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Acute spinal cord injury


Introduction

The estimated global incidence of spinal cord injury (SCI) is difficult to specify as there is wide variation between regions and discrepancies in reporting. It has been reported, however, that there are around 68 cases of SCI per million population and a prevalence as high as 116 per million in people ages 65 and older. The economic burden of SCI is an estimated 4 billion dollars in the United States alone. Likely due to more advanced medical treatments, increased safety and regulatory efforts and imaging modalities, the incidence of complete SCIs has decreased compared with incomplete injuries. However, the incidence of high cervical SCI has nearly doubled since the 1970s. Although the global incidence is difficult to estimate, SCI occurs three to four times more often in males than in females, with a bimodal age distribution occurring between 15 and 29 years and a second peak after 65 years of age. Also, the average age of SCI has increased from 28 years old in the 1970s to around 37 years old, which may be explained by the increasing median age of the overall population. The most common cause of SCI remains motor vehicle accidents, falls, recreation, and even violence. Patients >65 years of age are at an increased risk of SCI due to age-related degeneration. Underlying cervical spinal stenosis is an increased risk to have neurological morbidity in any hyperflexion or hyperextension injury of the cervical spine, whether that be from a ground level fall or high velocity motor vehicle accident. Older patients with degenerative narrowing of the spinal canal are at a higher risk even in the context of a minor trauma just based on these aged-related changes.

SCIs may be categorized as complete or incomplete based on patient presentation. Complete SCIs result in complete loss of motor and sensory function below the level of neurological injury, while incomplete injuries preserve some motor or sensation. The American Spinal Injury Association (ASIA) impairment scale was developed to classify the severity of SCIs and is important to use when diagnosing these patients. In older patients, central cord syndrome is the most common SCI. Central cord syndrome typically presents in patients with upper extremity motor deficits greater than lower extremity and generally has a good prognosis. In this chapter, we discuss the presentation and management of a patient with an acute SCI, relevant surgical anatomy, and possible treatment options to consider.

Example case

  • Chief complaint: neck pain and weakness after fall

  • History of present illness: This is a 67-year-old male who presents to the emergency department after a ground level fall. He complains of upper and lower extremity paresthesias and that he cannot lift his arms. The patient had a magnetic resonance image (MRI) that revealed evidence of multilevel cervical stenosis and an area of increase T2 signal at C3-4, concerning for an acute spinal cord injury ( Fig. 31.1 ).

    Fig. 31.1, Preoperative magnetic resonance images of the cervical spine. (A) Sagittal and (B) axial T2 images demonstrating severe central canal stenosis with spinal cord compression and increased T2 signal within the spinal cord.

  • Medications: acetaminophen, apixaban

  • Allergies: no known drug allergies

  • Past medical history: osteoarthritis, atrial fibrillation with rapid ventricular rate

  • Past surgical history: transurethral resection of the prostate (TURP)

  • Family history: noncontributory

  • Social history: none

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; Bilateral deltoids 1/5; bilateral biceps and triceps 2/5; bilateral lower extremities diffusely 3/5; rectal tone present; diffuse allodynia present in bilateral upper extremities; Hoffman’s + in bilateral arms; upgoing toes bilaterally

  • Laboratories: all within normal limits

  • Michelle J. Clarke, MD

  • Neurosurgery

  • Mayo Clinic

  • Rochester, Minnesota, United States

  • Takeshi Hara, MD

  • Neurosurgery

  • Juntendo University

  • Hongo, Bunkyo-ku, Tokyo, Japan

  • Peter Jarzem, MD

  • Orthopaedic Surgery

  • McGill University

  • Montreal General Hospital

  • Montreal, Canada

  • Frank M. Phillips, MD

  • Orthopaedic Surgery

  • Rush University

  • Chicago, Illinois, United States

Preoperative
Additional tests requested Anesthesia evaluation

  • CT C-spine

  • C-spine flexion-extension x-rays

  • CTA C-spine

  • C-spine upright x-rays

  • CT C-spine

  • Medicine evaluation

  • C-spine x-rays

  • CT C-spine

Surgical approach selected C2-T1 laminectomy and C2-T2 posterior fusion C3-4 laminectomy, C3-5 fusion C2-6 laminoplasty C3-4, C4-5, and possible C5-6 ACDF

  • Surgical approach if 21 years old

  • Surgical approach if 80 years old

  • Same approach

  • Same approach

  • Same approach

  • Same approach

  • Same approach

  • Same approach

  • Same approach

  • Same approach

Goal of surgery Decompress spinal cord, stabilize spine Decompress spinal cord, stabilize spine Decompress spinal cord, maintain spine mobility Decompress neural elements
Perioperative
Positioning Prone with pins on Jackson table Prone with pins Prone with pins Supine
Surgical equipment

  • IOM (MEP/SSEP)

  • Fluoroscopy

  • IOM (MEP)

  • Fluoroscopy

Fluoroscopy

  • IOM (MEP/SSEP)

  • Fluoroscopy

Medications Steroids Steroids Steroids, maintain MAPs Maintain MAPs
Anatomical considerations Spinal cord, vertebral artery Spinal cord, vertebral artery, nerve roots Spinal cord, C5 nerve root, muscle attachments at C2 and C7 Spinal cord, vertebral artery
Complications feared with approach chosen Persistent compression Spinal cord and/or nerve root injury, vertebral artery injury Epidural hematoma, wound infection C5 palsy Neural injury
Intraoperative
Anesthesia General General General General
Exposure C2-T2 C2-5 C2-7 C3-6
Levels decompressed C2-T1 C3 C3-6 C3-6
Levels fused C2-T2 C3-4 None C3-6
Surgical narrative Preflip baseline MEP, position prone, postflip MEP to confirm stable, x-ray to localize level and plan incision, midline incision, dissect to lateral mass and transverse processes bilaterally, laminectomy using Adson rongeur, lateral mass screws from C3-7 and possible C7 using Magrel technique, pedicle screws at T1 and T2 using Lenke technique, C2 pedicle screws freehand using Wolinsky technique, contour rods, adjust head if necessary, final tighten screws, x-rays to confirm location of hardware and contour of rods, arthrodesis using autograft and allograft, close in layers over a drain Preflip IOM, position prone, neutral position, midline incision, subperiosteal dissection exposing caudal parts of C2-C5, C3 laminectomy and removal of ligamentum flavum, place C3-4 lateral mass screws with fluoroscopy to confirm direction of screws, place titanium rods, layered closure Position prone, expose C2-C7 preserving muscle attachments to C2 and C7, remove spinous processes of C2-6, trim to make 12 mm laminoplasty spacers, attach spacers to arch plates, C2-3 and C6-7 laminotomies, remove ligamentum flavum, create longitudinal partial thickness laminotomy on right side and full thickness laminotomy down to ligamentum flavum on left using bur, pry open laminoplasty door from left side with hinge on right with use of Cobb, open to 12 mm and insert spacer starting at C6 going up to C3 with skipping C4, screw spacers onto remaining lamina and lateral masses, close with drain Fiberoptic intubation, preposition IOM, position supine with neck in neutral position, postposition IOM, standard anterior cervical approach, transverse incision, dissect between carotid sheath and esophagus/trachea, perform anterior cervical discectomy with removal of portions of adjacent vertebral bodies depending on extent of retrovertebral compression, place interbody fusion cage/structural allograft, anterior instrumentation, layered closure
Complication avoidance Pre- and postflip MEP, Magrel technique for lateral mass screws, Lenke technique for pedicle screws, C2 pedicle screws using Wolinksy technique, adjust head if necessary Preflip IOM, limit construct to desired levels Maintain muscle attachments to C2 and C7, laminoplasty with hinge door Pre- and postposition IOM, remove of portions of adjacent vertebral bodies depending on extent of retrovertebral compression
Postoperative
Admission ICU ICU ICU Floor
Postoperative complications feared Progression spinal cord injury Infection, instability, CSF leak, vertebral artery injury Epidural hematoma, wound infection C5 palsy Neural injury
Anticipated length of stay 3–4 days 10 days 3–5 days 2–3 days
Follow-up testing

  • Standing x-rays before discharge, 6 weeks, 6 months, 1 year after surgery

  • CT cervical spine 1 year after surgery

  • Physical therapy evaluation

  • CT C-spine within 24 hours, 3 months after surgery

  • C-spine x-ray within 24 hours of surgery

None C-spine x-rays 6 weeks, 3 months, 6 months, 1 year after surgery
Bracing None Soft collar for 3 months Soft collar for 2 weeks Philadelphia collar for 6 weeks
Follow-up visits 6 weeks, 6 months, 1 year after surgery 2–3 weeks, 3 months after surgery 6 weeks after surgery 2 weeks, 6 weeks, 3 months, 6 months, 1 year after surgery
ACDF , Anterior cervical decompression and fusion; CT , computed tomography; CTA , computed tomography angiography; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potential; SSEP , somatosensory evoked potential.

Differential diagnosis

  • ▪

    Acute SCI

  • ▪

    Central cord syndrome

  • ▪

    Severe cervical spondylosis

  • ▪

    Cervical spine fracture

  • ▪

    Transverse myelitis

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