A rapid review for post graduate general surgery residents about Traumatic spinal cord injury

1. TRAUMTIC SPINAL CORD
INJURY
Dr. Nabin Paudyal
Resident, Neurosurgery
Nobel Institute of Neurosciences

2. Introduction
• Spinal cord trauma remains one of the most devastating event often
resulting in severe and permanent disabilities
• AANS data 
• ~450,000 persons in USA have Traumatic Spinal Cord Injury (TSCI).
• ~11000 new cases are admitted to US hospitals every year.

4. Pathophysiology and Mechanism of injury
• TSCI pathophysiology can be categorized into 2 phases
• Primary injury Results from compression of spinal cord by pressure
(caused by bone fragments, blood products, soft tissues and/or
foreign bodies)
• Secondary events Vasogenic shock causing spinal ischemia
• (release of cytokines and vasoactive proteins cause inflammation and cord edema
worsen ischemia promoting cell death)
• Dying neurons release free radicals and cause oxidative damage and excitotoxicity.

5. Classification of traumatic spinal cord injury
• Universal stratification of the spinal injury and its severity is done
using American Spinal Injury Association (ASIA) scoring.
• Can present with either complete or incomplete injury to spinal cord.
• Each injury has distinct clinical features.

8. Complete Injury (ASIA-A)
• No motor and sensory function below the neurological level of injury
• NO SACRAL SPARING
• In acute settings
• Reflexes are absent, males have continuous priapism
• Urinary retention causing bladder distension may occur.
• In cervical and thoracic injury  sympathetic dysfunction including
hypotension and bradycardia

9. Incomplete injury (ASIA B through D)
• Preservation of voluntary anal contraction and bulbocavernosus reflex
• Various degrees of motor function and sensation caudal to the level of
injury
• Sensation is preserved to a greater extent than motor function.

10. Types of incomplete spinal injury
• Central cord syndrome
o Incomplete pattern of injury
oMechanism hyperextension injury
which is exacerbated by pre-existing
cervical spondylosis and/or cervical canal
stenosis
o Features
o  greater motor impairment in upper limbs
compared to lower
o bladder dysfunction
o variable degree of caudal sensory loss

11. Types of incomplete spinal injury
• Anterior cord syndrome
o Incomplete pattern of injury
oMechanism injury affecting the anterior
two thirds of the spinal cord often
secondary to anterior spinal artery injury
caused by vascular occlusion or ligation
oCorticospinal tracts, spinothalamic tracts
and descending autonomic tracts are
involved
o Features
o Complete motor paralysis
o Loss of pain and temperature

12. Types of incomplete spinal injury
• Lateral hemi section/ Hemi cord
syndrome/ Brown-Sequard syndrome
oUnilateral damage to the dorsal column/
corticospinal tract and spinothalamic tract
o Mechanism Ballistic and penetrating
injuries.
oFeatures
o ipsilateral weakness, loss of vibration and
proprioception
o  contralateral loss of pain and temperature
sensation two spinal levels below the injured
level

13. Spinal shock
• Condition immediately following spinal cord injury.
• Caused by physiologic insult rather than anatomic insult characterized by
reflex depression of spinal cord function.
• Transient and temporal course  Gradual return of ano-cutaneous reflex,
plantar reflex.
• Transient loss of complete spinal cord function below the level of injury
with unremarkable imaging.
• Pathophysiology: Loss of potassium within injured cells transient
weakness
• May be concurrent with neurogenic shock features of hypotension,
hypothermia and bradycardia

14. Management of spinal trauma
[ A polytraumatized patient should be assumed to have spinal trauma until
otherwise.]

15. Evaluation- In the field
• History of unconsciousness/ spinal cord trauma cervical
precautions using cervical collar
• Airway, Breathing, Circulation.
• Rapid transfer to trauma center.

16. In the trauma bay
• Reassess patient’s airway, breathing and circulation
• Vitals monitoring Keep targeted MAP between 85-90
• Trauma series CT  CT C-spine (with/without contrast), Contrast CT
chest and abdomen. Plain radiographs may be used
• Head and neck injury suspects  CT head with CT angiography of
brain (Rule out atlanto-occipital / atlanto-axial injury, C-spine
fracture)

18. Role of MRI in spinal trauma
• In cases where no spinal fracture is present MRI enables to
demonstrate spinal cord/ edema/ occult ligamentous injury
• MRI enables localizing hematoma, identifying ligamentous integrity,
traumatic disc herniation, degree of spinal stenosis
• Limitations less widely available, time for investigation, inability to
use in patient with metals.

19. • MRI should be used in all patients with spinal cord injury to help guide management
• MRI should be used in all patients with spinal cord injury to help guide prognostication.
• All MRI done should be sagittal T2 sequence.

20. Medical Management
Cardiovascular complication
• CVS complications require prompt medical
attention to prevent neurologic compromise
and morbidity
• Spinal injuries at T6 or above  autonomic
dysreflexia (hypotension, cardiac arrhythmia)
• Manage and prevent hypotension. Fluid
resuscitation and vasopressors may be used.
Target MAP > 85 to 90 mmHg for 7 days.
(Walter et al)
• If vasopressor required  Dopamine
followed by Norepinephrine can be used.
Management of Spinal Cord Injury

21. Respiratory complications
• Cervical trauma owing to C3- C5 level and thoracic accessory muscle
innervation may lead to respiratory complications
• Patients with high spinal injury often require ventilatory support and
continued mechanical ventilation
• Influenza vaccination, pneumococcal vaccination is recommended in patients
with SCI
• Aggressive chest physiotherapy, deep suctioning, respiratory recruitment
maneuvers (like spirometry) are beneficial in promoting airway compliance
and clearance.

22. Role of steroids
• In patients with acute non-penetrating
TSCI Methylprednisolone is
recommended.
• NASCIS I study
• compared high dose vs low dose
methylprednisolone Result was no
difference in high dose vs low dose with
wound infection and mortality rates being
higher in high dose group (p= 0.01)

23. • NASCIS II Study
• Methylprednisolone was
administered in initial dosage of
30mg/kg followed by 5.4mg/kg/h
for 23 hours.
• Post-hoc analysis Reported
improvement of motor and
sensory scores at 6 months.
• Findings were not statistically
significant
• NASCIS III study
• In patients who arrive within 3
hours of hospital 24 hours
regimen is appropriate
• In patients who arrive within 3-8
hours after injury 48 hours
regimen should be initiated.
• Statistically not significant

24. Other studies regarding the MPSS in acute SCI
• 2012 Cochrane review overall increase in ASIA motor scores when
MPSS was used, if given within 8 hours of injury.
• 2013 AANS/CNS spine guidelines MPSS not recommended
• AOSpine 2017 expert’s panel systematic review No significant
increase in motor scores in patients receiving MPSS therapy.

25. Surgical management of spinal cord injury.
• Prompt decompression and/or fixation enhances restoration neurological
function.
• Surgery is considered in patients who are
• likely to benefit from decompression
• Mechanical stabilization
• Fracture reduction
• Deformity correction
• Mechanism, type of injury, severity of other bodily injuries and clinical
examination findings are crucial in determining the timing of intervention
needed

26. • STASCIS trial showed that early surgery (< 24 hours) showed > 2 grade
improvement in ASIA IMPAIREMENT SCORE (AIR)
• Drovak et al found improved motor recovery in patients who
underwent decompression and stabilization within 24 hours.
• Early intervention within 72 hours of injury is associated with fewer
overall complications during admission such as pneumonia, pressure
sores and UTI.
• Badhiwala et al showed that decompressive surgery within 24 hours
experienced greater recovery, higher total motor and sensory scores
and had better ASIA grades at 1 year after surgery.

27. Rehabilitation
A. Dietary rehabilitation
• Nutritionist must be involved in designing diet plans when available
• Paraplegia 28kcal/kg ; quadriplegia 23 kcal/kg
• Early feeding within 72 hours recommended if safe
• NG feeding and other feeding routes may be used if required
B. Bowel management
• High cervical injury Impairment in esophageal sphincter control may increase
the risk of GERD and lead to delayed gastric emptying with high post-feed
residuals
• Lesions above T10 Gall bladder disease increases, colonic stasis, ileus occurs
• Lesions below T10 External anal sphincter dysfunction, loss of voluntary
control  Increases bowel distention

28. • Such patients should increase daily fluid intake, increase water content of stool
and increase fiber intake
• Stool softeners Docusate, PEG given on scheduled basis
• Bulk formers, Bowel stimulants (Cisapride) can be given dosage titrated as per
condition
• Target stool passage once every alternate day. PR should be performed on a daily
basis
C. VTE/ DVT prophylaxis
• Standard of care for patients in acute stage
• Mechanical and thromboprophylaxis should be used at least for initial 2 weeks
following injury
• LMWH is the recommended drug. To be started within 72 hours of injury.
• The Spinal Cord Consortium recommends 8 weeks of pharmacologic DVT
following acute SCI
• Use of IVC filters are not recommended

29. D. Urogenital complications
• Involuntary reflux detrusor contractions mimics overflow incontinence (detrusor-sphincter
dyssynergia)
• Patients have reduced awareness of bladder filling
• Increased risk of UTI, Hydronephrosis, renal stones and post-renal kidney failure.
• Bladder scans  followed by urinary catheterization  removed for void trials
• If patients cant void themselves Self intermittent catheterization, alpha-inhibitors,
acetylcholine antagonists
• If these don’t relieve symptoms Suprapubic catheterization
E. Increased prevalence of psychiatric disorders is seen among these patients
Low threshold to offer appropriate mental health resources when needed.
F. Mobility and disposition
• Early engagement using a physiotherapist assistance with at least 20 min of activity is
recommended.
• Physical therapy rehabilitation disposition during discharge in patients requiring specialized
care

30. Investigational Therapeutic Options in Spinal
Trauma
• Spinal cord cooling Limited evidence and conflicting evidence
• Role of Gangliosides (GM1)
• Animal studies show GM1 agents induce regeneration and sprouting of neurons.
• No such human studies Not recommended.
• Electric stimulation
• Shows promising results in improving neurologic function in chronic spinal injury.
• Most studies has revolved around lumbar region to help lower extremity
function.
• Electric current stimulates neuronal outgrowths and increases excitability of
neuronal networks below the lesion.
• Novel human oscillating field stimulator has been proven safe in Phase I trial

33. Role of Riluzole in Spinal cord injury
• Secondary spinal cord damage is often attributed to uncontrolled
activation of voltage-gated sodium channels.
• Riluzole (sodium channel blocker) has been postulated as a potential
tool to reduce neuronal apoptosis in acute phase following TSCI.
• Currently on Phase III trial.

34. To Summarize

35. To Summarize

36. To Summarize

37. References
• National Center for Biotechnology Information (2022). PubChem Compound Summary for CID
5070, Riluzole. Retrieved June 4, 2022 from https://pubchem.ncbi.nlm.nih.gov/compound/Riluzole.
• Wang, T. Y., Park, C., Zhang, H., Rahimpour, S., Murphy, K. R., Goodwin, C. R., ... & Abd-El-Barr, M. M. (2021).
Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature. Frontiers in surgery, 8.
• Young W. NASCIS. National Acute Spinal Cord Injury Study. J Neurotrauma. (1990) 7:113–4. doi:
10.1089/neu.1990.7.113
• Young W, Bracken MB. The second national acute spinal cord injury study. J Neurotrauma. (1992) 9:S397–
405. doi: 10.1089/neu.1992.9.151
• Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M, Fehlings MG, Herr DL, Hitchon PW,
Marshall LF, Nockels RP. Methylprednisolone or tirilazad mesylate administration after acute spinal cord
injury: 1-year follow up: results of the third National Acute Spinal Cord Injury randomized controlled trial.
Journal of neurosurgery. 1998 Nov 1;89(5):699-706.

38. Thankyou…