Spinal Cord Injuries: Traumatic

Spinal cord injury (SCI) has become epidemic in modern society. SCI remains a devastating event, often producing severe and permanent disability despite advances made in the understanding of the pathogenesis and improvements in early recognition and treatment. With a peak incidence in young adults, traumatic SCI remains a costly problem for society. Direct medical expenses accrued over the lifetime of one patient range from 500,000 to 2 million US dollars.¹

Approximately 3% of patients who experience blunt trauma sustain a spinal column injury, such as a spinal fracture or dislocation, and 1% sustain a spinal cord injury (SCI).² Spinal column injury rates reported in other studies range from 2 to 6%.³ The incidence is likely to be significantly higher in patients with head trauma and those who are unconscious at presentation. Fracture of the thoracolumbar spine, including spinous and transverse process fractures, may occur in as many as 8 to 15% of blunt trauma patients cared for at major trauma centers.⁴ Additional noncontiguous spine fractures are common in patients diagnosed with a spine fracture following high-energy blunt trauma.^5,6 A review of over 83,000 patients from the United States National Trauma Data Bank diagnosed with a spine fracture reported that 19% sustained a noncontiguous spine fracture.

A systematic review of 13 international studies found great variation (up to a threefold difference) in the rate of spinal column injury among nations, particularly between developed and developing nations.^7,8 Most studies demonstrate a bimodal age distribution where the first peak is found in young adults between 15 and 29 years of age and a second peak in adults older than 65 years of age. Mortality is significantly higher in elder patients.⁹ Spinal column injuries are more common in males.

It is of importance to note that statistics from trauma registries can be incomplete and inaccurate, depending on the inclusion criteria, and may underestimate the number of patients with spinal column injury. For examples, victims who die at the accident scene and patients whose neurologic deficits rapidly improve are often excluded.

• Motor vehicle-related accidents account for almost half of all spinal injuries: 38% incidence.¹⁰
  • Occupants involved in a rollover accident are at increased risk of a cervical spine injury.^11,12
• Falls, especially of older adults, account for a growing proportion of spinal injuries, reflecting the aging population of many developing countries: 30.5% incidence.
• Acts of violence (primarily gunshot wounds): 13.5% incidence.
  • Soldiers deployed in armed conflicts also have a substantial risk of TSCI.¹³
  • In Canada and western Europe, TSCI due to violence is rare, while in developing countries, violence is even more common.^14,15
• Sporting/recreation activities: 9% incidence.
• Medical/Surgical: 5% incidence.
• Other: 4% incidence.

• Speeding
• Failure to use lap and/or chest restraints
  • Alcohol intoxication
• Alcohol plays a role in at least 25% of TSCI. ^1,16
• Males continue to make up 77 to 80% of cases.^14,15,17,18
  • Prior to 2000, the most frequent victim was a young male with a median age of 22. Since that time, the average age has increased in the United States to 37 years in 2010, presumably as a reflection of the aging population.¹⁸
• Underlying spinal disease predisposes some patients to TSCI. These conditions include^1,19:
  • Cervical spondylosis
  • Atlantoaxial instability
  • Congenital conditions, e.g., tethered cord
  • Osteoporosis
  • Spinal arthropathies, including ankylosing spondylitis or rheumatoid arthritis
• Missed or delayed diagnosis of spinal column trauma results in a 7.5-fold increase in the incidence of neurologic injuries.¹⁰

The human spine consists of 33 bony vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral (fused), and 4 coccygeal (usually fused).²⁰ The vertebral column provides the body's basic structural support and protects the spinal cord, which extends from the midbrain caudally to the level of the second lumbar vertebra and then continues as the cauda equina (Figure 1).

Figure 1

Spine Anatomy Overview

Notice:

• The increase in size of the vertebrae as the column descends.
• The continuous, weight-bearing column of vertebral bodies and intervertebral (IV) discs forms the anterior wall of the vertebral canal.
• The lateral and posterior walls of the vertebral canal are formed by the series of vertebral arches.
• The intervertebral foramina are openings in the lateral wall through which spinal nerves exit the vertebral canal.
• The posterior wall is formed by overlapping laminae and spinous processes, like shingles on a roof.

Figure 2

A "typical" vertebra cross section

The 3rd-6th cervical vertebrae have a "typical" structure. The 1st, 2nd, and 7th cervical vertebrae are "atypical." Typical vertebrae demonstrate rectangular bodies with articular uncinate processes on their lateral aspects, triangular vertebral foramina, bifid spinous processes, and transverse foramina.

Figure 3a

Cervical Spine

Figure 3b

Vertebra C1 (Atlas)

• The occipital condyles articulate with the superior articular surfaces (facets) of the atlas (vertebra C1).
• The atlas, on which the cranium rests, has neither a spinous process nor a body. It consists of two lateral masses connected by anterior and posterior arches.
• The tooth-like dens characterize the axis (vertebra C2) and provides a pivot around which the atlas turns and carries the cranium. It articulates anteriorly with the anterior arch of the atlas ("Facet for dens") and posteriorly with the transverse ligament of the atlas.

Figure 3c

Vertebra C2 (Axis)

Figure 3d

C6

Figure 4

Thoracic vertebra

T1 has a vertebral foramen and body like a cervical vertebra. T5-T9 vertebrae have typical characteristics of thoracic vertebrae. T12 has bony processes and a body size like a lumbar vertebra. The planes of the articular facets of thoracic vertebrae define an arc that centers on an axis vertically traversing the vertebral bodies.

Superior and inferior costal facets (demifacets) on the vertebral body, costal facets on the transverse processes, and long sloping spinous processes are characteristic of thoracic vertebrae.

Due to its exposed location above the torso and its inherent flexibility, the cervical spine is the most commonly injured part of the spinal column. Within the cervical spine, the most common sites of injury are around the second cervical vertebra (C2, or axis) or in the region of C5, C6 and C7.³

The thoracic spine, in contrast, is rigidly fixed, since the thoracic ribs articulate with the respective transverse processes and sternum. As such, a great amount of force is necessary to damage the thoracic spine of an otherwise healthy adult. In older adults with osteoporosis or patients with bone disease or metastatic lesions, minor trauma may be sufficient to cause a compression fracture.

The second most commonly injured region is the thoracolumbar (TL) junction. The orientation of the facet joints at the TL junction may concentrate forces created from traumatic impact at this level.²¹ At the TL junction, the spinal column changes from a kyphotic to a lordotic curve. Ninety percent of all TL spine injuries occur in the region between T11 and L4. However, these injuries rarely result in complete cord lesions as the spinal canal is relatively wide at this level.²²

The vertebral column (and the spinal cord within it) is divided into cervical, thoracic, lumbar, sacral, and coccygeal regions. The peripheral nerves (called the spinal or segmental nerves) that innervate much of the body arise from the spinal cord's 31 segmental pairs.

• The cervical region of the cord gives rise to eight cervical nerves (C1-C8).
• The thoracic region gives rise to twelve thoracic nerves (T1-T12).
• The lumbar region gives rise to five lumbar nerves (L1-L5).
• The sacral region gives rise to five sacral nerves (S1-S5).
• The coccygeal region gives rise to one coccygeal nerve.

The segmental spinal nerves leave the vertebral column through the intervertebral foramina that lie adjacent to the respectively numbered vertebral body. Sensory information carried by the afferent axons of the spinal nerves enters the cord via the dorsal roots, and motor commands carried by the efferent axons leave the cord via the ventral roots. Once the dorsal and ventral roots join, sensory and motor axons (with some exceptions) travel together in the segmental spinal nerves.

Two regions of the spinal cord are enlarged to accommodate the greater number of nerve cells and connections needed to process information related to the upper and lower limbs.

1. The spinal cord expansion that corresponds to the arms is called the cervical enlargement and includes spinal segments C5-T1.
2. The expansion that corresponds to the legs is called the lumbar enlargement and includes spinal segments L2-S3.

Because the spinal cord is considerably shorter than the vertebral column, lumbar and sacral nerves run for some distance in the vertebral canal before emerging, thus forming a collection of nerve roots known as the cauda equina. This region is the target for a “lumbar puncture” that allows for the collection of cerebrospinal fluid by placing a needle into the space surrounding these nerves to withdraw fluid for analysis. In addition, local anesthetics can be safely introduced to produce spinal anesthesia. At this level, the risk of damage to the spinal cord from a poorly placed needle is minimized.

Spinal column injury may result in spinal cord or brain injury through many mechanisms:²³

Transection

• Penetrating or massive blunt trauma resulting in spinal column injury may transect all or part of the spinal cord.
• Less severe trauma may have similar neurologic effects by displacing bony fragments into the spinal canal or through disk herniation.

Compression

• When elderly patients with cervical osteoarthritis and spondylosis forcibly extend their neck, the spinal cord may be compressed between an arthritically enlarged anterior vertebral ridge and a posteriorly located hypertrophied ligamentum flavum.
• Injuries that produce blood within the spinal canal can also compress the spinal cord.

Contusion

• Contusions of the spinal cord can occur from bony dislocations, subluxations, or fracture fragments.

Vascular Compromise

• When there is a discrepancy between a clinically apparent neurologic deficit and the known level of spinal column injury primary vascular damage to the spinal cord should be suspected.
• In addition, many spinal fracture patterns are closely associated with vertebral artery injuries, which can cause stroke and permanent disability if diagnosis and appropriate interventions are delayed. Injuries of concern include fractures associated with displacement into the transverse foramen, fractures involving both the atlas (C1) and axis (C2), fractures involving the transverse foramen, and subluxation of two or more adjacent cervical vertebral levels.

The primary injury refers to the immediate effect of trauma which includes forces of compression, contusion, and shear injury to the spinal cord. In the absence of cord transection or frank hemorrhage (both relatively rare in nonpenetrating injuries), the spinal cord may appear pathologically normal immediately after trauma. Penetrating injuries (e.g., knife, gunshot injuries etc.) usually produce a complete or partial transection of the spinal cord. An increasingly described phenomenon, however, is a spinal cord injury following a gunshot wound that does not enter the spinal canal.²⁴ Presumably, the spinal cord injury in these cases results from kinetic energy emitted by the bullet.

A secondary, progressive mechanism of cord injury usually follows, beginning within minutes and evolving over several hours after injury.^1,25-28 The phenomenon of secondary injury is sometimes clinically manifest by neurologic deterioration over the first 8 to 12 hours in patients who initially present with an incomplete cord syndrome. The processes propagating this phenomenon are complex and incompletely understood.^29,30

Possible mechanisms include:^1,29,31

• Apoptosis
• Disturbances of ion homeostasis
• Edema
• Excitotoxicity
• Hypoxia
• Inflammation
• Ischemia

Because of these secondary processes, spinal cord edema develops within hours of injury, becomes maximal between the third and sixth day after injury, and begins to recede after the ninth day. This is gradually replaced by a central hemorrhagic necrosis.³²

TL Spinal Column Injury Classification

In contrast to the two-column scheme for cervical spinal column injury, a three-column scheme may be used to describe injuries of the thoracic and lumbar (TL) spinal column.⁴⁵ The three columns are anterior, middle, and posterior.

The anterior column includes the:

• Anterior longitudinal ligament
• Annulus fibrosus
• Anterior half of the vertebral body

The middle column includes the:

• Posterior longitudinal ligament
• Posterior annulus fibrosus
• Posterior half of the vertebral body

The posterior column includes the:

• Supraspinous ligaments
• Interspinous ligaments
• Facet joint capsule

According to the three-column scheme, stability is based upon the integrity of two of the three spinal columns. Spinal instability may be inferred when plain x-rays demonstrate a loss of 50% of vertebral height or excessive kyphotic angulation around the fracture.⁴⁶ The angle is determined by the intersection of two lines, one measured along the superior endplate of the vertebral body one level above the fracture and the other along the inferior endplate of the vertebral body one level below.⁴⁷ Compression fractures with greater than 30 degrees and burst fractures with greater than 25 degrees angulation are generally considered unstable. The presence of a neurologic deficit also indicates spinal instability, since the spinal column has failed to protect the spinal cord.⁴⁸

Few studies have been performed to validate the three-column scheme. In a biomechanical study of cadaveric human spines, researchers found the middle column to be the major determinant of spine stability when axial or flexion stress was applied.⁴⁹

TL injuries can be divided into four injury patterns:

1. Wedge compression fractures
2. Stable and unstable burst fractures
3. Flexion-distraction injuries
4. Translational injuries

All these fractures result from one or more of three mechanisms of injury:^45,50

1. Axial compression
2. Axial distraction
3. Translation

A widely used classification for TL spinal column injury combines a distinction between major and minor fracture patterns using the three-column scheme and the four injury patterns.

In 2005, the Spine Trauma Study Group introduced a classification system for thoracolumbar injuries called the Thoracolumbar Injury Classification and Severity Score (TLICS). This score assigns numeric values to each injury based upon morphology, neurologic status, and integrity of the posterior ligamentous complex, which includes the supraspinous ligament, interspinous ligament, ligamentum flavum, and facet joint capsules.⁵¹ Scoring of the TLICS is as follows:

Injury morphology

• Compression = 1 point
• Burst = 1 point
• Translational/rotational = 3 points
• Distraction = 4 points

Neurological Status

• Intact = 0 points
• Nerve root = 2 points

Cord, conus medullaris:

• Incomplete = 3 points
• Complete = 2 points
• Cauda equina = 3 points

Posterior Ligament Complex

• Intact = 0 points
• Injury suspected/indeterminate = 2 points
• Injured = 3 points

The total numerical score is used to guide treatment.⁵²

• A score ≥ 5 suggests instability and the need for operative treatment
• A score ≤ 3 suggests stability
• A score of 4 is considered indeterminate and either operative or conservative management may be indicated

A patient with a spinal cord injury typically has pain at the site of the spinal fracture. But this is not always a reliable feature to exclude traumatic spinal cord injury (TSCI). Patients with TSCI often have associated brain and systemic injuries (e.g., hemothorax, extremity fractures, intra-abdominal injury etc.) that may limit the patient's ability to report localized pain.^1,17 These associated injuries also complicate the initial evaluation and management of patients with TSCI and affect prognosis.

About half of TSCIs involve the cervical cord and as a result present with quadriparesis or quadriplegia.^15,17 The severity of cord syndromes is classified using the American Spinal Injury Association (ASIA) Scale (Table 2):⁶⁴

Muscle function is graded using the International Standards for Neurologic Classification of Spinal Cord Injury.

For an individual to receive a grade of C or D (i.e., motor incomplete status), he/she must have either:

(1) Voluntary anal sphincter contraction or

(2) Sacral sensory sparing with sparing of motor function more than three levels below the motor level for that side of the body.

Patients without an initial spinal cord injury do not receive an AIS grade.

A category of TSCI defines spinal cord injury without radiographic abnormality (SCIWORA). It originated prior to the use of MRI and but it is often defined as the presence of neurologic deficits in the absence of bony injury on a complete, technically adequate, plain x-ray series or CT scan. Because an MRI provides superior imaging of the spinal cord, it can detect injuries to the cord that exist despite the apparent absence of bony abnormalities.⁹⁸ Nevertheless, many patients with SCIWORA also have no detectable lesion on MRI.⁹⁹

A common explanation for this phenomenon is transient ligamentous deformation with spontaneous reduction. This injury pattern is more common in children who have weak paraspinal muscles, elastic spinal ligaments, lax soft tissues, disc prolapse and cervical sponylosis which fail to protect the spinal cord from force but has also been described in adults.

Other possible mechanisms for SCIWORA include radiographically occult intervertebral disc herniation, epidural or intramedullary hemorrhage, fibrocartilaginous emboli from an intervertebral disc that has ruptured into the radicular artery, and traumatic aortic dissection with spinal cord infarction. MRI is invaluable for the diagnosis of these conditions.

Clinicians should suspect a cervical ligamentous injury in the injured patient who has persistent severe pain or paresthesias or focal neurologic findings (e.g., upper extremity weakness) in the absence of a fracture seen on plain x-ray or CT. Such injuries may be unstable, although they are rarely associated with permanent neurologic damage.

Early death rates after admission for TSCI range from 4 to 20%. ^1,159-163 The patient's age, level of spinal cord injury, and neurologic grade predict survival. Severe systemic injuries, traumatic brain injury, and medical comorbidity also increase mortality.^162-164 Compared with spinal cord injuries in the thoracic cord or lower, patients with C1 to C3 injuries have a 6.6-fold increased risk of death, C4 to C5 injuries a 2.5 increased risk, and C6 to C8 a 1.5 increased risk.¹⁰⁸ Survivors of TSCI have a reduced life expectancy as well.

Rates of motor score improvements are also related to the initial severity and level of injury.^165-167 The greatest degrees of improvement are seen in those with incomplete injury and in those without significant comorbidities or medical complications, such as infection. ^168,169

Among patients with complete TSCI (ASIA grade A):

• 10 to 15% improve, 3% to ASIA grade D⁸⁹
• Less than 10% will be ambulatory at one year¹⁶⁶

Among patients with an initial ASIA grade B:

• 54% recover to grade C or D
• 40% regain some ambulatory ability.

Among patients with an initial ASIA grade C and D

• Independent ambulation is possible for 62 and 97% respectively.

Most recovery in patients with incomplete TSCI takes place in the first six months.¹⁷⁰ The general expectations for functional recovery based on motor level are outlined in the Table (Table 4).¹⁷¹ These assume an uncomplicated, complete SCI (ASIA grade A) followed by appropriate rehabilitation interventions in a healthy, motivated individual.

TSCI is a problem that largely affects young male adults because of motor vehicle accidents, falls, or violence. Blunt trauma, particularly motor vehicle collisions, accounts for most spinal column injuries. Approximately 3% of blunt trauma patients sustain such an injury. Elderly patients who fall are also at increased risk.

Most TSCI occurs with injury to the vertebral column, producing mechanical compression or distortion of the spinal cord with secondary injuries resulting from ischemic, inflammatory, and other mechanisms.

The cervical spine is the most commonly injured part of the spinal column. Within the cervical spine, the most common sites of injury are around the second cervical vertebra (C2, or axis) or in the region of C5, C6, and C7.

Associated injury of the spinal cord or possibly the brain (due to vascular compromise) are critical clinical considerations and must be investigated immediately. In the absence of apparent spinal cord or brain injury, the degree of fracture stability is the most important feature of any spinal column injury. Differences in the structure and location of the cervical and thoracolumbar portions of the spinal column lead to different types of injuries, although there is some overlap.

The cervical spinal column is susceptible to a wide range of fractures, dislocations, and ligamentous injuries. Compression fractures are the most common injury of the thoracolumbar spinal column.

Most TSCI is associated with injury to brain, limbs, and/or viscera, which can obscure its presentation. The neurologic injury produced by TSCI is classified according to the spinal cord level and the severity of neurologic deficits. Half of TSCIs involve the cervical spinal cord and produce quadriparesis or quadriplegia.

The initial evaluation and management of patients with TSCI in the field and emergency department focuses on the ABCDs (airway, breathing, circulation, and disability), evaluating the extent of traumatic injuries, and immobilizing the potentially injured spinal column.

Patients with suspected TSCI because of neck pain or neurologic deficits and all trauma victims with impaired alertness or potentially distracting systemic injuries require continued immobilization until imaging studies exclude an unstable spine injury.

All patients with potential TSCI should receive complete spinal imaging with plain x-rays or helical CT scan.

Patients with abnormal screening imaging studies or in whom TSCI remains strongly suspect despite normal screening imaging studies should have follow-up CT scanning with fine cuts through the region of interest (based on localized pain and/or neurologic signs).

MRI can be useful to further define the extent of TSCI and should be performed on stable patients with TSCI, as well as, on patients suspected to have TSCI (because of neck pain or neurologic deficits) despite a normal CT scan. Patients with TSCI require urgent neurosurgical consultation to manage efforts at decompression and stabilization.

Patients with acute TSCI require admission to an ICU for monitoring and treatment of potential acute, life-threatening complications, including cardiovascular instability and respiratory failure. Patients with TSCI should receive prophylaxis to protect against the plethora of medical complications associated with TSCI. There is limited evidence that glucocorticoid therapy improves neurologic outcomes in patients with acute TSCI, and such therapy is not endorsed by major society guidelines.

Because the neurologic benefits are uncertain, glucocorticoid therapy is NOT recommended in cases when there are clear risks associated with such therapy, such as penetrating injury, multisystem trauma, moderate to severe traumatic brain injury, and other comorbid conditions associated with risk of complications from glucocorticoid therapy.

In other patients who present within eight hours of isolated, nonpenetrating TSCI, administration of intravenous methylprednisolone can be considered with knowledge of potential risks and uncertain benefits. The standard dose of intravenous methylprednisolone is 30 mg/kg IV bolus, followed by an infusion of 5.4 mg/kg per hour for 23 hours.

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