SYNONYM

DEFINITION
Spinal cord injury (SCI) is damage to the spinal cord that results in a loss of function such as
mobility or feeling. The spinal cord does not have to be severed in order for a loss of function to
occur. In most SCI cases, the spinal cord is intact, but the damage to it results in loss of function.

Impairment or damage to these nerves can be fatal since it will affect functionality of the various
parts of the body. The result of spinal injury trauma can either be temporary or permanent. The
pathophysiology of spinal cord injury points out two possible end results of spinal damage which
are quadriplegia (now also termed as tetraplegia) or paraplegia. The result will depend on the
extent and area of the damage.

The spinal cord is divided into 31 segments composed of motor and sensory spinal nerve roots.
The spinal cord is also organized into a series of neuropath ways that carry information and
commands. According to the pathophysiology of any of these segments and spinal nerves will
result in either mild or sever dysfunction.

RISK FACTORS/PREDISPOSING FACTORS

According to the National Spinal Cord Injury Association (NSCIA), spinal cord injuries are
caused in the United States by motor vehicle accidents (44%), acts of violence (24%), falls
(22%), sports (8%), and other causes (2%) such as abscesses, tumors, polio, spina bifida and
Friedrich's Ataxia, a rare inherited disorder. For infants, motor vehicle crash is the leading cause
of SCI. Falls rank highest for ages two to nine years and sports for the 10 to 14 age group. The
most common injury level for the five to 13 age group is the high cervical spine (C1-C4).

• degenerative disease of spine

• spinal canal stenosis
• ankylosing spondylitis
• Down's syndrome
• Klippel-Feil syndrome
• Arnold-Chiari malformation
• metastatic CA
• osteomyelitis
• rheumatoid arthritis

Spinal cord injuries cause myelopathy or damage to nerve roots or myelinated fiber tracts that
carry signals to and from the brain.[1][2] Depending on its classification and severity, this type of
traumatic injury could also damage the grey matter in the central part of the cord, causing
segmental losses of interneurons and motorneurons. Spinal cord injury can occur from many
causes, including:
 • Trauma such as automobile crashes, falls, gunshots, diving accidents, war injuries, etc.
• Tumor such as meningiomas, ependymomas, astrocytomas, and metastatic cancer.
• Ischemia resulting from occlusion of spinal blood vessels, including dissecting aortic
aneurysms, emboli, arteriosclerosis.
• Developmental disorders, such as spina bifida, meningomyolcoele, and others
• Neurodegenerative diseases, such as Friedreich's ataxia, spinocerebellar ataxia, etc.
• Demyelinative diseases, such as Multiple Sclerosis.
• Transverse myelitis, resulting from stroke, inflammation, or other causes.
• Vascular malformations, such as arteriovenous malformation (AVM), dural
arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and aneurysm.

S/SX
SCI symptoms usually appear immediately after the injury. However, symptoms can develop
slowly, if an infection or tumor is gradually increasing pressure on the spinal cord. General
symptoms are as follows:

• weakness, poor coordination or paralysis, particularly below the level of the injury
• numbness, tingling, or loss of sensation
• loss of bowel or bladder control
• pain

LAB/DX
• Lateral c-spine generally taken as part of ATLS. CT cervical spine: indicated for
obtunded patients before c-spine clearance.
• Plain films: xrays of entire spine due to high incidence of non-contiguous injuries
(Keenen TL, J Trauma 1990;30:489).
• CT +/- MRI generally indicated.
• MRI: pre-reduction MRI remains controversial. Reduction should not be significantly
delayed for MRI. (Darsaut TE, Spine 2006;31:2085).

Although spinal cord injury (SCI) is often obvious, sometimes the extent of the injury to the
spinal column is not. That is why it is important to dial 911 first, keep the patient still to avoid
further spine or spinal cord damage, and use a rolled up blanket or thick towels placed on either
side of the neck (body) to help immobilize and stabilize the area.

When in the hands of medical care, the doctor or emergency room staff quickly assesses the
patient's condition. Quick assessment may include:
 • Asking questions
• Noting the level of consciousness
• Complaints of neck or back pain
• Inability to move extremities
• Difficulty breathing

The American Spinal Injury Association (ASIA) Impairment Scale was adapted from the Frankel
Classification System. ASIA helps to classify neurologic problems affecting movement (motor)
or feeling (sensory).

ASIA Impairment Scale1

A = Complete; no sensory or motor function exists in the fourth and fifth sacral elements (S4 and
S5).

B = Incomplete; sensory, but not motor, function is still working below the neurologic level of
injury and extends through S4-S5.

C = Incomplete; motor function is still working below the neurologic level. Most key muscles
below the neurologic level of injury have muscle grade less than 3 (muscle grades are explained
in the next section).

D = Incomplete; motor function is still working below the neurologic level. Most key muscles
below the neurologic level of injury have muscle grade greater than or equal to 3.

E = Normal; sensory and motor functions are normal.

Muscle and Sensory Grades

Part of the ASIA Impairment Scale refers to muscle grade. This means muscle strength against
resistance. It is graded on a scale from 0 to 5. For example:

• 0 = no strength
• 1 = minimal
• 4 = moderate
• 5 = normal strength

Ten different areas may be tested, such as the elbows (biceps, triceps), hip flexors, and knee
extensors.

Light touch and pinprick are used to test sensation. It uses a 0 to 2 scale:

• 0 = no feeling
• 1 = feeling is impaired or highly sensitized
• 2 = normal feeling
When in the hands of medical care, the doctor or emergency room staff quickly assesses the
patient's condition. Quick assessment may include:

• Asking questions
• Noting the level of consciousness
• Complaints of neck or back pain
• Inability to move extremities
• Difficulty breathing

The American Spinal Injury Association (ASIA) Impairment Scale was adapted from the Frankel
Classification System. ASIA helps to classify neurologic problems affecting movement (motor)
or feeling (sensory).

ASIA Impairment Scale1

A = Complete; no sensory or motor function exists in the fourth and fifth sacral elements (S4 and
S5).

B = Incomplete; sensory, but not motor, function is still working below the neurologic level of
injury and extends through S4-S5.

C = Incomplete; motor function is still working below the neurologic level. Most key muscles
below the neurologic level of injury have muscle grade less than 3 (muscle grades are explained
in the next section).

D = Incomplete; motor function is still working below the neurologic level. Most key muscles
below the neurologic level of injury have muscle grade greater than or equal to 3.

E = Normal; sensory and motor functions are normal.

Muscle and Sensory Grades

Part of the ASIA Impairment Scale refers to muscle grade. This means muscle strength against
resistance. It is graded on a scale from 0 to 5. For example:

• 0 = no strength
• 1 = minimal
• 4 = moderate
• 5 = normal strength

Ten different areas may be tested, such as the elbows (biceps, triceps), hip flexors, and knee
extensors.

Light touch and pinprick are used to test sensation. It uses a 0 to 2 scale:

• 0 = no feeling
• 1 = feeling is impaired or highly sensitized
• 2 = normal feeling
Diagnostic Studies
SCI evaluation includes x-rays, a CT, and / or MRI. Although injury (e.g., fracture) may be
visible on a x-ray, CT and MRI scans provide more structural information valuable for assessing
soft tissues in the spine, such as the spinal cord. A myelogram may be performed to further
evaluate the spine.

SURGICAL MGT
Surgery cannot reverse damage to the spinal cord but is often needed to stabilize the spine to
prevent future pain or deformity. It may involve fusing together vertebrae or inserting metal pins;
or removing bone chips, bullets, or other foreign objects; or draining fluid to relieve pressure.
Long-term treatment of spinal cord injuries usually involves drug therapy, the use of neural
prostheses, and rehabilitation. Complementary treatment includes nutrition management,
psychological counseling, and careful monitoring by physicians.

PICTURES/DRAWING
• C1-C3: ventilator dependent, limited talking ability. Head or chin control wheelchair.
Needs assistance for transfers, ADL's.
• C3-C4: Can become ventilator independent. Head or chin control wheelchair. Needs
assistance for transfers, ADL's.
• C5: ventilator independent, biceps/deltoid funtion, independent in ADLs. Head or chin
control wheelchair. Limited mobility hand control wheelchair. Needs assistance with
transfers/living.
• C6: Wrist flexion/extension, independent ADL's/living. Hand control wheelchair, can
drive hand control car. May need assistance with transfers.
• C7: Triceps. Manual wheelchair capable, can drive hand control car, independent
ADL's/living. May need assistance with transfers
• C8-T1: Hand/finger dexterity. Independent transfers/ADL's/living, manual wheelchair,
can drive hand control car.
• T2-T6: Normal upper extremity function, some trunk control. Independent
transfers/ADL's/Living, manual wheelchair, can drive hand control car.
• T7-T12: Unsupported sitting ability. Independent transfers/ADL's/Living, manual
wheelchair, can drive hand control car, walking possible with extensive bracing.
• L1-L5: variable lower extremity/bowel/bladder funtion. Independent
transfers/ADL's/Living, manual wheelchair, can drive hand control car, walking possible
with bracing.
• S1-S5: variable bowel/bladder/sexual function. Independent

Incomplete SCI: partial motor or sensory loss below the level of injury.
 • Central Cord Syndrome: most common; generally older patients with underlying spinal
stenosis. Hyperextension injury. Greater weakness in the upper extremities and lower
extremities. Favorable prognosis.
• Anterior Cord Syndrome: generally from vascular insult, HNP, vertebral body fracture.
Motor , light touch and pain sensation impaired. Deep pressure, proprioception and
vibration intact. Poor prognosis for functional improvement.
• Posterior-Cord Syndrome: proprioception, deep pressure and vibration impaired. Motor
funtion normal. Rare
• Brown-Sequard Sydrome: motor and proprioception on ipsilateral side of injury
impaired; pain and temperature on contralateral side impaired. Generally from
penetrating trauma. Favorable prognosis for functional recovery.
• Conus medullaris syndrome: injury to the sacral cord and lumbar nerve roots leading to
areflexic bladder, bowel, and lower limbs. Sacral segments occasionally show preserved
reflexes (bulbocavernosus and micturition reflexes).
• Cauda equina syndrome: injury to the lumbosacral nerve roots in the spinal canal leading
to areflexic bladder, bowel, and lower limbs

Spinal Cord Injury Acute Treatment

• ATLS Protocol.
• Any trauma pt with suspected C-spine injury should be immobilized on a spine board
with cervical collar and log-roll precautions until the c-spine has been cleared.
• Maintain oxygen saturation >96%. 100% oxygen via nasal cannula, intubation may be
required for upper cervical lesions.
• Maintain systolic BP >90mmHg. Neurogenic shock: Heart rate typically 50-70 beats per
minute; SBP 30-50 mm Hg below normal. Must be differentiated from hypovolemic
shock(tachycardia/hyptotension). Treatment =initial fluid challenge,Trendelenburg
positioning, central line placement, vasopressors (dopamine/phenylephrine
hydrochloride), atropine for bradyarrhythmia.
• Cervical traction with tongs or a halo ring indicated for neurologic deficit or evidence of
cervical spine instability. Contraindications= cervical distraction injuries at any level,
type IIA hangman's fractures.
• Surgery indicated for neural compression and neruologic deterioration/deficit and spinal
instability. Consider surgery for residual cord compression without deficit.
• Methylprednisolone bolus dose 30 mg/kg followed by 5.4 mg/kg per hour for 23hours if
given withing the first 3 hours of injury. If given 3 to 8 hrs after injury continue for 48
hours. Do not give if >8hrs from injury. (Bracken MB, JAMA 1997;277:1597). Steriod
administration for spinal cord injury is currently controversial and is associated with
higher risks for pneuonia, pulmonary embolism and wound infection/sepsis and has not
been studied for penetrating injuries.
• Future Considerations: Minocycline, erythropoietin, olfactor ensheathing cells (Baptiste
DC, J Neurotrauma 2006;23:318).

Spinal Cord Injury Complications

• Skin Breakdown
• Autonomic dysreflexia
• Osteoporosis / Fractures
• Pneumonia, atelectasis, aspiration
• Heterotopic ossification
• Spasticity
• DVT
• Cardivascular disease
• Syringomyelia
• Neuropathic pain