eMedicine Specialties > Emergency Medicine > Neurology

Spinal Cord Injuries: Follow-up

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

Updated: Apr 8, 2009

Follow-up

Further Inpatient Care

  • Admit all patients with an acute spinal cord injury (SCI). Depending on the level of neurologic deficit and associated injuries, the patient may require admission to the ICU, neurosurgical observation unit, or general ward.
  • Orthopedic and/or neurosurgical consultants should determine the need for and timing of any surgical intervention.
    • Studies from the 1960s and 1970s showed that the patients experienced no improvement with emergent surgical decompression. Gaebler et al reported that early decompression and stabilization procedures within 8 hours of injury allowed for a higher rate of neurologic recovery.23 Mirza et al reported that stabilization within 72 hours of injury in cervical spinal cord injury improved neurologic outcomes.24 Unfortunately, both these studies and others were not prospective controlled or randomized. In the only prospective, randomized, controlled study to determine whether functional outcome is improved in patients with cervical spinal cord injury, Vaccaro et al reported no significant difference between early (<3 d, mean 1.8 d) or late (>5 d, mean 16.8 d).25
    • A recent Cochrane Database of Systematic Reviews article of spinal fixation surgery for acute traumatic spinal cord injury concluded that, in the absence of any randomized controlled studies, no recommendations regarding risks or benefits could be made.26
    • Currently, no defined standards exist regarding the timing of decompression and stabilization in spinal cord injury. The role of immediate surgical intervention is limited. Emergent decompression of the spinal cord is suggested in the setting of acute spinal cord injury with progressive neurologic deterioration, facet dislocation, or bilateral locked facets.
    • Emergent decompression is also suggested in the setting of spinal nerve impingement with progressive radiculopathy and in those select patients with extradural lesions such as epidural hematomas or abscesses or in the setting of the cauda equina syndrome.
    • A prospective surgical trial, the Surgical Treatment for Acute Spinal Cord Injury Study (STASCIS) conducted by the Spine Trauma Study Group is currently in progress that hopefully will better define the benefits of early surgical decompression and stabilization.

Transfer

  • Depending on local policy, patients with acute spinal cord injury (SCI) are best treated at a regional spinal cord injury center.
  • Once stabilized, early referral to a regional spinal cord injury center is best. The center should be organized to provide ongoing definitive care.
  • Other reasons to transfer the patient include the lack of appropriate diagnostic imaging (CT scanning or MRI) and/or inadequate spine consultant support (orthopedist or neurosurgeon).

Deterrence/Prevention

  • Many patients experience spinal cord injury as a result of incidents involving drunk driving, assaults, and alcohol or drug abuse.
  • Industrial hazards, such as equipment failures or inadequate safety precautions, are potentially preventable causes.
  • Unfenced, shallow, or empty swimming pools are known hazards.

Complications

  • The neurologic deficit often increases during the hours to days following acute spinal cord injury, despite optimal treatment.
  • One of the first signs of neurologic deterioration is the extension of the sensory deficit cephalad. Careful repeat neurologic examination may reveal that the sensory level has risen 1 or 2 segments. Repeat neurologic examinations to check for progression are essential.
  • Careful and frequent turning of the patient is required to prevent pressure sores. Denervated skin is particularly prone to this complication. Remove belts and objects from back pockets such as keys and wallets.
  • Try to remove the patient from the backboard as soon as possible. Some patients may require spinal immobilization in a halo vest or a Stryker frame. Many patients with acute spinal cord injury have stable vertebral fractures yet needlessly spend hours on a hard backboard.
  • Patients with spinal cord injury are at high risk for aspiration. Nasogastric decompression of the stomach is mandatory.
  • Prevent hypothermia by using external rewarming techniques and/or warm humidified oxygen.
  • Pulmonary complications in spinal cord injury are common. Pulmonary complications are directly correlated with mortality, and both are related to the level of neurologic injury. Pulmonary complications of spinal cord injury include the following:
    • Atelectasis secondary to decreased vital capacity and decreased functional residual capacity
    • Ventilation-perfusion mismatch due to sympathectomy and/or adrenergic blockade
    • Increased work of breathing because of decreased compliance
    • Decreased coughing, which increases the risk of retained secretions, atelectasis, and pneumonia
    • Muscle fatigue
  • Severe sepsis or pneumonia frequently follows treatment with high-dose methylprednisolone that is frequently used in spinal cord injury.

Prognosis

  • Patients with a complete cord injury have a less than 5% chance of recovery. If complete paralysis persists at 72 hours after injury, recovery is essentially zero.
  • The prognosis is much better for the incomplete cord syndromes.
  • If some sensory function is preserved, the chance that the patient will eventually be able walk is greater than 50%.
  • Ultimately, 90% of patients with spinal cord injury (SCI) return to their homes and regain independence.
  • Providing an accurate prognosis for the patient with an acute SCI usually is not possible in the ED and is best avoided.
  • In the early 1900s, the mortality rate 1 year after injury in patients with complete lesions approached 100%. Much of the improvement since then can be attributed to the introduction of antibiotics to treat pneumonia and urinary tract infection.
  • Currently, the 5-year survival rate for patients with a traumatic quadriplegia is 89%. The hospital mortality rate for isolated acute SCI is low.4

Patient Education

  • As part of inpatient therapy, patients with spinal cord injury (SCI) should receive a comprehensive program of physical and occupational therapy.
  • For excellent patient education resources, see the eMedicineHealth Web site.

Miscellaneous

Medicolegal Pitfalls

  • Failure to establish the diagnosis of incomplete cord injury or radiculopathy when the neurologic findings are subtle
  • Failure to adequately immobilize the spine when the mechanism of injury is consistent with the diagnosis
    • Agitated intoxicated patients are often the most difficult to manage properly.
    • Pharmacological restraint may be required to allow proper assessment. Haldol and intravenous droperidol have been used successfully, even in large doses, without hemodynamic or respiratory compromise. Occasionally, rapid-sequence intubation and pharmacologic paralysis is required to treat these patients.
    • Physical examination and radiographic studies could be delayed until the patient is more cooperative, if his or her overall condition permits.
  • Attributing hypotension to neurogenic shock in the setting of spinal cord injury (SCI) - A potentially devastating error
  • Failure to interpret the radiographs correctly
    • On cervical radiography, subtle findings (eg, increased prevertebral soft tissue swelling or widening of the C1-C2 preodontoid space) indicate potentially unstable cervical spine injuries that could have serious consequences if they are not detected.
    • In many EDs, radiology support is limited. If unsure of a finding, request a formal interpretation or immobilize the patient appropriately, pending formal review of the studies.
    • Radiographs are only as good as the first and last vertebrae seen. Incomplete radiographs (eg, cervical spine radiograph that incompletely depicts the C7-T1 junction) are common in missed injuries.
 


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
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Further Reading

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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

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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

 
 
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