Introduction

With an estimated annual incidence of 300 per crore population, approximately 40,000 new spine injury cases are added every year in India. 40% of these are complete lesions i.e. tetra or paraplegia The socioeconomic impact of spinal injuries is huge with 85% of victims being male in the age group of 15 to 35 years. Management of patients who have sustained spinal cord injury requires careful assessment and management. In adequate assessment and management of these injuries may lead to worsening of existing spinal cord injury or the production of a new cord injury.

Case definition: For both situations of care (mentioned below*). Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function.

Incidence- In the absence of a national spinal cord injury registry in India, the exact incidence is not known. Approximately 30 cases per million population. Approximately 40% of these will be complete. Majority of the cases are due to road side accidents or fall from height.

Differential Diagnosis - All trauma patients should be assumed to have a spinal injury and treated as such till a detailed clinical examination and radiological investigation has been performed. Potential spinal cord injury should be suspected in following situations:

-  Altered mental status.

-  Evidence of intoxication.

-Associated head injury, extremity fracture

-  Focal neurological deficit.

-  Spinal pain or tenderness

Mechanism of injury e.g fall from height, fall on head, whiplash injuries, high energy injuries.

Clinical Diagnosis:

After the ABC have been taken care of, the patient is gently logrolled and whole of the spine is palpated for tenderness or a palpable step-off deformity.

Neurogenic shock, in continence of bowel, bladder and penile erection indicates ever spine injury. A careful and detailed neurological examination is then performed and meticulously documented.

Frankel's grades: Spinal Cord Injury is most commonly graded using Frankel's grades (A to E).

A           Complete motor and sensory loss

B           Sensation only present below lesion

C           Sensations present and motor function is present but useless

D           Motor useful but not normal

E           Noneurological deficit.

After the motor and sensory examination, presence of sacral sparing may be noted by voluntary rectal sphincter tone and toe flex or contractions. Presence of sacral sparing indicates a better neurological prognosis.

Although spinal shock is over by 24 hours, rarely it may be prolonged. A positive bulbocavernous reflex or a positive anal wink indicates the end of spinal shock. If no motor or sensory function can be documented at this stage, a complete spinal cord injury is present.

Investigations:

X-  Rays: All patients with suspected spinal injury should have radiographic evaluation.

·       Initial screening can be done by conventional antero-posterior and lateral x-rays.

·       The cervical spine radiographs must include the C7-T1 junction to be considered adequate

·       Additional Open-mouth views should be done to evaluate odontoid injury. •

Whole spine should be evaluated with a patient of spinal injury.

·       The patient should be referred for advanced diagnostic modalities only when the patient is stable:

CT Scan: CT scan cervical spine in all cases of head injuries or intoxication at the same time as the brain CT. CT should be done when plain X-Ray is inadequate, particularly for upper cervical spine injuries and C7-T1 junction.

MRI:         MRI is essential for evaluating injury to the soft tissues and ligaments, discs, intrinsic cord damage (oedema, hematoma, or contusion) and Para vertebral soft tissues. MRI is particularly useful in scenarios such as central cord syndrome where plain radiographs will not show any fractures or dislocations (SCIWORA). If possibIeMRl should be done before the cervical traction is applied. In patients with pre- injury morbidities such as Ankylosing Spondylitis, CT and MRI should be done

to rule out occult instability even if x-rays are normal.

Management:

CONSERVATIVE - If no neurological deficit

SURGERY – Refer the patient to higher centre for specialized care.

Anterior decompression and fixation with plating or post decompression with pedical screws General care of the patient is the most commonly neglected part

1.   Genitourinary Tract:

·       Place an indwelling urinary catheter as part of the initial patient assessment unless contraindicated

·       Leave indwelling urinary catheters in place atleast until the patient is haemodynamically stable

·       Care of indwelling catheter should be taught to patient or the relatives as soon as the patient is stable

2.   Gastrointestinal Tract

·       Initiate stress ulcer prophylaxis.

·       Evaluate swallowing function prior to oral feeding in any acute SCI patient.

3.   Measures to prevent bed sores:

·       Assess areas at risk for skin breakdown frequently.

·       Place the patient on a pressure-reduction mattress or a mattress overlay depending on the patient's condition.

·       Use a pressure-reducing cushion when the patient is mobilized out of bed to a sitting position.

·       Reposition to provide pressure relief or turn at least every2 hours while maintaining spinal precautions.

·       Keep the area under the patient clean and dry and avoid temperature elevation.

·       Assess nutritional status on admission and regularly thereafter.

·       Inspect the skin under pressure garments and splints.

·       Educate the patient and family on the importance of vigilance and early intervention in maintaining skin integrity