Spinal Cord Injury

American Spinal Injury Association Impairment Scale

The standard classification for SCI worldwide:

ASIA A - Complete:

• No motor or sensory function in sacral segments S4-S5
• No voluntary anal contraction
• No perianal sensation
• Prognosis: less than 5% regain functional ambulation

ASIA B - Incomplete (Sensory Only):

• Sensory function preserved below level including S4-S5
• No motor function below level
• Prognosis: 50% regain some walking ability

ASIA C - Incomplete (Motor less than 3):

• Motor function preserved below level
• Half of key muscles below level have grade less than 3
• Prognosis: 75% improve at least one ASIA grade

ASIA D - Incomplete (Motor 3 or more):

• Motor function preserved below level
• Half or more of key muscles grade 3 or greater
• Prognosis: 95% maintain community ambulation

ASIA E - Normal: Full motor and sensory function. May have abnormal reflexes.

Incomplete Spinal Cord Syndromes

Central Cord Syndrome:

• Most common incomplete pattern
• Upper limbs worse than lower limbs
• Usually from hyperextension with stenosis
• Cape distribution sensory loss
• Best prognosis of incomplete syndromes

Brown-Sequard Syndrome:

• Hemisection of cord
• Ipsilateral motor loss and proprioception
• Contralateral pain and temperature loss
• Often from penetrating trauma
• Good prognosis for ambulation

Anterior Cord Syndrome:

• Spared dorsal columns only
• Motor loss complete
• Pain and temperature lost
• Proprioception and vibration preserved
• Worst prognosis of incomplete syndromes

Posterior Cord Syndrome: Rare. Loss of proprioception and vibration with motor preserved. Usually from tumors or vitamin B12 deficiency.

ASIA Key Muscle Testing

10 paired myotomes tested bilaterally:

Grading 0-5 (MRC Scale): 0 = no movement, 3 = against gravity, 5 = normal.

Initial Management Priorities

Immobilization:

• Rigid cervical collar until cleared
• Log roll precautions
• Spinal board for transport only (pressure injury risk)

Airway and Breathing:

• Early intubation if GCS impaired or respiratory compromise
• C5 injury and above may need ventilatory support
• Avoid neck extension during intubation (fiber-optic if available)

Circulation - MAP Goals:

• Arterial line for continuous monitoring
• Target MAP 85-90mmHg for 5-7 days
• Vasopressors (norepinephrine first line)
• Avoid hypotension at all costs - causes secondary injury

NO Methylprednisolone: Previously given based on NASCIS trials but now recognized as flawed evidence. Current guidelines recommend AGAINST steroids due to no proven benefit and potential harm (infection, GI bleed).

Timing of Surgery

Early Surgery (within 24 hours):

• Recommended for incomplete SCI (ASIA B-D) with compression
• STASCIS trial suggests benefit within 24 hours
• Decompress and stabilize

Urgent Surgery:

• Deteriorating neurological status
• Unstable spine injury
• Irreducible fracture-dislocation

Deferred Surgery:

• Complete injury (ASIA A) - no urgency for neurological outcome
• Medically unstable patient
• No ongoing compression

Surgical Goals: Decompress neural elements, restore spinal alignment, and provide stability for early mobilization.

Critical Care Considerations

Respiratory:

• F ICU admission for cervical injuries
• May need tracheostomy if prolonged ventilation
• Aggressive pulmonary toilet
• Monitor for neurogenic pulmonary edema

Cardiovascular:

• Continuous MAP monitoring
• Vasopressor support as needed
• Bradycardia treatment if symptomatic
• Avoid hypothermia (impairs clotting)

DVT Prophylaxis:

• Very high DVT/PE risk in SCI
• LMWH + mechanical prophylaxis
• Consider IVC filter if anticoagulation contraindicated

Pressure Injury Prevention:

• Turn every 2 hours
• Specialty mattress
• Remove spinal board early

Bowel and Bladder: Indwelling catheter initially with early bowel regime (stool softeners, enemas). Transition to intermittent catheterization when stable.

Anterior Cervical Decompression and Fusion

Indications:

• Anterior compression (disc herniation, vertebral body)
• Corpectomy required
• Kyphotic deformity

Technique: Position supine with head in neutral. Approach through Smith-Robinson interval (medial to SCM). Perform discectomy or corpectomy as required. Decompress spinal cord under microscope. Place structural graft or cage. Apply anterior plate. Confirm alignment on fluoroscopy.

Advantages: Direct anterior decompression, restoration of lordosis.

Risks: Recurrent laryngeal nerve, esophageal injury, dysphagia.

Posterior Cervical Decompression and Fusion

Indications:

• Posterior compression (facet fracture, posterior mass)
• Multi-level pathology
• Failed anterior approach

Technique: Position prone (Mayfield head holder or Gardner-Wells tongs). Midline exposure to lateral masses. Laminectomy or laminoplasty for decompression. Place lateral mass screws (Magerl technique) or pedicle screws. Rod contouring for sagittal alignment. Decortication and bone grafting.

Advantages: Better fixation in osteoporotic bone, longer constructs.

Risks: Vertebral artery injury, wound complications.