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].

• Falling

  Falls with hyperextension, spondylosis, or disc disease, and motor vehicle accidents were the most common causes. Only one of the 37 had a cervical fracture. [ncbi.nlm.nih.gov]

  Falls Falls cause more than 25 percent of spinal cord injuries. Those over the age of 65 are most likely to suffer a spinal cord injury from a fall. [palegaladvice.com]

• 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]

• Unconsciousness

  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. [symptoma.com]

  Others are part of our unconscious system, things we take for granted, like breathing or swallowing saliva. The fourth cervical vertebra is the level where nerves run to the diaphragm, the main muscle that allows us to breathe. [medicinenet.com]

  […] cervical spine and surrounding musculature Perform upper/lower extremity sensory and motor assessment If assessment reports abnormal finding, prepare for emergency transport Presence of 4 clinical indicators warrants activation of CSI management protocol: Unconsciousness [ksi.uconn.edu]

  In an injured person who is unconscious, the degree of neurological injury may be hard to assess, so doctors must have a high degree of suspicion that a spinal cord injury has taken place and take steps to protect the spinal cord. [drugs.com]

• Ecchymosis

  There is often visible swelling and ecchymosis (bruising) over the fracture site. [uscspine.com]

• Soft Tissue Swelling

  The findings are: Fracture through the base of the dens Prevertebral soft tissue swelling Rupture of C1C2 interspinous ligament No visualisation of lower C-spine Look at the CT-images and then continue reading. [radiologyassistant.nl]

• Visual Impairment

  […] with recurrent ventricular fibrillation and cardiac arrest, 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 [ncbi.nlm.nih.gov]

• 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]

• Muscle Strain

  Injuries can range from relatively mild ligament and muscle strains, to fractures and dislocations of the bony vertebrae, to debilitating spinal cord damage. [mayfieldclinic.com]

  If, however, pain persists past this point—less indicative of muscle strain—then we would consider repeating the dynamic X-rays. Obtunded or comatose patients present a dilemma in determining the diagnosis and best further management. [pn.bmj.com]

  Muscle strain will have edema seen as high signal intensity on STIR images (Fig. 10 ), while muscle hemorrhage will have heterogeneous signal intensity depending upon the presence of varying degrees and stages of hemorrhage mixed with edema. [bmcmusculoskeletdisord.biomedcentral.com]

• Joint Dislocation

  Patients can have a combination of injuries including: atlanto-occipital dissociation occipital condyle fracture cervical spine fractures discoligamentous injury anterior subluxation (posterior ligamentous complex rupture) facet joint dislocation spinal [radiopaedia.org]

• Stroke

  Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis of the literature. Dysphagia 2002; 16 : 279–295. 15. Hoppers P, Holm SE. [nature.com]

  […] and Cerebrovascular Disease Acute Ischemic Stroke Treatment Study Aneurysmal Subarachnoid Hemorrhage Treatment Study ARAMIS Registry: Addressing Anticoagulant Management Issues in Stroke Drug Treatment Study for Acute Ischemic Stroke ENRICH Trial: Comparison [rush.edu]

  Arm Motor Control on Bi and Uni ADLs Cross-sectional study comparing bilateral ADL activities for stroke survivors, SCI paraplegics, UE amputees, adults with CP, and healthy controls. [centerwatch.com]

  Additional resources The National Institute of Neurological Disorders and Stroke offers this information: " Spinal Cord Injury: Hope Through Research ." Find help and support at the National Spinal Cord Injury Association. [livescience.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]

• Spinal Cord Syndrome

  Abstract The authors present a case report of a patient with cervical central spinal cord syndrome caused by a hyperextension injury after a motor vehicle collision in which the air bag deployed in the absence of shoulder or lap belt harnesses. [ncbi.nlm.nih.gov]

  Central spinal cord injury in a patient with a hyperextension injury and preexisting spondylosis and stenosis. Spinal cord syndromes (2): Central cord syndrome Most common incomplete cord syndrome. [radiologyassistant.nl]

  See also Hypercalcemia and Spinal Cord Injury, Spinal Cord Injury and Aging, Rehabilitation of Persons With Spinal Cord Injuries, Central Cord Syndrome, Brown-Sequard Syndrome, and Cauda Equina and Conus Medullaris Syndromes. [emedicine.medscape.com]

  True hemisection of the spinal cord (Brown-Séquard syndrome) is rare and usually associated with penetrating trauma. [aafp.org]

  Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med. 2007. 30: 215-24 22. Miranda P, Gomez P, Alday R. Acute traumatic central cord syndrome: Analysis of clinical and radiological correlations. [surgicalneurologyint.com]

• Focal Neurological Deficit

  Five criteria had to be met for the patient to be classified as having a low probability of injury: no midline cervical tenderness, no focal neurological deficit, normal alertness, no intoxication and no painful distracting injury. [pn.bmj.com]

  A focal neurological deficit or paraesthesia in the extremities. Midline cervical tenderness. For all patients presenting with acute whiplash injury [ 1 ] Exclude spinal cord compression; if this is suspected, admit immediately. [patient.info]

  No focal neurologic deficit is present. The patient does not have a painful distracting injury. Lateral view The lateral view is the most useful view. Approximately 85-90% of spinal injuries are evident on this view. [radiologyassistant.nl]

  The presence of amnesia, external signs of head injury or basilar skull fracture, focal neurologic deficits, associated alcohol intoxication or drug abuse, and a history of loss of consciousness mandates a thorough evaluation for intracranial injury, [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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