Spinal cord trauma

Background

• Penetrating injury
  • GSW
    • Most are stable injuries and only require supportive orthosis, analgesia
    • Give antibiotics if GSW traversed the abdomen before injuring the cord
    • Bullet removal does not improve neuro status for stable cervical and thoracic lesions
    • Bullet removal may improve neuro status for thoracolumbar region injury (T11-L2)
  • Stabbing
    • Vertebral instability is generally not an issue
    • Delayed deficits are rare
      • If do occur related to retained fragment of blade within spinal canal

Peds

• In patients <10yr spinal injury occurs mainly in upper cervical vertebrae
• In patients >10yr majority of injuries occur in lower cervical spine, similar to adults
• Odontoid fractures are among most common cervical spine injuries in children
  • Do not confuse with normal anatomic variations in odontoid seen in children up to 7yr old
• SCIWORA
  • Spinal cord injury without radiologic abnormality
  • MRI has shown significant pathology in many of these patients
  • Symptoms
    • Delayed onset (within 48hr) of numbness, paresthesias in extremities
• Transient quadriparesis ("stinger")
  • Occurs most often in boys after sports injuries
  • Paresthesias or weakness of extremities lasting from seconds to minutes
    • Complete recovery within 48hr

Evaluation

• Clinical (see spinal cord syndromes)
• X-ray
  • See C-spine (NEXUS) and C-Spine X-Ray
• Consider:
  • CT
  • MRI

Differential Diagnosis

Blunt Neck Trauma

• Spinal cord trauma
• Vertebral and carotid artery dissection
• Whiplash injury
• Cervical spine fractures and dislocations
• Strangulation

Spinal Cord Syndromes

• Complete spinal cord transection syndrome
• Anterior cord syndrome
• Central cord syndrome
• Brown-Sequard syndrome
• Epidural compression syndromes
  • Syringomyelia
  • Spinal cord compression (non-traumatic)
  • Cauda equina syndrome
  • Conus medullaris syndrome
  • Epidural abscess (spinal)
  • Epidural hematoma (spinal)

Management

• Consider intubation injuries at C5 or above
• Consider surgical intervention for:
  • Progressive neurologic deficits
  • Unstable spine fractures
• Steroids are no longer recommended
  • Administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) is not recommended. Clinicians considering MP therapy should bear in mind that the drug is not Food and Drug Administration (FDA) approved for this application. There is no Class I or Class II medical evidence supporting the clinical benefit of MP in the treatment of acute SCI. Scattered reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death.
  • See EBQ:High Dose Steroids in Cord Injury for further discussion

See Also

• Penetrating neck trauma
• Blunt neck trauma
• Neurogenic Shock
• Spinal Shock
• Autonomic Dysreflexia
• Thoracic and Lumbar Spine Injuries
• Cervical Spine Injuries
• Vertebral fractures

References

Authors

Ross Donaldson