Traumatic injuries to the spinal cord

Introduction :

A traumatic spinal cord injury (TSCI) is traumatic injury leading to damage of the spinal cord, resulting in temporary or permanent change to neurological function, including paralysis.

TSCIs are more common in males, and the majority are due to preventable causes such as falls (40\%), road traffic collisions (35\%), or sport injuries (12\%).

TSCI can be classified* as complete or incomplete:

A complete injury is damage occurring across the whole spinal cord width, leading to complete loss of sensation and paralysis below the level of injury

An incomplete injury is the injury is spread across part of the spinal cord thereby only partially affecting sensation or movement below the level of injury

Pathophysiology :

Trauma causes injury to the spinal cord from the initial acute impact, resulting in a concussion on the spinal cord compression on the spinal cord from increased pressures from nearby rigid structures (such as vertebrae and discs) that may have been displaced by the injury.

Based on pathophysiology, spinal cord injuries can be classified into primary or secondary injuries.

Primary injury refers to the destructive forces that directly damage the neural structures, such as the shear forces tearing an axon or the direct compressive force occluding a blood vessel, resulting in ischaemia.

Secondary injury refers to a cascade of vascular, cellular, and biochemical events which occur following the injury, which can worsen a concurrent primary injury.

Clinical features depend on the level and completeness of injury, and around 10\% of traumatic spinal injuries will result in tetraplegia or paraplegia. Pain may not be present in every case.

Clinical features :

Clinical signs can include loss of motor function, loss of sensory function, bowel incontinence, or urinary incontinence.

Investigations :

All trauma patients first require an A to E assessment, as per the ATLS guidelines.

The cervical spine must be immobilised as a priority in cases of trauma with a suggestive mechanism of injury, prior to any further examination or imaging of the region as a precaution.

NICE guidelines suggest the following imaging modalities following trauma to assess for potential traumatic spinal cord injuries.

Suspected Cervical Spine Injury

Perform a CT scan in adults, if suggested by Canadian C-spine rules
Perform MRI for children, if suggested by Canadian C-spine rules
Consider a plain film radiograph in those who do not fulfil the criteria for MRI but clinical suspicion remains after repeated clinical assessment

Suspected Thoracic or Lumbosacral Spine Injury

Perform a plain film radiograph as the first‑line investigation for those with suspected spinal column injury without abnormal neurological signs or symptoms

Perform a CT scan if the radiograph is abnormal or there are clinical signs or symptoms suggestive of a spinal column injury
If a new spinal column fracture is confirmed, image the rest of the spinal column

Management :

Conservative management includes a combination of bed rest, cervical collars, motion restriction devices, and traction, followed by early mobilisation and rehabilitation.

Surgical management :

Cervical spine surgery aims to realign the spine, decompress the neural tissue, and stabilise the spine with internal fixation (screws, plates, cages)

Thoracolumbar spine surgery typically involves spinal decompression, discectomy, spinal fixation, or spinal cord simulation

Physiotherapy and other specialist therapy input (e.g. speech and language or occupation therapy) should be utilised early (as soon as deemed safe), as patients often require extensive rehabilitation both as inpatient and outpatient.

Goals of therapy need to be discussed with the patient, to build a realistic rehabilitation plan.

Froala Editor

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