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Cervical Spinal Cord Injury

Cervical spinal cord injury is a serious clinical condition characterized by damage to segments C1 to C7 of the spinal cord. Trauma to cervical segments is associated with the most destructive consequences such as quadriplegia, loss of respiratory, autonomic system function etc.


Presentation

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].

High Fever
  • Neither high fever nor pharyngeal pain has recurred at latest follow-up, 5 years after surgery.[ncbi.nlm.nih.gov]
Muscle Spasticity
  • Symptoms may include: Muscle weakness or paralysis in the trunk, arms or legs Loss of feeling in the trunk, arms, or legs Muscle spasticity Breathing problems Problems with heart rate and blood pressure Digestive problems Loss of bowel and bladder function[hopkinsmedicine.org]
  • 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]
  • Musculoskeletal management Patients with SCIs typically experience muscle spasticity as spinal shock recedes and reflexes return. Spasticity may take a flexor or extensor pattern or a combination.[americannursetoday.com]
  • Motor function: A body function controlled by muscles. Spasticity: The permanent tightening of a joint into an abnormal position. Spinal cord: A long rope-like piece of nervous tissue that runs from the brain down the back.[encyclopedia.com]
Edema of the Upper Extremity
  • There were no significant between-group differences for TPM of the fingers, edema and upper-extremity motor scores at 1 week, 1 month and 3 months after injury, although TPM of the fingers tended to be lower in the control group.[ncbi.nlm.nih.gov]
Hip Pain
  • The clinical assessment suggested that her left-sided hip pain was attributable to severe right hip osteoarthritis. Her left hip pain resolved completely after she underwent a right total hip arthroplasty.[ncbi.nlm.nih.gov]
Hysteria
  • In some the neurologic problem was missed altogether; in others it was attributed to hysteria, intoxication, or to other neurologic or systemic diseases.[ncbi.nlm.nih.gov]
Cervical Enlargement
  • Impaired circulation in the artery of cervical enlargement is significant in extension of perifocal ischemia.[ncbi.nlm.nih.gov]
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]
  • ., legal actions, workers' compensation) Babinski's sign and hyperreflexia are widely understood to be cardinal signs of the upper motor neuron syndrome that typically occurs in spinal cord compression.[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]
Spastic Paralysis
  • Muscle relaxants: If spastic paralysis develops, muscle relaxants, such as baclofen or tizanidine, may be used.[merckmanuals.com]
  • The lower limbs exhibit spastic paralysis. If the space in which the spinal fluid flows between the spinal cord and the surrounding vertebral column is either compressed or enlarged, severe headache occurs.[chiro.org]
Encephalopathy
  • The initial diagnosis of hypoxic ischaemic encephalopathy delayed recognition of an upper cervical spinal and cord injury, which was subsequently confirmed by magnetic resonance imaging.[ncbi.nlm.nih.gov]
Lethargy
  • Uncontrolled hyponatremia may lead to lethargy, seizures, coma, cardiac arrhythmia and death. Therefore, the complication of hyponatremia should be paid attention after cervical spinal cord injury.[ncbi.nlm.nih.gov]
Apraxia
  • The oral phase was observed with respect to apraxia. After initiation of the swallowing reflex, the presence of predeglutitive aspiration, retentions, penetration or aspiration of yoghurt was noticed.[nature.com]

Workup

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].
Hyponatremia
  • Uncontrolled hyponatremia may lead to lethargy, seizures, coma, cardiac arrhythmia and death. Therefore, the complication of hyponatremia should be paid attention after cervical spinal cord injury.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Haemorrhage changes on MRI scans were closely associated with the onset of hyponatremia and could provide objective data for forecasting hyponatraemia in CSCI patients. Low BP was also a reasonable predictor of hyponatremia.[ncbi.nlm.nih.gov]

Treatment

  • Among these patients, 9 received conservative treatment and 33 underwent surgical treatment from June 2009 to March 2013.[ncbi.nlm.nih.gov]
  • 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]
  • We compared the rate of each acute treatment between the depressive state group and the non-depressive state group using chi-square tests, and a multiple logistic regression model was used to identify the association between the acute treatment and depressive[ncbi.nlm.nih.gov]
  • Surgical treatment was considered to be indicated for patients with cervical spinal canal narrowing, when satisfactory neurological improvement is not obtained by conservative treatment.[ncbi.nlm.nih.gov]
  • For the emergency treatment of multiple injuries headed by cervical spinal cord injury, the damage control strategy is the principle to follow.[ncbi.nlm.nih.gov]

Prognosis

  • It was not clearly demonstrated whether the MRI at any time correlates with neurologic prognosis.[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 neurological prognosis was relatively better in those with a unilateral cord injury type, but there was no statistical difference. Thirty-seven patients (82.2%) showed neurological improvement of at least one Frankel grade.[ncbi.nlm.nih.gov]
  • OBJECTIVES: To evaluate the relationship between magnetic resonance imaging (MRI) features and neurological prognosis in patients with traumatic cervical spinal cord injury (CSCI) without major bone injury.[ncbi.nlm.nih.gov]
  • Our objective is to determine radiologic findings related to neurologic prognosis in patients after incomplete acute traumatic cervical spinal cord injury, regardless of initial neurologic examination results.[ncbi.nlm.nih.gov]

Etiology

  • 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]
  • On the basis of our results, we hypothesized that the raised cervical articular facets might have an important role in the etiology of traumatic CSCI.[ncbi.nlm.nih.gov]
  • Traumatic etiologies accounted for 93.5%, and mean onset age was 47.6 15.8 years. Sixty patients (96.8%) had undergone tracheostomy and the other two received endotracheal intubation during acute phase.[ncbi.nlm.nih.gov]
  • 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]

Epidemiology

  • BACKGROUND: Aging of the population has modified the epidemiology of traumatic spinal cord injury (SCI) as evidenced by the establishment of a bimodal distribution of injuries with increased frequency of fall-related injuries among the elderly.[ncbi.nlm.nih.gov]
  • 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]
  • Author information 1 1 Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine , Baltimore, Maryland. 2 2 Department of Epidemiology and Public Health, University of Maryland School of Medicine , Baltimore, Maryland[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]
Sex distribution
Age distribution

Pathophysiology

  • 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]
  • Abstract We review the pathophysiology and imaging findings of acute traumatic spinal cord injury (SCI), cervical spondylotic myelopathy, and briefly review the much less common cord herniation as a unique cause of myelopathy.[ncbi.nlm.nih.gov]
  • 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 pathomechanics, pathophysiology and prevention of cervical spinal cord and brachial plexus injuries in athletics. Sports Med . 2010; 40(1):59-75. Cantu RC. Head and spine injuries in youth sports. Clin Sports Med . 1995; 14(3):517-532.[healio.com]
  • At the C4-C5 level below, HPLL itself without such ossification contributes to marked cord compromise Central cord injury: Pathophysiology, management, and outcomes Harrop et al . utilized Medline to evaluate the pathophysiology, management, and outcomes[surgicalneurologyint.com]

Prevention

  • 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]
  • A large fluid intake is recommended for these patients, as a high intake of fluids is still the most powerful and certainly the most economical means of prevention of nephrolithiasis.[ncbi.nlm.nih.gov]
  • Temporary transvenous ventricular pacing followed by oral propantheline was required to prevent further episodes. The investigation, physiology and treatment of this arrhythmia in tetraplegia are discussed.[ncbi.nlm.nih.gov]
  • INTRODUCTION: Several studies have demonstrated the role of decompression surgery in preventing secondary injury and improving the neurological outcome after spinal cord injury (SCI).[ncbi.nlm.nih.gov]
  • The risk for dysphagia should be evaluated to prevent aspiration pneumonia.[ncbi.nlm.nih.gov]

References

Article

  1. Van Middendorp JJ, Goss B, Urquhart S, Atresh S, Williams RP, Schuetz M. Diagnosis and Prognosis of Traumatic Spinal Cord Injury. Global Spine J. 2011;1(1):1-8.
  2. Wuermser LA, Ho CH, Chiodo AE, Priebe MM, Kirshblum SC, Scelza WM. Spinal cord injury medicine. 2. Acute care management of traumatic and nontraumatic injury. Arch Phys Med Rehabil. 2007 Mar. 88(3 Suppl 1):S55-61.
  3. Como JJ, Diaz JJ, Dunham CM, et al. Practice Management Guidelines for Identification of Cervical Spine Injuries Following Trauma: Update From the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma. September 2009; 67(3):651-659.
  4. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a Set of Clinical Criteria to Rule Out Injury to the Cervical Spine in Patients with Blunt Trauma. N Engl J Med 2000; 343:94-99.6. Nowak DD, Lee JK, Gelb DE, Poelstra KA, Ludwig SC. Central cord syndrome. J Am Acad Orthop Surg. 2009 Dec;17(12):756-65.
  5. Kirshblum SC, Burns SP, Biering-Sorensen F, et al. International standards for neurological classification of spinal cord injury (Revised 2011). J Spinal Cord Med. 2011 Nov; 34(6): 535–546.
  6. Nowak DD, Lee JK, Gelb DE, Poelstra KA, Ludwig SC. Central cord syndrome. J Am Acad Orthop Surg. 2009 Dec;17(12):756-65.
  7. Van Middendorp JJ, Goss B, Urquhart S, Atresh S, Williams RP, Schuetz M. Diagnosis and Prognosis of Traumatic Spinal Cord Injury. Global Spine J. 2011;1(1):1-8.
  8. Como JJ, Thompson MA, Anderson JS, et al. Is Magnetic Resonance Imaging Essential in Clearing the Cervical Spine in Obtunded Patients With Blunt Trauma? J Trauma: September 2007; 63(3):544-549.
  9. Mathen RBS, Inaba K, Munera F, et al. Prospective Evaluation of Multislice Computed Tomography Versus Plain Radiographic Cervical Spine Clearance in Trauma Patients. J Trauma.June 2007; 62 (6): 1427-1431
  10. Miyanji F, Furlan JC, Aarabi B, et al. Acute Cervical Traumatic Spinal Cord Injury: MR Imaging Findings Correlated with Neurologic Outcome—Prospective Study with 100 Consecutive Patients. Radiology. June 2007; 243(3).

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Last updated: 2019-07-11 20:22