If cervical spinal cord injury (SCI) is suspected, hemodynamic stability is an initial priority [1]. An assessment of respiratory and cardiovascular functions should be done afterward. Firstly, a historical data about concomitant chronic pulmonary and circulatory diseases should be collected as they may interfere with vital laboratory data results [2].

Cervical segments of the spinal cord are responsible for delivering autonomic commands and regulation of cardiovascular and respiratory system, impairment in these systems should always be suspected. For pulmonary function assessment, it is important to consider the frequency of respiration, the involvement of abdominal and accessory respiratory muscles in breathing, the mobility of chest wall and possible injuries to it e.g. pneumothorax, hemothorax. In auscultation investigate lungs for abnormal sounds and impaired functioning. To measure blood oxygenation, perform ABG analysis and pulse oximetry [2].

When judging circulatory functions, the possibility of damage to the autonomic system should cause alertness for likely hemorrhagic or neurogenic shock. As nervous system conduit is impaired, the typical signs of shock e.g. vasoconstriction may be absent [2].

On examination of the neck, physicians should look for signs that could indicate an injury to the spinal cord, like hematomas, inflammation (redness, swelling), pain, tenderness and potential interruption of vertebral alignment. It is recognized, that clinical examination, although reliable, is prone to error and further radiologic investigations are essential [3] [4].

To determine the location of injured segments, a standardized evaluation method like International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is available. It is widely used and recognized [1], and provides information about motor, sensory and neurologic outcomes of the SCI [5]. Sensory characteristics are graded using pinching maneuver or abrasion on various dermatomes innervated by certain root nerves [1]. Motor functions are graded performing flexion, extension, as well as specific movements of muscle groups (myotomes) innervated by the certain nerves. Evaluation of type of SCI, whether it is complete or incomplete is also possible with ASIA Impairment Scale (AIS) [1].

Patients with cervical SCI can develop a constellation of syndromes associated with the injury, some of them are described here. Central cord syndrome is the most common and is combined with weakness in upper and lower limbs [5] [6]. Brown-Sequard syndrome is derived from a spinal cord lesion dividing it in half and is characterized as ipsilateral loss of sensation [6].

• Swelling

  Cord swelling was observed in 2 patients who developed complete lesions. Another 5 cases had an incomplete lesions. Spinal cord swelling indicated severe cord damage. External decompression seemed to have little effect on cord swelling. [ncbi.nlm.nih.gov]

  Time may allow swelling to go down and function to return, or the swelling may get worse. As I write this, Mr. Everett's doctors are reporting that he can move his arms and legs and they are hopeful that he may walk again. [medicinenet.com]

  Steroid and anti-inflammatory drugs administered shortly after injury, such as methylprednisolone, can help reduce swelling, which is a common cause of secondary damage at the time of injury. [shepherd.org]

  On examination of the neck, physicians should look for signs that could indicate an injury to the spinal cord, like hematomas, inflammation (redness, swelling), pain, tenderness and potential interruption of vertebral alignment. [symptoma.com]

  In the past, corticosteroids were often given just after the injury to reduce swelling around the injured spinal cord. [drugs.com]

• Pallor

  As a result, pallor develops below the injury level while flushing, sweating, and pounding headache occur above it. Many patients with higher-level SCIs have a lower baseline BP. [americannursetoday.com]

  […] as a result of profound effects of massive paroxysmal sympathetic activity associated with this condition.[ 52 ] Other clinical features includes severe arterial hypertension, headache and visual impairment due to cerebral vasodilatation, cutaneous pallor [ncbi.nlm.nih.gov]

• Weight Loss

  Loss Diets on Brain Health and Cognitive Decline Study Rush Memory Clinic Data Repository Treatment Study of Memory and Thinking Problems Associated with Alzheimer's Disease Arthritis and Other Rheumatic Diseases Conservative Treatment to Reduce Arthritic [rush.edu]

  Weight loss and muscle atrophy are common soon after a spinal cord injury. Limited mobility may lead to a more sedentary lifestyle, placing you at risk of obesity, cardiovascular disease and diabetes. [mayoclinic.org]

• Cerebral Palsy

  In the case of cerebral palsy, which is caused by damage to the motor cortex either before, during (10%), or after birth, some people with tetraplegia are gradually able to learn to stand or walk through physical therapy. [ citation needed ] Quadriplegics [en.wikipedia.org]

• Cough

  CONCLUSION: Complete or sensory incomplete C-SCI patients, even with high neurological level can be successfully decannulated through NIV and aggressive use of mechanically assisted coughing. [ncbi.nlm.nih.gov]

  In case of aspiration, the respiratory tract will be cleared by an intact coughing reflex. In case this protecting reflex is lacking, a silent aspiration occurs. [nature.com]

  […] needed to produce an effective cough (2). [centerwatch.com]

• Fecal Incontinence

  Fecal incontinence is common. Stool softeners, mini-enemas, and digital stool removal may keep the rectum empty, reducing incontinence frequency. [americannursetoday.com]

• Muscle Weakness

  OBJECTIVES: Respiratory complications are most common cause of morbidity/mortality in patients with cervical spinal cord injury (cSCI) due to respiratory muscle weakness and lower diaphragm position resulting in limited availability of inspiration, reduced [ncbi.nlm.nih.gov]

  No muscle weakness was observed. Hypoesthesia was observed in bilateral forearms, hands, and extremities below the inguinal region. [healio.com]

  Symptoms may include: Muscle weakness or paralysis in the trunk, arms or legs: Quadriplegia (quad = four) — loss of movement and sensation in all four limbs (both arms and both legs). [columbianeurosurgery.org]

  The symptoms of SCI may include: Muscle weakness Loss of voluntary muscle movement in the chest, arms, or legs Breathing problems Loss of feeling in the chest, arms, or legs Loss of bowel and bladder function The symptoms of SCI may resemble other medical [chop.edu]

• Muscle Spasticity

  spasticity (increased muscle tone) management Medicines and alternative methods of managing pain and spasticity Psychological counseling Identifying problems and solutions for thinking, behavioral, and emotional issues Family support Assistance with [hopkinsmedicine.org]

  Muscle tone. Some people with spinal cord injuries experience one of two types of muscle tone problems: uncontrolled tightening or motion in the muscles (spasticity) or soft and limp muscles lacking muscle tone (flaccidity). Fitness and wellness. [mayoclinic.org]

  Spasticity can reduce venous pooling and stabilize the thoracic and abdominal muscles used in respiration. [americannursetoday.com]

  Spinal cord injury prevents the brain from telling the muscle to relax. The result is prolonged muscle contraction or spasticity. [encyclopedia.com]

• Hyperreflexia

  While the cause of oculosympathetic spasm remains speculative, it may represent a localized form of autonomic hyperreflexia. [ncbi.nlm.nih.gov]

  Autonomic hyperreflexia The chronic phase in which spinal reflexes reappear is characterized by autonomic hyperreflexia in a high proportion of patients. [trauma.org]

  Sympathetic hyperreflexia can develop suddenly and without warning. [ceaccp.oxfordjournals.org]

  One emergency department study found that nine patients who presented with severe myelopathy had a low incidence of extensor plantar responses and hyperreflexia. 1 View/Print Table TABLE 3 Levels of Spinal Nerve Root Supply and Measures for Evaluating [aafp.org]

  absent bulbocavernosus reflex reflex characterized by anal sphincter contraction in response to squeezing the glans penis or tugging on an indwelling Foley catheter timing variable but usually resolves within 48 hours at its conclusion spasticity, hyperreflexia [orthobullets.com]

• Confusion

  Minor injuries without cervical fracture or dislocation, advanced age, unusual or changeable neurologic deficits, intoxication, and psychiatric problems all contributed to the confusion. [ncbi.nlm.nih.gov]

  […] exam decreased ROM of the spine neurologic symptoms of myelopathy or spinal stenosis Imaging Radiographs recommended views AP and lateral spine radiographs of involved region findings Technetium bone scan increased uptake in areas of involvement may be confused [orthobullets.com]

  Conclusion Much confusion surrounds the terminology associated with spinal cord injury levels, severity, and classification. [sci-info-pages.com]

  View/Print Table TABLE 2 Conditions Making Spinal Pathology Difficult to Evaluate and Diagnose Mental illness, retardation or dementia Severe, disabling pain Moderate to severe polyneuropathy (e.g., in diabetes, alcoholism, etc.) that may mask or be confused [aafp.org]

  There is great debate as to the expected prognosis which is only further confused by possible influence of compensation-seeking behaviour. [patient.info]

• Flaccid Paralysis

  Immediately following a traumatic SCI, there is a period of spinal shock resulting in flaccid paralysis of the muscles below the level of injury, which lasts for a period of weeks to months [ 21 ]. [breathe.ersjournals.com]

  There is flaccid paralysis of voluntary muscles, areflexia, loss of sympathetic tone ( hypotension and bradycardia in high thoracic or cervical injuries, increased vascular capacitance ), poikilothermia and flaccidity of the GI tract and the bladder with [trauma.org]

  Incomplete deficit E Normal Normal Motor Normal Sensory Acute Phase Conditions Neurogenic shock Spinal shock defined as temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury. characterized by flaccid areflexic [orthobullets.com]

  Signs & symptoms of acute SCI Flaccid paralysis below level of injury Loss of spinal reflexes below level of injury Loss of sensation (pain, touch, proprioception, temperature) below level of injury Loss of sweating below level of injury Loss of sphincter [rch.org.au]

  Spinal cord injuries produce a state of spinal shock, characterized by flaccid paralysis, and complete loss of skin sensation at the time of injury. [medical-dictionary.thefreedictionary.com]

• Irritability

  See How Cervical Degenerative Disc Disease Causes Pain and Other Symptoms Article continues below Over time, these bone spurs can grow large enough to start irritating nearby nerve roots. [spine-health.com]

  Bowel and bladder care and attention to potential irritants prevent autonomic dysreflexia. It is treated by prompt removal of the irritant. Drugs to lower blood pressure are used when necessary. [encyclopedia.com]

  Autonomic dysreflexia is most often caused by an over-full bladder or bladder infection, impaction or hard impassable fecal mass in the bowel, or skin irritation from tight clothing, sunburn, or other irritant. [medical-dictionary.thefreedictionary.com]

  Patients who have an incomplete spinal cord injury and continued neurologic compression or irritation will have numbness or weakness in the arms and/or legs. There may or may not be associated radiating pain symptoms. [uscspine.com]

• Paresis

  OBJECTIVES: To determine the effects of orthotic therapeutic electrical stimulation (TES) on the hand in patients with paresis associated with acute cervical spinal cord injury. SETTING: Spinal Injuries Center, Fukuoka, Japan. [ncbi.nlm.nih.gov]

  Following that fall, he developed transient numbness and paresis of the lower limbs. [bmcfampract.biomedcentral.com]

  […] lower extremity motor score, education, decreased comorbidities, decreased spasticity, and rapid early improvement. [22] Brown-Sequard syndrome Often attributed to spinal cord hemisection, Brown-Séquard syndrome is characterized by relative ipsilateral paresis [emedicine.medscape.com]

Spinal cord injury can be primary (from trauma) as well as secondary (from consequent edematous or hemorrhagic compression), for that reason radiographic imaging and magnetic resonance imaging (MRI) are necessary. Diagnostics are necessary for distinguishing the location of the lesion, its size, and signs of compression for further treatment.

• Plain radiography has almost been dismissed from favorable technique list for its low sensitivity, and more sophisticated radiologic examinations, preferably, MRI are recommended [7]. If physicians choose an X-ray, anterospinal, lateral and odontoid views should be performed [8].
• Computed tomography (CT) is usually the first test to be executed when on suspicion of SCI, particularly if patient is lethargic, unconscious, has neurological disturbances, pain, and sensitivity in the cervical area [3]. CT detects most lesions of bone tissue but does not detect those of ligaments and spinal cord [8]. CT scans are more convenient than plain radiography and can demonstrate sites of the injury that are obscure to X-ray. Images of occiput to T1 segment should be obtained in coronal and sagittal planes [8].
• Magnetic resonance imaging is the most accurate and reliable test that is usually carried out after pathology in CT cervical scan is confirmed [9]. In MRI a radiologist usually looks for signs and level of compression in the spinal cord that could be due to hemorrhages and perifocal edemas. Parameters of the spinal cord lesions, surrounding soft tissue injuries, and herniations in disks are also established if present [10].

The SCIM improvement rate at discharge was 60% in the surgical treatment group and 20% in the non-surgical treatment group. [ncbi.nlm.nih.gov]

In regard to the signal changes in the spinal cord, the patients who showed no signal change on T1- and T2-weighted images had a better prognosis. [ncbi.nlm.nih.gov]

The etiology may have been mechanical due to patient positioning, or toxic, from contrast medium injection in the vessels feeding the spinal cord, or a combination of both. [ncbi.nlm.nih.gov]

[…] atlanto-occipital dissociation occipital condyle fracture cervical spine fractures discoligamentous injury anterior subluxation (posterior ligamentous complex rupture) facet joint dislocation spinal epidural hematoma spinal cord injury vertebral artery dissection Etiology [radiopaedia.org]

Reid DC, Henderson R, Saboe L, Miller JDR: Etiology and clinical course of missed cervical spine fractures. J Trauma 1987; 27:980-6. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC: The etiology of missed cervical spine injuries. [anesthesiology.pubs.asahq.org]

Clinical and epidemiologic data were recorded from the medical records along with several radiologic findings from the initial computed tomographic scan and MRI. Data were analyzed using a non-parametric test. [ncbi.nlm.nih.gov]

Patient Population: Prevalence and Epidemiology Knee // Shoulder & Elbow // Hip // Spine // Foot & Ankle // Hand & Wrist Fragility Fractures: Diagnosis and Treatment Shoulder & Elbow The Characteristics of Surgeons Performing Total Shoulder Arthroplasty [amjorthopedics.com]

Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine 2001;26S:2. Tator CH, Duncan EG, Edmonds VE, et al. Changes in epidemiology of acute spinal cord injury from 1947 to 1981. Surg Neurol 1993;40:207. [uscspine.com]

The rapid improvement in function following the operation in these patients was gratifying and emphasizes the pathophysiological importance of spinal compression in this condition. [ncbi.nlm.nih.gov]

Pathophysiology and pharmacologic treatment of acute spinal cord injury. Spine J 2004;4:451. Rizzolo SJ, Vacarro AR, Cotler JM: Cervical spine trauma. Spine 1994;19:2288. Sekhon LH, Fehlings MG. [uscspine.com]

Pathophysiology The goals of resuscitation should be stabilization of the cervical spine, prevention of secondary injury, reduction of the fracture as soon as possible and protection of the spinal cord. [trauma.org]

To this end, anesthesiologists must have a thorough understanding of pathophysiology and optimize their skills and equipment to make an anesthesia plan. [nrronline.org]

The emphasis of our presentation concerns the frequency of some of the main complications and their attempted prevention: the haemodynamic disturbances caused by over-hydration; the prevention of haemorrhagic stress ulcers is not only by the use of specific [ncbi.nlm.nih.gov]

View Article PubMed Google Scholar Pak CY: Medical prevention of renal stone disease. Nephron. 1999, 81: 60-65. 10.1159/000046300. View Article PubMed Google Scholar Pearle MS: Prevention of nephrolithiasis. [bmcfampract.biomedcentral.com]

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