Spinal Cord Injuries Workup

  • Author: Donald Schreiber, MD, CM; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Dec 15, 2011
 

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.[28, 29] 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.[23, 30, 31]

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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.[32, 33, 34] These algorithms may be used to guide physicians to determine whether or not imaging of the cervical spine is required.[32, 33, 34]

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%.[28]

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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.[28, 35]

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

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

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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

Additional Contributors

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

Segun T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed) Former Clinical Instructor, Mount Sinai Medical School; Current Director, Pain and Injuries Rehabilitation Services, PMRehab Pain and Sports Medicine Associates

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

Disclosure: Nothing to disclose.

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

References

  1. Westgren N, Levi R. Quality of life and traumatic spinal cord injury. Arch Phys Med Rehabil. Nov 1998;79(11):1433-9. [Medline].

  2. American Spinal Injury Association. International Standards for Neurological Classifications of Spinal Cord Injury. revised ed. Chicago, Ill: American Spinal Injury Association; 2000:1-23.

  3. Ditunno JF Jr, Young W, Donovan WH, Creasey G. The international standards booklet for neurological and functional classification of spinal cord injury. American Spinal Injury Association. Paraplegia. Feb 1994;32(2):70-80. [Medline].

  4. 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].

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

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

  7. Rhee P, Kuncir EJ, Johnson L, Brown C, Velmahos G, Martin M, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. Nov 2006;61(5):1166-70. [Medline].

  8. National Spinal Cord Injury Statistical Center (NSCIS). Spinal cord injury facts and figures at a glance. February 2011;Accessed August 30, 2011. Available at https://www.nscisc.uab.edu/public_content/pdf/Facts%202011%20Feb%20Final.pdf.

  9. Krause JS, Sternberg M, Lottes S, Maides J. Mortality after spinal cord injury: an 11-year prospective study. Arch Phys Med Rehabil. Aug 1997;78(8):815-21. [Medline].

  10. DeVivo MJ. Epidemiology of traumatic spinal cord injury. In: Kirshblum S, Campagnolo DI, DeLisa JA, eds. Spinal Cord Medicine. Baltimore, Md: Lippincott Williams & Wilkins; 2002:69-81.

  11. Go BK, DeVivo MJ, Richards JS. The epidemiology of spinal cord injury. In: Stover SL, DeLisa JA, Whiteneck GG, eds. Spinal Cord Injury. Gaithersburg, Md: Aspen; 1995:21-55.

  12. Avery JD, Avery JA. Malignant spinal cord compression: a hospice emergency. Home Healthc Nurse. Sep 2008;26(8):457-61; quiz 462-3. [Medline].

  13. Vitale MG, Goss JM, Matsumoto H, Roye DP Jr. Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000. J Pediatr Orthop. Nov-Dec 2006;26(6):745-9. [Medline].

  14. Krause JS. Years to employment after spinal cord injury. Arch Phys Med Rehabil. Sep 2003;84(9):1282-9. [Medline].

  15. Morse LR, Stolzmann K, Nguyen HP, Jain NB, Zayac C, Gagnon DR, et al. Association between mobility mode and C-reactive protein levels in men with chronic spinal cord injury. Arch Phys Med Rehabil. Apr 2008;89(4):726-31. [Medline]. [Full Text].

  16. Furlan JC, Fehlings MG. Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and management. Neurosurg Focus. 2008;25(5):E13. [Medline].

  17. Turner AP, Bombardier CH, Rimmele CT. A typology of alcohol use patterns among persons with recent traumatic brain injury or spinal cord injury: implications for treatment matching. Arch Phys Med Rehabil. Mar 2003;84(3):358-64. [Medline].

  18. Frisbie JH, Tun CG. Drinking and spinal cord injury. J Am Paraplegia Soc. Oct 1984;7(4):71-3. [Medline].

  19. Strauss DJ, Devivo MJ, Paculdo DR, Shavelle RM. Trends in life expectancy after spinal cord injury. Arch Phys Med Rehabil. Aug 2006;87(8):1079-85. [Medline].

  20. Budh CN, Osteråker AL. Life satisfaction in individuals with a spinal cord injury and pain. Clin Rehabil. Jan 2007;21(1):89-96. [Medline].

  21. Widerström-Noga E, Biering-Sørensen F, Bryce T, Cardenas DD, Finnerup NB, Jensen MP, et al. The international spinal cord injury pain basic data set. Spinal Cord. Dec 2008;46(12):818-23. [Medline].

  22. van Middendorp JJ, Hosman AJ, Donders AR, Pouw MH, Ditunno JF Jr, Curt A, et al. A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study. Lancet. Mar 19 2011;377(9770):1004-10. [Medline].

  23. 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].

  24. 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].

  25. 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].

  26. Claydon VE, Krassioukov AV. Orthostatic hypotension and autonomic pathways after spinal cord injury. J Neurotrauma. Dec 2006;23(12):1713-25. [Medline].

  27. Waters RL, Adkins RH, Yakura JS. Definition of complete spinal cord injury. Paraplegia. Nov 1991;29(9):573-81. [Medline].

  28. 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].

  29. 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].

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

  31. 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].

  32. 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].

  33. 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].

  34. 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].

  35. 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].

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

  37. 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].

  38. 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].

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

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

  41. 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].

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

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

  44. 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].

  45. 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].

  46. 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].

  47. 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].

  48. 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].

  49. 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].

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

  51. 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].

  52. Fisher CG, Noonan VK, Dvorak MF. Changing face of spine trauma care in North America. Spine (Phila Pa 1976). May 15 2006;31(11 Suppl):S2-8; discussion S36. [Medline].

  53. Hurlbert RJ. Strategies of medical intervention in the management of acute spinal cord injury. Spine (Phila Pa 1976). May 15 2006;31(11 Suppl):S16-21; discussion S36. [Medline].

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