Spinal Cord Injury (SCI): Diagnosis, Evaluation and Treatment

Signs and Symptoms of Possible Spinal Cord Injury

• Extreme pain or pressure in the neck, head or back
• Tingling or loss of sensation in the hand, fingers, feet, or toes
• Partial or complete loss of control over any part of the body
• Urinary or bowel urgency, incontinence, or retention
• Difficulty with balance and walking
• Abnormal band-like sensations in the thorax - pain, pressure
• Impaired breathing after injury
• Unusual lumps on the head or spine

Clinical Evaluation
A physician may decide that significant spinal cord injury does not exist simply by examining a patient who does not have any of the above symptoms, as long as the patient meets the following criteria: unaltered mental status, no neurological deficits, no intoxication from alcohol or other drugs or medications, and no other painful injuries that may divert his or her attention away from a SCI.

In other cases, such as when patients complain of neck pain, when they are not fully awake, or when they have obvious weakness or other signs of neurological injury, the cervical spine is kept in a rigid collar until appropriate radiological studies are completed.

Radiological Evaluation
The radiological diagnosis of spinal cord injury has traditionally begun with x-rays. In many cases, the entire spine may be x-rayed. Patients with a SCI may also receive both computerized tomography (CT or CAT scan) and magnetic resonance imaging (MRI) of the spine. In some patients, centers may proceed directly to CT scanning as the initial radiological test. For patients with known or suspected injuries, MRI is helpful for looking at the actual spinal cord itself, as well as for detecting any blood clots, herniated discs, or other masses that may be compressing the spinal cord. CT scans may be helpful in visualizing the bony anatomy, including any fractures.

Even after all radiological tests have been performed, it may be advisable for a patient to wear a collar for a variable period of time. If patients are awake and alert but still complaining of neck pain, a physician may send them home in a collar, with plans to repeat x-rays in the near future, such as in one to two weeks. The concern in these cases is that muscle spasm caused by pain might be masking an abnormal alignment of the bones in the spinal column. Once this period of spasm passes, repeat x-rays may reveal abnormal alignment or excessive motion that was not visible immediately after the injury. In patients who are comatose, confused, or not fully cooperative for some other reason, adequate radiographic visualization of parts of the spine may be difficult. This is especially true of the bones at the very top of the cervical spine. In such cases, the physician may keep the patient in a collar until the patient is more cooperative. Alternatively, the physician may obtain other imaging studies to look for radiologically evident injury.

Treatment
Treatment of spinal cord injury begins before the patient is admitted to the hospital. Paramedics or other emergency medical services personnel carefully immobilize the entire spine at the scene of the accident. In the emergency department, this immobilization is continued while more immediate life-threatening problems are identified and addressed. If the patient must undergo emergency surgery because of trauma to the abdomen, chest, or another area, immobilization and alignment of the spine are maintained during the operation.

Intensive Care Unit
Treatment If a patient has a spinal cord injury, he or she will usually be admitted to an intensive care unit (ICU). For many injuries of the cervical spine, traction may be indicated to help bring the spine into proper alignment. Standard ICU care, including maintaining a stable blood pressure, monitoring cardiovascular function, ensuring adequate ventilation and lung function, and preventing and promptly treating infection and other complications, is essential so that SCI patients can achieve the best possible outcome.

Steroid Therapy
Methylprednisolone, a steroid drug, became available as a treatment for acute SCI in 1990 when a multicenter clinical trial showed better neurological change scores in patients who were given the drug within the first eight hours of injury. These studies have been criticized in part because this increase in scores has never been shown to translate into better functional outcomes for patients. This area remains controversial. Perhaps clinicians should consider methylprednisolone infusion if its potential benefits are felt to outweigh the risks of potential associated complications.

NeurosurgeryToday.org
November, 2005

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