Spinal Cord

Injury

Dr Sanjay Gupta
Sr consultant Neurosurgeon

Goal of spine trauma care

Protect further injury during evaluation and
management
Identify spine injury or document absence of
spine injury
Optimize conditions for maximal neurologic
recovery

Goal of spine trauma care

Maintain or restore spinal alignment
Minimize loss of spinal mobility
Obtain healed & stable spine
Facilitate rehabilitation

Suspected Spinal Injury

High speed crash

Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness

Pre-hospital management
Protect spine at all times during the
management of patients with multiple injuries
Up to 15% of spinal injuries have a second
(possibly non adjacent) fracture elsewhere in
the spine
Ideally, whole spine should be immobilized in
neutral position on a firm surface

Pre-hospital
management

Cervical spine
immobilization
Transportation of
spinal cord-injured
patients

Cervical spine immobilization

Safe assumptions

Head injury and unconscious

Multiple trauma
Fall
Severely injured worker
Unstable spinal column

Hard backboard, rigid cervical collar and lateral

support (sand bag)
Neutral position

Philadelphia hard collar

Clinical assessment
Advance Trauma Life Support (ATLS)
guidelines
Primary and secondary surveys
Adequate airway and ventilation are the
most important factors
Supplemental oxygenation
Early intubation is critical to limit secondary
injury from hypoxia

Physical examination
Information
Mechanism
energy, energy

Direction of Impact
Associated Injuries

 Inspection and palpation

Physical examination

Occiput to Coccyx
Soft tissue swelling and
bruising
Point of spinal tenderness
Gap or Step-off
Spasm of associated
muscles

Neurological assessment
Motor, sensation and
reflexes

Neurogenic Shock
Temporary loss of autonomic function of the cord
at the level of injury
results from cervical or high thoracic injury

Presentation
Flaccid paralysis distal to injury site
Loss of autonomic function
hypotension
vasodilatation
loss of bladder and bowel control
loss of thermoregulation
warm, pink, dry below injury site
bradycardia

Comparison of neurogenic and hypovolemic shock

Neurogenic
Etiology

Hypovolemic

Loss of sympathetic Loss of blood volume

outflow

Blood
pressure

Hypotension

Hypotension

Heart rate

Bradycardia

Tachycardia

Skin
temperature

Warm

Cold

Urine
output

Normal

Low
13

Neurologic assessment
Spinal shock
Bulbocavernosus reflex

Complete VS incomplete cord injury

spinal shock
Sacral sparing
Voluntary anal sphincter control
Toe flexor
Perianal sensation
Anal wink reflex

X-ray requirement
Criteria:
1. Absence of tenderness in the posterior midline
2. Absence of a neurological deficit
3. Normal level of alertness (GCS score = 15)
4. No evidence of intoxication (drugs or alcohol)
5. No distracting injury/pain

 Plain films
Spine Imaging
Options

AP, lateral and open mouth

view
Optional: Oblique and
Swimmers

CT

Better for occult fractures

MRI

Very good for spinal cord,

soft tissue and ligamentous
injuries

Flexion-Extension Plain
Films
to determine stability

CT Scan
Thin cut CT scan should
be used to evaluate
abnormal, suspicious or
poorly visualized areas
on plain film
The combination of plain
film and directed CT scan
provides a false negative
rate of less than 0.1%

MRI
Ideally all patients with
abnormal neurological
examination should be
evaluated with MRI
scan

Management of SCI
Primary Goal
Prevent secondary injury

Immobilization of the spine begins in the initial

assessment
Treat the spine as a long bone
Secure joint above and below

Management of SCI
Spinal motion restriction: immobilization devices
ABCs
Increase FiO2
Assist ventilations as needed with c-spine control
Indications for intubation :
Acute respiratory failure
GCS <9
Increased RR with hypoxia
PCO2 > 50
VC < 10 mL/kg
IV Access & fluids titrated to BP ~ 90-100 mmHg

Management of SCI

Look for other injuries: Life

over Limb
Transport to appropriate SCI
center once stabilized
Consider high dose
methylprednisolone
Controversial as recent evidence
questions benefit
Must be started < 8 hours of injury
Do not use for penetrating trauma
30 mg/kg bolus over 15 minute
After bolus: infusion 5.4mg/kg IV
for 23 hours

 Spinal alignment
Principle of treatment

deformity/subluxation/di
slocation reduction

Spinal column stability

unstable stabilization

Neurological status
neurological deficit
decompression