Trauma to the Spine and Spinal Cord

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60 Trauma to the Spine and Spinal Cord

Stephen R. Freidberg, Subu N. Magge

Clinical Vignette

On a winter’s morning, this vigorous hypertensive, 68-year-old musician, went to pick his newspaper off his icy driveway. He was next found lying on the ground barely able to move any extremity with the exception of some spontaneous, brief dystonic posturing of his right arm. He had no recall of what occurred. Admission to a local hospital led to a diagnosis of a brainstem stroke.

When there was no sign of improvement after 48 hours, his son-in-law, a Lahey colleague, had him transferred to our hospital. Neurologic examination demonstrated an alert, articulate gentleman with absolutely normal brainstem function, full visual fields, and normal optic fundi. He had a severe spastic quadriparesis, and bilateral Babinski signs. There was a dense spinal cord level; he had absolutely no appreciation of touch, temperature, or pin sensation below the C6 dermatomes.

Magnetic resonance imaging (MRI) of the cervical spinal cord demonstrated a large herniated midline disc compressing the spinal cord at the C5–C6. An emergency anterior cervical diskectomy and fusion adequately decompressed the spinal cord. During the subsequent 6 months, he had a slow but marvelous recovery, fully regaining almost all his neurologic function.

This patient was most fortunate having a physician in his family who did not accept the initial diagnosis. Senior citizens are very prone to cervical spine fracture dislocation injuries particularly from such simple things as a fall in the home or on the ice as occurred here. Furthermore subsequent history led to yet another diagnosis of a cardiac arrhythmia. In retrospect it was thought that this arrhythmia led to a brief loss of consciousness, precipitating the fall that provoked his catastrophic cervical spine injury. Although acute spinal cord lesions are not often considered in the differential of a “brainstem stroke,” the demonstration of the “spinal cord level” at the time of the neurologic examination was the keystone to the diagnosis. This observation differentiated our patient’s clinical diagnosis from the initial impression of a brainstem stroke. This patient’s eventual excellent recovery was totally dependent on his consulting neurologic physician’s most careful clinical evaluation.

Traumatic spinal cord injury (TSCI) secondary to spinal column trauma is one of the most devastating human injuries in terms of morbidity, changes in the normal activities of daily living, and severe economic costs to the patient, family, and society. The recognition of the seriousness of spinal cord injury dates back to antiquity. It was noted in the Edwin Smith Surgical Papyrus dating to the 17th century BC. The recent major interest in stem cell research has brought hope to many TSCI individuals; however, no matter how promising one might think these techniques may prove to be, it is likely that successful clinical application of these technologies are many years removed. These patients and their physicians need to be realistic and take heart in the plethora of current research into rehabilitation problems and the opportunity to adequately confront the long-term medical, social, psychological, urological, and skin issues that they are faced with going forward. Unfortunately, war settings such as have recently occurred in Iraq and Afghanistan always lead to a major influx of TSCI patients.

When one reflects on the greatly shortened life spans that TSCI individuals faced 50 years ago, today’s survivors are a marvel to both their own courage as well as many medical advances. In spite of the neurologic injury, most TSCI patients are able to live active, productive lives. The Americans with Disabilities Act of 1990 has removed many physical barriers to wheelchair accessibility and has prevented discrimination in the workplace. To watch the wheelchair paraplegics come to the finish line of the Boston marathon speaks to these triumphs.

Major trauma centers evaluate two to three TSCI individuals out of every 100 patients brought to their emergency departments. The very high mortality (50%) associated with TSCI occurs mainly at the initial accident scene. Most often, these patients are accidentally injured while in an automobile (Fig. 60-1) or on a motorbike, particularly motorcycles. This type of injury also predisposes the patient to multiple-organ damage, for example, brain shear injury and/or intracerebral or subdural/epidural hematoma, cardiac tamponade, or a ruptured aorta, often leading to their very substantial fatality rate. In contrast, nonvehicular spinal cord injuries often occur with falls in (Fig. 60-2) or near the home (Fig. 60-3).

Figure 60-1 Cervical Spine Injury: Compression.

Figure 60-2 Cervical Spine Injury: Hyperextension.

Figure 60-3 Cervical Spine Injury: Hyperextension Flexion-Rotation.

These patients have a 16% mortality rate if they survive to get to the hospital. Young men sustain 85% of TSCI, and thus there is a high correlation with alcohol, motor vehicle accidents, or athletic injuries usually from contact sports or on occasion skiing, diving, or trampolines. In the older population, individuals having significant predisposing cervical spinal spondylosis and/or stenosis are much more likely to develop TSCIs, a central cord injury (Fig. 60-2), from relatively simple falls on stairs or precipitously while navigating icy walkways.

The dollar cost per year is estimated at $4 billion to care for the acute and long-term needs of the patient with TSCI. The costs to the patient and family are incalculable as their problems will last a lifetime. The patient with a spinal cord injury must adjust to limited mobility, psychiatric issues, urological problems, pulmonary difficulty, skin breakdown, sexual dysfunction, and frequently the inability to perform his or her job. The higher within the spinal cord the level of neurologic injury, the more difficult will be the patient’s adjustment to the injury. Clearly, TSCI is a condition where the opportunity for prevention far exceeds the potential for treatment. The patient in the opening vignette of this chapter was extremely fortunate and is not an example of the typical course of TSCI. The American Association of Neurological Surgeons sponsors an effective and aggressive program, Think First. This program has brought the very meaningful message of prevention to more than 8 million high school and elementary school pupils in almost all of the United States and seven foreign countries.

Pathophysiology

Different types of trauma can lend themselves to severe spinal cord injury. One of the most well-known, particularly among adolescents, is that related to diving or vehicular trauma leading to compression damage to the spine and concomitantly the spinal cord (see Fig. 60-1). The more senior population is primarily subject to TSCI in relation to seemingly simple falls in the home (see Fig. 60-2); similarly, alcoholics or abusers of other drugs are also at significantly increased risk of spinal cord trauma (see Fig. 60-3).

In addition to the various types of trauma to the vertebrae per se (Fig. 60-4

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