S13) Pathophysiology and Management of Spinal Cord Injuries

Question 1

Label the following structures in the spinal cord anatomy

Answer 1

Question 2

What is the general cause of spinal injuries?

Answer 2

Most often caused by physical trauma – cars, contact sports, assault, falls and alcohol

Question 3

What are the different mechanism of injury to the spinal cord?

Answer 3

• Hyperflexion
• Hyperextension
• Lateral stress (sideways movement)
• Rotation
• Compression (force along the axis of the spine downward from the head / upward from the pelvis)
• Distraction (pulling apart of the vertebrae)

Question 4

What are the different ways that flexion injuries might occur?

Answer 4

Often leads to neurological injury:

• Fractures – anterior wedge, flexion teardrop
• Dislocations – anterior subluxation, bilateral interfacet dislocation, antlanto-occipital dislocation, anterior atlanto-axial dislocation

Question 5

What are the different ways that extension injuries might occur?

Answer 5

• Fractures – Hangman’s, teardrop
• Dislocation – anterior atlanto-axial dislocation

Question 6

What are the causes of Complete Cord Transection Syndrome?

Answer 6

• Trauma
• Infarction
• Transverse myelitis
• Abscess
• Tumour

Question 7

What are the five clinical features of Complete Cord Transection Syndrome?

Answer 7

• Complete loss of sensation below the lesion
• Complete paralysis below the lesion
• Spinal shock and autonomic dysfunction with higher lesions
• Hypotension
• Priapism (prolonged sustained erection)

Question 8

What are the causes of Brown-Séquard Syndrome?

Answer 8

• Penetrating trauma
• Fractured vertebrae
• Tumour
• Abscess
• Multiple sclerosis

Question 9

What are the clinical features of Brown-Séquard Syndrome?

Answer 9

• Side of injury – loss of motor function (corticospinal tract), loss of conscious proprioception, vibration and touch sensations (dorsal column)
• Contralateral side of injury – loss of pain and temperature sensation (spinothalamic tract)

Question 10

What are the causes of Anterior Cord Syndrome?

Answer 10

• Flexion injury – leading to fractures or dislocations of vertebrae or herniated discs
• Injury to the anterior spinal artery – due to vascular/atherosclerotic disease in the elderly, iatrogenic secondary to cross-clamping of aorta

Question 11

What are the clinical features of Anterior Cord Syndrome?

Answer 11

Autonomic dysfunction – bowel, bladder, sexual function

Question 12

What are the causes of Central Cord Syndrome?

Answer 12

• Trauma (C-spine hyperextension in elderly / hyperflexion in young)
• Disruption of blood flow to the spinal cord
• Cervical spinal stenosis
• Degenerative spinal disease
• Syringomyelia
• Central canal ependymoma

Question 13

Describe the following for syringomyelia in Central Cord Syndrome:

• Aetiology
• Symptom development
• Modalities lost
• Modalities preserved

Answer 13

• Aetiology: unknown, due to development of a syrinx (cyst) in/within central canal
• Symptom development: arise from obliteration of spinothalamic fibres decussating in the white commissure
• Modalities lost: painful and thermal stimuli
• Modalities preserved: light touch, proprioception

Question 14

What are the clinical features of Central Cord Syndrome?

Answer 14

• Motor > Sensory
• Upper extremity > Lower extremity
• Distal > Proximal
• Bladder dysfunction and urinary retention

Question 15

Posterior Cord Syndrome is a very rare condition.

What are its possible causes?

Answer 15

• Chronic pathological processes – spondylosis, spinal stenosis, infections, vitamin B₁₂ deficiency
• Occlusion/infarction of the paired posterior spinal arteries

Question 16

What are the clinical features of Posterior Cord Syndrome?

Answer 16

Question 17

Describe the non-surgical management of spinal cord injuries

Answer 17

• Intubation (C5/above)
• ICU admission
• Early immobilisation of the C-spine
• C-spine restriction (approx. six weeks)
• Physiotherapy / OT

Question 18

Describe the surgical management of spinal cord injuries

Answer 18

• Progressive neurological deficits
• Unstable spinal fractures

Question 19

Describe the ABCDE approach in the initial evaluation and treatment of spinal cord injuries

Answer 19

• Airway (ask patient to talk)
• Breathing (resp rate, saturation, accesory muscles)
• Circulation (capillary refill, BP, HR, fluid challenge)
• Disability (GCS, AVPU, neuro exam, blood sugar)
• Exposure (rashes, scars)

Question 20

In the initial evaluation and treatment of spinal cord injuries, when should one assume that the patient has an injury?

Answer 20

Assume spine injury if:

• Head injury present
• Unconscious or confused
• Spinal tenderness
• Extremity weakness
• Loss of sensation

Question 21

In seven steps, outline the emergency management of a patient with spinal cord injuries

Answer 21

⇒ Continue ABCDE approach

⇒ Continuous vital sign monitoring (HR, RR, BP)

⇒ Address hypoxia → O₂ ± airway adjuncts

⇒ Address hypotension → fluid challenge, vasopressors

⇒ Address hypothermia → additional blankets

⇒ Neurological examination

⇒ Assess bladder volume & distension → insert urinary catheter

Question 22

One can “clear” the C-spine using the NEXUS method.

What are its six pre-requisites?

Answer 22

• Alert & oriented (to person, place, time, and event)
• No language barrier
• Not intoxicated
• No midline posterior tenderness
• No focal neurological deficit
• No painful distracting injuries