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Clinical Management of Acute Traumatic Spinal Cord Injury

Emergency Medicine
Surgery
Military Medicine
Read in Ukrainian
Margot Kelly-Hedrick MBE1, Joshua David Piche, MD2, Taylor Mitchell BS3, David Cron MD MS4, Rakesh Patel MD2, Ilyas Aleem MD MS FRCSC2, Theresa Williamson MD3.
  1. Duke University School of Medicine, Durham, NC, USA
  2. Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
  3. Department of Neurosurgery, Massachusetts General Hospital, Boston, MA USA
  4. Department of Surgery, Massachusetts General Hospital, Boston, MA, USA

 Introduction

Traumatic spinal cord injuries are debilitating and require prompt recognition and treatment to mitigate long-term outcomes, secondary damage, and complications. The floor or intensive care unit management after the initial trauma resuscitation is critical to minimize spinal cord ischemia and edema which can worsen the prognosis. Surgical decompression, when necessary, should happen within the first 24-hours following injury for the best neurological outcomes [1]. This paper will provide an overview to the clinical management of acute, traumatic spinal cord injury.

Clinical presentation of spinal cord injury

Spinal cord injury is described based on the level of the spinal nerve roots. A patient’s neurologic level is the most caudal level which has intact sensation and at least antigravity muscle strength. Injury can be complete or incomplete. Complete injury involves absence of any motor or sensory function below the level of the spinal cord injury. Incomplete injury can be further classified into five groups using the American Spinal Injury Association Impairment Scale (AIS), once spinal shock has resolved (Table 1) [2].
Table 1. American Spinal Injury Association Impairment Scale (AIS) [2]
CategoryDescription
Grade ANo motor or sensory function below the neurological level. There is no sacral sparing.
Grade BIncomplete injury. There is some sensory function, often sacral sparing. There is no motor function below the neurological level.
Grade CIncomplete injury. More than half of the key muscles below the level of the injury have a grade of less than 3 out of 5.
Grade DIncomplete injury. More than half of the key muscles below the level of the injury have a grade of more than 3 out of 5.
Grade ENormal muscle and sensory exam
A high cervical spine injury (above C5) can impair respiratory drive and may require intubation and mechanical ventilation. High thoracic or cervical spine injuries (T4-6 and above) affect the sympathetic innervation to the heart and can result in hypotension and bradycardia. Autonomic dysfunction (levels T1 to L2) can disrupt vascular tone which can contribute to hemodynamic instability [1]. 
A few specific named spinal cord injury syndromes warrant attention as their clinical presentation can help guide management.
Central cord syndrome. Central cord syndrome classically results from hyperextension of the cervical spine in patients with pre-existing cervical spine disease. This results in motor impairment that is greatest in the upper extremities (especially distally) and less severe in the lower extremities. This may be present without any apparent fracture or malalignment of cervical spine on CT, and thus an MRI is warranted [1,3].
Anterior cord syndrome. Anterior cord syndrome typically results from ischemic injury to the anterior spinal cord, penetrating injury, or direct injury from retropulsion of a bony fragment in a flexion injury. This syndrome results in loss of motor function, loss of pain and temperature sensation, but preserved vibration sense and proprioception [1,3].
Brown-Sequard syndrome. Brown-Sequard syndrome, also known as hemicord syndrome or lateral hemisection, results from penetrating injury to the unilateral spinal cord and causes ipsilateral weakness and loss of vibration sense and proprioception, in addition to contralateral loss of pain and temperature sensation. The contralateral pain and temperature loss begins a few spinal levels distal to the level of the injury [1,3].
Cauda equina and conus medullaris syndrome. Cauda equina and conus medullaris syndrome are similar types of incomplete spinal cord injuries that occur when there is compression on the cauda equina (terminal nerve roots after the spinal cord ends) or on the conus (terminal end of the spinal cord). Common presenting symptoms of these pathologies can include low back pain, leg pain and/or weakness, paraesthesias, bladder or bowel incontinence, and perineal numbness. Cauda equina presents with lower motor signs such as hyporeflexia. Conus medullaris syndrome can present with both upper and lower motor neuron signs. In general, the treatment for these conditions is emergent decompression and stabilization if necessary.

Spinal shock versus neurogenic shock

Neurogenic shock refers to the hemodynamic state resulting from loss of sympathetic tone to the heart and blood vessels. Spinal shock presents with bradycardia and hypotension, in contrast to other types of shock which typically present with tachycardia. The skin may be flushed and warm initially, but hypothermia can follow. Patients should be resuscitated with fluids and vasopressors [1,3]. Norepinephrine or vasopressin are preferred, but phenylephrine will also provide vascular tone for isolated neurogenic shock.
 Spinal shock refers to a transient loss of spinal cord function below the level of the injury with loss of all reflexes, including the bulbocavernosus reflex. Spinal shock is transient, and some degree of recovery may be seen [1]. Return of previously absent spinal reflexes can be an encouraging prognostic sign. Importantly, a patient’s neurologic status cannot be determined until the resolution of spinal shock, which is indicated by either return of the bulbocavernosus reflex, or 48 hours after injury. The bulbocavernosus reflex is tested by squeezing the glans penis or clitoris, or by pulling on an indwelling foley catheter, which should cause contraction of the anal sphincter if the reflex is intact [3].

 Acute evaluation of traumatic spinal cord injury

Prior to arrival. When any spinal cord injury is suspected, patients should be immobilized with a cervical collar and rigid backboard, ideally in the field and during transport to the health care facility [1]. Any patient with multiple traumatic injuries or high-impact mechanism of injury should be assumed to have a spinal cord injury [3].
Evaluation in the trauma bay. Upon arrival, standard trauma evaluation should begin with the primary survey (ABC: airway, breathing, circulation). As with any trauma patient, goals include avoiding hypoxia and providing hemodynamic stabilization. If a cervical collar was not placed in the field, this should be placed as soon as possible if a spinal injury is suspected. Typically, spinal cord injury is ruled out with imaging, however in select cases imaging may not be necessary before removing the cervical collar (see Table 2). The rigid backboard should be removed as soon as is safely possible to prevent skin breakdown.
Until a spinal cord injury is ruled out, the patient should be log rolled when examining for dorsal injuries. The entire spinal axis from occiput to sacrum should be palpated, assessing for areas of tenderness or bony step-off, as the latter can indicate a displaced and unstable spinal injury. Take special note of any deformities that exist, such as a rotational deformity in the cervical spine, as this can often be indicative of an underlying unilateral facet dislocation.
A comprehensive neurologic examination should be performed on all patients with suspected spinal cord injury as part of the secondary survey (see Table 2). Patients with complete spinal cord injuries may initially be hyporeflexic during the period of spinal shock [1]. As shock resolves, patients then typically become hyperreflexic as these injuries represent upper motor neuron lesions [1]. 
Urinary catheter placement is usually necessary as urinary retention can occur and patients will be limited to log roll precautions. Post-void residual measurements should be obtained if prior to placing a foley catheter, if possible, especially in cases of suspected cauda equina. Suspicion for other injuries should be high, as up to 80% of patients with SCI will have other significant injuries [3].
Table 2. NEXUS and Canadian C-Spine Criteria for Imaging of Cervical Spine for patients with suspected spinal injury [4,5]
 NEXUS CriteriaCanadian C-Spine Rule*
Consider imagingIf any of the following are present, consider imaging:- Focal neurological deficit present- Midline spinal tenderness present- Altered level of consciousness- Intoxication- Distracting injury presentIf any of the following are met patient is:- ≥65 years old- Injured by dangerous mechanism- Parathesias in extremities- Low risk factor (see below), but unable to rotate neck 45 degrees left and right
Imaging not recommendedIf none of the above criteria are met.If any of the following AND able to rotate neck 45 degrees left and right:- Low speed, rear end MVC- Sitting upright in health care setting- Ambulates any time after injury- Neck pain onset delayed- No tenderness over cervical spine
*Can be used on non-pregnant adults (≥16) with stable vital signs, normal alertness, and traumatic injury within the last 48 hours without paralysis, previous known vertebral disease, or penetrating trauma.
Table 3. Comprehensive neurologic examination for patients with suspected spinal cord injury
LocationExaminationAssessment
Upper extremityMotor  C5: tests deltoid function (arm abduction)C6: tests biceps function (elbow flexion) and wrist extensionC7: tests triceps function (elbow extension) and wrist flexionC8: tests finger flexionT1: tests interossei function (finger abduction)
 Sensory  C5: tests sensation along the upper lateral armC6: tests sensation along the thumbC7: tests sensation along the middle fingerC8: tests sensation along the small fingerT1: tests sensation over the medial elbow
 ReflexesC5: biceps reflexC6: brachioradialis reflexC7: triceps reflex
Lower extremityMotor L2: tests iliopsoas and adductor muscles (hip flexion and hip adduction)L3: tests quadriceps (knee extension)L4: tests tibialis anterior muscle (ankle dorsiflexion)L5: tests EHL (great toe extension) and glutes medius/minimus (hip abduction)S1: tests gastroc-soleus complex (ankle plantar flexion)
 SensoryL1: test along the groinL2: test along the inner thighL3: test along anterior and medial thigh/kneeL4: test along anterior knee and medial lower legL5: test along lateral leg and top of footS1: test along the back of the legS2: test along the bottom of the footS3/S4: test along the perianal region
 ReflexesL4: test patellar reflexS1: test achilles reflexRectal tone: via digital exam by clinicianBulbocavernosus reflex
Muscles strength is graded on a scale of 0 to 5, where 0=no motor function or contractions, 1= Muscle contraction only, 2=Muscle function with gravity eliminated, 3= Muscle can overcome gravity, 4= Muscle can overcome some resistance, 5= Full muscle strength against resistance.

Imaging

When spinal cord injury at any level is suspected, strong consideration should be given to imaging the entire spinal column, as non-contiguous injuries in the spine are relatively common.
Cervical spine imaging. Cervical spine CT is the gold standard test to evaluate cervical spine injury but is not necessary for some patients (Table 2). Plain films of the cervical spine are not reliable for use in the initial diagnosis of cervical spine injury. When evaluating a cervical spine CT, it is best to evaluate with the same method each time. For example, starting with the vertebral bodies and alignment, occipitocervical junction, spinous processes, facet joints.
MRI is useful when ligamentous injury is suspected. Pain with neck movement but with a normal CT is generally an indication for MRI. MRI may also be useful when a patient is not examinable (unconscious or sedated). 
CT Angiogram is indicated in certain cases of blunt cervical injury to diagnose cerebrovascular injuries such as dissection, pseudoaneurysm, or rupture to the carotid or vertebral arteries which can further progress to a stroke. CT angiogram should be performed based on the modified Denver criteria (Table 4). If any of the signs, symptoms, or risk factors are present in Table 4, CT angiogram is indicated.
Imaging for the thoracic or lumbar spine. Similar to the cervical spine, imaging of the thoracic and lumbar spine typically begins with CT imaging of these regions. 
Table 4. Modified Denver Criteria to determine whether CT angiography of the neck is indicated to detect blunt cerebrovascular injury [6,7].
Signs/SymptomsRisk Factors
-Arterial hemorrhage from neck/nose/mouth-Cervical bruit -Expanding cervical hematoma-Focal neurologic deficit-Neurologic examination incongruous with head CT scan findings-Stroke on secondary CT scan or MRI-High-energy transfer mechanisms-LeFort II or III fracture-Mandible fracture-Cervical-spine fracture patterns-Subluxation-Fractures extending into the transverse foramen-Fractures of C1 – C3-Basilar skull fracture with carotid canal involvement-Petrous bone fracture-Diffuse axonal injury-Near hanging with anoxic brain injury -1st or 2nd rib fractures-Scalp degloving
If any of the above criteria are present, CT angiogram is indicated.

Initial non-operative and critical care management

Optimization of all organ systems is critical to maintain perfusion to the injured spinal cord and minimize secondary injury from the downstream inflammatory response. Hemodynamics and body temperature can be labile in patients with severe spinal cord injuries. To reduce the risk of hypoperfusion, maintaining a mean arterial pressure (MAP) between 85 and 90 mmHg is recommended, although other injuries and hemorrhagic shock may impact MAP goals [3,8]. Arterial line monitoring can be used to continuously monitor MAPs. The recommended duration for maintaining MAPs >85mmHg is 5-7 days post-injury depending on clinical exam [9,10]. 
The role of steroids in the treatment of acute spinal cord injuries is highly controversial. Recent evidence has shown that the risks of high dose steroids such as respiratory complications, sepsis, wound issues, and infection, may outweigh any potential minimal neurologic benefits [11,12]. Thus, many societies and clinical practice guidelines, including the 2013 American Association of Neurological Surgeons guidelines for spinal cord injury management, now recommend against giving steroids for acute spine injuries [10,13].
Management of blunt cerebrovascular injury should involve a vascular surgeon or neurosurgeon. At a minimum, aspirin is indicated for low grade cerebrovascular injuries, but some injuries will warrant systemic anticoagulation, and higher-grade injuries may need angiographic or surgical intervention by a specialist. 

Basic tenants of operative management

Operative management of spinal injuries should be performed by a surgeon with appropriate training. The full breadth of operative management of complex spine injuries is out of the scope of this paper, however, we present some basic high yield principles here.
Cervical facet dislocations should be reduced on an urgent/emergent basis when associated with neurologic impairment. If the patient is awake and reliable, reduction can be attempted prior to obtaining an MRI. If the patient is obtunded or not reliably examinable, an MRI should be performed prior to any attempted reduction. Neuromonitoring is recommended if available, when performing reduction on an anesthetized patient. If at any time the patient’s neurologic exam worsens, the reduction should be aborted, and MRI should be obtained. 
Closed reduction can be attempted first using Gardner-Wells tongs and progressively increasing weights. The tongs should be secured approximately 1 cm above the pinna. Intermittent XR should be obtained with the addition of sequential weights to assess your reduction. Typically, traction should be initiated with 5-10 pounds of weight per cervical level of injury and can be increased in 10 pounds increments every 5-20 minutes until reduction is achieved [14]. Up to one-sixth of body weight can typically be safely applied in cases of facet dislocations without associated fracture [15]. If closed reduction is unsuccessful, the patient should be taken on an urgent/emergent basis for an open reduction and possible internal fixation in the operating room. 
In general, unstable spinal injuries with neurologic deficit should be taken on an urgent/emergent basis to the operating room for surgical decompression and fixation. Most current literature shows that early decompression (within 24 hours of injury) leads to a significantly increased rate of neurologic recovery [9]. 
A good rule of thumb is to think about the goals of surgery based on the patient’s imaging and exam. For example, if the patient has anterior compression, then a corpectomy or discectomy may be appropriate. If there is posterior compression or facet disease, then a posterior approach is appropriate.  Pedicle screw fixation is required when there is facet disease, or the surgical approach involves removing anterior or posterior column support structures. If considering a posterior approach for fracture fragments, be prepared to manage a traumatic cerebrospinal fluid leak.

Post-operative management and complications 

Respiratory complications are common after high spinal cord injuries. High cervical injuries often require mechanical ventilation given loss of diaphragm control [3]. Diligent pulmonary hygiene is critical. Risk of constipation and ileus can be reduced with bowel regimens (stool softeners and/or enemas) to ensure regular bowel movements [3]. Urinary catheters should be removed as soon as possible to decrease risk of infection, and intermittent straight catheterization should be used on a scheduled basis if needed. Nutritionists should be involved early in care to ensure proper caloric intake goals are met, especially in patients who may require feeding tubes due to their injury [3].
Spinal cord injury patients are at high risk of venous thromboembolism. Pharmacological prophylaxis with enoxaparin is recommended within 72 hours of injury for prophylaxis, pending other hemorrhagic trauma burden, and this is generally continued while the patient is in the hospital and rehabilitation facility [3,16]. Patients with motor/sensory loss are prone to skin breakdown and infection, and thus frequent repositioning of the patient should be performed to offload the skin, and diligent skin and wound care should be performed. Early physical and neurologic rehabilitation is key to functional recovery.

Summary

  • Traumatic spinal cord injuries are associated with significant morbidity and mortality which can be mitigated by early recognition and treatment.
  • Initial trauma evaluation always begins with the primary survey (airway, breathing, circulation), as well as early spine immobilization (cervical spine collar, log-roll precautions) when a spinal injury is suspected.
  • CT scan is the gold standard radiographic test to diagnose a spinal injury. MRI may be indicated when ligamentous injury is suspected even in absence of injuries on CT scan. CT angiogram of the neck is indicated if blunt cerebrovascular injury is suspected.
  • Initial non-surgical management targets a mean arterial pressure >85mmHg when possible to maintain spinal perfusion pressure.
  • Early surgical decompression and stabilization should be performed by a trained spine surgeon when indicated, within 24 hours of injury if possible. 

References

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