Spinal Cord Injury

Spinal Cord Injury (SCI)

Following injury (road or vehicle accidents, industrial and home accidents, sporting injury) temporary or permanent loss of neurological function. Non-traumatic causes include transverse myelitis and tumours. 65% are <35yrs. M>F. Approximately 11,000 cases/year in USA.

Quadriplegia/tetraplegia – lesion involve one of the cervical segment of the spinal cord  affects all four limbs
Paraplegia – lesion involves the thoracic, lumbar or sacral segment of the spinal cord  affects lower limbs

Most common mechanisms are hyperflexion, hyperextension, axial loading and penetrating injury.

Clinical features:
Acute transverse lesion, below level of lesion  immediate flaccid paralysis; loss of sensation; loss of reflexes; loss of pain; loss of autonomic function (vasomotor control, bladder and bowel control). Progresses over hours to days to a spastic paraplegia

If incomplete lesion  partial motor and sensory loss; sensory loss will depend on which tract is affected:
• Posterior columns  affects posture, vibration, light touch
• Spinothalamic tracts  affects pain, temperature, deep touch

Three patterns/syndromes of incomplete lesions are recognised:
1) Central cord syndrome:
from injury that only affects cental part of cord
occurs in cervical segment, producing greater weakness in upper than lower limbs
usually older person with cervical spondylosis who has a hyperextension injury – but can occur in other people with other types of injury

2) Anterior spinal cord syndrome:
usually from a forced flexion injury (eg motor vehicle accident); herniation of disc damages cord; posterior cord not affected.
damage occurs in anterior part of spinal cord  motor loss, loss of pain and temperature sensation (tactile and proprioception still intact)

3) Brown-Sequard syndrome:
• only one half of spinal cord is damaged – usually from penetration injury (eg knife), but can occur from motor vehicle or sporting accidents (eg fracture  hemisection)
• contralateral loss of pain and temperature sensation; ipsilateral loss of motor function and proprioception.

Frankel Classification:
A – motor and sensory function complete without any movement or sensation below the lesion
B – motor complete with some sensory sparing
C – motor and sensory incomplete without functional motor recovery
D – functionally useful movement below the lesion
E – motor and sensory recovery to normal function but residual clinical evidence of SCI may still be present

American Spinal Cord Injury Association (ASIA) Classification:
A – complete
B – incomplete sensory but no motor function preserved through S4-5
C – motor and sensory incomplete with strength of most muscles below the lesion at grade 3 or less
D – motor and sensory incomplete (motor functional) with most muscle 3/5 or greater in strength
E – normal motor and sensory function

Complications:
deep vein thrombosis (occurs in 47-100% after SCI; highest risk in first few weeks)
pulmonary embolism (usually in 2nd – 4th week)
paralysis of chest muscles  respiratory problems
contractures
para-articular ossification
oedema of feet and legs (from loss of vasomotor control and muscle tone)
osteoporosis

Management:
Immediate – immobilisation; attend to circulation and airway (ABC’s); brief neurological assessment; care with any movements following accident (inappropriate movements can precipitate more severe injury)  usually most cases are managed in specialised spinal injury units.
In-hospital – ABC’s; respiratory support; warmth lowers morbidity; large does of corticosteroids improve outcome. When spine has been stabilised  rest, analgesics, muscle relaxants; prevention of infections and ulcers; emotional care; some may need surgery (spinal cord decompression, correction of deformity, stabilisation procedures); prevention of complications.

Rehabilitation:
• Those with spinal cord injuries are totally dependant on others
• Urological management (catheterisation; pharmacological; artificial sphincter)
• Nursing (prevention of complications; pressure relief; psychosocial support)
• Physiotherapy (respiratory therapy; prevention of pressure sores; muscle rehabilitation; wheelchairs; gait training)
• Occupational therapy (aids to enhance independence)
• Psychological
• Social work
• Sport can have an important role in rehabilitation (see Sports Medicine chapter)

Prognosis:
If nerves totally severed  damage is permanent

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