NEUROLOGY AND NEUROSURGERY - Y. V. ALEKSEYENKO - 2014

TRAUMATIC SPINAL CORD INJURIES

Following the analogy of traumatic Brain injury (TBI), traumatic Spinal Cord injuries are traditionally classified into concussion of the spinal cord, spinal cord contusion, and spinal cord compression. In addition, certain isolated forms of injury may occur, such as complete anatomical transection of the spinal cord, hematomyelia (Hemorrhage into the spinal cord), hemorrhage into the intermeningeal spaces, damage to the major Blood Vessels of the spinal cord, and injury to the spinal nerve roots. Combined injuries involving the spinal cord, blood vessels, nerve roots, and Meninges are sometimes observed. Determining the true extent and nature of spinal cord damage in the acute phase of trauma is often extremely difficult due to spinal Shock, which is characterized by a severe disruption of spinal reflex activity lasting from several days to 2–3 weeks.

Acute spinal cord compression occurs at the moment of injury and is caused by bone fragments protruding into the spinal canal, traumatic disc herniation, damaged ligamentum flavum, or displaced vertebral bodies. Early compression develops within the first 10 days and may be caused by an epidural or intramedullary hematoma, progressive spinal cord edema, secondary displacement of vertebrae or bone fragments, etc. Late spinal cord compression forms several weeks or months after the injury As a result of osteo-cartilaginous proliferations, The Development of scarring and adhesive processes, and cyst formation within the spinal canal.

The clinical course of traumatic spinal cord disease comprises the acute period (first 3 days), early period (from 3 days to 3–4 weeks), intermediate period (1–3 months), and late period (more than 3 months).

The medical history focuses on the time and mechanism of injury, Location of pain, presence of sensory and motor deficits, and the dynamics of their progression. It is essential to account for the masking effect of spinal shock, which temporarily precludes a full clinical Assessment of the severity and extent of the spinal cord lesion. Other potential injuries must be ruled out, including TBI, chest trauma, and internal organ damage.

Physical examination reveals signs of trauma, as well as possible skeletal and soft tissue deformities. A thorough examination of the undressed patient is crucial; however, rough manipulations during the examination pose a risk of exacerbating neurological deficits. The severity and progression of neurological impairment are assessed using the ASIA/ISCOS scale (International Standards for Neurological and Structure/81.html">Functional Classification of Spinal Cord Injury). Key criteria include preserved Muscle strength, tactile and Pain Sensation, and anogenital reflex status.

Muscle strength in the upper and lower extremities is evaluated across five cervical-thoracic (C5–T1) and five lumbosacral (L2–S1) segments using a standardized grading scale.

Class="center">Table 16.1. Muscle Strength Grading Scale

Muscle strength is calculated by summing the scores for each segment on both sides. The maximum score for the 10 segments on each side is 50. The presence or absence of voluntary contraction of the external anal sphincter is noted; its preservation indicates an incomplete spinal cord injury.

Sensory function is assessed across 28 dermatomes bilaterally using the following scale:

Table 16.2. Sensory Impairment Grading Scale

The maximum possible sensory score for both sides combined is 56.

There are five grades of spinal cord injury.

A. Complete injury. No motor or sensory function is preserved in the sacral segments S4–S5;

B. Incomplete (nearly complete) injury. Sensory but no motor function is preserved below the neurological level, and sensory function extends to the sacral segments S4–S5;

C. Incomplete injury. Motor function is preserved below the neurological level, and more than half of key muscle Functions below the neurological level have a muscle grade less than 3;

D. Incomplete (mild/moderate) injury. Motor function is preserved below the neurological level, and at least half of key muscle functions below the neurological level have a muscle grade of 3 or greater;

E. Normal. Motor and sensory functions are intact.

Protocol for instrumental examination of patients with traumatic spinal cord injuries:

   • Spondylography in anteroposterior, lateral, and oblique projections

   • CT scan

   • CSF analysis and CEREBROSPINAL FLUID dynamics tests

   • Myelography

   • MRI

   • Somatosensory evoked potential testing

Lesions of the upper cervical spine (C1 - C4) lead to impaired function of the Respiratory Muscles, including the Diaphragm, as well as quadriplegia or tetraparesis with sensory deficits of all modalities below the level of the lesion, reflex changes characteristic of pyramidal tract lesions, and pelvic organ dysfunction (urinary and fecal retention or intermittent incontinence). Immediately following trauma, flaccid quadriplegia with muscle hypotonia and areflexia is observed, resulting from spinal shock. After several days or weeks, this gives way to spastic quadriplegia.

Lesions of the lower cervical spine (C5 - T1). These are characterized by spastic paralysis of the lower limbs and atrophic paralysis of the upper limbs, sensory deficits of all modalities below the level of the lesion following a conduction pattern, urinary and fecal retention, and Horner's syndrome.

Lesions of the upper thoracic spine (T2 - T4). Lower paraplegia, absent abdominal Reflexes, pathological reflexes and sensory deficits below the level of the lesion, and pelvic organ dysfunction (urinary and fecal retention).

Lesions of the lower thoracic spine (T8 - T12). A lower level of neurological impairment is detected; lower and middle abdominal reflexes are absent, while upper abdominal reflexes are diminished.

Lesions of the lumbar spine (L1 - L5). Flaccid paralysis of the proximal lower limb muscles is observed, knee reflexes are lost while Achilles reflexes are enhanced, and pathological signs (such as Babinski and Rossolimo reflexes) appear alongside sensory deficits below the inguinal folds.

Lesions of the conus medullaris (S1 - S2). Atrophic paresis of the distal lower limbs (LEGS AND FEET) is detected, along with loss of Achilles reflexes, sensory deficits of all modalities along the outer surfaces of the shanks and thighs and in the perineal region.

Lesions of the medullary cone (S3 - S5). Sensory loss is observed in the Perineum and the posteroinferior gluteal regions, accompanied by impaired urination and defecation (true Urinary Incontinence), loss of the anal reflex, and trophic disorders in the sacral region.

Cauda equina syndrome. Clinical Features include pain in the anus, perineum, sacrum, buttocks, and lower limbs; sensory deficits of all modalities within the areas innervated by the affected roots; peripheral paresis of the lower limbs and perineum; diminished or absent reflexes (knee, Achilles, plantar, and anal); FOOT drop; gait disturbances; and urinary and fecal incontinence.

If a spinal injury is suspected, the patient must be provided with spinal immobilization and prompt, careful transport to the nearest multidisciplinary hospital or specialized neurosurgical department.

Indications for emergency surgical intervention:

   • onset or progression of neurological spinal symptoms, or the presence of a "lucid interval", which is characteristic of early compression types not accompanied by spinal shock;

   • blockage of cerebrospinal fluid pathways;

   • compression of the spinal canal by compressing substrates in the presence of corresponding spinal symptoms;

   • isolated hematomyelia, particularly when combined with cerebrospinal fluid pathway blockage;

   • clinical and angiographic signs of compression of the main spinal cord vessel (urgent intervention is indicated);

   • unstable injuries to spinal motion segments that threaten secondary or intermittent spinal cord compression.

There are also contraindications for Surgical Treatment of acute spinal trauma:

   • traumatic or hemorrhagic shock with hemodynamic instability;

   • concomitant internal organ injuries (in cases of internal bleeding, risk of Peritonitis, cardiac contusion with signs of Heart Failure, or multiple rib fractures with hemopneumothorax and respiratory failure);

   • severe traumatic brain injury with a Glasgow Coma Scale score below 9, when intracranial hematoma is suspected;

   • severe comorbid conditions accompanied by anemia, cardiovascular, renal, or hepatic failure;

   • fat embolism, Pulmonary Embolism, Pneumonia, or unfixated limb fractures (in cases of posterior surgical approach).

Surgical intervention for spinal cord compression, in the absence of contraindications, should be performed as early as possible, since more than 70% of all ischemic injuries resulting from cord compression develop within the first 6-8 hours. Basic therapy includes the correction of respiratory and cardiac disorders, as well as biochemical parameters; management of pulmonary edema; Prevention of infectious complications and pressure ulcers; correction of hypovolemia and hypoproteinemia; regulation of pelvic organ functions (Monro's system, Urinary Bladder catheterization at least 4 times a day); and correction of microcirculatory and hemorheological disturbances. The administration of antihypoxants, angioprotectors, and neuroprotectors is indicated. Restoring circulating blood volume is essential under the control of central venous pressure and plasma osmolarity (280-310 mOsm/L), particularly in cases of hyperglycemia, renal failure, uncontrolled use of osmotic Diuretics, or alcohol intoxication.

Approximately 37% of patients with vertebromedullary trauma die at the prehospital stage, and another 13.3% in the hospital. A favorable outcome with complete neurological recovery following stab and slash wounds of the spinal cord is observed in 7.5-20% of cases, whereas in gunshot wounds, it drops to 2-3%. The majority of patients following spine and spinal cord injuries require prolonged, comprehensive rehabilitation utilizing pharmacotherapy, Therapeutic Exercises, massage, physical therapy, and psychotherapy.

Clinical Cases

Case 1

A 34-year-old male sustained a stab wound to the neck at the level of the 5th and 6th cervical vertebrae on the right side. Immediately following the injury, he developed weakness in the right limbs and sensory disturbances in the left half of the body below the clavicular level. Within a few hours, there was a complete loss of active movements in the legs, accompanied by urinary retention. Upon examination, restricted mobility of the right arm and a complete lack of movement in the legs were noted. Muscle hypotonia in the extremities was observed. Tendon and periosteal reflexes were depressed in the right arm and legs. Pathological plantar reflexes were absent. Hypesthesia (predominantly on the left) was present below the level of the clavicles.

   • List the main neurological disorders.

   • Describe the motor impairment syndrome.

   • Describe the sensory disturbance syndrome.

   • Formulate the topical Diagnosis.

   • Formulate and justify the preliminary clinical diagnosis.

   • Outline the main directions for Differential diagnosis.

   • Present the scheme of instrumental and Laboratory examination.

   • Describe the cerebrospinal fluid changes characteristic of this case.

   • Outline the patient management plan.

   • Describe The Scope of medical care during the initial examination.

   • Formulate the indications for surgical treatment.

   • Describe the principles and options of surgical treatment.

   • Indicate the Main Components of pharmacotherapy.

   • List the core Components of the rehabilitation program.

   • Determine the most likely prognosis.

   • Name the potential complications and long-term consequences of the injury.

Case 2

A 24-year-old male experienced weakness in his arms and legs, along with numbness in the trunk and extremities, following a motorcycle fall. Examination revealed a complete absence of active movements in the limbs, muscle hypotonia, absent tendon and periosteal reflexes, and no pathological plantar reflexes. Sensory loss was observed in the trunk and extremities starting from the C5 level. Pulse was 110 bpm, regular. Blood pressure was 110/60 mmHg. Later, urinary and fecal retention developed.

   • List the main neurological disorders.

   • Describe the motor impairment syndrome.

   • Explain The Nature and origin of changes in muscle tone and reflexes.

   • Describe the sensory disturbance syndrome.

   • Explain The Nature of pelvic organ dysfunction.

   • Formulate the topical diagnosis.

   • Formulate and justify the provisional clinical diagnosis.

   • Outline the main directions for differential diagnosis.

   • Outline the instrumental and laboratory examination plan.

   • Outline the patient management plan.

   • Describe the scope and Specific features of medical care during the initial on-scene assessment.

   • Describe the cerebrospinal fluid changes characteristic of this case.

   • State the signs of spinal shock.

   • State the indications for surgical treatment.

   • Describe the principles and options of surgical treatment.

   • Indicate the main components of pharmacotherapy.

   • List the core components of the rehabilitation program.

   • Determine the most likely prognosis.

   • Name the potential complications and long-term consequences of the injury.