Spinal Cord Injury
Examination and Evaluation of a Patient
Imagine this scenario- A patient was involved in a motor vehicle accident and the patient is now unable to move all four extremities. The examination would start with applying the ABC’s for a trauma patient. Airway, Breathing and ventilation, Circulation and hemorrhage control, Disability evaluation/checking neurologic status, and Exposure/Environmental control. Since the patient cannot move the extremities, then the patient should be examined for spinal cord injuries. The first question asked is, “is the patient in spinal shock?” Spinal shock means that the patient does not have the bulboavernosus reflex (the anal sphincter will not contract when the reflex is absent). The patient will also have flaccid paralysis.
Spinal shocks lasts about 48 hours, and the prognosis of the patient cannot be determined until the spinal shock is over, at which point the bulbocavernous reflex may return. At this point, it can be determined whether the patient has a complete or incomplete injury. Complete injury means that there is no motor or sensory below the level of the lesion and no sacral sparing. On the other hand, incomplete injury is shown if the bulbocavernosus reflex returns, which means there is sacral sparing, perianal sensation, or rectal tone.
After the 48 hours of spinal shock, the functional level should be assessed. Look for the lowest segment with bilaterally intact sensation or antigravity muscle function and strength, like three or more bilaterally, while the segment above is normal.
The ASIA impairment scale needs to be determined. This scale goes from complete to normal. A rating of A- E represent complete- normal injury, respectively. A means there is a complete injury with no motor function, no sensory function, and no sacral sparing. B means there is an incomplete injury with no motor function, but there is some sensory function or sacral sparing. C means there is an incomplete injury with incomplete motor function and more than 50% of the muscle groups have a grade less than 3/5 strength (patient cannot raise their arms or legs). D means there is an incomplete injury, but it is not a bad spinal cord injury. More than 50% of the muscle groups have grade 3/5 strength or more (patient can raise their arms and legs). E means the spinal cord is normal with normal motor and sensory functions.
When we talk about incomplete spinal cord injuries, we are talking about injuries with some neurologic function distal to the injury. In general, we are speaking of sacral sparing. If the sacral sparing is positive, then the patient has an incomplete spinal cord injury. However, if the sacral sparing is negative, then the patient has a complete spinal cord injury.
There are four types of incomplete spinal cord injuries. They are the central cord syndrome, the anterior cord syndrome, the posterior cord syndrome, and the Brown-Sequard syndrome. Central cord syndrome is the most common type of spinal cord injury. It is caused by hyperextension injuries, and is often seen in older patients. Anterior cord syndrome has poor prognosis, and is usually vascular in nature. The posterior cord syndrome is very rare, and is associated with loss of proprioception, deep touch, and vibration. Finally, Brown-Sequard is a hemisection of the spinal cord, and generally has a good prognosis. There will be loss of ipsilateral motor function and contralateral loss of pain and temperature sensation.
Neurogenic shock is sometimes seen in incomplete spinal cord injuries. It is hypotension and bradycardia due to loss of the sympathetic tone to the heart and wide spread vasodilation, with decreased systemic vascular resistance to descending sympathetic system. Careful fluid management is needed. Swan ganz monitoring and vasopressors may be needed to treat the hypotension.
Autonomic dysreflexia occurs in complete spinal cord injuries. This is due to uncontrolled sympathetic output (sympathetic system is overcharged in activity). It is usually associated with certain triggers, which are usually unchecked visceral stimulation such as fecal impaction or the folley catheter obstruction (kinked or blocked). It occurs in patients with spinal cord injuries above the level of T6. The patient will have a headache, agitation, severe hypertension, and sweating, and it can be fatal. So, fecal impaction and folley catheter obstruction should always be checked. Antihypertensives can be administered, as well as Atropine.
