Spinal Cord Injuries
Prepared by: Mrs Raheegehn Awni
Acute spinal cord injury primarily affects young,
otherwise healthy males ( 18 to 35 years)
A male to female ratio of 3 to 1.
10-15 per million population in UK
The permanent paralysis experienced by these 800 or
so patients a year leads to
a shorter life expectancy
significant economic costs.
Spinal cord injury (SCI) is damage to the spinal cord
that results in a loss of function such as mobility or
In most SCI cases, the spinal cord is intact, but the
damage to it results in loss of function.
( SCI )
Associated with car accidents, sports injuries, and other
The degree of paralysis is directly related to the level and
severity of the injury.
Injury below the first thoracic vertebra may produce
Injuries above the first thoracic vertebra may cause
Advances in the management of spinal cord-injured patients
have resulted in an improvement in overall survival and
quality of life.
The stability of the spine is dependent on the
integrity of the anterior, middle and posterior
Causes and Symptoms
According to the National Spinal Cord Injury Association
(NSCIA), spinal cord injuries are caused in the United States
by motor vehicle accidents (44%),
acts of violence (24%),
falls (22%), sports (8%),
and other causes (2%) such as abscesses, tumors, polio, spina
usually appear immediately after the injury.
However, symptoms can develop slowly, if an infection or tumor
is gradually increasing pressure on the spinal cord.
weakness, poor coordination or paralysis, particularly below the
level of the injury
numbness, tingling, or loss of sensation
loss of bowel or bladder control
• In acute spinal cord injury, shock may be neurogenic,
haemorrhagic, or both.
• Following injuries at or above T6 there is significant loss of
the sympathetic autonomic outflow.
• Consequently vasomotor tone is reduced and, if the lesion is
high enough, sympathetic innervation of the heart ceases.
• This loss of sympathetic tone results in hypotension and also
enhances vagal reflexes, causing profound bradycardia.
Spinal shock is defined as the complete loss of all neurological
function, including reflexes, rectal tone and autonomic control
below the level of spinal cord injury.
Spinal shock is unrelated to hypovolaemia or neurogenic shock
involves a 24- to 72-h period of complete loss of sensory,
motor and segmental reflex activity with flaccid paralysis and
areflexia below the level of the injury.
Despite this profound paralysis, areas of the cord are still
capable of a full recovery.
The possibility of SCI is usually suspected in anyone with
significant trauma to the head and/or neck.
Assume that such patients have a spine fracture until
x-rays of the spine
CT scan (computed tomography), MRI (magnetic
resonance imaging), and myelogram (x ray after injection
of dye into the spinal canal).
ASSESSMENT AND MANAGEMENT OF
PATIENTS WITH SPINAL INJURY
Reasons for missing significant spinal injuries are
failing to consider injuries in patients who are either
unconscious, intoxicated or have pre-existing risk
factors (such as arthritis),
Failing to examine patients adequately, and errors in
the interpretation of radiographs
Failing to examine patients adequately
AIRWAY WITH CERVICAL SPINE CONTROL
During assessment of Airway, Breathing and Circulation,
efforts must be made to protect the spinal cord from potential
This is assisted by early immobilization of
the whole spine.
The majority of trauma patients will have been
immobilized during the pre-hospital phase.
The adequacy of immobilization and the position of
and cervical collars.
If none is in place, immobilization can be achieved by
holding the head in the neutral position, or by the
use of head blocks and tape.
• Patients who are agitated and moving around should not have
their cervical spine immobilized in isolation.
• Long spine boards should be removed as soon as possible in a
controlled way, usually as part of the log-roll.
• This will decrease the risk of pressure sore development in
the spinally injured.
• Do not leave patients on long spine boards: remove
them during the log-roll
The airway is the first priority
A jaw thrust, clearing of oral secretions and insertion of oral or
nasal airway may be all that is required initially to maintain the
Supplemental oxygen should be administered to prevent
secondary damage from hypoxia.
The whole spine must be maintained in neutral alignment after
gentle controlled movement to a neutral position
Attempts to bring the head into neutral alignment against
palpable resistance or if the patient complains of pain should be
abandoned and the head immobilized as it is found.
Unconscious trauma patients should have orotracheal
In conscious patients with signs of a high spinal cord injury
(for example, weakness in arms and legs, neurogenic shock
or diaphragmatic breathing) early intubation and
ventilation should be considered.
Intubation is not contraindicated in the presence of spinal
The ideal technique is intubation with cervical spine control.
Oral suction, laryngoscopy and intubation may precipitate
severe bradycardia from unopposed vagal stimulation in
patients with autonomic disruption from cervical or high
thoracic spinal cord injury.
Atropine should be immediately available.
The most common sources of occult haemorrhage are:
• chest injuries (often associated with thoracic spine
• intra-abdominal haemorrhage
• retroperitoneal haemorrhage
• pelvic fractures and long-bone fractures.
Once occult sources of haemorrhage have been excluded, initial treatment of
neurogenic shock involves cautious fluid resuscitation.
Excessive fluid administration may precipitate pulmonary oedema.
The therapeutic goals for neurogenic shock are adequate
perfusion with a systolic blood pressure of 90-100 mmHg), a heart rate of 60-
100 beats per minute, urine output above 30 ml/h, and normothermia.
Patients with persisting bradycardia should be given atropine
0.5-1 mg intravenously, this being repeated if necessary until the heart rate is
A log-roll should be performed at the end of the primary
This allows assessment of the back and spinal column and the
removal of the long spine board if one is present.
Before the log-roll is commenced, mechanical stabilization
of the cervical spine should be removed and replaced by
manual in-line immobilization by the log-roll team leader.
At the same time, the neck can be checked for any
deformity, tenderness, bogginess or spasm.
To examine the remainder of the vertebral column the
patient must be 'log-rolled'.
This technique requires at least five people.
One person is responsible for maintaining the in-line
stabilization of the head and neck and coordination of the
log-roll (the team leader).
A second person holds the patient's shoulder with one hand
and places the other hand on the pelvis.
The third person holds the pelvis with one hand and places
the other hand under
the patient's opposite thigh.
The fourth person places both arms under the opposite
lower leg and supports it during the roll.
The fifth person is responsible for examining the back,
conducting a rectal and perineal examination, observing
pressure areas, and clearing debris.
Further staff will be needed to assist with the removal of a
long spine board.
The team leader must give clear audible instructions and
indicate in advance what these will be:
'The instruction will be ready, steady, move'.
The examination of the back
includes looking for evidence of bruising or swelling,
palpation over the spinous processes for deformity, swelling,
wounds or increased tenderness down the
whole length of the spine.
Local tenderness at any point should be used to guide
Patients with altered level of consciousness or other
distracting injuries may not have any features on examination
of the back to suggest spinal injury, and may be unable to
cooperate with neurological examination.
Despite these, spinal injury cannot be absolutely excluded
until a full neurological and radiological examination has
These patients will require spinal immobilization until they
Signs of spinal injury in the unconscious patient
• Diaphragmatic breathing
• Neurogenic shock (hypotension and bradycardia)
• Flaccid areflexia (spinal shock)
• Flexed posture of the upper limbs (loss of extensor
innervation distal to C5)
• Response to pain above the clavicles only
• Priapism (the erection may be incomplete)
Trauma in women
Trauma in women includes accidental injury to the pregnant
woman and to the fotus, and to the gynaecological organs in
association with major trauma to the abdomen and pelvis.
Also included is deliberate injury, encompassing domestic
When managing trauma in any female patient aged between
10 and 60 years, the
possibility of pregnancy must be considered.
Not one, but two lives may be at risk and
initial assessment and ongoing monitoring must include the
Outcome for the fetus is dependent upon successful
management of the mother.
A multidisciplinary approach is demanded, with early
involvement of an obstetrician
A neonatal paediatrician if appropriate, in addition to the
usual members of the trauma response team
In most cases these injuries are slight
and are the result of falls or direct blows to the abdomen.
Complications associated with pregnancy occur in over 8% of
women admitted to hospital.
The risk of foetomaternal transfusion must be considered in all
cases beyond 11 weeks'
injury to the fetus.
In a minority of cases, life-threatening maternal and fetal
injury will occur.
For example, trauma remains the most common cause of
MECHANISMS OF INJURY
• Road traffic accidents
• Motorcycle and bicycle accidents
• Burn injury
• Intentional injury
• Exposure to blast
Road traffic accidents (RTAs) still predominate among blunt
impact trauma cases, and deaths from head and intra-
abdominal injury are the leading cause of non-obstetric
Invariably this also results in fetal death; maternal death
remains the most common cause of fetal death, followed by
Is typically characterized by direct blows to the abdomen.
Falls are another common cause of maternal and fetal injury.
Seat belts have been shown to reduce maternal mortality,
though poorly applied or designed restraints may increase
belt placed above the pregnant uterus reduce the risk of
injury to the fetus, particularly due to placental abruption.
The abdominal wall musculature, the pregnant uterus and
amniotic fluid all afford some protection to both mother and
fetus by absorbing applied forces.
However, acceleration, deceleration and shearing forces or
direct blows applied to the abdominal wall in later pregnancy
may result in placental abruption, with or without
disseminated intravascular coagulation, ruptured uterus and
direct injury to the fetus.
Farmer et a/.12 have shown that the
extent of maternal injury does not necessarily correlate with
the degree of fetal injury.
Lethal fetal injury associated with placental disruption or
direct injury may occur in the
face or minimal maternal injury.
• penetration by vehicular parts or debris from the
environment (fences or railings);
• stab injury by knives or related objects;
• In the UK, the usual pattern of injury is by stabbing or
penetration by objects in RTAs, or following falls.
During the first trimester, patterns of injury in thepregnant
and non-pregnant woman are similar, provided that the
injury track does not extend into the pelvis.
In later pregnancy the uterus acts a shield for the mother,
but the fetus is at particular hazard.
The uterine musculature and the amniotic fluid
effectively retard missile velocity, reducing energy
transfer and wounding potential, with outcome for the
fetus being determined by the structures injured.
Penetration of the umbilical cord or placenta may result
in abruption and haemorrhage, which may be
catastrophic for both fetus and mother.
Operative intervention is recommended in all cases of
penetrating injury in the
At laparotomy, the uterus must be carefully assessed for
penetration and the viability of the fetus assessed.
Evidence of uterine penetration is
widely regarded as an indication for immediate Caesarean
In early pregnancy (less than 28 weeks), operative delivery of
the fetus is associated with risk of fetal death, and it
may be appropriate in carefully selected cases to preserve the
Burn injury caused by flame or hot liquid in the first
trimester differs little from a similar
injury in the non-pregnant patient.
Beyond the first trimester an increasing percentage of maternal
cardiac output is diverted to the uterine and placental
circulation, reducing maternal compensation in the face of
sudden loss of circulating volume.
INITIAL ASSESSMENT AND MANAGEMENT
and optimal care of the mother is the best immediate
management possible for the fetus.
The following management pathway is
recommended If advanced notification is given, the following
information should be obtained:
The number of weeks' gestation
• Mechanism of injury
• Obvious injuries sustained
• Vital signs at scene
• Treatment given.
Initial assessment and resuscitation
A logical and sequential approach is vital.
While the general approach should not
differ, pregnancy dictates some modifications.
AIRWAY AND CERVICAL SPINE CONTROL
The increased risk of airway compromise in the face of altered
conscious level which may result from silent regurgitation of
gastric contents should be recognized. Facial and oral
swelling may make intubation technically difficult.
In particular, neck swelling may mask
normal landmarks, including the cricothyroid membrane.
The need to secure and protect the airway must be
Intubation must be performed by a skilled anaesthetist
Cricothyroid pressure is essential until the airway is
definitively protected, and collar
and tape should be replaced by manual in-line stabilization for
the duration of the procedure.
BREATHING AND VENTILATION
The normal physiological hyperventilation associated with
advanced pregnancy should be recognized; it may be
necessary to hyperventilate artificially if ventilatory support
Swelling of the soft tissues of the neck and upper chest may
If a chest drain is required, the presence of a high diaphragm
should be considered.
CIRCULATION AND HAEMORRHAGE
Inferior vena caval compression must be avoided from the
outset by one of the following:
• elevation of the right hip with a wedge;
log-rolling into the left lateral position; or
manual displacement of the uterus to left.
Always relieve inferior vena caval compression
Following vascular access, blood should be taken for a
In the pregnant patient, the end-point of fluid
resuscitation should be
the maintenance of a normal or near-normal systolic
If surgical intervention is judged necessary in order to
control maternal haemorrhage in any cavity, this should not
be deferred because of the pregnancy.
Ongoing maternal haemorrhage will lead to fetal hypoxia and
fetal death. Controlling maternal haemorrhage is the best
means of ensuring fetal survival
If the level of consciousness is altered, the possibility of
eclampsia or severe pre-eclampsia
must be considered.
EXPOSURE AND ENVIRONMENT
Neither the mother nor foetus can be properly assessed
without full exposure. The patient
must be undressed in a warm environment, and hypothermia
Following initial assessment and stabilization of the mother,
attention should now be
turned to an initial assessment of the foetus. Although best
performed by an obstetrician,
this assessment should be within the competence of any
member of the attending trauma
resuscitation: the foetus
A detailed obstetric assessment of the maternal abdomen and
pelvis should only commence
following stabilization of the mother, and should include the
MATURITY AND PLACENTAL
A detailed obstetric history (if available) and a clinical
assessment of fundal height should
give an accurate estimate of foetal viability (over 24 weeks'
gestation). Gestational age,
foetal viability and placental position can also be confirmed
using pelvic ultrasound. This
investigation may also be used to diagnose placental
abruption and intrauterinehaemorrhage.
ASSESSMENT OF UTERINE INTEGRITY
The uterus should be examined per abdomen. Signs of
premature contractions, tenderness
or rigidity, or extrauterine foetal parts are sought and their
presence demands immediate
obstetric consultation and consideration of urgent surgical
intervention. Digital or
speculum examination of the vagina requires special
expertise and should be performed by
Vaginal examination may reveal bleeding or amniotic fluid
findings include the condition of the cervical os and the
presence of pelvic fracture. Vaginal
examination in the injured pregnant woman is fraught with
hazard, and injudicious or
clumsy examination may precipitate catastrophic bleeding
from unsuspected placenta
praevia or may reveal a previously concealed placental
abruption. Consequently, such
examinations are usually best performed by an obstetrician -
this having the additional
The normal foetal heart rate is 120-160 beats/min and is
best assessed using Doppler
ultrasound. This examination is only useful once the uterus
has risen above the pelvic brim
(after the 12th week). Bradycardia of less than 100 beats/min
is a clear sign of foetal distress.
If the mother is conscious and able to report foetal
movements, a cardiotocogram can be
utilized to monitor foetal heart rate during uterine
contractions. The presence of any of the
signs of foetal distress or decompensation summarized in
Table 14.1 should prompt
immediate skilled assessment by an obstetrician
• Bradycardia of <100 beats/min or abnormal foetal baseline
• Repeated decelerations in response to uterine contractions
• Absence of acceleration in response to foetal movements
• Increasing uterine activity
• Positive Kleihauer-Betke test
Traumatic foetomaternal haemorrhage can be detected by
the Kleihauer-Betke test
women with a positive Kleihauer-Betke test, anti-D
immunoglobulin should be
administered to prevent rhesu isoimmunization.
risks to mother and foetus.