Acute Traumatic Spinal Cord Injury

Under revision 25/07/24.

OVERVIEW

• patient requires synchronous resuscitation, evaluation, treatment and early transfer to a spinal unit following initial stabilisation
• ATLS/EMST protocol applies
• spinal shock is physiological response to spinal cord injury resulting in temporary loss or depression to most spinal reflex activity below the level of the injury (‘spinal cord concussion’)
• neurogenic shock is loss of sympathetic outflow resulting in a bradycardic, vasoplegic hypotensive state (a true shock state)

RESUSCITATION

Airway

• assess need for intubation

-> tetraplegia
-> VC < 10mL/kg and/or TV < 3.5mL/kg
-> respiratory distress (weak cough and shallow rapid breathing are early signs)
-> adequate gas exchange
-> diaphragmatic impairment
-> LOC

• if required: full neurological assessment prior, in-line stabilisation, may be difficult (AFOI), ETCO2

Breathing

• O2
• once intubated employ a protective lung ventilation strategy (VT 6mL/kg PBW and Pplat <30)

Circulation

• large bore IV access and fluid resuscitation
• rule out haemorrhage as a cause of possible hypotension
• optimize spinal cord perfusion

Disability

• neurological examination (see below)

Exposure

• keep warm

EVALUATION

History

• mechanism
• other injuries
• events
• AMPLE

Examination

• head to toe examination
• motor level (highest myotome level of grade > 3/5)
• sensory level (high sensory dermatome with normal sensation)
• back: step, deformity, haematoma, open # (when logged rolled)
• perineal: anal sensation and tone (active and passive), bulbocavernosus reflex
• injury complete or incomplete
• if incomplete define the zone of partial preservation
• priapism
• presence of a cord syndrome (central, anterior, Brown-Sequard, conus, cauda equina)
• American Spinal Injury Association classification (ASIA) (A-E)
• pressure areas

Investigations

• trauma x-ray series
• trauma bloods
• CT whole spine
• MRI

TREATMENT

• invasive monitoring (usually subclavian due to collar)
• once haemorrhage ruled out -> begin noradrenaline and aim for MAP >70 for spinal cord perfusion
• log roll 2 hourly
• analgesia
• replace hard collar with a more comfortable stabilizing collar (Philadelphia, Miami J)
• IDC

DISPOSITION

• early liaison with spinal centre and spinal surgeon

ASIA IMPAIRMENT SCALE

• The American Spinal Injury Association (ASIA) Standard Neurological Classification of Spinal Cord Injury is a standard method of assessing the neurological status of a person who has sustained a spinal cord injury.
• Scale assessments can be carried out using this ASIA Impairment Scale worksheet (PDF).
• The neurological level of injury is the most caudal segment of the cord with intact sensation and antigravity (3 or more) muscle function strength, provided that there is normal  (intact) sensory and motor function rostrally respectively.

Category	Description
A = Complete	No motor or sensory function is preserved in the sacral segments S4-S5
B = Incomplete	Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5
C = Incomplete	Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade of less than 3
D = Incomplete	Motor function is preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more
E = Normal	Motor and sensory function are normal

• Loss of motor function’ means a person has no voluntary control of their muscles.
• ‘Loss of sensory function’ means a person has no sense of touch and cannot feel hot or cold, pain, or pressure. They also have no sense of where in space their limbs are (proprioception).

References and Links

LITFL

• Trauma! Spinal Injury

Journal articles

• Consortium for Spinal Cord Medicine. Early Acute Management in Adults with Spinal Cord Injury –  A Clinical Practice Guideline for Health-Care Professionals. J Spinal Cord Med. 2008; 31(4): 408–479. PMC2582434

FOAM and web resources

• SCI Info Pages — Spinal Cord Injury Levels & Classification
• ENLS — Traumatic spine injury
• ICN — PODCAST #3: The acute management of spinal cord injury
• ICN — SMACC: FLOWER – TIME IS SPINE (2013)
• Resus.ME — Another reason to be skeptical about collars
• Resus.ME — Cervical spine guideline
• Resus.ME — Neck movement in spite of collar