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Spinal Cord Injury

 

A patient was involved in a motor vehicle accident, and the patient is unable to move all four extremities. We will start the examination with applying the ABC’s for trauma patients: Airway, Breathing and ventilation, Circulation and hemorrhage control, Disability evaluation, Exposure/Environmental control. Because the patient cannot move their extremities, then we examine the patient for a spinal cord injury. First, we will examine if the patient is in spinal shock. Spinal shock means that the patient does not have the bulbocavernosus reflex. The anal sphincter will not contract when the reflex is absent. The patient will have flaccid paralysis and no bulbocavernosus reflex.


 The spinal shock will take about 48 hours to return, and we cannot tell the prognosis of the patient until that reflex comes back. The anal sphincter will contract when the reflex is present. Then we decide if the patient has a complete or incomplete injury. This is decided when the bulbocavernosus comes back (end of spinal shock). Complete injury means that there is no motor or sensory below the level of the lesion and no sacral sparing. Incomplete injury means that the bulbocavernosus reflex is back (the sacral sparing, there is perianal sensation, or there is rectal tone). Next, you try to see what the functional level is. The lowest segment with bilaterally intact sensation or antigravity muscle function and strength, like three or more bilaterally, while the segment above is normal. When we talk about incomplete spinal cord injuries, we are talking about spinal cord injury with some neurological function distal to the injury. In general, we are talking about sacral sparing (rectal tone and perianal sensation). If the sacral sparing is positive, then the patient has incomplete spinal cord injury. If the sacral sparing is negative, then the patient has a complete spinal cord injury. Central cord syndrome is the most common type. It is caused by hyperextension injuries, and it is seen in older patients. Anterior cord syndrome has a poor prognosis, and it is usually vascular. Brown-Sequard syndrome is a hemisection of the spinal cord, and it has a good prognosis. There will be loss of ipsilateral motor function, and contralateral loss of pain and temperature sensation. Posterior cord syndrome is very rare and is associated with loss of proprioception, deep touch, and vibration. Neurogenic shock is hypotension and bradycardia due to loss of the sympathetic tone to the heart and wide spread vasodilation with decreased systemic vascular resistance to the descending sympathetic system. Careful fluid management is needed. You may need swan Ganz monitoring and vasopressors to treat the hypotension. Hypotension and tachycardia is hypovolemic shock. Hypotension and bradycardia is neurogenic shock. Autonomic dysreflexia occurs in complete spinal cord injury due to uncontrolled sympathetic output (sympathetic system is overcharged in activity). Autonomic dysreflexia is usually associated with certain triggers. Unchecked visceral stimulation such as check for fecal impaction, check for folley catheter obstruction (kinked or blocked). It occurs in patients with spinal cord injuries above T6. It can be fatal. Patient will get headache, agitation, severe hypertension and sweating. You may want to give the patient antihypertensives and atropine.
 

Author
Nabil Ebraheim, MD

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