eMedicine Specialties > Emergency Medicine > Neurology

Spinal Cord Injuries: Differential Diagnoses & Workup

Author: Donald Schreiber, MD, CM, Associate Professor of Surgery (Emergency Medicine), Stanford University School of Medicine
Contributor Information and Disclosures

Updated: Apr 8, 2009

Differential Diagnoses

Dissection, Aortic
Epidural and Subdural Infections
Hanging Injuries and Strangulation
Neck Trauma
Spinal Cord Infections
Syphilis

Other Problems to Be Considered

Transverse myelitis
Acute intervertebral disk herniation
Extradural spinal cord compression

Workup

Laboratory Studies

  • Arterial blood gas measurements may be useful to evaluate adequacy of oxygenation and ventilation.
  • Lactate levels to monitor perfusion status can be helpful in the presence of shock. 
  • Hemoglobin and/or hematocrit levels may be measured initially and monitored serially to detect or monitor sources of blood loss.
  • Perform urinalysis to detect associated genitourinary injury.

Imaging Studies

  • Diagnostic imaging begins with the acquisition of standard radiographs of the affected region of the spine. Recent investigators have shown that CT scanning is exquisitely sensitive for the detection of spinal fractures and is cost effective.8,9 However, a properly performed lateral radiograph of the cervical spine that includes the C7-T1 junction can provide sufficient information to allow the multiple trauma victim to proceed emergently to the operating room if necessary without additional intervention other than maintenance of full spinal immobilization and a hard cervical collar. In some centers, CT scanning has supplanted plain radiographs.
    • The standard 3 views of the cervical spine are recommended: anteroposterior, lateral, and odontoid.
    • Anteroposterior and lateral views of the thoracic and lumbar spine are recommended.
    • Radiographs must adequately depict all vertebrae.
    • The cervical spine radiographs must include the C7-T1 junction to be considered adequate.
    • A common cause of missed injury is the failure to obtain adequate images.
  • CT scanning is reserved for delineating bony abnormalities or fracture. Some studies have suggested that CT scanning with sagittal and coronal reformatting is more sensitive than plain radiography for the detection of spinal fractures.8,10
    • Radiography is insensitive to small fractures of the vertebra.
    • Perform CT scanning in the following situations:
      • When plain radiography is inadequate or fails to visualize segments of the axial skeleton
      • Convenience and speed: If a CT scan of the head is required, then it is usually simpler and faster to obtain a CT of the cervical spine at the same time. Similarly, CT images of the thoracic or lumbar spine might be easier and faster to obtain than plain radiographs.
      • To provide further evaluation when radiography depicts suspicious and/or indeterminate abnormalities
      • When radiography depicts fracture or displacement: CT scanning provides better visualization of the extent and displacement of the fracture.
    • Recently published clinical criteria have established guidelines for cervical spine radiography in symptomatic trauma patients with neck pain. The NEXUS criteria and the Canadian C-spine rules have recently been validated in large clinical trials. These algorithms may be used to guide physicians to determine whether or not imaging of the cervical spine is required.11,12,13
    • Adequate spinal radiography supplemented by CT scanning through areas that are difficult to visualize or are suspicious detects the vast majority of fractures with a reported negative predictive value between 99% and 100%.8
    • Dynamic flexion/extension views are safe and effective for detecting occult ligamentous injury of the cervical spine in the absence of fracture. The negative predictive value of a normal 3-view cervical spine series and flexion/extension views exceeds 99%. The incidence of occult injury in the setting of normal findings on cervical spine radiography and CT scanning is low, so clinical judgment and the mechanism of injury should be used to guide the decision to order flexion/extension views.
  • MRI is best for suspected spinal cord lesions, ligamentous injuries, or other soft tissue injuries or pathology.
    • MRI should be used to evaluate nonosseous lesions, such as extradural spinal hematoma; abscess or tumor; disk rupture; and spinal cord hemorrhage, contusion, and/or edema.
    • Neurologic deterioration is usually caused by secondary injury, resulting in edema and/or hemorrhage. MRI is the best diagnostic image to depict these changes.
  • Noncontiguous spinal fractures are defined as spinal fractures separated by at least one normal vertebra. Noncontiguous fractures are common and occur in 10-15% of patients with spinal cord injury. Therefore, once a spinal fracture is identified, the entire axial skeleton must be imaged, preferably by CT, to assess for noncontiguous fractures.14,5,15

More on Spinal Cord Injuries

Overview: Spinal Cord Injuries
Differential Diagnoses & Workup: Spinal Cord Injuries
Treatment & Medication: Spinal Cord Injuries
Follow-up: Spinal Cord Injuries
Multimedia: Spinal Cord Injuries
References
[ CLOSE WINDOW ]

References

  1. Kriss VM, Kriss TC. SCIWORA (spinal cord injury without radiographic abnormality) in infants and children. Clin Pediatr (Phila). Mar 1996;35(3):119-24. [Medline].

  2. Pang D. Spinal cord injury without radiographic abnormality in children, 2 decades later. Neurosurgery. Dec 2004;55(6):1325-42; discussion 1342-3. [Medline].

  3. Yucesoy K, Yuksel KZ. SCIWORA in MRI era. Clin Neurol Neurosurg. May 2008;110(5):429-33. [Medline].

  4. National Spinal Cord Injury Statistical Center, Birmingham, Alabama. Spinal Cord Injury: Facts and Figures at a Glance. January 2008;Accessed February 24, 2009. Available at www.spinalcord.uab.edu.

  5. Harris MB, Sethi RK. The initial assessment and management of the multiple-trauma patient with an associated spine injury. Spine. May 15 2006;31(11 Suppl):S9-15; discussion S36. [Medline].

  6. Ho CH, Wuermser LA, Priebe MM, Chiodo AE, Scelza WM, Kirshblum SC. Spinal cord injury medicine. 1. Epidemiology and classification. Arch Phys Med Rehabil. Mar 2007;88(3 Suppl 1):S49-54. [Medline].

  7. Wuermser LA, Ho CH, Chiodo AE, Priebe MM, Kirshblum SC, Scelza WM. Spinal cord injury medicine. 2. Acute care management of traumatic and nontraumatic injury. Arch Phys Med Rehabil. Mar 2007;88(3 Suppl 1):S55-61. [Medline].

  8. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma. May 2005;58(5):890-5; discussion 895-6. [Medline].

  9. Grogan EL, Morris JA Jr, Dittus RS, et al. Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan. J Am Coll Surg. Feb 2005;200(2):160-5. [Medline].

  10. Acheson MB, Livingston RR, Richardson ML, Stimac GK. High-resolution CT scanning in the evaluation of cervical spine fractures: comparison with plain film examinations. AJR Am J Roentgenol. Jun 1987;148(6):1179-85. [Medline].

  11. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. Jul 13 2000;343(2):94-9. [Medline].

  12. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma. N Engl J Med. Dec 25 2003;349(26):2510-8. [Medline].

  13. Stiell IG, Wells GA, Vandemheen KL. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. Oct 17 2001;286(15):1841-8. [Medline].

  14. Keenen TL, Antony J, Benson DR. Non-contiguous spinal fractures. J Trauma. Apr 1990;30(4):489-91. [Medline].

  15. Powell JN, Waddell JP, Tucker WS, Transfeldt EE. Multiple-level noncontiguous spinal fractures. J Trauma. Aug 1989;29(8):1146-50; discussion 1150-1. [Medline].

  16. Congress of Neurologic Surgeons. Blood pressure management after acute spinal cord injury. Neurosurgery. Mar 2002;50(3 Suppl):S58-62. [Medline].

  17. Bracken MB, Shepard MJ, Hellenbrand KG, et al. Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study. J Neurosurg. Nov 1985;63(5):704-13. [Medline].

  18. Bracken MB, Shepard MJ, Holford TR, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA. May 28 1997;277(20):1597-604. [Medline].

  19. Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials. J Trauma. Dec 1998;45(6):1088-93. [Medline].

  20. Hadley MN, Walters BC, Grabb PA, et al. Pharmacological therapy after acute spinal cord injury. Neurosurgery. 2002;50 Suppl:63-72.

  21. Eck JC, Nachtigall D, Humphreys SC, Hodges SD. Questionnaire survey of spine surgeons on the use of methylprednisolone for acute spinal cord injury. Spine. Apr 20 2006;31(9):E250-3. [Medline].

  22. Geisler FH, Dorsey FC, Coleman WP. Recovery of motor function after spinal-cord injury--a randomized, placebo-controlled trial with GM-1 ganglioside. N Engl J Med. Jun 27 1991;324(26):1829-38. [Medline].

  23. Gaebler C, Maier R, Kutscha-Lissberg F, Mrkonjic L, Vecsei V. Results of spinal cord decompression and thoracolumbar pedicle stabilisation in relation to the time of operation. Spinal Cord. Jan 1999;37(1):33-9. [Medline].

  24. Mirza SK, Krengel WF 3rd, Chapman JR, Anderson PA, Bailey JC, Grady MS. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop Relat Res. Feb 1999;(359):104-14. [Medline].

  25. Vaccaro AR, Daugherty RJ, Sheehan TP, et al. Neurologic outcome of early versus late surgery for cervical spinal cord injury. Spine. Nov 15 1997;22(22):2609-13. [Medline].

  26. Bagnall AM, Jones L, Duffy S, Riemsma RP. Spinal fixation surgery for acute traumatic spinal cord injury. Cochrane Database Syst Rev. Jan 23 2008;CD004725. [Medline].

  27. American Spinal Injury Association. Guidelines for Facility Categorization and Standards of Care: Spinal Cord Injury. 1981.

  28. Annual Report for the Model Spinal Cord Injury Care Systems [database online]. Birmingham, Alabama, USA: National Spinal Cord Injury Statistical Center; December 2007.

  29. Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2002;CD001046. [Medline].

  30. Bracken MB, Shepard MJ, Collins WF, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. May 17 1990;322(20):1405-11. [Medline].

  31. Burney RE, Maio RF, Maynard F, Karunas R. Incidence, characteristics, and outcome of spinal cord injury at trauma centers in North America. Arch Surg. May 1993;128(5):596-9. [Medline].

  32. CJEM. Steroids in acute spinal cord injury. CJEM. Jan 2003;5(1):7-9. [Medline].

  33. Ducker TB, Zeidman SM. Spinal cord injury. Role of steroid therapy. Spine. Oct 15 1994;19(20):2281-7. [Medline].

  34. Fehlings MG, Perrin RG. The role and timing of early decompression for cervical spinal cord injury: update with a review of recent clinical evidence. Injury. Jul 2005;36 Suppl 2:B13-26. [Medline].

  35. Fisher CG, Noonan VK, Dvorak MF. Changing face of spine trauma care in North America. Spine. May 15 2006;31(11 Suppl):S2-8; discussion S36. [Medline].

  36. Green BA, Eismont FJ, O'Heir JT. Spinal cord injury--a systems approach: prevention, emergency medical services, and emergency room management. Crit Care Clin. Jul 1987;3(3):471-93. [Medline].

  37. Hadley MN, Walters BC, Grabb PA, et al. Guidelines for the management of acute cervical spine and spinal cord injuries. Clin Neurosurg. 2002;49:407-98. [Medline].

  38. Hurlbert RJ. Strategies of medical intervention in the management of acute spinal cord injury. Spine. May 15 2006;31(11 Suppl):S16-21; discussion S36. [Medline].

  39. Hurlbert RJ, Hamilton MG. Methylprednisolone for acute spinal cord injury: 5-year practice reversal. Can J Neurol Sci. Mar 2008;35(1):41-5. [Medline].

  40. Janssen L, Hansebout RR. Pathogenesis of spinal cord injury and newer treatments. A review. Spine. Jan 1989;14(1):23-32. [Medline].

  41. Krompinger WJ, Fredrickson BE, Mino DE, Yuan HA. Conservative treatment of fractures of the thoracic and lumbar spine. Orthop Clin North Am. Jan 1986;17(1):161-70. [Medline].

  42. Marshall LF, Knowlton S, Garfin SR, et al. Deterioration following spinal cord injury. A multicenter study. J Neurosurg. Mar 1987;66(3):400-4. [Medline].

  43. Meyer PR. Surgery of Spine Trauma. New York, NY: Churchill Livingstone; 1989.

  44. Meyer PR Jr, Cybulski GR, Rusin JJ, Haak MH. Spinal cord injury. Neurol Clin. Aug 1991;9(3):625-61. [Medline].

  45. Reid DC, Henderson R, Saboe L, Miller JD. Etiology and clinical course of missed spine fractures. J Trauma. Sep 1987;27(9):980-6. [Medline].

  46. Saboe LA, Reid DC, Davis LA, Warren SA, Grace MG. Spine trauma and associated injuries. J Trauma. Jan 1991;31(1):43-8. [Medline].

  47. Sansam KA. Controversies in the management of traumatic spinal cord injury. Clin Med. Mar-Apr 2006;6(2):202-4. [Medline].

  48. Savitsky E, Votey S. Emergency department approach to acute thoracolumbar spine injury. J Emerg Med. Jan-Feb 1997;15(1):49-60. [Medline].

  49. Tator CH. Acute management of spinal cord injury. Br J Surg. May 1990;77(5):485-6. [Medline].

  50. Woodring JH, Lee C. The role and limitations of computed tomographic scanning in the evaluation of cervical trauma. J Trauma. Nov 1992;33(5):698-708. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

spinal cord injury, SCI, anterior cord syndrome, Brown-Séquard syndrome, central cord syndrome, conus medullaris syndrome, cauda equina syndrome, incomplete SCI syndromes, spinal cord concussion, spinal cord injury syndromes, SCIWORA, spinal cord injury without radiologic abnormality

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Donald Schreiber, MD, CM, Associate Professor of Surgery (Emergency Medicine), Stanford University School of Medicine
Donald Schreiber, MD, CM is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Abbott Point of Care Inc Research Grant and Speaker''''''''''''''''s Bureau Speaking and teaching; Bristol-Myers Squibb Inc Honoraria Speaking and teaching; Sanofi-Aventis, Inc Honoraria Speaking and teaching; Nanosphere Inc Grant/research funds Research; Singulex Inc Grant/research funds Research

Medical Editor

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Associate Professor, Department of Emergency Medicine, University of Texas-Houston
Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.