Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 24-25: Spinal Trauma + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ History of trauma Development of an acute neurologic deficit Signs of myelopathy on examination +++ General Considerations ++ Although spinal cord damage may result from whiplash injury, severe injury usually relates to fracture-dislocation causing compression or deformity of the cord either in the cervical or in the lower thoracic and upper lumbar regions Extreme hypotension following injury may also lead to cord infarction + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs +++ Total cord transection ++ Immediate flaccid paralysis and loss of sensation below the level of the lesion Reflex activity is lost for a variable period; urinary and fecal retention As reflex function returns, spastic paraplegia or quadriplegia develops, with hyperreflexia and extensor plantar responses A flaccid atrophic (lower motor neuron) paralysis may be found depending on the segments of the cord affected The bladder and bowels regain some reflex function, permitting urine and feces to be expelled at intervals As spasticity increases, flexor or extensor spasms (or both) of the legs become troublesome, especially if bed sores or a urinary tract infection develops Paraplegia with the legs in flexion or extension may eventually result +++ Lesser degrees of injury ++ Mild limb weakness, distal sensory disturbance, or both Sphincter function may be impaired, urinary urgency and urge incontinence being especially common A unilateral cord lesion leads to an ipsilateral motor disturbance with accompanying impairment of proprioception and contralateral loss of pain and temperature appreciation below the lesion (Brown-Séquard syndrome) A central cord syndrome may lead to a lower motor neuron deficit at the level of the lesion and loss of pain and temperature appreciation below it, with sparing of posterior column functions With more extensive involvement, posterior column sensation may also be impaired and pyramidal weakness develops A radicular deficit may occur at the level of the injury—or, if the cauda equina is involved, there may be evidence of disturbed function in several lumbosacral roots +++ Differential Diagnosis ++ The history of the preceding trauma distinguishes the disorder from other causes of nontraumatic myelopathy + Diagnosis Download Section PDF Listen +++ +++ Diagnostic Procedures ++ Obtain history of trauma + Treatment Download Section PDF Listen +++ +++ Medications ++ Early treatment with high doses of corticosteroids (eg, methylprednisolone, 30 mg/kg by intravenous bolus, followed by 5.4 mg/kg/h for 23 hours) Can improve neurologic recovery if commenced within 8 hours after injury However, evidence is limited and some neurosurgical guidelines do not recommend their use +++ Surgery ++ If there is cord compression, early decompressive laminectomy and fusion (within 24 hours) +++ Therapeutic Procedures ++ Immobilization Anatomic realignment of the spinal cord by traction and other orthopedic procedures is important + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Subsequent care of the residual neurologic deficit—paraplegia or quadriplegia—requires treatment of spasticity and care of the skin, bladder, and bowels +++ Complications ++ Pressure injuries (formerly pressure ulcers) Urinary tract infection Renal calculi Depression Pneumonia +++ When to Refer ++ All patients with focal neurologic deficits +++ When to Admit ++ Patients with neurologic deficits Patients with spinal cord injury, compression, or acute epidural or subdural hematoma Patients with vertebral fracture-dislocation likely to compress the cord + Reference Download Section PDF Listen +++ + +Alizadeh A et al. Traumatic spinal cord injury: an overview of pathophysiology, models and acute injury mechanisms. Front Neurol. 2019 Mar 22;10:282. [PubMed: 30967837] + +Fehlings MG et al. A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Global Spine J. 2017 Sep;7(3 Suppl):84S–94S. [PubMed: 29164036] + +Freund P et al. MRI in traumatic spinal cord injury: from clinical assessment to neuroimaging biomarkers. Lancet Neurol. 2019 Dec;18(12):1123–35. [PubMed: 31405713] + +Karsy M et al. Modern medical management of spinal cord injury. Curr Neurol Neurosci Rep. 2019 Jul 30;19(9):65. [PubMed: 31363857] + +Venkatesh K et al. Spinal cord injury: pathophysiology, treatment strategies, associated challenges, and future implications. Cell Tissue Res. 2019 Aug;377(2):125–51. [PubMed: 31065801]