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  • Epidemiology
    • incidence
      • 11,000 new cases/year in US
        • 34% incomplete tetraplegia
          • central cord syndrome most common
        • 25% complete paraplegia
        • 22% complete tetraplegia
        • 17% incomplete paraplegia
    • demographics
      • bimodal distribution
        • young individuals with significant trauma
        • older individuals that have minor trauma compounded by degenerative spinal canal narrowing
    • location
      • 50% in cervical spine
  • Mechanism
    • MVA causes 50%
    • falls
    • GSW
    • iatrogenic
      • it is estimated that 3-25% of all spinal cord injuries occur after initial traumatic episode due to improper immobilization and transport.
  • Pathophysiology
    • primary injury
      • damage to neural tissue due to direct trauma
      • irreversible
    • secondary injury
      • injury to adjacent tissue due to
        • decreased perfusion
        • lipid peroxidation
        • free radical / cytokines
        • cell apoptosis
      • methylprednisone used to prevent secondary injury by improving perfusion, inhibiting lipid peroxidation, and decreasing the release of free radicals
  • Associated conditions
    • acute phase conditions  (see below)
      • spinal shock
      • neurogenic shock 
    • associated injuries
      • closed head injuries
      • noncontiguous spinal fractures
      • vertebral artery injury
        • risk factors for vertebral artery injury include
          • atlas fractures
          • facet dislocations
        • most people with unilateral injury remain asymptomatic
        • imaging
          • magnetic resonance angiography is least invasive method
        • treatment
          • stenting only if patient is symptomatic from basilar arterial insufficiency
  • Prognosis
    • only 1% have complete recovery at time of hospital diagnosis
      • conus medullaris syndrome has a better prognosis for recovery than more proximal lesions 
Relevant Anatomy
  • See Spinal Cord Anatomy topic
  • Descriptive
    • tetraplegia
      • injury to the cervical spinal cord leading to impairment of function in the arms, trunk, legs, and pelvic organs
    • paraplegia
      • injury to the thoracic, lumbar or sacral segments leading to impairment of function in the trunk, legs, and pelvic organs depending on the level of injury. Arm function is preserved
    • complete injury
      • an injury with no spared motor or sensory function below the affected level.
      • patients must have recovered from spinal shock (bulbocavernosus reflex is intact) before an injury can be determined as complete
      • classified as an ASIA A
    • incomplete injury
      • an injury with some preserved motor or sensory function below the injury level
      • incomplete spinal cord injuries include
        • anterior cord syndrome 
        • Brown-Sequard syndrome 
        • central cord syndrome 
        • posterior cord syndrome 
        • conus medullaris syndromes
        • cauda equina syndrome 
ASIA Classification
  1. Determine if patient is in spinal shock
    • check bulbocavernosus reflex
  2. Determine neurologic level of injury
    • lowest segment with intact sensation and antigravity (3 or more) muscle function strength
    • in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level.
  3. Determine whether the injury is COMPLETE or INCOMPLETE
    • COMPLETE defined as  (ASIA A)
      • no voluntary anal contraction (sacral sparing) AND
      • 0/5 distal motor AND
      • 0/2 distal sensory scores (no perianal sensation) AND
      • bulbocavernosus reflex present (patient not in spinal shock)
    • INCOMPLETE defined as
      • voluntary anal contraction (sacral sparing)
      • sacral sparing critical to determine complete vs. incomplete
      • OR palpable or visible muscle contraction below injury level OR
      • perianal sensation present
  4. Determine ASIA Impairment Scale (AIS) Grade:     
ASIA Impairment Scale
A Complete No motor or sensory function is preserved in the sacral segments S4-S5.
B Incomplete  Sensory function preserved but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
C Incomplete Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
D Incomplete Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.
E Normal Motor and sensory function are normal.
Acute Phase Conditions
  • Neurogenic shock
    • characterized by hypotension & relative bradycardia in patient with an acute spinal cord injury  
      • potentially fatal
    • mechanism
      • circulatory collapse from loss of sympathetic tone
        • disruption of autonomic pathway within the spinal cord leads to
          • lack of sympathetic tone
          • decreased systemic vascular resistance
          • pooling of blood in extremities
          • hypotension
    • treatment
      • Swan-Ganz monitoring for careful fluid management
      • pressors to treat hypotension
  • Spinal shock
    • defined as temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury.
    • characterized by
      • flaccid areflexic paralysis
      • bradycardia & hypotension (due to loss of sympathetic tone)
      • absent bulbocavernosus reflex
        • reflex characterized by anal sphincter contraction in response to squeezing the glans penis or tugging on an indwelling Foley catheter
    • timing
      • variable but usually resolves within 48 hours
      • at its conclusion spasticity, hyperreflexia, and clonus slowly progress over days to weeks
    • mechanism
      • neurophysiologic in nature
        • neurons become hyperpolarized and unresponsive to stimuli from brain
    • evaluation
      • important because one cannot evaluate neurologic deficit until spinal shock phase has resolved 
        • end of spinal shock indicated by return of the bulbocavernous reflex
        • conus or cauda equina injuries may lead to permanent loss of the bulbocavernous reflex
  Spinal Shock Neurogenic Shock Hypovolemic Shock
BP Hypotension  Hypotension Hypotension
Pulse Bradycardia Bradycardia Tachycardia
Reflexes / Bulbocavernosus Reflex Absent Variable/independent
Motor Flaccid Paralysis Variable/independent Variable/independent
Time ~48-72 hours immediately after spinal cord injury ~48-72 hours immediately after spinal cord injury Following excessive blood loss
Mechanism Peripheral neurons become temporarily unresponsive to brain stimuli. Disruption of autonomic pathway leads to loss of sympathetic tone and decreased systemic vascular resistance. Decreased preload leads to decreased cardiac output.
  • Field treatment
    • treatment of potential spinal cord injuries begins at the accident scene with proper spinal immobilization
    • immobilization
      • immobilization should include rigid cervical collar and transport on firm spine board with lateral support devices
      • patient should be rolled with standard log roll techniques with control of cervical spine
    • athletes
      • in the setting of sports-related injuries helmets and shoulder pads should be left on until arrival at hospital or until experienced personnel can perform simultaneous removal of helmet and shoulder pads in a controlled situation
  • Initial evaluation
    • primary survey
      • airway
      • breathing
        • SCI above C5 likely to require intubation
      • circulation
      • initial survey to inspect for obvious injuries of head and spine
        • visual and manual inspection of entire spine should be performed
          • seat belt sign (abdominal ecchymoses) should raise suspicion for flexion distraction injuries of thoracolumbar spine
    • secondary survey
      • cervical spine exam
        • remove immobilization collar
        • examine face and scalp for evidence of direct trauma
        • inspect for angular or rotational deformities in the holding position of the patient's head
          • rotational deformity may indicate a unilateral facet dislocation
        • palpate posterior cervical spine looking for tenderness along the midline or paraspinal tissues
          • absence of posterior midline tenderness in the awake, alert patient predicts low probability of significant cervical injury
        • log roll patient to inspect and palpate entire spinal axis
        • perform careful neurologic exam
    • cervical spine clearance 
Acute Treatment
  • Nonoperative
    • high dose methylprednisone
      • indications
        • nonpenetrating SCI within 8 hours of injury
          • recommended by NASCIS III
      • contraindications include
        • GSW
        • pregnancy
        • under 13 years
        • > 8 hours after injury 
        • brachial plexus injuries
      • technique
        • load 30 mg/kg over 1st hour (2 grams for 70kg man)
        • drip 5.4 mg/kg/hr drip
          • for 23 hours if started < 3 hrs after injury 
          • for 47 hours if started 3-8 hours after injury
      • outcomes
        • leads to improved root function at level of injury
        • may or may not lead to spinal cord function improvement
      • has historically been recommended, but the current literature and available guidelines recommend against administration due to the lack of clear clinical benefit and the risk of complications 

    • monosialotetrahexosylganglioside (GM-1)
      • indications
        • remains controversial
          • large multicenter RCT did not show long term benefit
          • some evidence of faster recovery
    • acute closed reduction with axial traction
      • indications
        • alert and oriented patient with neurologic deficits and compression due to fracture/dislocation
          • bilateral facet dislocation with spinal cord injury in alert and oriented patient is most common reason to perform acute reduction with axial traction
      • technique
        • reasons to abort
          • overdistraction
          • worsening neurologic exam
          • failure to obtain reduction
    • DVT prophlaxis
      • indications
        • most patients
        • contraindications include
          • coagulopathy
          • hemorrhage
      • modalities
        • low-molecular weight heparin
        • rotating bed
        • pneumatic compression stocking
    • cardiopulmonary management
      • careful hemodynamic monitoring and stabilization is critical in early treatment
        • hypotension should be avoided
      • implement immediate aggressive pulmonary protocols
  • Operative
    • rarely indicated in acute setting
Definitive Treatment
  • Nonoperative
    • bracing and observation
      • indications
        • most GSWs
          • exceptions listed below
        • metastatic CA patients with < 6 mos life expectancy
          • presence of six variables below correspond to short life expectancy
            1. multiple spinal mets
            2. multiple extraspinal mets
            3. unresectable lesions in major organs
            4. SCI (complete or incomplete)
            5. aggressive CA: lung, osteosarcoma, pancreas
            6. critically ill
  • Operative
    • surgical decompression and stabilization 
      • indications
        • most incomplete SCI (except GSW)
          • decompress when patient hits neurologic plateau or if worsening neurologically
          • decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)
        • most complete SCI (except GSW)
          • stabilize spine to facilitate rehab and minimize need for halo or orthosis
          • decompression may facilitate nerve root function return at level of injury (may recover 1-2 levels)
          • consider for tendon transfers
            • e.g. Deltoid to triceps transfer for C5 or C6 SCI 
        • metastatic CA patients with > 6 mos life expectancy
          • ~ no for six question above
        • GSW with
          • progressive neurological deterioration with retained bullet within the spinal canal
          • cauda equina syndrome (considered a peripheral nerve)
          • retained bullet fragment within the thecal sac
            • CSF leads to the breakdown of lead products that may lead to lead poisoning
  • Skin problems
    • treatment is prevention
    • start in ER
      • do not leave on back board
      • start log rolling early
      • proper bedding
  • Venous Thromboembolism
    • prevent with immediate DVT prophylaxis
  • Urosepsis
    • common cause of death
    • strict aseptic technique when placing catheter
    • don't let bladder become overly distended
  • Sinus bradycardia
    • most common cardiac arrhythmia in acute stage following SCI
  • Orthostatic hypotension
    • occurs as a result of lack of sympathetic tone
  • Autonomic dysreflexia 
    • potentially fatal
    • presents with headache, agitation, hypertension
    • caused by unchecked visceral stimulation
      • check foley
      • disimpact patient
  • Major depressive disorder
    • ~11% of patients with spinal cord injuries suffer from MDD 
    • MDD in spinal cord injury patients is highly associated with suicidal ideation in both the acute and chronic phase.
  • Goals
    • goal is to assess and identify mechanisms for reintegration into community based on functional level and daily needs
    •  patients learn transfer techniques, self care retraining, mobility skills
  • Restoring hand function 
    • hand function is often limiting factor for many patients
    • tendon transfers can be used to restore function to paralyzed arms and hands by giving working muscles different jobs
  • Modalities
    •  functional electrical stimulation is a technique that uses electrical currents to stimulate and activate muscles affected by paralysis

Patient Function
C1-C3 - Ventilator dependent with limited talking.
- Electric wheelchair with head or chin control
C3-C4 - Initially ventilator dependent, but can become independent
Electric wheelchair with head or chin control

- Ventilator independent
- Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to feed oneself
- Independent ADL’s;
electric wheelchair with hand control, minimal manual wheelchair function 

C6 - C6 has much better function than C5 due to ability to bring hand to mouth and feed oneself (wrist extension and supination intact)
- Independent living;
manual wheelchair with sliding board transfers, can drive a car with manual controls
C7 - Improved triceps strength
- Daily use of a
manual wheelchair with independent transfers
C8-T1 - Improved hand and finger strength and dexterity
- Fully independent transfers
T2-T6 - Normal UE function
- Improved trunk control
- Wheelchair-dependent
T7-T12 - Increased abdominal muscle control
- Able to perform unsupported seated activities; with extensive bracing walking may be possible
L1-L5 - Variable LE and B/B function
- Assist devices and bracing may be needed

- Various return of B/B and sexual function
- Walking with minimal or no assistance



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