Describe Spinal Cord Injury — Syndromes & Management in detail.

Definition & Levels

Spinal cord injury (SCI) is damage to the cord producing motor, sensory and autonomic dysfunction below the level of the lesion. The cord ends at the conus medullaris (~L1); below this the cauda equina (lumbosacral nerve roots) continues. Injury is described by its neurological level and whether it is complete (no motor or sensory function in the lowest sacral segments) or incomplete.

Primary VS Secondary Injury

The primary injury is the mechanical insult at the moment of trauma. Secondary injury is the subsequent cascade of oedema, ischaemia, hypoxia and inflammation over the ensuing hours — and it is preventable. Much of acute SCI care is directed at limiting secondary injury by maintaining oxygenation, blood pressure (cord perfusion) and spinal alignment.

Spinal Shock

Spinal shock is the transient loss of all cord function below the lesion — flaccid paralysis, areflexia and loss of sensation — immediately after injury. Its resolution is heralded by return of the bulbocavernosus reflex (usually within 24–48 h). The neurological examination can only be called ‘complete’ (and prognosticated) once spinal shock has resolved.

Neurogenic Shock

In injuries above T6, loss of sympathetic outflow causes neurogenic shock: hypotension with bradycardia and warm peripheries (distinguishing it from hypovolaemic shock, which causes tachycardia). It is managed with fluids, vasopressors and atropine for symptomatic bradycardia, while excluding concurrent haemorrhage.

Management

Follow ATLS with full spinal immobilisation. Prevent secondary injury: secure the airway, maintain oxygenation and an adequate mean arterial pressure for cord perfusion, and keep the spine aligned. Perform CT and MRI to define the bony and cord injury. Unstable injuries and compressive lesions with deficit are treated by reduction, decompression and stabilisation (early surgery may benefit selected incomplete injuries). Meticulous supportive care prevents complications: bladder management, bowel care, pressure-area and skin care, DVT prophylaxis, respiratory care (high lesions) and early rehabilitation. High-dose steroids are controversial and not routinely recommended.

Prognosis & Rehabilitation

Prognosis depends chiefly on whether the injury is complete or incomplete and on the neurological level. Incomplete injuries (some sacral sparing) have the best potential for recovery; among the syndromes, Brown-Séquard fares best and anterior cord worst. Rehabilitation is multidisciplinary and lifelong, aiming to maximise function and independence and to prevent the complications of paralysis: pressure sores, contractures, urinary infection and stones, venous thromboembolism, spasticity, and respiratory compromise in high lesions. Bladder and bowel programmes, seating and wheelchair provision, physiotherapy and psychological support are central.

Sacral sparing indicates an incomplete injury — better prognosis.

• Complete = no motor/sensory in the lowest sacral segments; assess after spinal shock resolves.
• Return of the bulbocavernosus reflex marks the end of spinal shock.
• Central cord (commonest, arms>legs) < Brown-Séquard (best prognosis) < anterior cord (worst).
• Neurogenic shock (lesion >T6): hypotension + bradycardia; treat with fluids + vasopressors.
• Prevent secondary injury: oxygenation, perfusion, alignment; decompress/stabilise unstable injuries.