Spinal Cord Injury: Assessment, Management, and Complications
I. Introduction to Spinal Cord Injuries (SCI)
Spinal Cord Injury (SCI) is a highly debilitating condition often encountered by paramedics. Treatment is primarily focused on rehabilitation, emphasizing the crucial role of preventive measures by healthcare providers to reduce both primary and secondary SCI, which is considered the "Best option for decreasing morbidity and mortality associated with SCI."
A. Incidence and Demographics (Canada)
• New Cases: Approximately 1,050 new cases of SCI occur annually in Canada, translating to "35 new cases of SCI per million people."
• Prevalence: "36,000 Canadians live with SCI."
• Major Causes:
◦ Motor vehicle collisions: 35%–40%
◦ Acts of violence: 24.5%
◦ Falls: 21.8% (particularly common in older adults)
◦ Recreational/athletic injuries: 7.2% (especially diving injuries)
◦ Other: Includes diseases such as spina bifida, polio, and Friedrich ataxia.
B. In-Hospital Mortality
• Isolated SCI: Mortality rate is "7% for isolated SCI."
• Early Post-Injury: Can be "as high as 20% the first few months after injury."
• Leading Causes of Death (Discharged Patients): "pulmonary embolus and septicemia from pneumonia, urosepsis, or decubitus ulcers."
II. Anatomy and Physiology of the Spine and Nervous System
A. The Spine
The human spine consists of "33 vertebrae" stabilized by ligaments and muscles. Its primary functions are to "Support and protect neural components; allow for fluid movement and erect stature." Vertebrae are identified by location: cervical, thoracic, lumbar, sacral, or coccyx.
• Vertebral Structure: Each vertebra, except C1 (atlas) and C2 (axis), shares basic structural characteristics including a vertebral body, lamina, pedicles, and spinous processes. These form the vertebral foramen, through which the spinal cord passes, and intervertebral foramina for nerve roots.
• Regions of the Spine:
◦ Cervical Spine: First seven bones (C1-C7). The atlas (C1) and axis (C2) are crucial for rotational movement of the skull.
◦ Thoracic Spine: 12 vertebrae, supported by ribs, muscles, and ligaments.
◦ Lumbar Spine: Five largest bones, "Integral in carrying a large portion of body weight" and "Susceptible to injury."
◦ Sacral Spine: Five fused bones, forming the posterior pelvis.
◦ Coccyx: Three to five fused bones.
• Intervertebral Discs: Separate and cushion vertebrae. Discs can "herniate into the spinal canal," causing "pressure on nerve root or spinal cord."
B. The Brain and Meninges
The Central Nervous System (CNS) comprises the brain and spinal cord.
• Brain: Located in the cranial cavity, includes the cerebrum, cerebellum, and brainstem. The brainstem connects to the spinal cord, and "10 of 12 cranial nerves exit here."
• Meninges: Three membranes enclosing the entire CNS:
◦ Dura mater: Outer layer.
◦ Arachnoid mater: Middle layer.
◦ Pia mater: Inner layer.
• Cerebrospinal Fluid (CSF): "CSF (cerebrospinal fluid) bathes the brain and spinal cord," providing a protective cushion.
C. The Spinal Cord
The spinal cord "Transmits nerve impulses between the brain and the rest of the body." It exits the skull through the foramen magnum and extends to L2, where it branches into the "cauda equina."
• Cross Section: Shows inner grey matter (neural cell bodies, with posterior/dorsal horn for sensory input and anterior/ventral horn for motor input) and outer white matter (myelinated ascending and descending fiber pathways).
• Spinal Nerves: "Pairs of 31 spinal nerves are named for vertebral level and region where they arise."
◦ Cervical (8 roots): Functions in scalp, neck, shoulders, arms. Includes the "phrenic nerve (C3–C5), which innervates the diaphragm."
◦ Thoracic (12 roots): Upper nerves supply chest muscles for coughing/breathing; lower nerves supply sympathetic nervous system and abdominal muscles.
◦ Lumbar (5 nerves): Supply hip flexors, leg muscles, sensation to anterior legs.
◦ Sacral (5 nerves): Supply bowel and bladder control, sexual function, sensation to posterior legs and rectum.
◦ Coccygeal (1 nerve).
• Plexuses: Clusters of spinal nerves.
◦ Cervical plexus (C1–C5)
◦ Brachial plexus (C5–T1): Nerves controlling upper extremities.
◦ Lumbar plexus (L1–L4): Nerves of abdominal wall, external genitalia, lower limbs.
◦ Sacral plexus (L4–S4): Includes pudendal and sciatic nerves supplying buttocks, perineum, lower limbs.
D. Autonomic Nervous System
• Sympathetic Nervous System (SNS): Controlled by the hypothalamus. Responsible for sweating, pupil dilation, temperature regulation, and "Shunting of blood from the periphery to the core (fight or flight response)." SCI at T6 or below can disrupt sympathetic communication, leading to "disruption of homeostasis" and "Autonomic dysreflexia."
• Parasympathetic Nervous System (PNS): Carries signals from the brainstem and upper spinal cord to organs (abdomen, heart, lungs) and skin above the waist. The vagus nerve's tone "remains intact following a spine injury." Lower parasympathetic nerves (S2–S4) supply reproductive organs, pelvis, and legs; their disruption leads to "loss of bladder and bowel tone, sexual function."
III. Pathophysiology of Spinal Injuries
Spinal injuries are classified by "Associated mechanism," "Location," and "Stability of the injury." Vertebral fractures can occur with or without SCI. The spine is divided into three columns: posterior, middle, and anterior. "Injuries with incompetence of two or three columns are inferred to be unstable."
A. Types of Injuries
• Flexion Injuries: Result from forward movement of the head (e.g., fast deceleration, direct occipital blow). Can cause unstable dislocations (C1-C2), anterior wedge fractures, and "Teardrop fractures" which are "hyperflexion injuries of significant force" raising "concern for SCI."
• Rotation With Flexion: Often from high acceleration forces. C1-C2 is the only area allowing significant rotation, making injuries unstable. Can cause stable dislocations in the cervical spine or fractures in the thoracolumbar spine.
• Vertical Compression: Forces transmitted through the vertebral body (e.g., direct blow to parietal region, rapid deceleration from a fall on feet/legs/pelvis). Often produces "burst" or compression fractures, potentially with SCI if bone embeds in the cord. "Serious airway compromise is possible if there is retropharyngeal edema."
• Hyperextension: Can result in fractures and ligament injury of variable stability, including "hangman’s (C2) fracture." A teardrop fracture of the vertebral body can also occur.
B. Categories of Spinal Cord Injuries (SCI)
• Primary SCI: "Injury occurs at the moment of impact." Penetrating trauma typically causes "complete transection injury," while blunt injury causes "compression of spinal cord."
◦ Spinal cord compression: Ranges from "cord concussion with brief transient neurologic deficits" to "complete and permanent paralysis."
◦ Spinal cord concussion: Temporary dysfunction (24–48 hours) in 3%–4% of SCIs.
◦ Spinal cord contusion: Associated with edema, tissue damage, vascular leakage.
◦ Cord laceration: Results in hemorrhage, swelling, and disruption of communication pathways.
• Secondary SCI: "Occurs when multiple factors permit a progression of primary SCI," involving an inflammatory response, leading to "further hypoxia, hypoglycemia, and hypothermia." Minimizing this through "Spinal motion restriction, neutral alignment," "Minimize heat loss," and "Maintain oxygenation/perfusion" is crucial.
C. SCI Classifications
• Complete SCI: "Permanent loss of all spinal cord–mediated functions below the level of injury."
• Incomplete SCI: "Some degree of cord function remains."
D. Spinal Cord Syndromes
• Anterior Cord Syndrome: From bony fragment displacement into the anterior cord due to flexion injuries or fractures. Disrupted blood flow from the anterior spinal artery results in "Paralysis below level of insult."
• Central Cord Syndrome: Hyperextension injury to the cervical area with hemorrhage and edema, often in older patients with spinal stenosis. Patients have "greater loss of function in upper than lower extremities." Prognosis is generally good.
• Posterior Cord Syndrome: Associated with extension injuries, rare. Dysfunction of dorsal columns leading to loss of sensation of light touch, proprioception, and vibration. Good prognosis.
• Brown-Séquard Syndrome: Associated with penetrating trauma causing hemisection of the cord. Results in "Motor loss on same side of injury below lesion level," loss of light touch, proprioception, and vibration sensation if dorsal column damaged, and "loss of sensation of temperature and pain on opposite side of body."
• Spinal Shock: Temporary condition due to edema in the spinal cord. Symptoms "improve and resolve in hours or weeks."
• Neurogenic Shock Syndrome: Temporary loss of autonomic function controlling cardiovascular function. Characterized by "Hypotension," "Relative hypovolemia," "Bradycardia," and "Warm, red skin."
IV. Patient Assessment for SCI
"Suspect SCI when MOI, history taking, or scene suggest it is possible." The major goal is "Limiting progression of secondary SCI."
A. When to Suspect SCI
• High-Risk Mechanisms of Injury:
◦ High-velocity collision (> 60 km/h)
◦ Unrestrained occupant (mid/high speeds)
◦ Vehicular intrusion of 30 cm or more
◦ Fall from greater than 1 m (significantly greater from 3 m)
◦ Penetrating trauma near spine with neurologic deficit
◦ Ejection from moving vehicle
◦ Motorcycle collision > 30 km/h with rider separation
◦ Diving injury
◦ Vehicle-pedestrian/bicycle collision > 10 km/h
◦ Death of occupant in same compartment
◦ Rollover collision (unrestrained)
• Other Clues: Patients with multiple trauma or who are unresponsive after trauma should be treated as if SCI exists. Major trauma "above the clavicle indicates risk for associated spine injury."
• History Taking: Determine circumstances, types of energy involved (force, speed, trajectory), blunt or penetrating trauma, torsion injury or extreme neck motion, height of fall, exact injury time, and changes in patient presentation. For MVCs, note restraints, patient positioning, and vehicle damage.
• Physical Examination Modification: Based on level of consciousness, patient reliability, and MOI. "Apply manual stabilization." Document suspected SCI, noting area, sensation, dermatomes, motor function, and weakness.
B. Scene Assessment
• Activate the trauma system.
• Note patient's age and gender, and position found.
• Determine life-threatening conditions.
• Maintain head and neck in neutral position with manual stabilization.
• Determine level of consciousness.
C. Initial Assessment (ABC)
• Airway: Open airway (jaw-thrust maneuver), suction obstructions. Consider OPA/NPA, but avoid OPA with intact gag reflex and NPA with basilar skull fracture. "Orotracheal intubation if indicated" (GSC below 8). Consider invasive airway if conventional methods fail, opening cervical collar with a second practitioner supporting the head.
• Breathing: Assess rate, depth, symmetry. Injuries at or above C3–C4 can paralyze the diaphragm. Lower cervical or upper thoracic injuries can paralyze intercostal muscles. Assist breathing for inadequate patterns. For head injury, maintain CO2 levels at 35–45 mm Hg.
• Circulation: Verify radial and carotid pulses (rate, quality, regularity, equality). Check skin color, temperature, moisture. Control external bleeding. Initiate CPR if no pulse. "Volume resuscitation may be needed" for multisystem trauma or hypovolemic shock. "Pure neurologic shock rarely needs fluids" but may require vagolytic drugs (atropine) and vasopressors (dopamine).
D. Transport Decision
Decide early whether to complete history/physical on scene or transport immediately. "Unstable or potentially unstable = transport ASAP to appropriate hospital."
E. Focused History and Physical Examination
"Accurate H&P is critical in SCI injury." Patient reliability is key; if unreliable, immobilize.
• Obtain baseline vital signs.
• Assess pupils.
• Use SAMPLE and DCAP-BTLS.
• Perform "Distal PMS check to all extremities (pulse, motor, and sensory check)."
• Use AVPU and GCS for responsiveness and trend monitoring.
F. Placement on the Backboard
Backboards facilitate safe patient movement, aiming for "spinal motion restriction." Minimize patient moves. "Patients can be log rolled to visualize the neck and back" for pain, deformity, or step off.
• Reliable Patient: Alert, oriented, no language barrier, no brain injury/intoxication. Emotional upset and pain can distract from spinal pain. Severe pain may require alternative transfer (scoop stretcher).
• Time on Backboard: "Should be kept to a minimum." "32% of patients with SCI develop skin breakdown within 24 hours of injury." Use padding for comfort.
• Techniques: Scoop stretcher, six-plus-person lift and slide, straddle lift and slide (five people), four-person log roll. Select collar based on manufacturer specs. Neutral positioning is best, but do not force.
• Use "five spider straps" for proper restriction. Do not elevate the head of the bed. Concave backboards are more comfortable.
G. Detailed Physical Examination
Perform a head-to-toe exam on patients with significant MOI, potentially en route.
• Examine head, neck, chest, abdomen, pelvis, extremities, back, buttocks.
• Evaluate chest/abdomen for internal/external injury. Assess for priapism.
• Continually monitor cardiovascular system for shock (neurogenic, spinal, hypovolemic).
• Palpate extremities for deformity, contusions, abrasions, punctures, lacerations, edema. Note abnormal posturing and distracting painful injuries.
H. Neurologic Examination
"Establish a baseline level of lesion." A normal exam does not rule out SCI. Helps determine completeness of lesion and identify cord syndromes.
• Initial Step: AVPU and GCS. If paralyzed, ask patient to blink or demonstrate cranial nerve responses. Note trends.
• Motor Components: Assess myotomes. Cranial nerve assessment is critical for high cervical injury. Look for "Horner syndrome" (upper eyelid droop, small pupil, ipsilateral anhydrosis) indicating sympathetic pathway injury.
• Motor Assessment: Bilaterally assess major motor groups. Monitor for ascending lesions. Pay attention to respiration pattern alterations in cervical spine lesions.
• Pain Response: Test in various places.
• Dermatomes: Sensory components controlling specific body areas. Ask about abnormal sensations ("electric shock," "pins and needles," hyperacute pain sensitivity). Assess sensory integrity bilaterally from feet upward to determine the lowest level of normal sensation.
• Reflexes: Note if any are intact.
• Babinski Reflex: "A 'positive' Babinski is when toes move upward (dorsiflex)."
• Key: Most important is whether findings are changing and in what direction.
I. Ongoing Assessment
• Vital Signs: Monitor every 5 minutes for unstable patients, every 15 minutes for stable.
• Cardiovascular Status: Pay special attention.
◦ Hypotension with normal to slow pulse and warm skin: "possible neurogenic shock." May also show flaccid paralysis and complete sensation loss below injury.
◦ Hypovolemic shock: "tachycardia and pale, cool, clammy skin."
• Check oxygen flow and effectiveness of spinal motion restriction often.
• Document suspected SCI: area involved, sensation, dermatomes, motor function, weakness.
V. Management of Spinal Injuries
A. General Principles
• Recognize potential for actual injury.
• Appropriate immobilization, remembering potential pressure points (lumbosacral and occiput).
• "Reduction or prevention of secondary injuries."
• "Rigid cervical collars can contribute to elevation of ICP."
• Time goal is "platinum 10 minutes" or less on scene.
• Cervical spine clearance protocols vary locally; no definitive protocol yet.
B. Spinal Splinting Procedures
"There is no such thing as partial spinal motion restriction!" The spine is considered "one long bone" articulating with the head and pelvis; "You cannot isolate and splint any one vertebra."
• Supine Patients: Effective spinal motion restriction by securing to a backboard. Methods in order of spinal motion generated: Scoop stretcher, six-plus-person lift and slide, straddle lift and slide (five people), four-person log roll. Maintain neutral positioning; do not force.
• Straddle Lift Technique: Four rescuers lift patient 2-3 cm while a fifth slides the board.
• Straddle Lift and Slide Technique: Patient moved to board, used in tight spots.
• Patients found in Prone Position: Requires specific rotation.
• Unresponsive Patient: Requires specific handling.
• Seated Patients: Require specific maneuvers.
C. Rapid Extrication
Patient should be moved from sitting to backboard within "2 minutes." Used when:
• Vehicle or scene is unsafe.
• Patient cannot be properly assessed.
• Patient needs immediate intervention requiring supine positioning.
• Patient condition requires immediate transport.
• Patient is blocking access to another seriously injured patient.
• Delay from applying vest or half board is unacceptable. Manual support carries greater risk; use only if urgent.
Rapid Extrication Procedure (3 paramedics):
• First Rescuer: Manual in-line stabilization (behind/beside patient).
• Second Rescuer (Team Leader): From driver doorway, applies cervical collar, does initial assessment, provides continuous support of patient torso (body hug/cross-chest shoulder hug), coordinates rotation as a unit.
• Third Rescuer: From front passenger seat, rotates legs and feet, ensures no obstructions. Moves nearest leg laterally, then both legs as a unit with patient.
• Rotation: Patient rotated 90 degrees (back facing driver door, feet on passenger seat) in 3-4 quick turns. First rescuer directs turns. Hand positions change between moves.
• Backboard Placement: Once rotated, backboard placed under buttocks on seat (not wedged). Fourth rescuer (if available) can assist.
• Lowering onto Board: Second and third rescuers lower patient onto board. First rescuer holds backboard until secured.
• Sliding onto Board: Fourth rescuer takes over head support/commands. Second rescuer grasps shoulders/armpits, third rescuer at patient's hips. On command, slide patient onto board until hips are firm.
• Final Board Placement: Third rescuer moves to opposite side, controls shoulders. Second rescuer controls hips. Move patient completely onto board.
• Transport: Carry board to stretcher. Begin life-saving treatment immediately. Relocate to safe area if scene was dangerous. Adapt to each situation.
D. Standing Patients
Minimum of three rescuers needed for immobilization.
• Establish manual in-line stabilization and apply cervical collar. Instruct patient to remain still.
• Position board upright behind patient. Two rescuers on either side of patient. Third rescuer directly behind patient/board, maintaining spinal motion restriction.
• Two rescuers grasp handholds at shoulder level; two reach under patient's arms.
• Carefully lower patient as a unit. Rescuer at head directs all movement, ensuring head stays against board and rotating hands.
E. Packaging and Removal from Water
Maintain head, neck, and trunk alignment. "Diving accidents often include spinal injuries or trauma." "Spinal motion restriction must be implemented before patient removal from water."
• Respiratory Arrest: Ventilations can begin in water.
• Cardiac Arrest: Evaluate MOI. If no obvious spinal injury, remove and begin CPR. If spinal injury indicated:
◦ Approach prone patient from head. Support head on arm, chest on hand.
◦ Two rescuers (or one if possible) rotate entire upper half of body as a unit. Open airway, begin ventilations.
◦ Float buoyant backboard under patient. Secure head and trunk to board. "Do not remove patient from water until secured."
◦ Remove patient, wet clothing, cover with blankets. Give O2 if breathing, PPV if inadequate/apneic.
◦ Start CPR if pulseless (cannot do effective compressions in water).
◦ Consider advanced airway. Place on cardiac monitor and treat dysrhythmias.
◦ Submersion patients with loss of consciousness or significant aspiration should be transported.
F. Patients Wearing Helmets
Helmets reduce brain injury but "inhibit full exposure of head" and can "interfere with airway management" and "spinal immobilization." Can provide some stabilization if fitted properly. "Removal of helmet will cause some spinal motion."
• Recommended Removal Situations (Inter-Association Task Force):
◦ Helmet and chin strap fail to hold head securely.
◦ Helmet design prevents adequate airway control.
◦ Face mask cannot be removed in reasonable time.
◦ Helmet design prevents proper immobilization for transport.
◦ If helmet removed, shoulder pads must also be removed.
• Recommended Removal Procedures:
◦ Kneel at patient's head, leave room for helmet removal. Partner at patient's side.
◦ Stabilize helmet (hands on sides, fingers on lower jaw).
◦ Partner loosens chin strap, opens face shield, assesses airway/breathing, removes glasses.
◦ Partner places one hand on lower jaw, other behind helmet.
◦ Pull sides of helmet away, slip partially off (stop halfway).
◦ Partner slides hand from back of helmet to occiput to prevent head fall.
◦ Remove helmet once partner's hand is in place.
◦ Provide manual in-line cervical spine stabilization. Apply rigid cervical collar. Secure patient on backboard, possibly adding padding under shoulders.
• Note: "You do not need to remove the helmet if you can access the airway." Helmet removal in prehospital setting is controversial.
VI. Complications and Non-Traumatic Conditions
A. Pharmacotherapy
• Short-acting reversible sedatives and pain medications may be used.
• "The American Association of Neurological Surgeons and the Congress of Neurological Surgeons recommend that steroids not be administered in the management of acute spinal injury."
B. Complications of SCI
• High Morbidity and Mortality: Significant financial costs.
• Respiratory: Potential for aspiration and arrest, impaired coughing/deep breathing, atelectasis, pneumonia.
• Vascular: Deep-vein thrombosis and pulmonary embolism (especially with lower cervical lesions).
• Autonomic Dysreflexia: "Late complication of SCI," most commonly with injuries above T4–T6, due to loss of parasympathetic stimulation. Patients present with "massive, uninhibited, uncompensated cardiovascular compromise."
C. Non-Traumatic Spinal Conditions
• Back Pain: Common in emergency departments. Upright posture stresses lumbar spine (L4–L5). Occupations with repetitive lifting/vibrations can cause injury.
• Spinal Tumors.
• Lower Back Pain: Mostly idiopathic, difficult to diagnose. Often from strain or sprain.
• Degenerative Disc Disease: Common in older patients; linked to osteoporosis and spinal degeneration.
• Disc Herniations: Usually from trauma. Patients present with pain, tenderness, limited range of motion.
• Prehospital Management (Non-Traumatic): Symptom relief, focused on decreasing pain or discomfort.