervical, 12 thoracic, 5 lumbar, 5
sacral & 1 coccygeal

9. Anatomy…

10. Anatomical Levels
 Cervical spine
 Segmental level of cord transection corresponds to the
level of bony damage.
 T1 and T10 vertebrae
 The first lumbar cord segment in the adult is at the
level of the T10.
 Cord transection at that level spares the thoracic cord.

11. Anatomical Levels…
 Below T10 vertebra
 The cord forms conus
medullaris between T10
& L1 vertebrae & tapers
to end at the L1/L2.
 The L2 to S4 nerve roots
arise from the conus
medullaris & stream
downwards in a bunch
(cauda equina) to emerge
at successive levels of the
lumbosacral spine.

12. Clinical Manifestations
Complete paralysis of:
 Motor
 UMN
 LMN
 Sensory
 pain, temperature, touch
 Position & discrimination
 Autonomic
 Vasomotor control
(above T5)
 Temperature control
Incomplete
 Anterior cord syndrome
 Central cord syndrome
 Posterior cord syndrome
 Brown – sequard syndrome

13. Clinical Manifestations…
Central Cord Syndrome
 Due to hyperextension of C-spine
 Disproportional greater UL weakness
 Sensory loss is usually minimal
 Some control over the bowel & bladder
 Recovery is possible

14. Clinical Manifestations…
Anterior Cord Syndrome
 Due to compression of anterior SC
 Damage to corticospinal & spinothalamic tract
 Impaired pain, temperature & touch sensations
 Pressure & position sensation may be preserved
 Motor paralysis
 Some recovery is possible

15. Clinical Manifestations…
Brown-Sequard Syndrome
 Hemisection of the SC.
 Ipsilateral
 Impaired or loss of movement
 Preserved pain and temperature sensation
 Contralateral
 Normal movement,
 Impaired pain & temp. sensation

16. Clinical Manifestations…
Posterior Cord Syndrome
 Damage is towards the back of the spinal cord.
 Good muscle power, pain & temperature sensation
 Difficulty in coordinating movement of the limbs.

17. Clinical Manifestations…
Conus medullaris syndrome
 Bladder dysfunction
 Bowel dysfunction
 Sexual dysfunction
 Low back pain
 Unilateral or bilateral leg pain
 Diminished rectal tone

18. Clinical Manifestations…
Caudal equina syndrome
 Injury to nerve roots
 Muscle weakness
 Decreased sensation
 Decreased bowel & bladder control

19. Clinical Manifestations…
Neurogenic Shock
 Seen in cervical injuries
 Due to interruption of the sympathetic input from hypothalamus
 Hallmark:
 Hypotension
 Bradycardia
 Avoid over-enthusiastic use of IVF
 Rx: Atropine & vasopressors

20. Clinical Manifestations…
Spinal Shock
 Temporary complete cessation of spinal cord function
 Occurs immediately after injury
 Complete loss of all reflexes
 Flaccidity of all muscles
 Duration:
 Rarely last for > 48hrs
 May be delayed up to 6–8 weeks

21. Clinical Manifestations…
Hypovolaemic shock
 Tachycardia
 Peripheral shutdown
 Hypotension

22. Clinical Manifestations…

23. Clinical Manifestations…
Frankel Classification of SCI
 A. Complete: Absent motor & sensory function
 B. Sensation present, motor power absent
 C. Sensation present, motor power not useful
 D. Sensation present, motor power present & useful
 E. Normal Sensory & Motor
Frankel observed that 60% of patients with partial cord lesions
improved spontaneously by one grade regardless of the
treatment type & a significant number are able to walk again.

24. Clinical Manifestations…
ASIA Classification
 A. Complete: No sensory or motor function preserved in the
sacral segments S4 & S5
 B. Incomplete: Sensory but not motor function preserved
below neurological level including S4 and S5
 C. Incomplete: Sensory and motor function preserved below
neurological level but more than half of the muscles have a
grade of 3/5 or less
 D. Motor function preserved below neurological level and at
least half of muscles have better than grade 3/5 function
 E. Normal motor and sensory function

25. Management
Pre-hospital care
 All trauma patients are at risk of SCI
 Proper extrication & immobilization of the C – spine
 Cervical collar, sandbags
 Fore-head Tape & spine board
 Transportation
 Log-rolling
 Avoid cervical extension
 To level I trauma centre

26. Management…
Hospital care
 ATLS Protocol
 Primary survey: ABCDE
 Secondary survey
Inappropriate movement
& examination can
irretrievably change the
outcome for the worse!

27. Clinical History
 High index of suspicion
Every patient with a blunt
injury above the clavicle or
a head injury (Cervical)
Every patient who fall from
a height or a high-speed
deceleration accident
(Thoracolumbar)
 Mechanism of injury
 Initial care
 Change in neurologic status
Document Findings

28. Physical Examination
 Head, neck & back
Bones & soft tissues are
gently palpated for
tenderness, bogginess or
increased space btw the
spinous processes.
 Neurological Examination
 Dermatome
 Myotome
 Reflexes
 Rectal examination(mandatory)
 Complete
 Incomplete

29. Physical Examination…

30. Physical Examination…
 C5: Elbow flexors
 C6: Wrist extensors
 C7: Elbow extensors
 C8: Finger flexors
 T1: 5th digit abductors
 L2: Hip flexors
 L3: Knee extensors
 L4: Ankle dorsiflexors
 L5: Big toe extensors
 S1: Ankle plantarflexors

31. Physical Examination…
 Deep Tendon Reflexes
 Arm
 Bicipital: C5
 Styloradial: C6
 Tricipital: C7
 Leg
 Patellar: L3, some L4
 Achilles: S1
 Pathological reflexes
 Babinski (UMN lesion)
 Hoffman (UMN lesion at
or above cervical spinal
cord)
 Clonus (long standing
UMN lesion)

32. Level of Injury
 Motor level
 The last level with at least 3/5 function
 This is the most important for clinical purposes
 Sensory level
 The last level with preserved sensation
 Radiographic level
 The level of fracture on plain X-rays / CT scan / MRI

33. Diagnostic Tests…
X-ray
 Indication: Neck or back pain following trauma
 Head or severe facial injuries (C-spine)
 Rib # or seat-belt bruising (Thoracic spine)
 Severe pelvic or abdominal injuries (Thoracolumbar)

34. Diagnostic Tests…
CT Scan
 Good in acute situations
 Shows bone very well
 Soft tissues are poorly visualized
 Avoid contrast in trauma patients

35. Diagnostic Tests…
MRI
 Usually not done as emergency
 Method of choice for
 IVD
 Ligamentum flavum
 Neural structures
 Indicated for patients with
 Neurological sign
 For surgery

36. Treatment
Goal of treatment
 Prevention of further injury
 Reduction & stabilization of bony injury
 Prevention of complications
 Rehabilitation

37. Treatment…
 Prevent hypotension
 Volume expander
 Vasoressors
 Atropine
 Maintain oxygenation
 O2 supplement
 If intubation is needed,
do NOT move the neck
Hypotension & hypoventilation
immediately following an
acute traumatic SCI is not
only life threatening but may
increase neurological
impairment!

38. Treatment…
 NGT to suction
 Prevents aspiration
 Decompresses the abdomen
(Ileus is common)
 Foley’s catheter
 Prevent bladder over
distention.
 Methylprednisolone
 Within 8 hours of injury
 Exclusion criteria
 Cauda equina
syndrome
 Pregnancy
 Age < 13 years
 Patient on steroids

39. Skull Traction
Gardner-Wells tongs
Crutchfield caliper
 Temporary stability of the cervical spine
 Weight: 5lb/level, start with 3lb/level, not exceed 10lb/level)
 Cervical collar can be removed while patient is in traction
 Pin care
 X-rays at regular intervals & after every move from bed

40. Halo vest, Minerva vest & jacket

41. Lumbar corset & Cast

42. Other Minerva orthosis

43. Surgical Decompression…
Indications:
 Deteriorating neurological status
 Caudal equina syndrome(Emergency)
 Compression of the cord is evident on MRI
 Penetrating cord injuries
 Gunshot injuries
 Bony fragments in the spinal canal
 Unstable vertebral body

44. Surgical Decompression
Timing
 Emergent
 Incomplete lesions with progressive neurologic deficit
 Caudal equina syndrome
 Elective
 Complete lesions
 Presence of life threatening conditions

45. Treatment…
 Skin care
 Creases & crumbs in bed
 2hrly turning, Special bed
 Dry & powdered
 Bladder & Bowel care
 Intermittent catheterization
 Continuous closed drainage
 Bladder training
 Enema, laxatives
 Muscles & Joints
 Passive ROM
 Splints & Calipers
 Psychological support
 Doctors
 Physiotherapist
 Nurses

46. Complications
 Pressure sores
 Pneumonia
 Osteoporosis & fractures
 Heterotrophic ossification
 Spasticity
 Urinary tract infection
 Autonomic dysreflexia
 Deep venous thrombosis
 Orthostatic hypotension
 Thermal instability

47. Prevention of SCI
When SCI follows a traumatic incident, the transition is often
from good health to permanent disability in a matter of seconds.
The good news is that a large proportion of these injuries are
preventable.
 Primary prevention
 Avoid the cause
 Secondary prevention
 Prompt diagnosis & Rx
 Tertiary prevention
 Proper rehabilitation

48. Recent Advances
“Get up! Pick up your mat and walk"
 A cure for SCI while it is not yet available, is conceivable.
 Regeneration Therapy
transplanting of fetal tissue into the injured spinal cord in
hopes of regenerating the damaged tissue
 Recently, four young men in the US who had been paralyzed
for years were able to voluntarily move their legs as a result of
epidural electrical stimulation of the spinal cord.

49. Conclusion
 SCI is commonly caused by MVA, falls and violence.
 It disconnect the communication channel between the brain
and the body, causing functional problems like sensory loss,
neuropathic pain and lifetime paralysis.
 Multidisciplinary management approach is a key to promising
outcome
 The most important – and sometimes frustrating – thing to
know is that each person’s recovery from SCI is different.

50. References
 Stephen Eisenstein, Wagih El Masry. Injuries of the spine. Apley's System
of Orthopaedics & Fractures 9th Edition. Hodder Arnold 2010; 806– 28.
 Andrew H. Kaye. Spinal injuries. Essential Neurosurgery. 3rd Edition.
Chapter 16: Blackwell Publishing Ltd 2005; 225 – 34.
 Sohail K, Carlo B, Jens R. Principles of Spine Trauma Care. Rockwood &
Green's Fractures in Adults, 6th Edition. 2006; Chapter 37.
 David Grundy, Andrew Swain. ABC of spinal cord injury. 4th Edition.
 Jerome Bickenbach, Alana Officer, Tom Shakespeare, Per von Groote.
International Perspectives on Spinal Cord Injury. The international spinal
cord society(ISCOS). World health organization (WHO) 2013.