Spinal cord trauma

Background

• Surgical intervention indicated for:
  • Progressive neurologic deficits
  • Spinal instability
• Penetrating injury
  • GSW
    • Most are stable injuries and only require supportive orthosis, analgesia
    • Give Abx if GSW traversed the abdomen before injuring the cord
    • Bullet removal does not improve neuro status for stable cervical and thoracic lesions
    • Bullet removal may improve neuro status for thoracolumbar region injury (T11-L2)
  • Stabbing
    • Vertebral instability is generally not an issue
    • Delayed deficits are rare
      • If do occur related to retained fragment of blade within spinal canal

Peds

• In pts <10yr spinal injury occurs mainly in upper cervical vertebrae
• In pts >10yr majority of injuries occur in lower cervical spine, similar to adults
• Odontoid fractures are among most common cervical spine injuries in children
  • Do not confuse w/ normal anatomic variations in odontoid seen in children up to 7yr old
• SCIWORA
  • Spinal cord injury without radiologic abnormality
  • MRI has shown significant pathology in many of these pts
  • Symptoms
    • Delayed onset (w/in 48hr) of numbness, paresthesias in extremities
• Transient quadriparesis ("stinger")
  • Occurs most often in boys after sports injuries
  • Paresthesias or weakness of extremities lasting from seconds to minutes
    • Complete recovery w/in 48hr

Management

• Consider intubation for pt w/ injury at C5 or above
• Steroids are no longer recommended
• Complete lesion means absence of sensory and motor function below level of injury
  • May be confused w/ spinal shock

Anatomy

• Doral columns
  • Proprioception, vibration touch
  • Decussation at medulla
• Corticospinal Tract
  • Voluntary motor
    • Upper extremity fibers more central, lower extremity fibers more lateral
  • Decussation at medulla
• Spinothalamic
  • Pain, temp, touch
  • Decussates one level above entry point to spinal cord

Spinal Cord Syndromes

Complete Transection

• Higher lesions are a/w spinal shock and autonomic dysfunction
• Priapism implies a complete injury
• Sacral sparing excludes complete transection
  • Perianal sensation, rectal tone, bulbocavernosus/cremasteric reflexes

Anterior Cord

• Etiology
  • Direct anterior cord compression
  • Flexion of cervical spine
  • Thrombosis of anterior spinal artery
• Symptoms
  • Complete paralysis below the lesion with loss of pain and temperature sensation
  • Preservation of proprioception and vibratory function
• Prognosis poor

Central Cord

• Etiology
  • Hyperextension injuries
  • Disruption of blood flow to the spinal cord
  • Cervical spinal stenosis
• Symptoms
  • Quadriparesis (greater in upper extremities than lower extremities)
  • Some loss of pain and temperature sensation also greater in the upper extremities
• Prognosis good

Brown-Sequard

• Etiology
  • Transverse hemisection of spinal cord
  • Unilateral cord compression
• Symptoms
  • Ipsilateral spastic paresis
  • Loss of proprioception and vibratory sensation
  • Contralateral loss of pain and temperature sensation
• Prognosis good

Cauda Equina

• Etiology
  • Peripheral nerve injury
• Symptoms
  • Variable motor and sensory loss in the lower extremities
  • Sciatica
  • Bowel/bladder dysfunction
  • Saddle anesthesia
• Prognosis good

See Also

• Neurogenic Shock
• Cord Compression
• C-spine (NEXUS)

Source

• Tintinalli's