Acute Traumatic Spinal Cord Injury (TSCI)

Incidence:
40 million persons per year

Causes of TSCI:
●Motor vehicle accidents: 47 percent
●Falls: 23 percent
●Violence (especially gunshot wounds): 14 percent
●Sports accidents: 9 percent
●Other: 7 percent

S/S:  Based on severity, assess by American Spinal Injury Association Scale (ASIA):
1. Complete cord injury (ASIA grade A): reduced S+M at the level below, then no sensory + motor at all
        Acute: reflex (-), flaccid muscle tone, plantar stimulation (-), bulbocavernosus reflex (-), anal sensation (-), urinary retention, bladder distension, (priapism)

2. Incomplete cord injury (ASIA grades B through D): S+M partially preserved below the level of injury.               
        1. S preserved>M b/c more peripheral
        2. bulbocavernosus reflex, anal sensation (+)      

3. Central cord syndrome: preexisting cervical spondylosis + mild trauma
        1. M impairment > S in upper ext. than lower ext.
        2. Bladder dysfunction
        3. Sensory loss below level of lesion      
      *esp. hyperextension injury

4. Anterior Cord Syndrome: usu. anterior spinal a. injury by bone fragments
        1. Weakness and reflex changes
        2. Bilateral loss of pain and temperature sensation
        3. Urinary incontinence
        4.  Tactile, position, and vibratory sensation are normal (Dorsal column spared)

Spinal shock: hrs ~ wks
        Immediately after injury, loss of all spinal cord function caudal to level of injury
             ●Bradycardia, hypotension, flaccid paralysis, anesthesia, bowel and bladder control (-), reflex (-),                  (priapism)
        Mechanism: reduced axonal transmission due to K+ loss in cells of the cord


Risk factors:
●Cervical spondylosis
●Atlantoaxial instability
●Congenital conditions, eg, tethered cord
●Osteoporosis
●Spinal arthropathies, ex. ankylosing spondylitis/rheumatoid arthritis

Pathophysiology:
●Fracture of 1 or more of the bony elements
●Dislocation at 1 or more joints
●Ligament tear(s)
●Disruption and/or herniation of the intervertebral disc

Two types of injury: 
    1.Primary: immediate effect from the trauma
    2.Secondary: several hours after trauma, may be from ischemia, hypoxia, inflammation, edema, etc.
           Susp. if neurological deterioration over 1st 8 -12 hrs in patients with incomplete cord syndrome
    3.Spinal cord edema: occurs within hrs of injury, max btw 3rd and 6th day, recede after 9th day --> central hemorrhagic necrosis.

ER:
ABCD
1. Vital signs
2. A+B: intubation, mechanical ventilation
3. C: On A-line. Elevation of the legs, the head-dependent position, blood replacement, and/or vasoactive agents
4. Cervical collar until spinal injury has been ruled out
5. Neurological exam to assess complete or incomplete
6. Check for bladder distension
7. A: CT if available (MRI if cord transection)
    B. Full set of cervical Spine X-ray (AP+ Lateral + open-mouth odontoid, (Oblique? Swimmer's?)), unless:
        a: Patients without neurologic deficits
        b: Alert and not confused
        c: Not intoxicated
        d: No neck/midline pain or tenderness
        e: No other injury
      * NPV: 99.8%, sen: 99%; spf: 12.9%
      *Pts with pain in the T/L areas, esp w/ neurologic deficit --> AP, lateral, oblique of T/L areas --> CT --> MRI

Management:
1. Surgery 
    A. Decompression and stabilization
         a. Closed reduction: cervical spine fracture with subluxation
    B. Surgery indications:
         a. Significant cord compression with neurologic deficits
         b. Do not respond to closed reduction
         c. Unstable vertebral fracture/dislocation
    C. Surgery w/i 8hrs improve neurologic outcome?
       
2. Medical Management for pts with no neurological signs + stability of vertebral column
     1. Pain control
     2. LMW heparin
     3. NPO + PPI
     4. On Foley
     5. TPN
     6. Methyprednisolone w/i 8 hrs (controversial)
                30 mg/kg IV bolus, followed by an infusion of 5.4 mg/kg per hour for 23 hours
                Contraindication: traumatic brain injury     
     7. Admit to ICU
     8. OT + PT later

Monitor
     1. CV complications: MAP > 85 ~ 90 mmHg
              *Beware of Autonomic dysreflexia
     2. Respiratory complications:  respiratory failure, pulmonary edema, pneumonia, and pulmonary                             embolism most common
              A. Chest care ASAP
              B. Intubation: 1. Rapid Sequence 2. Fiberoptic scope
     3. DVT: 50 ~100% of untreated patients, greatest incidence btw 72 hrs ~ 14 days
              A. On LMW heparin + pneumatic compression stockings 
              B. IVC filter if heparin contraindicated

(Reference: Uptodate)