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SCI Traumatic: Part 1 (Disease/Disorder, Essentials of Assessment)

  1. Disease/Disorder:
    Definition

    Traumatic spinal cord injury (SCI) refers to a traumatic insult to the ​​spinal cord that results in impaired motor, sensory and/or autonomic function below the injured spinal cord level.  Injury to the cervical segments results in impaired function in both the arms and the legs, referred to as tetraplegia, while injury to the thoracic, lumbar or sacral segments of the spinal cord causes paraplegia, characterized by impaired function in the legs but sparing of the arms.

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    Etiology

    Motor vehicle accidents are the most common cause of SCI, followed by acts of violence, falls and sports injuries.​  Diving accidents are the most common cause of SCI among sports injuries. According to the most recent figures, acts of violence have overtaken falls as the second leading cause of SCI. The proportion of injuries due to falls increases with advancing age and falls become the leading cause of SCI in persons older than 45.

    Epidemiology including risk factors and primary prevention

    ​In the United States (US), there are 12,000 to 20,000 new SCI annually. Although SCI primarily affects young males between the ages of 15 and 35, the age at injury has been steadily increasing. The most common type of injury is incomplete tetraplegia, followed​ by complete paraplegia, incomplete paraplegia, then complete tetraplegia. Of all injuries, 45% are complete, 55% are incomplete. ​The proportion of injuries with tetraplegia increases with age after 45. In the US, violence is a more common cause of SCI than in other countries. Vehicular injuries have been steadily declining, most likely due to national safety initiatives; legislation controlling speed and alcohol consumption, mandatory use of seatbelts and helmets and the safer design and use of roads and vehicles have been instituted as primary prevention efforts.

    Patho-anatomy/physiology

    SCI can be characterized as follows:   

    1. Primary insult is disruption of neural and vascular structures of the spinal cord at the time of initial trauma. Fractures, ruptures of intervertebral discs and ligaments can result in abnormal spinal movement that can cause further compression.
    2. Secondary injury refers to a cascade of events following the initial injury that cause further tissue damage. Possible mechanisms include inflammation, ischemia, increased vascular permeability, and release of free radicals and neuroexcitatory neurotransmitters. These events cause spinal cord swelling, cell death and neurological deterioration.
    3. SCI without radiological abnormalities (SCIWORA) refers to an acute SCI that occurs without evidence of vertebral fractures on plain radiographs or on computed tomography (CT) scans.

    Treatment during the acute phase of SCI is aimed at limiting the extent of secondary events.

    Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
    1. Onset of motor, sensory and autonomic dysfunction after SCI is usually sudden.
    2. Spinal shock occurs in the initial hours to days postinjury with loss of reflexes and sensorimotor function below the level of injury.
    3. Motor and sensory recovery depend on the extent and location of the insult; persons with incomplete SCI recover faster and to a greater extent than do those with complete injuries.
    4. Regardless of level and completeness of injury, most recovery occurs within the first 6 months after injury.
    5. Acute SCI often results in a disruption of autonomic regulation of the bowel and bladder as well as reduction of cardiopulmonary reserve, characterized by a decline in blood pressure and lung volumes. With time there is a gradual return of the sacral reflexes that control bowel and bladder function.
    6. Recovery can occur for several years after SCI, although rate of progression is slow and may not yield functional gains.
    7. SCI exacerbates the normal physical and physiological decline associated with aging; persons with SCI manifest medical, cognitive and functional  problems associated with aging at an earlier age.
    Specific secondary or associated conditions and complications

    Medical complications involving every organ system are common after SCI; genitourinary and respiratory complications and pressure ulcers are common causes for hospitalization.

    Loss of lung volumes, impaired cough and difficulty clearing secretions predispose individuals with cervical and high thoracic injuries to respiratory impairment and lung infections.  Vent​ilatory failure due to diaphragmatic paralysis occurs in people with high tetraplegia.

    Impaired sensation, nutritional status and mobility, together with bowel and bladder incontinence, can result in skin breakdown and pressure ulcers.

    Urinary tract infections are the most common source of infections in individuals with SCI and contribute to other conditions, such as urinary stones and bladder cancer.

    Constipation, fecal impaction, and anorectal problems are common consequences of impaired bowel control.

    Neurogenic shock is characterized by autonomic dysfunction with interruption of sympathetic tone following SCI. It manifests with hypotension, relative bradycardia and peripheral vasodilatation.

    Autonomic dysreflexia is a potentially life-threatening condition associated with SCI above T6. It is characterized by an abrupt rise in blood pressure resulting from a noxious stimulus below the level of injury.

    Autonomic impairment results in sexual dysfunction.

    Late neurological decline may result from development of post-traumatic syringomyelia or from development of compressive neuropathies.

    SCI can result in a variety of endocrine and metabolic conditions including electrolyte dysfunction, impaired lipid metabolism and osteoporosis.

    Pain is common after SCI and can be neuropathic or nociceptive in origin.  Overuse syndromes are common causes of musculoskeletal pain.

    Incidence of depression and substance abuse is increased after SCI.

    Concomitant injuries, including  traumatic brain injury, may be sustained at the time of trauma.

  2. Essentials of Assessment
    History

    The mechanism of injury determines the extent of SCI and likelihood of other significant injuries. Details of the trauma, including mechanism, speed of impact and loss of consciousness, can be helpful. 

    Altered mental status, neurologic deficit and evidence of intoxication should be assessed.

    Concomitant rheumatoid arthritis, atlanto-odontoid subluxation (common in Down's syndrome), osteoarthritis, ankylosing spondylitis, osteoporosis and spinal stenosis predispose individuals to SCI.

    Physical examination

    The spine should be palpated for local tenderness. Spinal precautions directed at immobilizing the spine must be maintained.

    Tone and reflexes should be evaluated. Loss of reflexes, which is common immediately postinjury, is termed spinal shock.

    Neurogenic shock can occur, characterized by hypotension in the absence​ of tachycardia and vasoconstriction.

    A careful neurological examination must be performed according to the International Standards for Neurological Classification of SCI (ISNCSCI).  The International Standards are published and revised periodically, and outline details of the neurological examination and classification procedures. The level and completeness of SCI should be determined with a careful sensory examination for light touch and pin prick at key sensory points for 28 dermatomes on each side of the body, and motor examination of 10 designated key muscles bilaterally. The neurological completeness of SCI is classified according to the American Spinal Injury Association (ASIAImpairment Scale. 

    The ASIA Impairment Scale (SCI classified A-E by severity of injury) is used to predict neurological recovery. Serial examinations track neurological progress and deterioration. The classifications are as follows:

    1. Complete -- No preservation of any motor or sensory function below the zone of injury, including sacral segments S4-S5.
    2. Incomplete -- Sensory but not motor function is preserved below the neurological level of injury, including the sacral segments S4-S5.
    3. Incomplete -- Motor function is preserved below the neurological level and more than half of the key muscles below the neurological level have a grade of less than 3.
    4. Incomplete -- Motor function is preserved below the neurological level and at least half the key muscles below the neurological level have a​grade greater than or equal to 3.
    5. Motor and sensory function are normal.

    Physical examination of the relevant body systems is conducted to detect the presence of associated conditions and complications outlined in the section above.

    Functional assessment

    The Functional Independence Measure (FIM) - common and reliable measure of level of independence and functioning.

    Spinal Cord Independence Measure (SCIM) - designed as an alternative to the FIM to assess 16 categories of functional independence.

    The Quadriplegia Index of Function (QIF) - assesses function for individuals with tetraplegia.

    The Walking Index for Spinal Cord Injury (WISCI)  - measures the patient's ability to walk and describes the amount of assistance needed for walking.

    The neurological designation (International Standards for Neurological Classification using the ASIA Impairment Scale described above) allows prediction of corresponding functional expectations depending on patient's age and other comorbidities. For example, a person with C6  tetraplegia can become independent with a manual wheelchair.

    Laboratory studies

    Laboratory studies are performed to assess presence of medical conditions, such as bleeding, infections, electrolyte and acid-base disturbances, that can accompany SCI.

    Imaging

    ​Anterior-posterior (AP), lateral and open-mouth atlantoaxial radiographs should be ordered if any suspicion for SCI exists.

    ​Flexion extension views can be ordered in alert patients without neurological abnormalities who have spine tenderness and normal routine x-rays

    CT scans are superior to radiographs in detecting fractures and should be ordered if there is suspicion for spinal injury despite normal radiographs, or if radiographs are unable to visualize the spine adequately.

    Magnetic resonance imaging (MRI) is excellent in detecting presence and extent of SCI and associated soft tissue injuries. It also has a role in establishing prognosis for recovery.

    Imaging allows recognition of spinal instability, which is abnormal spinal movement that puts neural structures at risk for further injury.

    Supplemental assessment tools

    ​Head CT scan should be performed if there is suspicion for head injury.

    Intraoperative neurophysiological monitoring, including somatosensory and motor evoked potentials, can assist in identifying evolving spinal cord injury during spine surgery by continuous monitoring of sensory and motor pathways.

    Electromyography (EMG) and nerve conduction studies can be performed to evaluate presence of associated plexopathies and nerve root lesions, if indicated by clinical assessment.

    Neuropsychological testing should be considered of there is suspicion for traumatic brain injury.

    Early predictions of outcomes

    Motor function is the primary determinant of overall function.

    ​Incomplete injuries have a better prognosis than complete injuries and recover faster.

    In individuals with motor complete tetraplegia, 97% of key muscles with trace or greater motor strength recovered to at least grade 3.

    Of persons with SCI initially classified as ASIA B,  50% will become ambulatory.

    Persons with incomplete tetraplegia who have a lower extremity motor score of 20 or greater become community ambulators.

    Environmental

    Environmental modifications, the use of assistive equipment and technology and acquisition of personal attendants are ways to support individuals with SCI. Home and work modifications such as providing ramps, widening doors, lowering workspaces and removing rugs facilitate wheelchair access and independence. Environmental control devices allow persons with high injuries to access their environment independently.

    Social role and social support system

    ​Persons with a strong support system are more likely to adapt well to their injury.

    Level and completeness of SCI do not correlate with subjective sense of well being.

    Divorce rates are higher after SCI.

    Persons with SCI can assume fulfilling relationships and parental roles.

    Professional Issues

    Improper radiographic interpretation or incomplete imaging can result in failure to identify spinal fractures and instability.

    Patients with one spinal fracture may have secondary fractures that can be missed. Failure to identify these may result in neurological deterioration.

    Absence of spinal fractures does not exclude SCI; a detailed neurological examination is required.​​​

  3. Rehabilitation Management and Treatments
  4. Cutting edge/emerging and unique concepts and practice
    Cutting edge concepts and practice

    ​Not applicable

  5. Gaps in the evidence-based knowledge
    Gaps in the evidence-based knowledge

    ​Not applicable

    References

    Bibliography

    American Spinal Injury Association.  International Standards for Neurological and Functional Classification of Spinal Cord Injury--Revised 2011.  Atlanta, GA: ASIA. 2011.

     Burns AS, Ditunno JF. Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future directions in rehabilitation management. Spine. 2001;26(24)(suppl):S137-S145.​

    Consortium for Spinal Cord Medicine. Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care professionals. Chicago, IL: Paralyzed Veterans of America. 1999.

    Devivo MJ, Chen Y. Trends in new injuries, prevalent cases and aging with spinal cord injury. 2011; 92(3):332-8.

     DeVivo MJ, Kartus PL, Rutt RD, et al. The influence of age at time of spinal cord injury on rehabilitation outcome. Arch Neurol. 1990;47(6):687-91.

    Domeier RM, Evans RW, Swor RA, et al. Prehospital clinical findings associated with spinal injury. Prehosp Emerg Care. 1997; Jan-Mar(1):11-15.​

    Marino RJ, Burns S, Graves DE. Upper-and lower- extremity motor recovery after traumatic cervical spinal cord injury: an update from the National Spinal Cord Injury Database. Arch Phys Med Rehabil. 2011; 92: 368-75.

    Spinal cord injury facts and figures at a glance. National Spinal Cord Injury Statistical Center. J Spinal Cord Med 2010; 33 (4):439-40.