1. The document discusses various types of spinal cord injuries including complete injuries which involve a complete loss of motor and sensory function below the level of injury, and incomplete injuries which partially compromise spinal cord function with some sensation and muscle movement retained below the injury site. 2. It provides details on specific spinal cord syndromes like anterior cord syndrome, Brown-Séquard syndrome, and central cord syndrome which are characterized by variable patterns of motor and sensory loss. 3. The management of spinal cord injuries involves stabilizing the spine, treating shock, addressing airway and breathing issues, screening for associated injuries, and preventing complications like pressure sores through regular turning of immobilized patients.

1. SPINAL CORD
INJURIES (2)
BALQEES MAJALI.

3. Complete VS Incomplete injuries
 Complete injuries :
A complete cord syndrome is characterized clinically as complete loss of
motor and sensory function below the level of the traumatic lesion.
In the days immediately following your spinal cord injury, the symptoms
of a complete and incomplete spinal cord injury are virtually
indistinguishable. Over time, though, small differences may begin to
emerge.
Those characteristics include:
-Loss of sensation below the site of the injury.
-Complete loss of motion below the site of the injury.
-Difficulty controlling bladder and bowels.
-If the injury is high enough in the spinal cord, difficulty breathing on
patients own.

4.  Incomplete :
With an incomplete spinal cord injury, the spinal cord's functions
are only partially compromised.The effects of an incomplete
spinal cord injury, then, vary more widely.
Some characteristics of an incomplete spinal cord injury include:
-Retaining some sensation below the site of the injury.
-The feelings may come and go, and may be much weaker than
the sensations you used to experience.
-Being able to move some muscles below the site of the injury.
-The extent of movement may vary, and the patient may have
good control over some muscles, but no control over others.
-Pain below the injury; many incomplete spinal cord injury
survivors report issues with chronic pain.

5. Anterior cord syndrome involves a lesion causing variable loss of motor
function and pain and/or temperature sensation, with preservation of
proprioception
Brown-Séquard syndrome, which is often associated with a
hemisection lesion of the cord, involves a relatively greater ipsilateral
loss of proprioception and motor function, with contralateral loss of
pain and temperature sensation
Central cord syndrome usually involves a cervical lesion, with greater
motor weakness in the upper extremities than in the lower extremities,
with sacral sensory sparing.The pattern of motor weakness shows
greater distal involvement in the affected extremity than proximal
muscle weakness. Sensory loss is variable, and the patient is more likely
to lose pain and/or temperature sensation than proprioception and/or
vibration. Dysesthesias, especially those in the upper extremities (eg,
sensation of burning in the hands or arms), are common.

7. Other cord syndromes
Conus medullaris syndrome is a sacral cord injury, with or without involvement
of the lumbar nerve roots.This syndrome is characterized by areflexia in the
bladder, bowel, and to a lesser degree, lower limbs, whereas the sacral
segments occasionally may show preserved reflexes (eg, bulbocavernosus and
micturition reflexes). Motor and sensory loss in the lower limbs is variable.
Cauda equina syndrome involves injury to the lumbosacral nerve roots in the
spinal canal and is characterized by an areflexic bowel and/or bladder, with
variable motor and sensory loss in the lower limbs. Because this syndrome is a
nerve root injury rather than a true spinal cord injury, the affected limbs are
areflexic. Cauda equina syndrome is usually caused by a central lumbar disk
herniation
A spinal cord concussion is characterized by a transient neurologic deficit localized to the
spinal cord that fully recovers without any apparent structural damage.

8. Neurogenic shock
Neurogenic shock refers to the hemodynamic
triad of hypotension, bradycardia, and peripheral
vasodilation resulting from severe autonomic
dysfunction and the interruption of sympathetic
nervous system control in acute spinal cord injury.
Hypothermia is also characteristic.
This condition does not usually occur with spinal cord
injury below the level ofT6 but is more common in
injuries aboveT6, secondary to the disruption of the
sympathetic outflow fromT1-L2 and to unopposed
vagal tone, leading to a decrease in vascular
resistance, with the associated vascular dilatation.

9. Spinal shock
spinal shock is defined as the complete loss of all
neurologic function, including reflexes and rectal tone,
below a specific level that is associated with
autonomic dysfunction.That is, spinal shock is a state
of transient physiologic (rather than anatomic) reflex
depression of cord function below the level of injury,
with associated loss of all sensorimotor functions.
An initial increase in blood pressure due to the release
of catecholamines, followed by hypotension, is noted.
Flaccid paralysis, including of the bowel and bladder, is
observed, and sometimes sustained priapism
develops.These symptoms tend to last several hours
to days until the reflex arcs below the level of the
injury begin to function again (eg, bulbocavernosus
reflex, muscle stretch reflex [MSR])

10. History and physical examination
 As with all trauma patients, initial clinical evaluation of
a patient with suspected spinal cord injury (SCI) begins
with a primary survey.The primary survey focuses on
life-threatening conditions. Assessment of airway,
breathing, and circulation (ABCs) takes precedence.A
spinal cord injury must be considered concurrently.
 Perform careful history taking, focusing on symptoms
related to the vertebral column (most commonly pain)
and any motor or sensory deficits.Ascertaining the
mechanism of injury is also important in identifying the
potential for spinal injury.
 The axial skeleton should be examined to identify and
provide initial treatment of potentially unstable spinal
fractures from both a mechanical and a neurologic
basis.

11. Pulmonary evaluation
• The clinical assessment of pulmonary function in acute spinal cord
injury begins with careful history taking regarding respiratory
symptoms and a review of underlying cardiopulmonary comorbidity
such as chronic obstructive pulmonary disease (COPD) or heart failure
• Carefully evaluate respiratory rate, chest wall expansion, abdominal
wall movement, cough, and chest wall and/or pulmonary injuries.
Arterial blood gas (ABG) analysis and pulse oximetry are especially
useful, because the bedside diagnosis of hypoxia or carbon dioxide
retention may be difficult.
• The degree of respiratory dysfunction is ultimately
dependent on preexisting pulmonary comorbidity, the level
of the spinal cord injury, and any associated chest wall or
lung injury

12. • vital capacity is only 5-10% of normal, and cough is
absent
high lesions
(ie, C1 or C2)
• vital capacity is 20% of normal, and cough is weak
and ineffective
lesions at
C3 through C6
• vital capacity is 30-50% of normal, and cough is
weak
high thoracic cord
injuries
(ie,T2 throughT4)
• respiratory function improveslower cord injuries
• respiratory dysfunction is minimal; vital capacity is
essentially normal, and cough is strong.
injuries atT11,

13. Hemorrhage, hypotension, and
hemorrhagic and neurogenic shock
In all patients with spinal cord injury and
hypotension, a diligent search for sources of
hemorrhage must be made before hypotension is
attributed to neurogenic shock. In acute spinal
cord injury, shock may be neurogenic,
hemorrhagic, or both.

14. Neurogenic shock occurs only in the presence of acute spinal
cord injury aboveT6; hypotension and/or shock with acute
spinal cord injury at or belowT6 is caused by hemorrhage
Hypotension with a spinal fracture alone, without any
neurologic deficit or apparent spinal cord injury, is invariably
due to hemorrhage
The presence of vital sign confusion in acute spinal cord injury
and a high incidence of associated injuries requires a diligent
search for occult sources of hemorrhage
Patients with a spinal cord injury aboveT6 may not have the
classic physical findings associated with hemorrhage (eg,
tachycardia, peripheral vasoconstriction); this vital sign
confusion attributed to autonomic dysfunction is common in
spinal cord injury
Howtodifferentiate

15. Workup

16. Labs
 Arterial blood gas (ABG) measurements may
be useful to evaluate adequacy of oxygenation
and ventilation
 Lactate levels to monitor perfusion status can
be helpful in the presence of shock
 Hemoglobin and/or hematocrit levels may be
measured initially and monitored serially to
detect or monitor sources of blood loss
 Urinalysis can be performed to detect any
associated genitourinary injury

17. Imaging
 Diagnostic imaging traditionally begins with the acquisition of
standard radiographs of the affected region of the spine.
Investigators have shown that computed tomography (CT) scanning
is exquisitely sensitive for the detection of spinal fractures and is cost
effective. In many centers, CT scanning has supplanted plain
radiographs.
 A properly performed lateral radiograph of the cervical spine that
includes the C7-T1 junction can provide sufficient information to
allow the multiple trauma victim to proceed emergently to the
operating room if necessary without additional intervention other
than maintenance of full spinal immobilization and a hard cervical
collar.
 Noncontiguous spinal fractures are defined as spinal fractures
separated by at least 1 normal vertebra. Noncontiguous fractures are
common and occur in 10-15% of patients with spinal cord injury.
Therefore, once a spinal fracture is identified, the entire axial
skeleton must be imaged, preferably by CT scanning, to assess for
noncontiguous fractures

18. Plain radiography
The standard 3 views of the cervical spine are recommended in patients with
suspected spinal cord injury (SCI): anteroposterior (AP), lateral, and odontoid
The cervical spine radiographs must include the C7-T1 junction to be considered
adequate. Subtle findings (eg, increased prevertebral soft tissue swelling or
widening of the C1-C2 preodontoid space) indicate potentially unstable
cervical spine injuries that could have serious consequences if they are not
detected.
Dynamic flexion/extension views are safe and effective for detecting
occult ligamentous injury of the cervical spine in the absence of fracture
Anteroposterior and lateral views of the thoracic and lumbar spine are
recommended for suspected injuries to the thoracolumbar spine.

19. Computed tomography scanning
Perform CT scanning in the following situations:
When plain radiography is inadequate or fails to visualize segments of the axial
skeleton
Convenience and speed: If a CT scan of the head is required, then it is usually
simpler and faster to obtain a CT of the cervical spine at the same time.
Similarly, CT images of the thoracic or lumbar spine might be easier and
faster to obtain than plain radiographs
To provide further evaluation when radiography depicts suspicious and/or
indeterminate abnormalities
When radiography depicts fracture or displacement, CT scanning provides better
visualization of the extent and displacement of the fracture

21. MRI
 Magnetic resonance imaging (MRI) is best for
suspected spinal cord lesions, ligamentous injuries,
or other soft-tissue injuries or pathology.This
imaging modality should be used to evaluate
nonosseous lesions, such as extradural spinal
hematoma; abscess or tumor; disk rupture; and
spinal cord hemorrhage, contusion, and/or edema.
 Neurologic deterioration is usually caused by
secondary injury, resulting in edema and/or
hemorrhage. MRI is the best diagnostic image to
depict these changes.

23. Management

24. Approach Considerations
Admit all patients with an acute spinal cord injury (SCI). Depending on the level of
neurologic deficit and associated injuries, the patient may require admission to the
intensive care unit (ICU), neurosurgical observation unit, or general ward.
The most common levels of injury on admission are C4, C5 (the most common), and
C6, whereas the level for paraplegia is the thoracolumbar junction (T12).The most
common type of injury on admission isAmerican Spinal InjuryAssociation (ASIA) level
A
Transfer
Depending on local policy, patients with acute spinal cord injury are best treated at a regional
spinal cord injury center.Therefore, once stabilized, early referral to a regional spinal cord injury
center is best.The center should be organized to provide ongoing definitive care.
Other reasons to transfer the patient include the lack of appropriate diagnostic imaging
(computed tomography [CT] scanning or magnetic resonance imaging [MRI]) and/or inadequate
spine consultant support (orthopedist or neurosurgeon).
Consultations
Consultation with a neurosurgeon and/or an orthopedist is required, depending on local
preferences. Because most patients with spinal cord injury have multiple associated injuries,
consultation with a general surgeon or a trauma specialist as well as other specialists may also
be required.

25. Prehospital management
 Most prehospital care providers recognize the need to
stabilize and immobilize the spine on the basis of
mechanism of injury, pain in the vertebral column, or
neurologic symptoms. Patients are usually transported
to the emergency department (ED) with a cervical hard
collar on a hard backboard. Commercial devices are
available to secure the patient to the board.
 The patient should be secured so that in the event of
emesis, the backboard may be rapidly rotated 90°
while the patient remains fully immobilized in a neutral
position. Spinal immobilization protocols should be
standard in all prehospital care systems.

26. Emergency department management
 Most patients with spinal cord injuries (SCIs) have
associated injuries. In this setting, assessment and
treatment of airway, respiration, and circulation
(ABCs) takes precedence.
 The patient is best treated initially in the supine
position. Occasionally, the patient may have been
transported prone by the prehospital care
providers. Logrolling the patient to the supine
position is safe to facilitate diagnostic evaluation
and treatment. Use analgesics appropriately and
aggressively to maintain the patient's comfort if he
or she has been lying on a hard backboard for an
extended period.

28. Airway
The cervical spine
must be maintained
in neutral alignment
at all times.
Clearing of oral
secretions and/or
debris is essential to
maintain airway
patency and to
prevent aspiration
The modified jaw
thrust and insertion
of an oral airway may
be all that is required
to maintain an
airway in some cases
However, intubation may be required in
others. Failure to intubate emergently
when indicated because of concerns
regarding the instability of the patient's
cervical spine is a potential pitfall.

29. Hypotension, hemorrhage and shock
The most common sources of occult
hemorrhage are injuries to the chest, abdomen,
and retroperitoneum and fractures of the pelvis or
long-bones. Appropriate investigations, including
radiography or computed tomography (CT)
scanning, are required. In the unstable patient,
diagnostic peritoneal lavage or bedside FAST
(focused abdominal sonography for trauma)
ultrasonographic study may be required to detect
intra-abdominal hemorrhage.

30. Treatment of neurogenic shock
initial treatment of neurogenic shock focuses
on fluid resuscitation.
Judicious fluid replacement with isotonic
crystalloid solution to a maximum of 2 L is the
initial treatment of choice.
Overzealous crystalloid administration may cause
pulmonary edema, because these patients are at
risk for the acute respiratory distress syndrome
(ARDS).

31. Our goals are
1. A systolic blood pressure (BP) of 90-100 mm Hg should be achieved; systolic BPs
in this range are typical for patients with complete cord lesions.Compelling animal
and human studies recommend maintenance of systolic BP above 90 mm Hg and to
avoid any hypotensive episodes
2.The most important treatment consideration is to maintain adequate
oxygenation and perfusion of the injured spinal cord; supplemental oxygenation
and/or mechanical ventilation may be required
3. Heart rate should be 60-100 beats per minute (bpm) in normal sinus rhythm
4. Hemodynamically significant bradycardia may be treated with atropine
5. Urine output should be more than 30 mL/h; placement of a Foley catheter to
monitor urine output and to decompress the neurogenic bladder is essential
6. Rarely, inotropic support with dopamine or norepinephrine is required; this should
be reserved for patients who have decreased urinary output despite adequate fluid
resuscitation; usually, low doses of dopamine in the 2- to 5-mcg/kg/min range are
sufficient
7. Prevent hypothermia

32. Head injuries and neurologic
evaluation
Associated head injury occurs in about 25% of
patients with spinal cord injury. A careful neurologic
assessment for associated head injury is
compulsory.
The presence of amnesia, external signs of head
injury or basilar skull fracture, focal neurologic
deficits, associated alcohol intoxication or drug
abuse, and a history of loss of consciousness
mandates a thorough evaluation for intracranial
injury, starting with noncontrast head CT scanning.
 GCS

33.  Ileus
Ileus is common. Placement of a nasogastric (NG)
tube is essential. Aspiration pneumonitis is a serious
complication in the patient with a spinal cord injury
with compromised respiratory function (see
Antiemetics should be used aggressively.
 Pressure sores
Prevent pressure sores. Denervated skin is particularly
prone to pressure necrosis.Turn the patient every 1-2
hours. Pad all extensor surfaces. Undress the patient
to remove belts and back pocket keys or wallets.
Remove the spine board as soon as possible

34. Medications

35. Steroid therapy
The National Acute Spinal Cord Injury Studies (NASCIS) II and III,
[42, 43] a Cochrane Database of Systematic Reviews article of all
randomized clinical trials, and other published reports, have verified
significant improvement in motor function and sensation in
patients with complete or incomplete spinal cord injuries (SCIs) who
were treated with high doses of methylprednisolone within 8 hours
of injury.
The current recommendation is to treat all patients with spinal
cord injury according to the local/regional protocol. If steroids
are recommended, they should be initiated within 8 hours of
injury with the following steroid protocol: methylprednisolone 30
mg/kg bolus over 15 minutes and an infusion of
methylprednisolone at 5.4 mg/kg/h for 23 hours beginning 45
minutes after the bolus.

36. Analgesics
Pregabalin (Lyrica):
Indicated for neuropathic pain associated with
spinal cord injury.The precise mechanism of action
is unknown but is a GABA analog which binds to a
subunit of voltage-gated calcium channels in CNS.
It does not affect sodium channels, opiate
receptors or cyclooxygenase enzyme activity. Its
interactions with descending noradrenergic and
serotonergic pathways originating from the
brainstem appear to reduce neuropathic pain
transmission from the spinal cord.

37. Treatment for pulmonary complications
 Indications for intubation in spinal cord injury are:
- acute respiratory failure
- decreased level of consciousness (Glasgow score < 9)
- increased respiratory rate with hypoxia
-partial pressure of carbon dioxide (PCO2) greater than 50
mm Hg, and vital capacity less than 10 mL/kg
 In the presence of autonomic disruption from cervical or
high thoracic spinal cord injury, intubation may cause
severe bradyarrhythmias from unopposed vagal
stimulation. Simple oral suctioning can also cause
significant bradycardia. Preoxygenation with 100% oxygen
may be preventive.Atropine may be required as an
adjunct.Topical lidocaine spray can minimize or prevent
this reaction.

38. Surgical intervention
Emergent decompression of the spinal cord is
suggested in the setting of acute spinal cord injury
with :
 progressive neurologic deterioration
 facet dislocation
 bilateral locked facets.
 spinal nerve impingement with progressive
radiculopathy
 patients with extradural lesions such as epidural
hematomas or abscesses or in the setting of the
cauda equina syndrome.

39. Evidence
A prospective surgical trial, the Surgical Treatment for Acute Spinal Cord Injury
Study (STASCIS) conducted by the Spine Trauma Study Group, is ongoing.
Preliminary data from this study are showing that 24% of patients who receive
decompressive surgery within 24 hours of their injury experience a 2-grade or
better improvement on the ASIA scale, compared with 4% of those in the delayed-
treatment group. Furthermore, the study found that cardiopulmonary and urinary
tract complications were found to be 37% in the early surgery group compared
with the delayed group rate of 48.6%. The hope is that the final data from STASCIS
will better define the benefits and timing of early surgical decompression and
stabilization.

40. Complications

41. Neurologic deterioration :
The neurologic deficit of spinal cord injury (SCI) often increases during the hours to
days following acute injury, despite optimal treatment.
One of the first signs of neurologic deterioration is the extension of the sensory deficit
cephalad. Careful repeat neurologic examination may reveal that the sensory level has
risen 1 or 2 segments. Repeat neurologic examinations to check for progression are
essential.
Pressure sores :
Careful and frequent turning of the patient is required to prevent pressure sores.
Denervated skin is particularly prone to this complication. Remove belts and objects from
back pockets, such as keys and wallets.
Aspiration and pulmonary complications
Other complications :
Severe sepsis or pneumonia frequently follows treatment with high-dose
methylprednisolone that is frequently used in spinal cord injury

42. Prognosis
 Patients with a complete spinal cord injury (SCI) have a less than
5% chance of recovery. If complete paralysis persists at 72 hours
after injury, recovery is essentially zero
 In the early 1900s, the mortality rate 1 year after injury in patients
with complete lesions approached 100%. Much of the
improvement since then can be attributed to the introduction of
antibiotics to treat pneumonia and urinary tract infection (UTI).
 The prognosis is much better for the incomplete cord syndromes
 If some sensory function is preserved, the chance that the patient
will eventually be able walk is greater than 50%.
 Ultimately, 90% of patients with spinal cord injury return to their
homes and regain independence.
 Providing an accurate prognosis for the patient with an acute SCI
usually is not possible in the emergency department (ED) and is
best avoided.

43. Patient education
 As part of inpatient therapy, patients with
spinal cord injury (SCI) should receive a
comprehensive program of physical and
occupational therapy.

44. Prevention
 Many spinal cord injuries result from
incidents involving drunk driving, assaults,
and alcohol or drug abuse. Spinal cord injuries
from industrial hazards, such as equipment
failures or inadequate safety precautions, are
potentially preventable causes. Unfenced,
shallow, or empty swimming pools are known
hazards.

45. THANK YOU ..