Spinal Cord Injuries

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Spinal cord injury (SCI) is damage to the spinal cord that results in loss of sensory, motor, and autonomic function below the level of the injury. It can be classified as complete (total loss of function) or incomplete (partial preservation of function).

Aetiology

1. Traumatic Causes (Most Common):

  • Road traffic accidents.
  • Falls (especially in elderly individuals).
  • Sports injuries (e.g., diving accidents, rugby injuries).
  • Violence (e.g., gunshot wounds, stab wounds).

2. Non-Traumatic Causes:

  • Degenerative diseases: cervical spondylosis, spinal stenosis.
  • Tumours: primary or metastatic spinal cord tumours.
  • Infections: puberculosis (Pott’s disease), meningitis, spinal abscess.
  • Autoimmune disorders: multiple sclerosis, transverse myelitis.
  • Vascular causes: spinal cord infarction, arteriovenous malformations (AVMs).

Pathophysiology

  • Primary injury: direct damage to the spinal cord due to trauma, compression, or ischaemia.
  • Secondary injury: ongoing cellular damage from inflammation, oxidative stress, and excitotoxicity, leading to further neuronal loss.
  • Loss of motor, sensory, and autonomic function below the level of injury.

Risk factors

  • High risk activities (e.g., extreme sports, motorcycling).
  • Osteoporosis (increased fracture risk in elderly individuals).
  • Previous spinal surgery.
  • History of malignancy with spinal metastasis.
  • Congenital spinal abnormalities.

Signs and symptoms

Motor and Sensory Impairment:

  • Complete SCI: total loss of motor and sensory function below the injury level.
  • Incomplete SCI: partial preservation of function, varies depending on the affected tracts.

Autonomic Dysfunction:

  • Neurogenic shock: hypotension and bradycardia due to autonomic dysfunction.
  • Bladder dysfunction: urinary retention or incontinence.
  • Bowel dysfunction: constipation or faecal incontinence.
  • Loss of temperature regulation: hypothermia or hyperthermia.

Syndromes Based on Injury Location:

  • Cervical (C1–C5): quadriplegia/tetraplegia, respiratory failure (C3–C5 affects diaphragm).
  • Thoracic (T1–T12): paraplegia, loss of lower limb function.
  • Lumbar/Sacral (L1–S5): lower limb weakness, bladder and bowel dysfunction.

Investigations

  • Clinical assessment: neurological examination using the ASIA (American Spinal Injury Association) scale.
  • Imaging:
    • CT spine: first-line in trauma cases for bony injuries.
    • MRI spine: gold standard for assessing spinal cord injury and soft tissue damage.
  • Bladder scan: assess for urinary retention.
  • Blood tests: FBC, U&Es (monitor renal function), inflammatory markers.

Management

1. Immediate Management (Spinal Immobilisation):

  • Follow the ABCDE approach in trauma patients.
  • Apply a rigid cervical collar and spinal precautions.
  • Ensure airway protection if high cervical injury (C3–C5) affects breathing.
  • Maintain mean arterial pressure (MAP) >85 mmHg to optimise spinal cord perfusion.

2. Pharmacological Management:

  • High-dose steroids (e.g., methylprednisolone) within 8 hours of injury (controversial, used selectively).
  • Pain control: opioids, NSAIDs, neuropathic pain agents (gabapentin, amitriptyline).
  • DVT prophylaxis: LMWH to prevent thromboembolism.

3. Surgical Management:

  • Spinal decompression if there is ongoing cord compression.
  • Spinal stabilisation with fixation (e.g., rods, screws).

4. Rehabilitation and Long-Term Management:

  • Physiotherapy and occupational therapy for mobility and function.
  • Bladder and bowel training.
  • Psychological support and counselling.
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