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Spinal Cord Injuries Workup

  • Author: Lawrence S Chin, MD, FACS; Chief Editor: Brian H Kopell, MD  more...
 
Updated: May 12, 2016
 

Approach Considerations

With regard to laboratory studies, the following may be helpful:

  • Arterial blood gas (ABG) 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
  • Urinalysis can be performed to detect any associated genitourinary injury

Diagnostic imaging traditionally begins with the acquisition of standard radiographs of the affected region of the spine. Investigators have shown that computed tomography (CT) scanning is exquisitely sensitive for the detection of spinal fractures and is cost effective.[34, 35] In many centers, CT scanning has supplanted plain radiographs.

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.

Noncontiguous spinal fractures are defined as spinal fractures separated by at least 1 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 scanning, to assess for noncontiguous fractures.[31, 36, 37]

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Plain Radiography

In many emergency departments (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.

In addition, note that the failure to adequately immobilize the spine when the mechanism of injury is consistent with the diagnosis is a pitfall.

Agitated, intoxicated patients are often the most difficult to manage properly. Pharmacologic restraint may be required to allow proper assessment. Haldol and intravenous (IV) droperidol have been used successfully, even in large doses, without hemodynamic or respiratory compromise. Occasionally, rapid-sequence intubation and pharmacologic paralysis is required to manage these patients.

Physical examination and radiographic studies could be delayed until the patient is more cooperative, if his or her overall condition permits.

Radiographic views

Radiographs are only as good as the first and last vertebrae seen, therefore, radiographs must adequately depict all vertebrae. A common cause of missed injury is the failure to obtain adequate images (eg, cervical spine radiograph that incompletely depicts the C7-T1 junction). However, be aware that radiography is insensitive to small fractures of the vertebra.

Published clinical criteria have established guidelines for cervical spine radiography in symptomatic trauma patients with neck pain. The NEXUS (National Emergency X-Radiography Utilization Study) criteria and the Canadian C-spine rules were validated in large clinical trials.[38, 39, 40] These algorithms may be used to guide physicians to determine whether or not imaging of the cervical spine is required.[38, 39, 40]

The standard 3 views of the cervical spine are recommended in patients with suspected spinal cord injury (SCI): anteroposterior (AP), lateral, and odontoid.

The cervical spine radiographs must include the C7-T1 junction to be considered adequate. 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.

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.

Anteroposterior and lateral views of the thoracic and lumbar spine are recommended for suspected injuries to the thoracolumbar spine.

Adequate spinal radiography supplemented by computed tomography (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%.[34]

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Computed Tomography Scanning

Computed tomography (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.[34, 41]

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
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Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is best for suspected spinal cord lesions, ligamentous injuries, or other soft-tissue injuries or pathology. This imaging modality 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.

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Contributor Information and Disclosures
Author

Lawrence S Chin, MD, FACS Robert B and Molly G King Endowed Professor and Chair, Department of Neurosurgery, State University of New York Upstate Medical University

Lawrence S Chin, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association for Cancer Research, Children's Oncology Group, Society for Neuro-Oncology, Congress of Neurological Surgeons, American Association of Neurological Surgeons, American College of Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM Attending Interventional Physiatrist, Wellspan Health

Segun Toyin Dawodu, JD, MD, MS, MBA, LLM, FAAPMR, FAANEM is a member of the following medical societies: American College of Sports Medicine, American Academy of Physical Medicine and Rehabilitation, Royal College of Surgeons of England, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine

Disclosure: Nothing to disclose.

Fassil B Mesfin, MD, PhD Assistant Professor of Neurosurgery, Director of Complex Spine and Spine Oncology Program, University of Missouri-Columbia School of Medicine

Fassil B Mesfin, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American Association of Neurological Surgeons, American Medical Association, National Medical Association, Congress of Neurological Surgeons, American Academy of Neurological Surgery

Disclosure: Nothing to disclose.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, International Parkinson and Movement Disorder Society, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from St Jude Neuromodulation for consulting; Received consulting fee from MRI Interventions for consulting.

Acknowledgements

Denise I Campagnolo, MD, MS Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers

Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers

Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching; Genzyme Corporation Grant/research funds investigator; Biogen Idec Grant/research funds investigator; Genentech, Inc Grant/research funds investigator; Eli Lilly & Company Grant/research funds investigator; Novartis investigator; MSDx LLC Grant/research funds investigator; BioMS Technology Corp Grant/research funds investigator; Avanir Pharmaceuticals Grant/research funds investigator

Daniel J Dire, MD, FACEP, FAAP, FAAEM Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

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.

Milton J Klein, DO, MBA Consulting Physiatrist, Heritage Valley Health System-Sewickley Hospital and Ohio Valley General Hospital

Milton J Klein, DO, MBA is a member of the following medical societies: American Academy of Disability Evaluating Physicians, American Academy of Medical Acupuncture, American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, American Pain Society, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine

Richard Salcido, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Physician Executives, American Medical Association, and American Paraplegia Society

Disclosure: Nothing to disclose.

Tom Scaletta, MD Chair, 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

Disclosure: Nothing to disclose.

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 Speakers Bureau Speaking and teaching; Nanosphere Inc Grant/research funds Research; Singulex Inc Grant/research funds Research; Abbott Diagnostics Inc Grant/research funds None

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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American Spinal Injury Association (ASIA) method for classifying spinal cord injury (SCI) by neurologic level.
 
 
 
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