Advanced Trauma Life Support ATLS Student Course Manual 2018

DOCUMENTATION OF SPINAL CORD INJURIES 135
massive resuscitation can result in fluid overload and/
or pulmonary edema. Judicious use of vasopressors may
be required after moderate volume replacement, and
atropine may be used to counteract hemodynamically
significant bradycardia.
Spinal shock refers to the flaccidity (loss of muscle
tone) and loss of reflexes that occur immediately after
spinal cord injury. After a period of time, spasticity ensues.
Effects of Spine Injury on Other
Organ Systems
When a patient’s spine is injured, the primary concern
should be potential respiratory failure. Hypoventilation
can occur from paralysis of the intercostal muscles (i.e.,
injury to the lower cervical or upper thoracic spinal
cord) or the diaphragm (i.e., injury to C3 to C5).
The inability to perceive pain can mask a potentially
serious injury elsewhere in the body, such as the usual
signs of acute abdominal or pelvic pain associated
with pelvic fracture.
Documentation of SpiNAl
Cord Injuries
Spinal cord injuries can be classified according to level,
severity of neurological deficit, spinal cord syndromes,
and morphology.
Level
The bony level of injury refers to the specific vertebral
level at which bony damage has occurred. The
neurological level of injury describes the most caudal
segment of the spinal cord that has normal sensory
and motor function on both sides of the body. The
neurological level of injury is determined primarily
by clinical examination. The term sensory level is used
when referring to the most caudal segment of the spinal
cord with normal sensory function. The motor level is
defined similarly with respect to motor function as the
lowest key muscle that has a muscle-strength grade
of at least 3 on a 6-point scale. The zone of partial
preservation is the area just below the injury level where
some impaired sensory and/or motor function is found.
Frequently, there is a discrepancy between the bony
and neurological levels of injury because the spinal
nerves enter the spinal canal through the foramina
and ascend or descend inside the spinal canal before
actually entering the spinal cord. Determining the level
of injury on both sides is important.
Apart from the initial management to stabilize the
bony injury, all subsequent descriptions of injury level
are based on the neurological level.
Severity of Neurological Deficit
Spinal cord injury can be categorized as:
••
Incomplete or complete paraplegia
(thoracic injury)
••
Incomplete or complete quadriplegia/
tetraplegia (cervical injury)
Any motor or sensory function below the injury
level constitutes an incomplete injury and should be
documented appropriately. Signs of an incomplete
injury include any sensation (including position sense)
or voluntary movement in the lower extremities, sacral
sparing, voluntary anal sphincter contraction, and
voluntary toe flexion. Sacral reflexes, such as the
bulbocavernosus reflex or anal wink, do not qualify
as sacral sparing.
Spinal Cord Syndromes
Characteristic patterns of neurological injury are
encountered in patients with spinal cord injuries, such
as central cord syndrome, anterior cord syndrome, and
Brown-Séquard syndrome. It is helpful to recognize
these patterns, as their prognoses differ from complete
and incomplete spinal cord injuries.
Central cord syndrome is characterized by a disproportionately
greater loss of motor strength in the
upper extremities than in the lower extremities,
with varying degrees of sensory loss. This syndrome
typically occurs after a hyperextension injury in
a patient with preexisting cervical canal stenosis.
The mechanism is commonly that of a forward fall
resulting in a facial impact. Central cord syndrome
can occur with or without cervical spine fracture or
dislocation. The prognosis for recovery in central cord
injuries is somewhat better than with other incomplete
injuries. These injuries are frequently found in
patients, especially the elderly, who have underlying
spinal stenosis and suffer a ground-level fall.
Anterior cord syndrome results from injury to the
motor and sensory pathways in the anterior part of
the cord. It is characterized by paraplegia and a bilateral
loss of pain and temperature sensation. However,
sensation from the intact dorsal column (i.e., position,
vibration, and deep pressure sense) is preserved. This
syndrome has the poorest prognosis of the incomplete
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