Spinal Cord Injuries

Spinal cord injuries are complex injuries that involve damage to the neural tissue within the spinal canal. Spinal cord injuries are commonly the result of trauma. Clinical presentation varies depending on the site of injury and on whether the injury is complete or incomplete. Diagnosis is by clinical exam and imaging. Management is 2-fold, with immediate supportive care and stabilization of spine followed by long-term rehabilitation with physiotherapy and treatment of complications. Spinal cord injuries are associated with multisystem complications.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

A spinal cord injury is a complex injury that involves damage to the neural tissue within the spinal canal. This damage results in temporary or permanent damage and disrupts motor, sensory, or autonomic functions.

Types

  • Complete injury: loss of motor and sensory function below the site of injury (through the S4–S5 area of the spinal cord)
  • Incomplete injury: 
    • Preservation of some sensory and/or motor function (through the S4–S5 area of the spinal cord) 
    • The different spinal lesions that cause incomplete injury are:
      • Central cord lesion 
      • Brown-Séquard syndrome Brown-Séquard syndrome Brown-Séquard syndrome (BSS) is a rare neurologic injury that causes hemisection of the spinal cord, resulting in weakness and paralysis of one side of the body and sensory loss on the opposite side. Brown-Séquard Syndrome 
      • Anterior cord lesion 
      • Posterior cord lesion 
      • Conus medullaris lesion  

Epidemiology

  • Incidence: 40 cases per million (based on a study from the 1990s)
  • 50% of injuries occur between the ages of 16–30 years. 
  • The average age of incidence is 40 years. 
  • Mortality is higher in individuals > 60 years of age. 
  • Incidence is higher in males.

Etiology

The major etiologic factors of spinal cord injuries are: 

  • Motor vehicle accidents 
  • Falls, especially in older people 
  • Gunshot wounds 
  • Stab injuries 
  • Sports injuries 
  • Tumors 
  • Spondylosis 
  • Vertebral fractures
  • Arterial occlusion 

Risk factors

Spinal cord injuries are mostly the result of accidents, and risk factors are usually hard to determine. But studies suggest that certain groups of individuals are more at risk than others: 

  • Men are more affected than women. Women account for only 20% of spinal cord injuries. 
  • Alcohol abuse 
  • Individuals > 65 years old 
  • Individuals in the age group 16–30 years
  • Osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis 
  • Failure to use protective equipment, such as seat belts, helmets, etc., while driving 
  • Engaging in risky sports, such as skydiving, etc., without appropriate safety equipment

Pathophysiology

Clinically relevant anatomy

The spinal cord is formed by 31 segments protected by the bony vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column:

  • The vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column is longer than the spinal cord.
  • Depending on the level, vertebral level and spinal cord level are not necessarily the same.

Cervical: 

  • 8 segments: C1–C8
  • Cervical cord segments give rise to nerve roots that exit above their corresponding vertebrae.
  • C8 nerve root emerges between C7 and T1.
  • C1–C8 segments lie within the C1–C7 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column.
  • Cervical spinal segments innervate:
    • Diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm (C3–C5):
      • Phrenic nerve
      • Chief inspiratory muscles
    • Proximal upper limb sensory and motor structures (C4–C7)
    • Distal upper limb sensory and motor structures (C6–C8)
    • Hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand sensory and motor structures (C8–T1)

Thoracic:

  • 12 segments: T1–T12
  • Thoracic cord segments give rise to nerve roots that exit below their corresponding vertebrae.
  • T1–T12 segments lie within the T1–T8 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column.
  • Thoracic nerve roots give rise to intercostal nerves:
    • Innervate the thoracic dermatomes and intercostal muscles, which participate in exhalation
    • Innervate the abdominal wall dermatomes and muscles of the abdominal wall, which participate in exhalation
  • Sympathetic innervation of the thoracic, abdominal, and pelvic viscera exits from the thoracic cord segments (as well as contributions from L1 and L2 segments).

Lumbar: 

  • 5 segments: L1–L5
  • Lumbar cord segments give rise to nerve roots that exit below their corresponding vertebrae.
  • L1–L5 segments lie within the T9–T11 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column.
  • Lumbar (combined with sacral) spinal segments innervate:
    • Proximal and distal lower limb and foot sensory structures (L1–S2)
    • Proximal and distal lower limb and foot motor structures (L2–S2):
      • Hip flexion (L2 and L3)
      • Knee extension (L3 and L4)
      • Ankle dorsiflexion and hip extension (L4 and L5)
      • Knee flexion (L5 and S1)
      • Ankle plantar flexion (S1 and S2)

Sacral:

  • 5 segments: S1–S5
  • Sacral cord segments give rise to nerve roots that exit below their corresponding vertebrae.
  • S1–S5 segments lie within the T12–L1 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column.
  • Contribute to lower limb sensory and motor function as above
  • Parasympathetic innervation of the abdominal and pelvic viscera exit from sacral segments S2–S4.

Coccygeal: 

  • 1 segment
  • Arises from the conus medullaris
  • Lies within the L1 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column
Cross sectional view of the 31 spinal segments and their relationship to the bony vertebral column

Cross-sectional view of the 31 spinal segments and their relationship to the bony vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column

Image by Lecturio.

Individual spinal segments

  • Each segment consists of:
    • Pair of anterior/motor spinal nerve roots (left and right)
    • Pair of dorsal/sensory spinal nerve roots (left and right)
  • The anterior and dorsal roots combine with each other on the lateral sides to form the spinal nerve.
  • The spinal nerve passes through the neural foramen as it exits the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column
  • The extent of the spinal cord: base of the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull to lower margin of the L1 vertebral body 
  • Cauda equina and the segmental spinal nerves comprise the area below L1.
    • Cauda equina made up of contributions from:
      •  Lumbar nerve roots
      • Sacral nerve roots
      • Coccygeal nerve roots
  • Injuries below L1 are not classified as spinal cord injuries.
Cross-sectional view of an individual spinal segment

Cross-sectional view of an individual spinal segment

Image by Lecturio.

Spinal tracts

The spinal cord consists of 4 major tracts: 

  • Corticospinal tracts 
  • Dorsal columns 
  • Lateral spinothalamic tract 
  • Anterior spinothalamic tract 

The tracts are organized on the basis of their function: motor (descending) or sensory (ascending).

  • Corticospinal tracts: descending motor tracts located anteriorly within the spinal cord
  • Dorsal columns: ascending sensory tracts, responsible for transmitting the sensations of fine touch, proprioception, and vibration
  • Lateral spinothalamic tracts: ascending, responsible for the transmission of gross touch, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and temperature sensation
  • Anterior spinothalamic tracts: ascending tracts that transmit gross touch and pressure
Major ascending and descending tracts of the spinal cord

Major ascending and descending tracts of the spinal cord

Image by Lecturio.

Autonomic nerves

  • Originate in the hypothalamus Hypothalamus The hypothalamus is a collection of various nuclei within the diencephalon in the center of the brain. The hypothalamus plays a vital role in endocrine regulation as the primary regulator of the pituitary gland, and it is the major point of integration between the central nervous and endocrine systems. Hypothalamus and brain stem Brain Stem The brain stem is a stalk-like structure that connects the cerebrum with the spinal cord and consists of the midbrain, pons, and medulla oblongata. It also plays a critical role in the control of cardiovascular and respiratory function, consciousness, and the sleep-wake cycle. Brain Stem
  • Descend in a poorly defined manner in the lateral aspects of the cord
  • Sympathetic fibers exit from T1–L2.
  • Parasympathetic fibers exit at the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull base via the vagus nerve and from S2–S4.

Vascular supply

  • Single anterior spinal artery lies in the midline of the anterior cord and provides perfusion to the anterior ⅔ of the cord.
  • The 2 posterior spinal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries lie in the sulci of the dorsal columns and provide perfusion to the dorsal columns.
  • Anterior and posterior spinal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries originate from the vertebral arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries at the base of the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull.
  • Small radicular arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries from the thoracic and abdominal portions of the aorta may also contribute to arterial supply.
  • The area most vulnerable to ischemia is in the midthoracic region distant from the vertebral arterial origin and proximal to the aortic contributions.

Mechanisms of injury

Spinal cord injuries occur in association with injury to the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column. The main abnormalities that cause tissue damage are: 

  • Injury from direct trauma 
  • Compression injury resulting from:
    • Bone fragments
    • Spinal stenosis Spinal stenosis Spinal stenosis is the progressive narrowing of the central spinal canal, intervertebral foramen, and lateral recess, leading to compression of the nerve root. Spinal stenosis can occur in the cervical, thoracic, and lumbar spine and is commonly caused by degenerative bone disease (mostly affecting the elderly). Spinal Stenosis
    • Hematoma
    • Spinal discs
    • Tumor 
  • Ischemia related to the spinal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries

Classification

Spinal cord injuries can be primary or secondary.

Primary injuries:

  • These injuries are usually the result of mechanical disruption, transection, or disruption of the neural elements. 
  • Primary injuries are usually coincidental with fractures and/or dislocation of the spine. 
  • Nontraumatic causes of primary injury include:
    • Spinal tumors
    • Hematomas
    • Abscesses 

Secondary injuries (main causes):

  • Arterial disruption
  • Arterial thrombosis
  • Hypoperfusion secondary to shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock

Clinical Presentation

Clinical presentation of spinal cord injuries depends on the site of the injury and the extent (i.e., complete versus incomplete injury). Impairment is determined by the American Spinal Injury Association (ASIA) impairment scale.

Table: American Spinal Injury Association (ASIA) impairment scale
Impairment scale Description
A: Complete No motor or sensory function preserved in the S4–S5 segments
B: Incomplete
  • Sensory function is preserved below the neurologic level (S4–S5).
  • Motor function is not preserved below the neurologic level.
C: Incomplete
  • Motor function is preserved below the neurologic level.
  • More than half the key muscles below the neurologic level have a muscle grade < 3.
D: Incomplete
  • Motor function is preserved below the neurologic level.
  • At least half of the key muscles below the neurologic level have a muscle grade ≥ 3.
E: Normal Motor and sensory functions are normal.

General signs and symptoms observed:

  • Pain, numbness, and loss of sensation in the area of injury and throughout the corresponding dermatome 
  • Paresthesia 
  • Reduced or absent response to painful stimuli 
  • Spastic, weak, or paralyzed muscles in the corresponding area of injury 
  • Loss of neural activity and reflexes below the level of injury
Table: Signs and symptoms specific to the area of injury
Area of injury Clinical presentation
Lumbosacral
  • Loss of control of lower limbs and hips
  • Loss of bowel and bladder control
  • Sexual dysfunction
Thoracic
  • Autonomic dysreflexia:
    • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
    • Anxiety
    • Headache
    • Nausea
    • Blurred vision
    • Flushed skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
    • Nasal congestion
    • Ringing in the ears
  • Disruption in body-temperature regulation
  • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Bradycardia
  • Pooling of blood in the limbs
Cervical
  • Quadriplegia
  • Bradycardia
  • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Disruption in body-temperature regulation
  • Breathing dysfunction

Diagnosis

Spinal cord injuries are a medical emergency and require immediate assessment and intervention. The different diagnostic methods are discussed.

History and physical examination

The important aspects to concentrate on in clinical presentation are:

  • Traumatic or nontraumatic history 
  • Site of injury based on neurologic examination:
    • Complete or incomplete injury 
    • Loss of motor or sensory function or both 
    • Grade of muscle strength 
    • Type of paralysis: quadriplegia/paraplegia/triplegia

X-ray

  • Plain radiographs are taken to detect any fractures, dislocations, or soft tissue swelling.
  • These radiographs are usually taken in the ED for a quick assessment.
  • Views of the suspected area of vertebral injury:
    • Anteroposterior
    • Lateral 
    • Oblique
    • Open-mouth odontoid views for cervical injuries

CT

  • Detects fractured bones, blood clots, and blood vessel damage
  • Preferred method for delineating bony abnormalities
  • Helical CT is more sensitive than a plain radiograph.
  • CT scan provides better visualization of extent and displacement of fractures than a plain radiograph.

MRI

  • Obtained to visualize the spinal cord and soft tissues.
  • Superior to CT scans and plain radiographs for soft tissue visualization
  • MRI is used to assess nonosseous lesions, such as:
    • Extradural spinal hematoma
    • Abscess
    • Tumors
    • Disk rupture
    • Hemorrhage
    • Infarction
    • Contusion
    • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema 
  • MRI is conducted in an enclosed space; during this examination, it is difficult to monitor vital signs and maintain the airway.

Myelography

  • Myelography is used in combination with CT when MRI is contraindicated.
  • A soluble contrast medium is used to provide better visualization than a noncontrast CT.

Management

Immediate intervention

  • Stabilization and immobilization of the spine 
  • Maintenance of airway, breathing, and circulation
  • Hemodynamic support with vasopressors such as phenylephrine, dopamine, or norepinephrine, if necessary
  • Administration of IV corticosteroids to reduce inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, improve blood flow, and preserve nerve function
  • Trauma surgery, neurosurgery Neurosurgery Neurosurgery is a specialized field focused on the surgical management of pathologies of the brain, spine, spinal cord, and peripheral nerves. General neurosurgery includes cases of trauma and emergencies. There are a number of specialized neurosurgical practices, including oncologic neurosurgery, spinal neurosurgery, and pediatric neurosurgery. Neurosurgery consultation

Surgical intervention

  • To remove bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones fragments and foreign objects 
  • To repair herniated discs 
  • Emergency decompression is done in selected cases: 
    • Acute spinal injury with progressive neurologic deterioration
    • Facet dislocation
    • Dislocated discs

Management of complications

  • Cardiovascular complications:
    • Neurogenic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock causes hypotension and bradycardia and is managed with vasopressors and IV fluids IV fluids Intravenous fluids are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids.
    • External pacing and atropine are considered in cases of extreme bradycardia.
    • Autonomic dysreflexia → hypertension may require fast-acting antihypertensive therapy
  • Respiratory complications: 
    • Airway management in cases of impending respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure 
    • Tracheostomy is considered in severe cases.
    • Secretions are frequently cleared to prevent aspiration.
    • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia is managed according to the type.
  • Deep venous thrombosis: 
    • Low-molecular-weight heparin 
    • Subcutaneous unfractionated heparin 
    • Oral anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are not generally administered.
    • Intermittent pneumatic compression
  • Management of other complications:
    • Pressure sores are managed with backboards and with logrolling every couple of hours after spinal stabilization.
    • Urinary catheterization in individuals with no bladder control
    • Proton pump inhibitors for individuals with or at risk for gastric stress ulcers
    • A liquid diet is recommended in cases of paralytic ileus.
    • Psychological counseling in individuals with depression
    • Skeletal muscle relaxants and/or botulinum toxin injections for muscle spasticity
    • Enteral or parenteral feeding in individuals deprived of essential nutrients owing to a liquid diet

Long-term management and rehabilitation

  • Short- and long-term physiotherapy may be necessary to enable the individual to perform daily activities independently.
  • Individuals will likely require evaluation for durable medical equipment:
    • Wheelchair
    • Cushions, padding, bedding
    • Braces, orthotics
    • Urinary catheters

Prognosis

Several factors contribute to the prognosis of spinal cord injuries, such as age, sex, and site and type of injury.

  • Early death rate after admission: 4%–20%
  • Individuals with a cervical injury have a higher risk of death than individuals with thoracic or lumbar injury.
  • Individuals with incomplete injuries have a higher chance of making a full recovery than individuals with complete injury.
  • Life expectancy is reduced owing to the increased risk of complications.

Differential Diagnosis

  • Aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a "false lumen." Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection: tear in the inner layer of the aorta that presents as a sudden, severe pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the chest or upper back. Paralysis may occur below the dissection owing to interruption in spinal arterial perfusion. Diagnosis is with radiography, CT scan, and MRI transesophageal echocardiography. Management is with an endovascular stent-graft repair or a hybrid approach including open surgery and a stent repair.
  • Tertiary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis: late phase of the syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis infection that usually occurs years after the initial exposure. Tertiary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis presents with neurologic and cardiovascular complications. Neurologic complications may include tabes dorsalis, which affects the posterior columns of the spinal cord. Diagnosis is based on history and laboratory investigations. Management includes the administration of antibiotics.   
  • Transverse myelitis: disorder caused by inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the spinal cord characterized by weakness in upper and lower limbs, paresthesia, and bladder and bowel disturbances. Transverse myelitis is a common presentation of multiple sclerosis Multiple Sclerosis Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis and other neuroinflammatory disorders. Diagnosis is with clinical presentation and imaging. Management is with IV steroids and plasma exchange. 
  • Stroke: brain damage due to disrupted blood supply. Stroke presents with paralysis or numbness of the face, arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm, or leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, headache, and trouble walking and speaking. Diagnosis os by clinical presentation, imaging, and cerebral angiography. Management includes anticoagulant therapy, supportive treatment, and in severe cases, stenting. 
  • Guillain-Barré syndrome Guillain-Barré syndrome Guillain-Barré syndrome (GBS), once thought to be a single disease process, is a family of immune-mediated polyneuropathies that occur after infections (e.g., with Campylobacter jejuni). Guillain-Barré Syndrome: disorder of the peripheral nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. General Structure of the Nervous System triggered by an acute bacterial or viral infection that presents with initial paresthesia in the feet and legs progressing to ascending paralysis. Other symptoms include walking abnormalities, fatigue, tachycardia, hypertension, urinary retention. Diagnosis is by CSF analysis, electromyography, nerve conduction studies. Management is with plasmapheresis and immunoglobulin therapy, analgesics, blood thinners, and physiotherapy.
  • Tick paralysis: occurs as a result of the injection of toxin by the bite of a tick. Symptoms occur within 2–7 days. Clinical presentation includes initial numbness and weakness in both legs that progresses to ascending paralysis and respiratory distress within hours. Deep tendon reflexes are decreased or absent. Diagnosis is based on symptoms and finding an embedded tick, usually on the scalp. Managed by detecting/removing the tick, cleaning the bite location, and monitoring for respiratory distress.

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