Symptoms, diagnosis and treatment of spinal cord injury
Injuries to the spine and spinal cord are common. Spine injuries include fractures and dislocations. They may or may not be associated with spinal cord injuries. Spinal cord injuries may be seen without spine injuries. Their causes include falls, motor vehicle accidents, blunt trauma, gunshot wounds, stab wounds and sports injuries. Spinal cord injuries are a significant cause of disability in young people.
The majority of injuries are seen in the cervical (neck) spine followed by the thoracic (chest) spine and the lumbar (low back) spine. Spinal cord injuries are divided into two main types: complete and incomplete. Complete injuries are those where there is no function below the level of the injury. About 3 percent of patients with complete injuries will show some improvement over the first 24 hours after injury. After 24 hours post-injury improvement is almost never seen.
Injuries to other parts of the body are often seen in the setting of spinal cord injury. The reverse is also common; that is to say, spinal cord injuries are often seen in patients with other injuries (head, chest, abdomen etc.). Because of this, it is important to treat all major trauma patients as if they have a spine injury until proven otherwise.
Symptoms
The symptoms range from nothing to complete paralysis. In patients who are awake, pain is a common symptom of spine injury. Depending on the degree of injury and amount of pressure on the spinal cord or spinal nerves, various amounts of weakness and or sensory loss can be seen. There may also be loss of bowel and or bladder control. Depending on the type of injury, various patterns may be seen in patients with incomplete spinal cord injuries.
The central cord syndrome is a syndrome that is usually associated with an extension injury (the head is forced backwards). It is seen frequently in older patients who have cervical spinal stenosis. In central cord injuries, significant loss of strength in the arms and hands is seen in the setting of relatively preserved strength in the legs. Sensory loss is variable.
The anterior spinal cord syndrome (anterior spinal artery syndrome) is usually seen as a result of compression of the artery that runs along the front of the spinal cord. The compression may be from bone fragments or a large disc herniation. Patients with anterior spinal cord syndrome usually have complete loss of strength below the level of injury. Sensory loss is incomplete. Generally, sensitivity to pain and temperature are lost while sensitivity to vibration (tested with a tuning fork) and position are preserved.
Another typical incomplete injury is the Brown-Séquard syndrome. This is a result of interruption of signals from one half of the spinal cord. This syndrome may be seen in cases of stab wounds, blood clots or disc herniation. In the Brown-Séquard syndrome, there is loss of motor strength and sensitivity to vibration and position below the injury on the same side as the injury. On the side opposite the injury, there is loss of sensitivity to pain and temperature below the level of the injury.
Diagnosis
As always, a careful history and physical examination are the first steps in diagnosis. In trauma cases, x-rays of the cervical spine are obtained as soon as possible. If there is the possibility of injury to the thoracic or lumbar spine x-rays of these areas are also taken. Depending on the individual case, further evaluation with MRI scanning, CT scanning or myelogram may be performed.
Treatment
Treatment is usually begun in the field by paramedics or other first responders. The ABC’s of trauma are as follows, A for airway, the patient’s airway is cleared if necessary. B for breathing, if the patients is not breathing, artificial respiration is begun. C for circulation, this refers to both hemorrhage and shock. Severe hemorrhage is controlled and intravenous fluids are given as necessary. All these treatments are carried out while keeping the possibility of an unstable spine in mind. Immobilization is performed as soon as possible. This consists of a cervical collar and a back board. The patient is transported to the emergency room as soon as possible.
If there is evidence of spinal cord injury, high-dose steroid treatment is usually begun. This should be started within the first eight hours after injury to have effect. Specific neurosurgical treatment depends on the type and degree of injury. The treatment of spinal cord injuries is complex and must be individualized to each patient.