Assessment Of Spinal Cord Injury by Dr Zaheer ahmed Nishtar Hospital Multan and compiled by Dr Taha Bashir

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3. Welcome

5. Assessment of
Spinal Cord Injury
Incidence
Pathophysiology and Mechanics
Classification
Assessment
Cases
The ASIA/ISCoS Exam
Management
Complications

6. Assessment of
Spinal Cord InjuryIncidence

7. Assessment of
Spinal Cord Injury
• Approximately 55% of spinal injuries occur in the cervical region
• 15% in the thoracic region
• 15% at the thoracolumbar junction
• and 15% in the lumbosacral area.
Approximately 10% of patients with a cervical spine fracture have a
second, noncontiguous vertebral column fracture.
( Advanced Trauma Life Support.ATLS.9th.Edition)
Incidence

8. Assessment of
Spinal Cord InjuryIncidence
• Approximately one-third of patients with upper cervical
spine injuries die at the injury scene from apnea caused by
loss of central innervation of the phrenic nerves caused by
spinal cord injury at C1.
• When a fracture-dislocation in the thoracic spine does
occur, it almost always results in a complete spinal cord
injury because of the relatively narrow thoracic canal.
( Advanced Trauma Life Support.ATLS.9th.Edition)

9. Assessment of
Spinal Cord Injury
Pathophysiology and Mechanics

10. Assessment of
Spinal Cord InjuryPathophysiology and Mechanics
The Secondary Injury
Hemorrhage, oedema, ischemia results in
biochemical cascade that causes the
secondary injury, accentuated by
hypotension, hypoxia, spinal instability and
persistent compression of the neural
elements.
The Primary Injury
This is the direct insult to the
neural elements and occurs at
the time of initial injury.
(Bailey and Love’s Short Practice Of Surgery 26th Edition)

11. Assessment of
Spinal Cord InjuryPathophysiology and Mechanics
Trauma causes a wide variety of injury patterns in the spine.
• Flexion/extension: Flexion loads the spine anteriorly (the
vertebral bodies) and distracts the spine posteriorly (the spinous
process and interspinous ligaments).
• Compression/Distraction: Force applied along the spinal axis
(axial loading) compresses the spine.
• Rotation:Force applied tangential to the spinal axis rotates the
spine.
(Schwartzs Principles of Surgery, 10th Ed)

12. Assessment of
Spinal Cord Injury
Classification

13. • It can be classified According to
1.Level
2.Severity of
Neurologic
Deficit
3.Spinal cord
Syndromes 4.Morphology
Assessment of
Spinal Cord InjuryClassification
( Advanced Trauma Life Support.ATLS.9th.Edition)

14. Assessment of
Spinal Cord Injury
Assessment

15. Assessment of
Spinal Cord Injury
Assessment
Patient Assessment
Relevant history
Physical Examination

16. Assessment of
Spinal Cord InjuryAssessment
Patient Assessment
• The spine should initially be immobilized on the
assumption that every trauma patient has a spinal
injury until proven otherwise.
• In unconcious patient, definitive clearance of the
spine may not be possible in the initial stages and
spinal immobliziation should be maintained, until
MRI or equivalent can be used to rule out unstable
spinal injury.
(Bailey and Love’s Short Practice Of Surgery 26th Edition)

17. Assessment of
Spinal Cord InjuryAssessment
Patient Assessment
• Patients who have no findings on examination,
demonstrate no decreased level of consciousness,
and have no distracting injuries can undergo
clearance of the spine by clinical means alone.
• Although plain radiographs of the spine are
acceptable, the high-quality images and rapid
availability associated with CT have made this the
modality of choice in most emergency departments.
(Sabiston Textbook of Surgery)

18. Assessment of
Spinal Cord InjuryAssessment
• The mechanism and velocity of injury
• Presence of spinal pain
• Onset of neurological sypmtoms
• Duration of neurological sypmtoms
Relevant history
(Bailey and Love’s Short Practice Of Surgery 26th Edition)

19. Assessment of
Spinal Cord InjuryAssessment
Physical Examination
• Initial Assessment
The primary survey followed by carefull systems examination.
• Identification of shock
Three categories of shock may occur in spinal trauma:
1. Hypovolaemic shock
2. Neurogenic shock
3. Spinal shock
• Spinal Examination:
• The entire spine must be palpated and the overlying skin is inspected and formal
log roll should be performed to achieve this.
(Bailey and Love’s Short Practice Of Surgery 26th Edition)

20. • Initial Assessment
The primary survey followed by carefull systems examination.
• Identification of shock
Three categories of shock may occur in spinal trauma:
1. Hypovolaemic shock
2. Neurogenic shock
3. Spinal shock
Assessment of
Spinal Cord InjuryAssessment
• Neurogenic shock results from impairment of the descending
sympathetic pathways in the cervical or upper thoracic spinal cord.
This condition results in the loss of vasomotor tone and in
sympathetic innervation to the heart.
Neurogenic shock Loss of
sympathetic
Loss of vasomotor tone innervation of heart
Vasodilation of blood vessels
Hypotension Bradycardia
or normal heart rate
Beacause of cervical cord injury above the level of sympathetic
outflow(C7/T1) .….. Warm peripheries ….
Physical Examination
( Advanced Trauma Life Support.ATLS.9th.Edition)

21. • Initial Assessment
The primary survey followed by carefull systems examination.
• Identification of shock
Three categories of shock may occur in spinal trauma:
1. Hypovolaemic shock
2. Neurogenic shock
3. Spinal shock
Assessment of
Spinal Cord InjuryAssessment
Physical Examination
• The classic presentation of neurogenic
shock is hypotension in the setting of
warm, well-perfused extremities in the
paralyzed patient.
(Sabiston Textbook of Surgery)

22. • Initial Assessment
The primary survey followed by carefull systems examination.
• Identification of shock
Three categories of shock may occur in spinal trauma:
1. Hypovolaemic shock
2. Neurogenic shock
3. Spinal shock
Assessment of
Spinal Cord InjuryAssessment
Physical Examination
• Spinal shock. There is initial loss of all
neurological function below the level of the injury
Paralysis Hypotonia Areflexia
Usually lasts 24 hours following spinal cord injury.
Once it has resolved the bulbocavernosus reflex
returns.
(Bailey and Love’s Short Practice Of Surgery 26th Edition)

23. • Initial Assessment
The primary survey followed by carefull systems examination.
• Identification of shock
Three categories of shock may occur in spinal trauma:
1. Hypovolaemic shock
2. Neurogenic shock
3. Spinal shock
Assessment of
Spinal Cord InjuryAssessment
Physical Examination
(Bailey and Love’s Short Practice Of Surgery 26th Edition)
Spinal Examination:
The entire spine must be palpated and the
overlying skin is inspected and formal log
roll should be performed to achieve this.

24. • Initial Assessment
The primary survey followed by carefull systems examination.
• Identification of shock
Three categories of shock may occur in spinal trauma:
1. Hypovolaemic shock
2. Neurogenic shock
3. Spinal shock
Assessment of
Spinal Cord Injury
Assessment
(Bailey and Love’s Short Practice Of Surgery 26th Edition)

25. • Initial Assessment
The primary survey followed by carefull systems examination.
• Identification of shock
Three categories of shock may occur in spinal trauma:
1. Hypovolaemic shock
2. Neurogenic shock
3. Spinal shock
Assessment of
Spinal Cord InjuryAssessment
Patient Assessment
Relevant History
Physical Examination

26. Assessment of
Spinal Cord Injury
Cases
( Advanced Trauma Life Support.ATLS.9th.Edition)

27. Assessment of
Spinal Cord InjuryCases
The presence of paraplegia or quadriplegia is
is presumptive evidence of spinal instability.

28. Assessment of
Spinal Cord InjuryCases
1
Patients who are awake, alert, sober, and
neurologically normal, and have no neck pain or
midline tenderness, or a distracting injury
• Remove the c-collar and palpate the spine. If there is
no significant tenderness, ask the patient to
voluntarily move his or her neck from side to side
then flex and extend
• If no pain, c-spine films are not necessary.

29. Assessment of
Spinal Cord InjuryCases
1
2
• Patients who are awake and alert, neurologically normal, cooperative,
and do not have a distracting injury and are able to concentrate on their
spine, but do have neck pain or midline tenderness
• Where available, all such patients should undergo multi-detector axial CT
from the occiput to T1 with sagittal and coronal reconstructions.
• Lateral, AP, and openmouth odontoid x-ray examinations of the c-spine
• If these films are normal, remove the c-collar.
• if any of these films are suspicious, obtain consultation from a spine
specialist.

30. Assessment of
Spinal Cord InjuryCases
1
2
3
• Patients who have an altered level of consciousness or are too young to
describe their symptoms
• Where available, all such patients should undergo multi-detector axial
CT from the occiput to T1 with sagittal and coronal reconstructions.
• Where not available, all such patients should undergo lateral, AP, and
open-mouth odontoid films with CT supplementation through suspicious
areas.
• If the entire c-spine can be visualized and is found to be normal, the
collar can be removed after appropriate evaluation

31. Assessment of
Spinal Cord InjuryCases
123
4
When in doubt
leave the collar on.
• Backboards: Patients who have neurologic deficits (e.g.,
quadriplegia or paraplegia) should be evaluated quickly and
removed from the backboard as soon as possible. A paralyzed
patient who is allowed to lie on a hard board for more than 2
hours is at high risk for pressure ulcers.

32. Assessment of
Spinal Cord Injury
Cases
1
2 3 4 5

33. Assessment of
Spinal Cord Injury
Neurological Examination
• The American Spinal Injury Association (ASIA) neurological
evaluation system is an internationally accepted method of
neurological evaluation.
• This is a system of tests used to define and describe:
• Extent
• Severity
• Future Rehabilitation
• Recovery needs

34. Assessment of
Spinal Cord Injury
The ASIA/ISCoS Exam

35. Assessment of
Spinal Cord InjuryThe ASIA/ISCoS Exam
Steps in Classification
1. Determine sensory levels for right and left sides.
2. Determine motor levels for right and left sides.
3. Determine the neurological level of injury (NLI)
4. Determine whether the injury is Complete or
Incomplete.
5. Determine ASIA Impairment Scale (AIS) Grade:

36. The ASIA/ISCoS Exam
Assessment of
Spinal Cord Injury

37. The ASIA/ISCoS Exam
Assessment of
Spinal Cord Injury
Level of neurological impairment
The ASIA neurological impairment scale is
based on the Frankel classification of spinal
cord injury:
• A, complete;
• B, sensation present motor absent;
• C, sensation present, motor present but not
useful (MRC grade <3/5);
• D, sensation present, motor useful (MRC
grade 3/5);
• E, normal function

38. Assessment of
Spinal Cord Injury
Management
( Advanced Trauma Life Support.ATLS.9th.Edition)

39. Assessment of
Spinal Cord InjuryManagement
Primary Survey and Resuscitation—Assessing Spine Injuries

40. Assessment of
Spinal Cord Injury
Management
Secondary Survey--Neurologic Assessment

41. Assessment of
Spinal Cord InjuryManagement
Treatment Principles for Patients with Spinal Cord Injuries

42. Assessment of
Spinal Cord Injury
Complications

43. Assessment of
Spinal Cord Injury
Complications
• Pain and spasticity
• Autonomic dysreflexia
• Neurological deterioration
• Thromboembolic events
• Osteoporosis, heterotopic ossification
• Contractures

44. Assessment of
Spinal Cord Injury

45. Thankyou

46. Thankyou