Incomplete Spinal Cord Injury (SCI)

Spinal cord injury with sparing of sensorimotor function below the level of injury
including perirectal sensation. The prognosis and functional outcomes are sig-
nificantly better for incomplete vs. complete SCIs, and should be managed
urgently for optimal chance of neurologic recovery.

History

Do you have any extremity weakness, loss of sensation, and/or paresthesias?

Are you having back pain?
Do you have a history of spinal disorders?

Physical Exam

– Maintain cervical spine in stable position

– Inspect and palpate posterior spine
– Assess for tenderness palpation or step-off deformity
– Trauma Evaluation (Appendix A)
– Complete Neurologic Evaluation (Appendix A)
– Full neurological exam including cranial nerves, bulbocavernosus reflex,
Babinski reflex, voluntary anal contraction, bladder sphincter, triceps/biceps/
ankle/patellar reflexes, strength, and sensation (light touch and pinprick)
– Bulbocavernosus reflex
• Squeeze glans penis/pressure on clitoris/pull foley
• Resultant anal sphincter contraction if reflex intact

© Springer International Publishing Switzerland 2017 37

M.C. Makhni et al. (eds.), Orthopedic Emergencies,
DOI 10.1007/978-3-319-31524-9_12
38 J. Shillingford

• Must have bulbocavernosus reflex to indicate end of spinal shock

• Cannot determine incomplete vs. complete SCI until this reflex returns
– Sacral neural exam
• Sacral sparing (sensory, or sensory/motor) signifies incomplete spinal cord
injury *IMPORTANT*
• perianal sensation
• anal sphincter contraction
• FHL motor function
– Palpable/visible muscle contraction below injury level
– Rectal exam—perianal sensation and sphincter tone

Diagnosis

Imaging

– XR in obtunded patient or patient w/pain, tenderness, and/or neurological symptoms

– MRI in obtunded or unreliable patient
– CT or MRI for patient with ankylosing spondylitis or diffuse idiopathic skeletal
hyperostosis

Classification

Neurologic level: Lowest level with intact neurologic function

Clinical Classification

– 1: Central cord syndrome (most common) (see Chapter “Central Cord

Syndrome”)
– 2: Posterior cord syndrome (rare)
• Loss of proprioception but preserved motor, light touch, and pain sensation
– 3: Brown-Sequard syndrome (best prognosis)
• Secondary to complete cord hemi-transection from penetrating trauma
• Ipsilateral motor, proprioception, and vibratory sensation deficits below the
level of the injury. Contralateral pain and temperature deficit below the lesion
Incomplete Spinal Cord Injury (SCI) 39

– 4: Anterior cord syndrome (worst prognosis)

• Anterior spinal cord injury secondary to direct compression or injury to the
anterior spinal artery that supplies the anterior 2/3 of the cord
• Lower extremities affected more than upper extremities
• Loss of motor, pain, and temperature sensation. Preserved proprioception/
vibratory sensation

ASIA Impairment Scale

– A (Complete): No sensorimotor function in S4–S5

– B (Incomplete): Preserved sensation. No motor function below neurological
level (sacral sensory sparing)
– C (Incomplete): Muscle function preserved but more than half of key muscles
with strength < 3 below the involved neurological level
– D (Incomplete): Muscle function preserved and more than half of key muscles
with strength > 3 below the involved neurological level
– E (Normal): Normal sensorimotor function

Treatment Plan

Initial Management

– ICU admission
– Immobilization
– Externally immobilize (cervical orthosis, lateral support, tape across fore-
head, body straps, secure to backboard in adult) and protect spine especially
during transport
– Log rolling to prevent further injury
– Use recessed head backboard for pediatric patient to avoid neck flexion
in child
– Limit fluids in spinal shock
– Cardiac monitoring for bradycardia
– GI: NGT/bowel regimen for ileus ppx, H2 blocker for PUD ppx (especially if
given steroids)
– Consider steroid protocol (within 8 h)
– Methylprednisolone bolus of 30 mg/kg body weight
– Infusion at 5.4 mg/kg/h for 23 h if <3 h, and 48 h if between 3 and 8 h
– Do not give to patient >8 h from injury, GSW, pregnant, <13 years old, high
risk for systemic infection, receiving steroids for other reasons, or for cauda
equina syndrome
40 J. Shillingford

Surgery

– Emergent surgical decompression ± stabilization in patients with acute progres-

sive neurological deficits the setting of cord compression may improve chance
for recovery

References

Schouten R, Albert T, Kwon BK. The spine-injured patient: initial assessment and emergency
treatment. J Am Acad Orthop Surg. 2012;20:336–46.
Gupta R, Bathen ME, Smith JS, Levi AD, Bhatia NN, Steward O. Advances in the management of
spinal cord injury. J Am Acad Orthop Surg. 2010;18:210–22.