Dr. Ebraheim’s educational animated video describes spinal cord injury in detail.
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Spinal Cord Injury Detailed
A patient was involved in a motor vehicle accident, and the patient is unable to move all four extremities. We will start the examination with applying the ABC’s for trauma patients: Airway, Breathing and ventilation, Circulation and hemorrhage control, Disability evaluation, Exposure/Environmental control. Spinal cord injury above C5 will most likely require intubation, especially if the patient has complete quadriplegic. Spinal cord injury patients are at risk for hemodynamic shock and neurogenic shock. You are going to finish the initial survey. Next, you are going to resuscitate the patient. The patient is then examined and a thorough neurological exam should be done. To check if the patient is in spinal shock, check the bulbocavernosus reflex (S3). Spinal shock means that the patient does not have the bulbocavernosus reflex. The anal sphincter will not contract when the reflex is absent. In spinal shock, the peripheral neurons are temporarily unresponsive to the brain stimuli. The injury is similar to a hurricane that wipes out everything and shocks everything. There is no motor or sensory below the level of the lesion. There is flaccid paralysis and no bulbocavernosus reflex. The bulbocavernosus reflex returns in about 48 hours. The local activity and functions start to return. When the bulbocavernosus reflex comes back, this signals the end of the spinal shock. Assess how much damage was done to the structures. We are going to try and establish the connection (similar to a functional internet). The brain controls everything. The brain sends a signal, and we are going to see if that signal is present in the destroyed areas. Complete spinal cord injury is the loss of motor and sensation below the level of the lesion following a spinal cord injury. Incomplete means spinal cord injury with some neurological function distal to the injury. It can be motor, sensory, or sacral sparing, which can be voluntary rectal tone, anal contraction, or perianal sensation. If there is sacral sparing, this means that the injury is incomplete. If there is no sacral sparing, then the injury is complete. Grade 1/5 means a flicker of contraction alone. Grade 2/5 will have some movement if gravity is eliminated. Grade 3/5 means muscle contraction against gravity. Grade 4/5 means muscle contraction against gravity and some resistance. Grade 5/5 means normal. Next, determine if the injury is complete or incomplete by focusing on sacral sparing. You want to find sacral sparing because that will mean that the patient’s injury is incomplete, and this will have a better prognosis. Central cord syndrome is the most common type. It is caused by hyperextension injuries, and it is seen in older patients. Anterior cord syndrome has a poor prognosis, and it is usually vascular. Brown-Sequard syndrome is a hemisection of the spinal cord, and it has a good prognosis. There will be loss of ipsilateral motor function, and contralateral loss of pain and temperature sensation. Posterior cord syndrome is very rare and is associated with loss of proprioception, deep touch, and vibration. The sensory level is used when there is no motor level to test, such as in the thoracic spine. Neurogenic shock is hypotension and bradycardia following acute spinal cord injury, due to disruption of the autonomic pathway and loss of the sympathetic tone to the heart. There will be wide spread vasodilation with a decrease in the systemic vascular resistance due to injury to the descending sympathetic system. Monitoring with swan ganz may be helpful for careful fluid management. Swan ganz will really guide the appropriate fluid management and resuscitation. You may give vasopressors to the patient to treat the hypotension. Hypotension and tachycardia is hypovolemic shock. Hypotension and bradycardia is neurogenic shock. Autonomic dysreflexia occurs in complete spinal cord injury due to sympathetic overcharge (increased activity). Uncontrollable sympathetic output associated with certain triggers. Usually unchecked visceral stimulation such as fecal impaction or obstruction of the Foley catheter. It occurs in patients with spinal cord injuries above T6. It can be fatal. Patients will get headaches, agitation, almost malignant hypertension, sudden very high blood pressure, and profuse sweating. Check the patient for fecal impaction or unkink the Foley catheter. You may want to give the patient antihypertensive medications.
