Key Facts

Spinal injuries range from stable vertebral fractures requiring conservative management to unstable injuries with spinal cord damage causing permanent disability. Rapid assessment, immobilisation, and specialist management are essential to prevent secondary injury.

Epidemiology

Traumatic spinal cord injury affects approximately 1,000 new patients per year in the UK. Peak incidence in young males (15-30 years) from RTCs and falls, with a second peak in the elderly from falls. Male-to-female ratio is 4:1. Complete cervical cord injury carries the most significant morbidity.

Aetiology

• Road traffic collisions (40-50%): Most common cause in young adults
• Falls (30-40%): Most common cause in the elderly
• Sports injuries (10-15%): Rugby, diving, horse-riding
• Violence: Penetrating injuries, assault
• Non-traumatic: Tumour, infection, vascular (anterior spinal artery syndrome)

Pathophysiology

Primary injury: Mechanical disruption of neural tissue at the time of trauma — irreversible. Secondary injury: Cascade of ischaemia, oedema, inflammation, excitotoxicity, and apoptosis — occurs hours to days after injury and is potentially preventable.

Key cord syndromes:

• Complete transection: Loss of all motor and sensory function below the level
• Central cord syndrome: Upper limb weakness > lower limb (hyperextension injury in elderly with cervical spondylosis)
• Anterior cord syndrome: Motor paralysis + pain/temperature loss; preserved proprioception/vibration
• Brown-Séquard syndrome: Ipsilateral motor + proprioception loss; contralateral pain/temperature loss
• Cauda equina syndrome: Lower motor neurone signs, saddle anaesthesia, urinary retention

Acute Spinal Cord Injury

• Motor deficit below the level of injury
• Sensory deficit (dermatomal level)
• Respiratory compromise if cervical (C3-C5 — phrenic nerve)
• Priapism (sign of high spinal cord injury)
• Loss of anal tone (complete injury)

Spinal Shock

• Flaccid paralysis, areflexia below the lesion
• Loss of bladder and bowel function
• Resolves over days to weeks — replaced by upper motor neurone signs (spasticity, hyperreflexia)

Neurogenic Shock

• Hypotension + bradycardia (loss of sympathetic outflow T1-L2)
• Warm, vasodilated peripheries (unlike hypovolaemic shock)
• Must exclude haemorrhagic shock first in trauma

Red Flags

• Midline spinal tenderness with neurological deficit — immobilise immediately
• Bilateral leg weakness + urinary retention — cauda equina syndrome (emergency MRI)
• Progressive neurological deficit — consider expanding haematoma or instability
• Respiratory deterioration in cervical injury — ascending oedema, ventilatory support needed

Bedside

• ATLS primary survey: ABCDE — airway with C-spine control
• Neurological examination: Detailed motor and sensory exam, anal tone, bulbocavernosus reflex
• ASIA classification: Grade A (complete) to E (normal)
• Log-roll: Palpate spinous processes for tenderness, step deformity

Bloods

• FBC, U&Es, coagulation: Baseline trauma bloods
• Group and save/crossmatch: If haemodynamic compromise
• Lactate: Tissue perfusion assessment
• ABG: Respiratory function in cervical injuries

Imaging

• CT whole spine: Gold standard for bony injury in major trauma (NICE NG41)
• MRI spine: Essential to assess cord compression, ligamentous injury, disc herniation, haematoma
• CT angiography: If vertebral artery injury suspected (cervical fractures involving foramen transversarium)
• CXR: Assess for associated thoracic injuries

Special Tests

• Canadian C-spine rules / NEXUS criteria: Clinical decision rules for imaging
• Somatosensory evoked potentials (SSEPs): Assess cord function intraoperatively
• Urodynamic studies: Later assessment of neurogenic bladder

Non-pharmacological

• Immobilisation: In-line stabilisation, scoop stretcher, blocks and tape (not rigid cervical collars long-term)
• Log-rolling: For examination and pressure area care
• ICU/HDU admission: For cervical cord injuries (respiratory monitoring)
• Specialist spinal cord injury centre transfer: As soon as patient is stable (NICE NG41)
• Pressure care: Spinal cord injury patients at extremely high risk of pressure ulcers
• Bladder management: Intermittent self-catheterisation or indwelling catheter initially

Pharmacological

• Analgesia: Multimodal — paracetamol, NSAIDs (if no contraindication), gabapentin/pregabalin for neuropathic pain
• VTE prophylaxis: LMWH (enoxaparin 40mg SC OD) + mechanical prophylaxis — high VTE risk
• Vasopressors: Noradrenaline for neurogenic shock (target MAP ≥85 mmHg for 5-7 days per AANS guidelines)
• Bowel management: Regular aperients to prevent autonomic dysreflexia triggers
• Methylprednisolone: NOT routinely recommended (NASCIS trials were flawed; risks outweigh benefits per most guidelines)

Surgical/Interventional

• Emergency decompression: For progressive neurological deficit or cord compression
• Spinal fixation: Stabilise unstable fractures/dislocations
• Halo vest: External fixation for unstable upper cervical fractures
• Timing of surgery: Early surgery (<24 hours) for incomplete injuries is increasingly supported (STASCIS trial)

Referral Criteria

• All spinal cord injuries — specialist spinal cord injury centre
• Unstable spinal fractures — spinal surgery
• Cauda equina syndrome — emergency MRI and decompression

• Complete injury (ASIA A): <5% chance of neurological recovery if still ASIA A at 72 hours
• Incomplete injury: Significant potential for recovery — Brown-Séquard has best prognosis (~90% regain ambulation)
• Central cord syndrome: Variable recovery; younger patients have better outcomes
• Life expectancy: Reduced by 10-20 years for complete cervical injuries; respiratory complications are the leading cause of death
• Cervical injuries: 1-year mortality ~20% for complete tetraplegia
• Autonomic dysreflexia: Can cause fatal hypertension if not recognised and managed

ASIA Impairment Scale

Spinal Cord Syndromes

Denis Three-Column Model of Spinal Stability

Injury to ≥2 columns = unstable.