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Spinal Cord Injuries
1
What is the difference between a spinal column injury and a spinal cord injury?
Injuries to the spinal column can include damage to bone, disks, and/or ligaments. These injuries may induce spinal instability. Instability results when the spine can no longer maintain its alignment, protect the neural elements, or prevent incapacitating pain under physiologic loads. Injuries to the spinal column may also be associated with spinal cord injury, which is damage to the neural tissue within the spinal canal. This is often accompanied by a clinically detectable neurologic deficit. When evaluating trauma patients, it is crucial to determine the presence of a spinal column injury, a spinal cord injury, and/or the presence of spinal instability. Unstable spinal injuries often require surgical intervention to reestablish the “Holy Trinity of Spine.” Upholding this triad (alignment, stability, neurology) mandates that treatment restore appropriate spinal alignment, proper decompression and protection of the neural elements, and provision of rock-solid stability.
2
Describe the evaluation of a patient with a suspected spinal injury
Assume that all trauma patients have a spinal injury until proven otherwise. Start by ensuring that the patient is adequately immobilized while maintaining strict log-roll precautions. Initially, all trauma patients should be placed in a rigid cervical immobilizer. These cervical collars should be kept in place until the cervical spine is “cleared.” Clearance is the process by which the treatment team confirms that a spinal injury is absent. Once this is done, the brace can be removed. On the contrary, if a spinal injury is identified, then a spinal surgery consult should be placed to determine the proper course of treatment. The care team should also work as a unit to remove patients from the back-board as soon as possible. This involves log-rolling the patient with a sufficient number of care team members so that it can be done safely. Simultaneously, the care provider should inspect the entire spine for external trauma while also palpating for irregularities and areas of step-off. A complete and thorough neurologic examination must then occur. Strength must be assessed in all myotomes of the four extremities. Sensory exam should include assessment of light-touch, proprioception, pain, and temperature in all dermatomes. Reflex examination should evaluate the upper and lower extremities, while also evaluating pathologic reflexes like Hoffman’s and clonus. A complete sphincter exam must also be performed. This includes inspection of the anus, evaluation of perianal sensation with dull and sharp probes, detection of resting rectal tone with digital insertion, evaluation of voluntary anal sphincter contraction, and determining the presence or absence of the bulbocavernosus reflex. The examiner should also check for priapism. All examination results should be completely and thoroughly documented.
3
How do you minimize the risk of additional spinal injury in the hospital?
The best way to prevent further spinal injury in the hospital setting is to assume that a spinal injury exists until proven otherwise. This includes immobilization of the neck in a rigid cervical brace while also maintaining log-roll precautions. It is also important that the care team works together quickly and thoroughly to evaluate the entire spine. If it can be determined that no spinal injury is present, then the patient can be removed safely from braces and mobility precautions. If spinal injuries are detected, then a spinal surgery consultation must be obtained to determine the proper treatment course. Once this is accomplished, the care team must ensure that the appropriate precautions are obeyed and that the proper bracing is utilized effectively. Some patients may require acute internal fixation to provide rock-solid spinal stability. This will allow early mobilization of the patient. Spine boards should be removed very early in the course of the evaluation while the patient is still in the trauma bay. When in doubt, the care team should treat patients as if an unstable spinal injury exists. Only after completion of the spinal clearance pathway should providers be confident that spinal injuries are confirmed absent. If evaluation leads to detection of an injury then collar immobilization and log-roll precautions should be maintained until spinal surgery recommendations provide further guidance. A definitive treatment plan should be finalized and executed as soon as possible.
4
How is the level of the spinal cord injury defined?
The spinal cord injury level does not refer to the level of the injury to the spinal column (vertebrae, disks, and/or ligaments). Rather, it refers to the most caudal level of normal spinal cord function. For example, if a patient has normal function of the deltoid musculature (C5) but little or no function of the musculature of the biceps (C6) or below, then the patient is said to have a “C5 motor-level” injury. Right and left sides should be documented separately.
5
Which type of injury is commonly associated with cervical spinal injury?
Head injury. Forces associated with significant head and brain injury may be transmitted to the cervical spine. Of patients with spinal cord injuries, 50% have associated head injuries. Approximately 15% of patients with one spinal injury also have a noncontiguous second spinal injury. This highlights the importance of a complete and total spinal evaluation in all trauma patients.
6
How can the spinal cord be evaluated in patients with associated head injury?
Trauma patients with head injuries can be very difficult to examine. In addition to significant cranial trauma, which limits the neurologic evaluation, these patients are also frequently intubated, sedated, and can even be pharmaceutically paralyzed. It is important for the examiner to be aware of these confounding variables. Despite these challenges, it is still possible to obtain important information concerning the neurologic examination and spinal cord function. Flaccid motor tone and absent reflexes should raise suspicion of spinal cord injury. These findings are extremely unusual with isolated brain injury. When patients cannot be assessed for motor and sensory function, it is important to examine reflexes and also to perform a complete and thorough sphincter examination. Spinal cord injured patients typically have flaccid paralysis with associated areflexia. It is important to compare the reflexes of the upper and lower extremities. The examiner should check for priapism. Priapism is common with spinal cord injury but not caused by head injury. The examiner should also perform a thorough anorectal examination as described above in Question 2. This detailed examination can be a “window” to the spinal cord. Examiners should have knowledge of spinal cord injury, conus medullaris syndrome, and cauda equina syndrome. Radiographic imaging should also be used liberally when a neurologic deficit is suspected.
7
At presentation, which other significant injury may mimic a high thoracic cord injury?
Thoracic aortic dissection. Also known as the “great masquerader,” presenting symptoms of aortic dissection can mimic pathology from any organ system including a high thoracic spinal cord injury. Diagnosis can be very challenging. Symptoms can include tearing, stabbing pain in the chest and/or back, and lower extremity ischemia and paraplegia. A thoracic aortic dissection may present as a T4-level spinal cord injury. T4 is typically a vascular watershed zone in the spinal cord between the vertebral arterial distribution and the aortic radicular arteries. Given the diagnostic dilemma associated with this condition, careful history and physical examination should be combined with liberal use of advanced diagnostic imaging.
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