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.
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.
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
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
oedema of feet and legs (from loss of vasomotor control and muscle tone)
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.
• 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)
• Social work
• Sport can have an important role in rehabilitation (see Sports Medicine chapter)
If nerves totally severed damage is permanent