Spinal Trauma - An Imaging Approach E-Book

Victor N. Cassar-Pullicino

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 658

Veröffentlichungsjahr: 2006

Beschreibung

The diagnosis of trauma to the spine -- where the slightest oversight may have catastrophic results -- requires a thorough grasp of the spectrum of resultant pathology as well as the imaging modalities used in making an accurate diagnosis. In Spinal Trauma, the internationally renowned team of experts provides a comprehensive, cutting-edge exposition of the current vital role of imaging in the diagnosis and treatment of injuries to the axial skeleton. Beginning with a valuable clinical perspective of spinal trauma, the book offers the reader a unique overview of the biomechanics underlying the beautifully illustrated pathology of cervical trauma. Acute trauma topics include: Optimization of imaging modalities Malalignment -- signs and significance Vertebral fractures -- detection and implications Classification of thoraco-lumbar fractures -- rationale and relevance Neurovascular injury Distilling decades of clinical and teaching expertise, the contributors further discuss the current role of imaging in special focus topics, which include: The pediatric spine Sports injuries The rigid spine Trauma in the elderly Vertebral collapse, benign and malignant Spinal trauma therapy Vertebral fractures and osteoporosis Neuropathic spine All throughout the book, the focus is on understanding the injury, and its implications and complications, through "an imaging approach." Complete with hundreds of superb MR images and CT scans, and clear full-color drawings, the authors conclude with a look into the future, defining clinical trends and research directions. Spinal Trauma -- with its broad scope, practical imaging approach, and current focus -- is designed to enhance confidence and accuracy, making it essential reading for clinicians and radiologists at all levels.

Leseprobe

Library of Congress Cataloging-in-Publication Data

Cassar-Pullicino, V. N. (Victor N.), 1954-Spinal trauma : an imaging approach/Victor N. Cassar-Pullicino, Herwig Imhof ; with contributions by R. Bodley… [et al.].

p. ; cm. Includes bibliographical references.

ISBN 3-13-137471-3 (alk. paper) - ISBN 1-58890-348-6 (alk. paper) 1. Spine-Wounds and injuries. 2. Spine-Wounds and injuries-Imaging. 3. Spine-Diseases-Diagnosis.

[DNLM: 1. Spinal Injuries. 2. Spinal Cord Injuries. 3. Spinal Injuries-diagnosis. WE 725 C343s 2006] I. Imhof, H. (Herwig) II. Title. RD533.C33 2006 617.5'6044—dc22

2006000850

Chapter 2 translated by John Grossman, Berlin, Germany

Illustrator: Salvador Beltran, M.D., E-mail: [email protected]

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10-ISBN 3-13-137471-3 (GTV)

13-ISBN 978-3-13-137471-4 (GTV)

10-ISBN 1-58890-348-6 (TNY)

13-ISBN 978-1-58890-348-8 (TNY)

1 2 3 4 5

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Dedication

To:

Wendy, my wife, my secretary, and best friend Amy and James, my children Guze and Celine, my parents

Victor Cassar-Pullicino

Ilse, my wife

Andrea, Klaus and Nini, my children

Grete, my mother

Herwig Imhof

and

to all the patients whose injuries have taught us,

so we can teach others.

Foreword

Diagnostic imaging of spinal trauma has been revolutionized: findings obscured in the shadows of radiography have been brought to light by computed tomography (CT) and magnetic resonance imaging (MRI).CT and MRI illuminate much that was previously unseen and still more that was unsuspected. The pace of change has been swift and the cumulative impact of imaging on the initial diagnosis and subsequent treatment of patients with spinal cord injury has been enormous.

While these contributions have been chronicled in numerous reports in the radiologic, orthopedic, and neurosurgical scientific literature, there is great need for a compilation and integration of these advances in a single text. Drs. Cassar-Pullicino and Imhof have admirably fulfilled this need by putting together a major, cutting-edge, integrated resource on imaging the injured spine.

The editors assembled a cast of internationally recognized authorities in diagnostic radiology, orthopedic surgery, and neurosurgery to contribute to this text. Anatomic, pathophysiologic, clinical considerations and surgical treatment of spinal injuries are presented to provide an essential background for the proper performance and accurate interpretation of CT and MRI, as well as radiographic examinations, in those suspected of spinal injury.

The indications and contraindications for the use of various imaging modalities in the assessment of spinal injury are thoroughly explained. In keeping with their importance, the roles of CT and MRI in the detection and evaluation of spinal injury are emphasized. The text and illustrations admirably provide the how, where, and what to look for when imaging those who either have or may have sustained a spinal injury.

The text is profusely illustrated with outstanding illustrations of the pertinent imaging findings. Most chapters cite from 40 to 100 references that include essentially all the classic articles as well as the important recent scientific publications devoted to spinal trauma.

The entire range of spinal cord injury is covered; from low-impact to high-impact trauma and in all ages from childhood to the elderly. The underlying pathology and imaging assessment of patients with spinal cord injury without radiographic abnormalities (SCIWORA) is fully explored.

Controversial topics are presented in a non-dogmatic fashion: classifications of injury are described and their advantages and disadvantages discussed; the problems of interobserver variability and other potential difficulties encountered with the use of classification systems are acknowledged. The concept of stability is explored and both the potential and limitations of imaging in the determination of spinal stability are explained.

Chapters are devoted to injuries that may occur in the ankylosed, rigid spine and in the elderly with degenerative changes and osteoporosis. The text also contains interesting and informative chapters on spondylolysis and stress injuries as well as Scheuermann's disease. The vexing problems of Charcot's spine and benign versus malignant vertebral collapse are the subject of separate chapters.

There is also a chapter devoted to imaging the longterm multisystem effects of spinal cord injury. This includes the pulmonary, genitourinary, and gastrointestinal as well as spinal, neurologic, musculoskeletal complications. The role of CT and MRI in such patients is outlined and the cause and appearance of the lesions encountered are described.

Spinal trauma is a significant health problem in modern society. Spinal cord injury carries with it substantial morbidity and mortality, and the resources and expenditures required for the treatment and care of the spinal injured are considerable. Motor vehicle accidents (MVAs) are the plague of high-speed auto travel and the most frequent cause of spinal cord injury in developed countries the world over. Aging of the global population carries with it an increased risk of because those with degenerative changes in the spine are susceptible to spinal injury from even low-impact trauma, usually no more than simple falls. As a result, radiologists and their clinical colleagues worldwide are now commonly called upon to assess and treat spinal cord injuries.

The primary objectives of the assessment and treatment of patients with potential spinal injury are to either accurately exclude or correctly identify injuries, to preserve neurologic function when injuries are present, and to restore spinal stability in those so afflicted. Imaging plays an essential role in these endeavors. The editors have produced a work that will aid radiologists and all other physicians in achieving these objectives. To that end, this book should be on the shelves, if not in the hands, of all physicians involved in the care of patients with spinal injuries.

Drs. Cassar-Pullicino and Imhof and their collaborators are to be congratulated on this superb and timely text.

Lee F. Rogers, M.D.

Contributors

R. Bodley, M.D. Consultant Radiologist Department of Radiology Stoke Mandeville Hospital Aylesbury, Bucks U.K.

Victor N. Cassar-Pullicino, M.D. Consultant Radiologist and Clinical Director Department of Radiology The Robert Jones & Agnes Hunt Orthopaedic Hospital Oswestry, Shropshire U.K.

Alain Chevrot, M.D. Professor and Head Department of Radiology B Cochin Hospital Paris France

Richard H. Daffner, M.D. Professor of Radiologic Sciences Department of Diagnostic Radiology Drexel University College of Medicine Allegheny General Hospital Pittsburgh, Pennsylvania U.S.A.

Scott D. Daffner, M.D. Department of Orthopedic Surgery Thomas Jefferson University School of Medicine Philadelphia, Pennsylvania U.S.A.

J.L. Drapé, M.D. Department of Radiology B Cochin Hospital Paris France

Shigeru Ehara, M.D. Professor and Chair Department of Radiology Morioka Japan

Georges Y. El-Khoury, M.D. Professor of Radiology and Orthopedics Director of the Musculoskeletal Radiology Section University of Iowa Hospitals and Clinics Department of Radiology Iowa City, Iowa U.S.A.

W.S. El Masry, M.B., B.Ch., F.R.C.S. (Ed.) Director of Midland Centre for Spinal Injuries The Robert Jones & Agnes Hunt Orthopaedic Hospital Oswestry, Shropshire U.K.

A. Feydy, M.D. Department of Radiology B Cochin Hospital Paris France

S. Grampp, M.D. a.o. Professor Section of Osteology Department of Radiodiagnostics University and General Hospital Vienna Austria

J.H. Harris, Jr., M.D., D.Sc. Professor Emeritus Radiology and Emergency Medicine Sedona, Arizona U.S.A.

A. Herneth, M.D. a.o. Professor Section of Osteology Department of Radiodiagnostics University and General Hospital Vienna Austria

Herwig Imhof, M.D. Professor of Radiology and Nuclear Medicine Head of the Department of Radiodiagnostics University and General Hospital Vienna Austria

F. Kainberger, M.D. a.o. Professor Section of Osteology Department of Radiodiagnostics University Hospital Vienna Austria

Gerhard Kernbach Wighton, M.D., D.R.M., S.F.M., Ph.D. Professor Head of the Institute of Forensic Medicine University of Edinburgh Medical School Teviot Place - Wilkie Building Edinburgh U.K.

Philip H. Lander, M.D. Associate Professor Department of Radiology University of Alabama Health Services The Kirklin Clinic Birmingham, Alabama U.S.A.

F.C. Oner, M.D. Orthopedic Surgeon University Medical Center Utrecht Utrecht The Netherlands

A.E. Osman, M.B., Ch.B., M. Med. Sci., F.R.C.S. Centre for Spinal Injuries The Robert Jones & Agnes Hunt Orthopaedic Hospital Oswestry, Shropshire U.K.

Philipp Peloschek, M.D. Department of Radiodiagnostics University and General Hospital Vienna Austria

James Julian Rankine, M.D., M.R.C.P., M. Rad., F.R.C.R. Consultant Musculoskeletal Radiologist Chancellor Wing X-ray Department St. James' University Hospital Leeds U.K.

Klaus-Steffen Saternus, M.D. Professor and Head Institute of Forensic Medicine Georg-August-University of Göttingen Göttingen Germany

D.J. Short, F.R.C.P. Centre for Spinal Injuries The Robert Jones & Agnes Hunt Orthopaedic Hospital Oswestry, Shropshire U.K.

Bernhard Tins, M.D. Consultant Radiologist Department of Radiology The Robert Jones & Agnes Hunt Orthopaedic Hospital Oswestry, Shropshire U.K.

J.M. Trivedi, M.Ch. (Orth.), F.R.C.S. (Tr. & Orth.) Director Centre of Spinal Disorders Consultant Orthopaedic Surgeon The Robert Jones & Agnes Hunt Orthopaedic Hospital Oswestry, Shropshire U.K.

P.N.M. Tyrrell, M.D. Consultant Radiologist Department of Radiology The Robert Jones & Agnes Hunt Orthopaedic Hospital Oswestry, Shropshire U.K.

C. Vallée, M.D. Department of Radiology Raymond Pointcarré Hospital Garches France

Matthew L. White, M.D. Associate Professor Department of Radiology University of Nebraska Nebraska U.S.A.

Preface

“Spinal trauma” often generates a sense of unease in both trainee and experienced diagnostic clinicians owing to the potentially catastrophic implications of missing significant acute trauma. Diagnostic dilemmas and uncertainty are further encountered when dealing with other aspects of vertebral column injury. With the reader in mind, this book covers a broad spectrum of spinal trauma topics. General as well as special focus categories are comprehensively covered, each incorporating all aspects of diagnostic imaging in a practical and cohesive manner.

An Imaging Approach is fundamental to providing the crucial information that firstly aids an accurate understanding of the underlying pathology, and secondly forms the basis of therapeutic decisions. To ensure best medical practice, attending radiologists and clinicians need to understand and incorporate the clinical applications of imaging.

The international cast of expert authors are all recognized teachers. Their vast wealth of experience, logical approach, and diagnostic principles are distilled in their excellent contributions. Each chapter is designed to reflect the manner in which the authors currently regard the role of imaging in their area of expertise within the field of spinal trauma. Well-chosen illustrations complement the text throughout and enhance the understanding of the reader; this is further aided by the superb drawings of Salvador Beltran, the renowned medical illustrator.

We hope that the finished product accurately reflects the state of the art, furthers and improves the knowledge of the readers, enhancing their confidence and diagnostic skills so that they can “get it right” for the benefit of the patient.

V.N. Cassar-Pullicino and H. Imhof

Contents

1 Clinical Perspectives on Spinal Injuries

W. S. El Masry and A. E. Osman

Introduction

Effects of Spinal Cord Injury

Clinical and Radiological Assessment in the Acute Stage

Missed Spinal injuries

Clinical Diagnosis of SCI in the Conscious Patient

Clinical Diagnosis in the Semiconscious or Unconscious Patient

Associated Injuries

Radiological Assessment

The Subacute Stage and Long Term

Assessment of the Cardiovascular System

Assessment of the Respiratory System

Assessment of the Abdomen

Bladder and Urinary System

Assessment of Level of Consciousness

Psycho-Social Assessment of Cognitive Functions

Electrophysiological Assessment

Standards for Neurological Examination and Documentation

Frankel's Classification

The ASIA/IMSOP Classification

Management of the Spinal Injury

The Secondary Injury

Biomechanical Instability of Injuries to the Spinal Column

Unstable Injuries Without Neurological Damage

Physiological Instability of the Spinal Cord

Stable and Unstable Injuries with Neurological Damage

Canal Encroachment

Cord Compression

Natural History of Complete Spinal Cord Injuries

Natural History of Incomplete Cord Injuries

The Role of Surgery

Conclusion

References

2 Understanding Cervical Spinal Trauma: Biomechanics and Pathophysiology

K.-S. Saternus and G. Kernbach-Wighton

Introduction

Atlanto-Occipital and Atlanto-Axial Joints

Condylar Fracture

Alar Ligaments

Cruciform Ligament, Apical Ligament,

Anterior Atlanto-Occipital Membrane, and Anterior Longitudinal Ligament

Atlas Fracture

Anterior Arch

Jefferson Fracture

Lateral Mass

Posterior Arch

Axis Fracture

Odontoid Fracture

Hangman's Fracture

Injuries to the Intervertebral Disk and Major Longitudinal Ligaments

Traumatology

Biomechanics

Vertebral Injury

Compression Fracture

Avulsion Fracture of the Margin of the Vertebra

Injuries to the Facet Joints and Intervertebral Foramina

Spinous Process Fractures

Conclusion

References

3 Optimizing the Imaging Options

B. Tins and V. N. Cassar-Pullicino

Introduction

Imaging Modalities

Pros and Cons

Imaging Approaches and Dilemmas

Specific Scenarios and Technical Considerations

An Approach to Imaging of Spinal Injuries

Conclusion

References

4 Classification: Rationale and Relevance

F. C. Oner

Why Classify?

Classification of Thoracolumbar Spine Fractures

The Three-Column CT Era

The Load-Sharing Classification

The AO (Comprehensive) Classification

Influence of Imaging Modality

Problems of Reproducibility

The Concept of Stability

Do We Need Any Classification at All?

References

5 Malalignment: Signs and Significance

J. H. Harris, Jr

Introduction

Normal Alignment

Cervicocranium (Occiput-C2-C3 Interspace)

Lower Cervical Spine (C3-C7)

Malalignment

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8

Case 9

Case 10

Case 11

Case 12

Case 13

Case 14

Case 15

Case 16

Case 17

References

6 Vertebral Injuries: Detection and Implications

R. H. Daffner and S. D. Daffner

Introduction

Indicators of High Risk for Injury

Mechanisms of Injury and Their Imaging "Fingerprints"

"Footprints" of Vertebral Injury—the ABCS

Vertebral Stability Following Trauma

Implications

References

7 Neurovascular Injury

M. L. White and G. Y. El-Khoury

Introduction

MR Imaging/Histopathological Correlation of Acute Spinal Cord Injury

MRI Features of Spinal Cord Hemorrhage

Prognostic Role of MR Imaging in Neurological Outcome

Vascular Injury

Vertebral Artery Injury

Conclusion

References

8 Trauma to the Pediatric Spine

P. N. M. Tyrrell and V. N. Cassar-Pullicino

Introduction

Development of the Vertebral Column

Normal Variants

Birth Injury

Nonaccidental Injury (NAI)

Cervical Spine Injuries

Atlanto-Occipital Dissociation (AOD)

Fractures of C1

Injury of C2

Os Odontoideum

Atlanto-Axial Dislocation

Atlanto-Axial Rotatory Fixation

Thoracolumbar Spine Injury

Physeal Injury

SCIWORA

Slipped Vertebral Apophysis

Spondylolysis

Prognosis

References

9.1 Sports Injuries: Spondylolysis

F. Kainberger

Introduction

Indications for Imaging

Investigation Techniques

Radiography

Computed Tomography

Magnetic Resonance Imaging

Nuclear Medicine Studies

Ultrasound

Image Interpretation

Imaging Anatomy

Signs

Differential Diagnosis

Conclusion

References

9.2 Sports Injuries: Diskovertebral Overuse Injuries

J.J. Rankine

Introduction

Anatomy

Scheuermann's Disease

Disk Degeneration

References

10 The Rigid Spine

P. H. Lander

Introduction

Ankylosing Spondylitis

Disseminated Idiopathic Skeletal Hyperostosis (DISH)

Mechanisms and Imaging Techniques

Cervical Spine Injuries

Thoracolumbar Spine Injuries

References

11 Spinal Trauma in the Elderly

S. Ehara

Background

Cervical Spine

Biomechanical Characteristics

Clinical Features

Imaging Techniques

Radiological Features

Thoracolumbar Spine

Biomechanical Characteristics

Clinical Features

Imaging Techniques

Imaging Features

Conclusion

References

12 Therapy—Options and Outcomes

J. M. Trivedi

Introduction

Epidemiology of Spinal Trauma

Pathophysiology of Spinal Cord Injury

Anatomical Classification of Spinal Fractures

Patterns of Injury

Flexion Injury

Burst Fractures

Flexion Distraction Injury

Flexion Rotation

Management

Initial Management

Pharmacological Intervention

Nonsurgical Management of Spinal Fractures

Surgical Treatment of Spinal Fractures

Burst Fractures

Osteoporotic Vertebral Fractures

Conclusion

References

13 Imaging in Chronic Spinal Cord Injury: Indications and Benefits

R. Bodley

Abbreviations

Introduction

Neurological System

Cord Changes Post-SCI

Reported Series

Treatment

Imaging

Urological Investigations

Surveillance

Imaging in Specific Conditions

Deteriorating Neurology

Spinal Instability

The Acutely Unwell Patient

Deteriorating Renal Function and Renal Tract Complications

Pressure Sores

Ectopic Ossification

Pain

Muscular Spasms

Airway Problems

Elective Management of the Renal Tract

Conclusion

References

14 Vertebral Fractures and Osteoporosis

P. Peloschek and S. Grampp

Introduction

Definition

Osteoporosis

T-Score and Z-Score

Vertebral Fragility Fracture

Epidemiology and Outcome of Osteoporotic Spinal Fractures

The Radiologist's Role in Diagnosis

Screening during Routine Chest Radiography

Diagnosis of Osteoporosis on Lateral Radiographs of the Spine

Bone Densitometry

Dual X-ray Absorptiometry

Quantitative Computed Tomography

Quantitative Ultrasonography of Bone

Radiographic Absorptiometry

Single-Photon Absorptiometry

The Radiologist's Role in Therapy—Percutaneous Vertebroplasty

Conclusion

Ten Things to Remember

Case Study

References

15 Vertebral Collapse—Benign or Malignant

A. M. Herneth

Introduction

Clinical Evaluation

Age

History of Trauma

Imaging Findings

New Imaging Methods

Biopsy

Conclusion

References

16 Neuropathic Osteo-Arthropathy of the Spine

A. Chevrot, A. Feydy, C. Vallée, J. L. Drapé

Introduction

Mechanism

Clinical Findings

Imaging Findings

Differential Diagnosis

Treatment

References

17 The Future: Trends and Developments in Spinal Cord Regeneration

A. E. Osman, D. J. Short, V. N. Cassar-Pullicino, H. Imhof, W. S. El Masry

Introduction

Spinal Cord Research

Neuroprotection

Regeneration

Transplantation

Rehabilitation

Future Trends—Role of Imaging

Conclusion

References

Index

1 Clinical Perspectives on Spinal Injuries

W. S. El Masry and A. E. Osman

Introduction

Traumatic spinal column injuries are potentially catastrophic events in an individual's life. When associated with neurological damage they result in devastating medical, psychological, social, emotional, financial, vocational, environmental, and economic consequences.

The impact of the effects of the neurological damage on the individual and those related to him/her can, however, be minimized. With good management of all aspects of paralysis from the time of the injury, many initially paralyzed patients can make significant neurological recovery and walk again. With ongoing expert monitoring, care, and support, those who do not recover are able to lead fulfilling and fruitful lives, as well as contribute to society.

A thorough assessment of the patient, including full neurological examination, appropriate radiological investigations, and accurate documentation of the findings, is of paramount importance in initiating good management and in monitoring progress.

As spinal cord injury (SCI) affects the physiology of almost all systems of the body, any assessment should encompass more than spinal column or spinal cord functions.

Fig. 1.1Heterotrophic ossifications in a tetraplegic patient. They can be detected early with an ultrasound scan. Early treatment with biphosphonates and anti-inflammatory medication minimizes the severity of the outcome.

Effects of Spinal Cord Injury

A spinal cord injury results in a generalized physiological impairment that involves most systems of the body either directly or indirectly.

The physiological impairment and the consequent multi-system malfunction caused by SCI are dynamic in nature throughout the patient's life. The rate of change in the functioning of the various systems of the body is more rapid, though predictable, in the early stages (first 4-6 months) following injury.

Unpredictable changes in functions will inevitably occur throughout the patient's life, when the condition is likely to be perceived by most clinicians as being stable. The importance of frequent reassessments and repeated documentation at all stages following injury cannot be overemphasized. The only difference in the requirement for monitoring between the acute stage and the lifelong follow-up is the frequency of the monitoring.

In the absence of complete neurological sparing or full neurological recovery, the majority of patients with spinal cord injuries have sensory impairment or sensory loss below the level of their injury. Associated injuries and/or pathological complications can, therefore, develop in the absence of the conventional symptoms and signs, resulting in delay of diagnosis often with unpleasant consequences (Fig. 1.1).

When a complication develops, the interruption of the higher coordinating and moderating functions of the brain at the site of the spinal cord injury usually results in multiple and/or cascading intersystem effects, which are rarely seen in other conditions and which are seldom easy to manage. For example, an anal fissure, while painless, may nevertheless cause excess spasticity, which in turn may cause a fall and fracture of a long bone. Alternatively, excess spasticity involving the pelvic floor muscles may result in urinary retention, autonomic dysreflexia, and possibly a cerebrovascular accident.

The multi-system malfunction caused by the spinal cord injury is not only a source of multiple disabilities, but also a potential source of a wide variety and range of complications. What is perhaps not widely appreciated is that almost all complications following spinal cord injury are preventable.

Fortunately, the incidence of spinal cord injuries is the lowest of all major traumas. However, a combination of low incidence and high complexity necessitates an even more thorough and time-consuming systematic assessment than usual. The management of such patients, once they are stable for transfer, is therefore easier and safer to conduct in spinal injuries centers. These centers are usually equipped with the infrastructure of both the required expertise of adequately trained multidisciplinary teams and the necessary equipment. They are geared to provide comprehensive management, while giving equal attention to details that are necessary to ensure safety, comfort, and a good outcome for the patient, as well as medico-legal protection for the clinician and the institution.

Clinical and Radiological Assessment in the Acute Stage

Missed Spinal injuries

Missed spinal injuries are regularly reported in the literature.1–4 It is probable that in a significant number of patients the diagnosis of a spinal cord injury is delayed without being reported. Delaying diagnosis can result in increased neurological impairment.4,5 This is likely to result in more paresis or paralysis, increased disability, more disturbance of function of the various systems of the body and more complications. It is indeed a disaster to miss a spinal fracture or delay its diagnosis. It can easily be alleged that the neurological impairment has been caused or at best aggravated by failure to diagnose the fracture promptly. A delay in diagnosis is not unusually perceived by some patients and lawyers as having led to delays in ensuring appropriate precautions and adequate treatment. It is therefore paramount that no effort is spared in making as accurate a diagnosis in the accident and emergency department as possible. A high level of suspicion is a major prerequisite to early diagnosis in patients presenting following major trauma. The knowledge that a small group of patients with certain bone conditions, for example ankylosing spondylitis, osteoporosis, osteogenesis imperfecta, is more vulnerable to spinal injuries following minor trauma is at least equally important.

A thorough assessment of the patient including a full neurological examination together with appropriate radiological investigations, and accurate documentation of the findings are of paramount importance for initiating good management and monitoring progress.

Clinical Diagnosis of SCI in the Conscious Patient

A conscious alert patient, who is able to communicate and has symptoms of neck or back pain, rigidity, or tenderness in the spine following trauma is likely to have sustained a spinal column injury.6 There are, however, some rare exceptions. Pain may not be a feature in elderly patients with pure cervical ligamentous injuries without major vertebral damage in spondylotic spines. The author has personally witnessed this in a small number of patients, some of whom successfully pursued litigation. Extreme pain from other associated injuries may also mask pain from a spinal fracture with consequences to the timely diagnosis of a spinal injury.7 Neck pain, loss of consciousness following injury (regardless of duration), and/or neurological deficit are clinical predictors of unstable cervical spinal injuries requiring immediate radiological investigation of the cervical spine.8,9 The clinical diagnosis of a spinal cord injury in the conscious patient, who has no associated major injuries can be made without difficulty. Loss or impairment of motor power, sensation, and reflexes are indicative (individually or in combination) of damage to the spinal cord or the cauda equina depending on the level of impairment. Extra care should be taken in patients with L2 injuries and below. A traumatic injury below the level of S1 without injury to the cauda equina is rare. If present, it can, however, present with normal tendon reflexes and unimpaired motor power.

It is essential to determine at the earliest stage possible both the level and the density of the neural tissue damage.

The level of the injury is defined by the last normal dermatome and myotome. It is now internationally accepted by all experts in the field that the dermatomal and myotomal distributions may be abnormal for three segments below that level. In other words both sensation and motor power could be present but impaired in three segmental distributions below the last normal segment. For example if the last normal sensation is at the dermatomal distribution of C5 but there is hypoesthesia or analgesia in the dermatomal distribution of C6, C7, and C8 the level of the injury should be defined as C5. The impairment of sensation in the dermatomal distribution of C6, C7, and C8 can be explained by the logical assumption that the spinal cord segments C6, C7, and C8 are not completely damaged. Damage of these segments is incomplete; hence these segments represent the “zone of partial preservation.”

The density of the deficit from the damaged area in the spinal cord is defined by the presence or absence of sparing of sensation with or without sparing of motor power below the zone of partial preservation.

Absence of motor power including voluntary contraction of the anal sphincter and loss of sensation including loss of anal sensation below the zone of partial preservation are usually indicative of a clinically complete cord injury at the time of the examination. It is important, however, to appreciate that not all clinically complete injuries in the early hours or days following SCI remain clinically complete.10,11 Spinal shock can also mimic an initially complete injury following which significant recovery can occur.

The presence of sensation, however patchy or impaired, below the level of the zone of partial preservation is indicative of some anatomical sparing of sensory tracts and possibly also of corticospinal tracts which may be dormant in function at the time of the examination. Sensory sparing limited to the anal canal without motor sparing below the zone of partial preservation is also indicative of an incomplete SCI. A number of such patients can subsequently recover significantly. A rectal examination to elicit sensation in the S5 dermatome and voluntary/involuntary contraction of the anal sphincter is therefore an essential component of the neurological examination of patients diagnosed or suspected to have sustained an SCI.

An accurate and thorough neurological examination at an early stage following the injury is paramount for monitoring purposes and for prognosis.

A repeated accurate neurological assessment, with thorough documentation initially at frequent intervals (3-4 hours), is not only essential for the adequate clinical management of any neurological deterioration, it would also help resolve some of the controversies around the indications and effectiveness of the various methods of management of the SCI (conservative versus surgical decompression and/or stabilization).

It is not advisable to rely entirely on the neurological and general examination carried out in the accident and emergency department to make a definitive diagnosis of the density of the spinal cord injury. The patient's attention can, at this early stage, be distracted by anxiety, confusion, and pain. These may also limit performance of motor functions and responses to sensory testing. It is therefore possible that the neurological examination in the first few hours may not be very accurate with a tendency to underscore the motor power and underscore or overscore the sensory sparing. The documentation of the state of consciousness and cooperation of the patient during the neurological examination is understandably essential.

Clinical Diagnosis in the Semiconscious or Unconscious Patient

Unconscious or semiconscious patients with head injuries and the intoxicated patient present particular problems to the clinician which can result in delays of the diagnosis of a spinal injury.12 It is therefore, in my opinion, imperative that such patients, following major trauma, are nursed as having sustained a spinal injury until otherwise proven clinically and radiologically when the patient becomes alert.

In such patients a clear entry should be made in the medical records that the patient's neurological assessment could not be made because of the poor level of consciousness. This fact should also be communicated verbally to the nursing staff looking after the patient.

I would strongly advise that a written instruction

“NOT TO SIT THE PATIENT UP IN BED OR OUT OF BED PRIOR TO THE EXCLUSION OF A SPINAL INJURY CLINICALLY AND RADIOLOGICALLY AND UNTIL THE PATIENT REGAINS CONSCIOUSNESS” is clearly documented in the medical records and communicated verbally to the nursing staff.

This simple, logical, and easy documentation can result in the prevention of paralysis or further neurological deterioration as well as the prevention of litigation against the clinician and/or the institution.

The general examination of the unconscious patient can also yield a number of clinical signs that, in combination, can increase the clinician's level of suspicion regarding the presence of a neurological impairment of spinal cord origin.

During a systematic examination of the patient the following signs can be strongly suggestive of a cervical spinal cord injury:

Facial or scalp lacerations;Miosis of one or both pupil(s);Bruising or swelling of the neck;Absence of chest expansion during inspiration associated with increasing abdominal girth and retraction of intercostal muscles (diaphragmatic breathing);Differences in the pattern of spontaneous movement of the limbs;Difference in tone between the proximal and distal muscles in the upper limbs and between the muscles of the upper and the lower limbs;Response to painful stimuli by pressure over bony prominences along the segmental dermatomal distribution of the cord throughout the body;The combination of hypotension and bradycardia;The presence of priapism.

Bruising over the chest or thoracolumbar spine in association with the presence of normal breathing, the absence of responses to painful stimuli applied to the bony prominences of the lower limbs, and the absence of reflexes in the lower limbs, could be indicative of a lower thoracic cord or cauda equina injury.

Unlike a patient with head injury who is likely to be incontinent of urine on presentation at the accident and emergency department, a patient with combined head and spinal cord injury is likely to be dry for some time before developing overflow incontinence. In the author's experience, a palpable bladder in a semiconscious or unconscious patient following trauma is a highly suspicious sign of a spinal injury with neurological damage.

Associated Injuries

Double injury and occasionally multiple noncontiguous injuries of the spinal axis are not uncommon following major trauma. Following the diagnosis of a primary injury in the spinal axis, the diagnosis of a secondary injury is often delayed. The incidence of multi-level spinal injuries is reported to be as high as 16.7 %.13

Early recognition is important for the assessment and planning of the treatment in order to avoid further neurological damage when the nondamaging second spinal fracture is proximal to the primary injury. In our series, 55% of patients with multi-level injuries had incomplete neurological lesions on admission.14 Although no definite pattern of injury could be identified in terms of the relationship between the primary and the secondary level, the lower cervical and cervicothoracic lesions were the most frequently involved followed by the upper cervical region. Once a spinal injury has been identified we strongly recommend that the whole spine be examined clinically and radiologically.

The incidence of extra-spinal fractures associated with spinal cord injuries is reported to be about 28%.15,16 When all levels of spinal cord injuries were pooled the most common areas of fracture reported were chest followed by lower extremity, upper extremity, head, and pelvis.15

Loss or impairment of sensation below the level of the spinal cord injury presents one of the greatest challenges to the clinician in the diagnosis of the associated injuries. A thorough clinical examination is paramount to the diagnosis.

The importance of bruises, lacerations, or swellings in these patients cannot be overestimated. Facial bruises with or without bruises on the neck in an unconscious patient should heighten the suspicion of a cervical spinal injury with associated facial, dental, or mandibular injuries. Although there could be any combination of associated injuries with the injury of the spinal axis, there are nonetheless certain patterns of association.

Head injuries, facial injuries, dental, and mandibular injuries can be associated with cervical injuries, and vice versa.17 Thoracic injuries can be associated with fractures of the sternum,18 fracture ribs, hemothorax, fracture clavicle, or fracture scapula.19 A case of upper thoracic spine fracture was reported to be associated with tracheo-esophageal perforation.20

Abdominal injuries are not uncommonly associated with thoracolumbar fractures and lumbar fractures.21,22 Children involved in motor vehicle collisions are particularly at high risk. In one series, almost 10 % of adults with blunt trauma of the thoracolumbar spine had associated abdominal injuries.22 Solid organs and viscus injuries (spleen, kidneys, adrenals, liver, small intestine, and mesentery) have been reported. Patients who sustained multi-level vertebral fractures were more severely injured and had a higher number of solid organ injuries.22 Blunt, abdominal, aortic trauma in association with thoracolumbar spine fractures have been reported mainly when the fracture was caused by a distractive mechanism with or without translation.23

Injuries of the upper limbs including shoulders, wrists, and hands are worthy of specific mention. In the paraplegic and tetraplegic patients the upper limbs will also substitute the functions of the lower limbs during transfer and some activities of daily living, personal care, and hygiene.

Radiological Assessment

In the accident and emergency department, AP and lateral radiographs of the spine are still the commonest procedures and probably the most practical for the diagnosis or the exclusion of an injury of the spinal axis. It is important that the transfer and positioning of the patient is supervised by an experienced clinician and is documented to have been supervised. The absence of a fracture radiologically does not exclude a serious ligamentous injury of the spine nor indeed serious cord damage. An enlarged prevertebral soft tissue shadow can be the only radiological manifestation of a serious spinal injury. The cervicodorsal junction and upper thoracic vertebrae are usually difficult to visualize despite pulling on the arms of the patient while taking a lateral radiograph. The quality of the exposure is likely to improve if an attendant gently pushes the shoulders downward while two other attendants hold a gentle pull on the arms from both the elbow and the wrist. Swimmer's views are helpful in patients with short thick necks.

Spinal cord injuries without radiologic abnormality (SCIWORA) have been reported in the literature for many decades and may have contributed to a delay in diagnosis in some patients. Although SCIWORA is generally expected in some children, it can also occur in elderly patients with central cord syndrome due to hyperextension injuries of the cervical spine. In the author's opinion the term SCIWORA needs to be reviewed in the light of the advanced radiological investigations (CT and MRI).

Once a traumatic injury to the spinal axis has been suspected and/or confirmed, in my opinion it is imperative that the whole of the spinal column is radiologically investigated. There is a significant incidence of double injury of the spinal column that ranges between 9.5% and 17%.13,14

Although the CT scan is the investigation of choice for assessing spinal fractures, an MRI scan is usually essential to assess ligamentous injuries, stability, and cord damage. MRI scans are also very valuable in detecting single or multiple vertebral contusions adjacent or noncontiguous to the fracture. The prognostic value of the MRI scan (in terms of neurological recovery) in the acute stage is discussed elsewhere. A baseline MRI scan is, however, essential to compare with subsequent MRI scans in case of neurological deterioration. This deterioration does not only occur in the acute stage, it can also occur anytime throughout the patient's life. The incidence of MRI-evident posttraumatic syringomyelia is up to 30 % in these patients.24 Fortunately, the clinically manifested effects occur in a much smaller percentage. El Masry and Biyani discussed the pathophysiology and documented the incidence of posttraumatic syringomyelia at various levels and for various densities of lesions.25,26

A baseline chest radiograph is highly advisable especially in tetraplegic/paretic patients and patients with thoracic injuries. Most patients with cervical cord injuries will have impaired respiratory functions. Those patients with thoracic spinal injuries are likely to have associated rib fractures, and/or sternal fractures both of which may add to the biomechanical instability of the thoracic spinal fracture. A lateral radiograph of the sternum is therefore also advisable in all patients with thoracic spinal injuries.

The interpretation of the film taken in the supine position requires radiological expertise. A hemothorax may not result in blunting of the costophrenic angle, but the collection is likely to be seen over the apex of the lungs.

Most patients with thoracic fractures will develop an increase in the paravertebral shadow and an appearance of widening of the mediastinum. Further radiological investigations may be required to exclude mediastinal damage.

Caution needs to be exercised during any procedure undertaken on patients with suspected cord damage, especially those with higher thoracic or cervical cord injury. Because during the stage of spinal shock the sympathetic nervous system is areflexic, patients are usually poikilothermic. In a cold environment they can readily become hypothermic. Hypothermia in patients with cord injury above the level of T5 can result in bradycardia and cardiac arrest. Radiology departments in trauma centers are advised to keep some atropine ready to administer if the pulse of the patient drops below 45/min. In a hot environment the patient can easily become pyrexial.

The Subacute Stage and Long Term

A repeat radiograph of the chest should be considered on the second, third, or fourth post-injury day in patients with thoracic spinal injuries. In the author's experience about 40-50% of these patients are likely to have an increase in the size of the hemothorax 2448 hours following the injury.

Patients with spinal cord injuries, at all levels, are at risk of developing a delayed ileus and care should be taken not to commence hydration and oral feeding before normal bowel sounds are heard at least 24 hours following injury.

Patients with thoracolumbar and lumbar injuries are likely to develop a retroperitoneal hematoma and a paralytic ileus for a period of time even when the spinal cord has not been damaged. An associated intraabdominal injury is not easy to exclude clinically. Often the radiologist has to come to the rescue. An abdominal ultrasound scan and/or a CT scan are likely to be required if the bowel sounds do not return by the fourth or fifth day post injury. A perforation in the lesser sac can remain undiagnosed for a number of days and requires a high degree of suspicion for exclusion.

In the absence of normal sensation, the combination of vomiting and a distended abdomen with or without pyrexia offer a great diagnostic challenge to the clinician treating spinal cord injury patients. This can happen on a number of occasions during the patient's life. Although constipation is likely to be the commonest cause, this diagnosis can only be made by exclusion.

Assessment of the Cardiovascular System

The combination of: bradycardia (pulse of 45-60/min), hypotension (systolic blood pressure of 80-90), warm peripheries, visible veins, and good peripheral pulse volume in a patient presenting to hospital following trauma is indicative of a spinal cord injury until otherwise proven. Unlike patients with hemorrhagic shock who exhibit tachycardia in association with hypotension, cold peripheries, and poor volume pulse, and who require bigger intravascular volume replacements, great care should be taken with intravenous fluid administration to patients with bradycardia and hypotension due to SCI. The impaired sympathetic system of the patient, which is responsible for the hypotension and partly responsible for the bradycardia, is usually unable to cope with any excess amount of fluid. The patient can easily develop pulmonary edema and respiratory failure.

Bradycardia can be aggravated by hypoxia, hypothermia, and tracheal suction all of which can cause cardiac standstill. The highest risk is during the stage of spinal areflexia “spinal shock” when the vagus nerve activity is unopposed by the sympathetic nervous system activity. The patient without a previous history of cardiac disease responds readily to cardiac massage and atropine 0.3 mg intravenously provided the cause of the cardiac standstill is effectively treated.

Following the stage of spinal shock (return of reflex activity) patients with tetraplegia and paraplegia above T5 are at risk of developing autonomic dysreflexia. This is one of the major emergencies in spinal injuries. Patients develop a pounding headache associated with high blood pressure in the magnitude of 220/110 or over, and can also develop cerebrovascular accidents. Viscus distension as in urinary retention or bowel obstruction; or painful stimuli below the level of the injury as in appendicitis, diskitis, severe urinary infection, or fracture of a long bone are likely to send volleys of afferent stimuli which travel unsuppressed up and down the spinal cord and initiate this sympathetic mega-discharge.

Assessment of the Respiratory System

The presence of diaphragmatic breathing (absence of chest expansion during inspiration associated with increasing girth with or without retraction of intercostal muscles) in a trauma patient is strongly suggestive of a cervical or upper thoracic cord injury. Frequent clinical examinations of the chest to ensure good air entry throughout the lung and exclude associated chest injuries, hemothorax or pneumothorax, are of paramount importance. These should be combined with monitoring of the vital capacity and oxygen saturation. An initial chest radiograph is advisable in all patients suspected of having sustained an SCI. Patients with dorsal column injuries are at higher risk of developing hemothorax than patients with cervical or thoracolumbar injuries. Frequently, the hemothorax does not become apparent until the third or fourth day following the injury, hence the need for the repeat chest radiograph.

A vital capacity below one liter in a tetraplegic patient requires intensive monitoring and chest physiotherapy. If, despite these measures, the vital capacity drops further (below 600 mL) and the oxygen saturation cannot be maintained ventilation may have to be considered.

With these simple measures the great majority of patients with C5 lesions or below do not require ventilation unless they have associated major chest trauma, an ascending lesion involving the phrenic nerve motor neurons or indeed a respiratory problem prior to their injury. Ventilation should, whenever possible, be avoided since during tracheal suction stimulation of the vagus nerve can result in further bradycardia and cardiac standstill. It is also difficult to wean tetraplegic patients off ventilators. Intensive physiotherapy, frequent assessment of the neurology and breathing, as well as timely intervention can prevent death from hypoxia due to retention of secretions and respiratory failure. Hypoxia can cause death by aggravating the bradycardia to a cardiac standstill. Hypoxia can also destabilize the physiologically impaired, traumatized spinal cord further, resulting in further neurological deterioration.27 In a patient with a C5 lesion, ascent of the neurological lesion by one or two segments due to edema of the spinal cord (involving the motor neurons of the phrenic nerves) will likely necessitate ventilation for 2-3 weeks and a recovery is likely.

The respiratory system of the tetraplegic and paraplegic patient due to a spinal cord injury above T6 remain impaired throughout the patient's life.

The absence of motor power in the intercostal muscles results in a marked reduction in vital capacity. Paralysis of the abdominal muscles results in a reduced ability to cough and expectorate. Patients with high cord injuries are always at risk of chest infections, lung collapse, and consolidation. They are also at risk of drowning in their own secretions. This improves a little following the stage of spinal shock in patients with upper motor neuron lesions, when spasticity of the abdominal wall becomes established.

Assessment of the Abdomen

A conscious, alert, and cooperative patient who is unable to cough or who is only able to effect a weak cough in the absence of rigidity or with loss of tone in the abdominal musculature is highly likely to have sustained an SCI above the level of D6. A weak cough associated with a positive Beaver's sign (movement of the umbilicus proximally in the process of coughing) indicates paralysis of the lower abdominal muscles with some function of the upper abdominal muscles. In Brown-Sequard syndrome patients, the umbilicus can be seen shifting laterally from the mid-line opposite the side of the hemicord lesion when the patient is asked to cough. Auscultation of the bowels may give good bowel sounds in the first few hours following injury, only to disappear later. It is therefore important to avoid oral fluids and food intake for 2448 hours following injury. During this period monitoring of the abdomen and documentation of a girth chart and regular auscultation for bowel sounds should be ensured. Occasionally the bowel sounds remain silent for longer and parenteral feeding should be considered. Early oral intake of food and or fluid in the presence of paralytic ileus is likely to cause abdominal distension, which invariably leads to further embarrassment of respiration. Death from respiratory failure or from cardiac arrest caused by hypoxia can easily occur in tetraplegic and high paraplegic patients with paralytic ileus.

Bladder and Urinary System

A palpable distended bladder in an unconscious patient who lies in a dry bed is very suggestive of a spinal cord injury in shock or a cauda equina lesion. A distended bladder which does not cause discomfort to a conscious patient on palpation especially when the patient is unable to void urine is similarly a useful diagnostic sign of an injury. Unconscious patients with head injury and an intact spinal cord or cauda equina are likely to be incontinent in the accident and emergency department.

An indwelling catheter is inserted for 48 hours in the bladder in order to facilitate hourly or two hourly measurement of the urinary output. The presence of hematuria should be investigated with an intravenous urogram or an ultrasound scan of the urinary system in order to exclude renal damage or damage elsewhere in the urinary tract.

Oliguria is commonly observed following SCI and is expected to last for a few days. Vigorous intravenous fluid infusion should be avoided.

It is not advisable to leave an indwelling catheter in the bladder for longer than 48 hours as it is likely to be a source of urethral and bladder complications.

Following removal of the indwelling catheter fourhourly intermittent catheterization by the nursing staff should be carried out and the residual volume should be recorded on each occasion. This is to ensure that the residual urine does not exceed 500 mL in order to avoid bladder over distension. A week or two following the injury a number of patients will develop polyuria for variable periods of time. Various strategies are usually adopted including reduction of fluid intake, increase of the frequency of intermittent catheterization or the insertion of an indwelling catheter for a short period of time until the urinary output is readjusted.

Patients with upper motor neuron lesions may start to develop reflex micturition 3-4 weeks following the injury. Effective reflex micturition may not, however, be established before 3-5 months following the injury. During this period the patient on intermittent catheterization should be advised to keep an accurate record of the voided and of the residual urine.

A baseline urodynamic study (cysto-urethro-metrography) and a baseline IVU/renogram are generally recommended for all patients with spinal cord injury during their first admission. This is in order to evaluate upper and lower urinary tract functions and to use for comparison in the future.

Repeat ultrasound scans/IVU or a renogram together with plain X-rays of the urinary tract on an annual or alternate year basis are paramount in patients with spinal cord injuries as they are at risk of developing silent hydronephrosis, renal scaring, lithiasis of the upper and lower urinary tract, and lower urinary tract problems (Fig. 1.2)

Fig. 1.2 Asymptomatic prostatic calcifications due to detrusor-sphincter dyssynergia resulting in reflux of urine into the ejaculatory ducts, the seminal vesicles, and the prostate.

There is no general consensus about the frequency of urodynamic studies in the asymptomatic patient with a normal ultrasound scan/IVU/renogram of the upper urinary tract. The author has to date reserved repeat urodynamics for patients with symptomatic infections, mild or severe symptoms of autonomic dysreflexia, or changes in the upper urinary tract.

Assessment of Level of Consciousness

It is paramount to make a clinical assessment of the level of consciousness in the accident and emergency department and with each subsequent neurological examination until the patient recovers consciousness completely. The level of consciousness influences the interpretation of the neurological findings and examination. The Glasgow coma scale is the most commonly used and useful scoring system.28

Psycho-Social Assessment of Cognitive Functions

It is good practice to assess cognitive functions during the early stages of mobilization and before intensive rehabilitation commences. Cognitive functions can significantly influence the method and goals of rehabilitation, the content of the rehabilitation process as well as the outcome. The psychological state of the patient prior to and after the injury, the social, financial, and vocational background, and the adequacy of accommodation are all equally important aspects that also influence the rehabilitation process and its outcome.

Electrophysiological Assessment

Numerous electrophysiological tests are available, however, they are not widely nor routinely used except in a few clinical settings. The commonest are nerve conduction studies (NCS), somatosensory-evoked potentials (SSEP), and motor-evoked potentials (MEP).

Nerve conduction studies are commonly used and can help differentiate between upper motor neuron (UMN) and lower motor neuron (LMN) lesions in both upper and lower limbs. In a root lesion, plexus lesion, or with peripheral nerve damage both motor and/or sensory conduction are impaired. In the upper limbs study of the median and ulnar nerves can predict recovery of hand function.29,30 In the lower limbs study of the peroneal and tibial nerves can help differentiate between conus or cauda equina and epiconal lesions.31

Somatosensory evoked potentials evaluate primarily the function of the dorsal columns but can also reflect function in other spinal tracts and in peripheral nerves. They may help differentiate between complete and incomplete lesions in the acute stage following injury as they are not affected by the state of consciousness of the patient or by spinal shock. In the acute SCI patient,

recording of tibial and pudendal SSEP has been found to be predictive of ambulation and of the function of the somatic component of the external urethral sphincter.32,33 They cannot, however, predict recovery of detrusor muscle functions.34

Motor evoked potentials can be elicited by magnetic or electrical cortical stimulation. MEP assess the function of the corticospinal tract by recording from different peripheral muscles during cortical stimulation thus enabling the assessment of both the level and extent of the lesion.35,36 Magnetic cortical stimulation can be applied to conscious patients as it is less painful and more powerful than electrical stimulation. Unfortunately, it is not advisable to use magnetic stimulation in the presence of metal implants.

In general patients with early MEP recovery have the best chance of recovery of motor and ambulatory functions.37,38

Standards for Neurological Examination and Documentation

Michaelis in the late 1960s conducted an international enquiry on paraplegia and tetraplegia in order to establish an agreement on terminology and timing of examination for accurate prognosis. Unfortunately, no agreement between the specialists from 15 countries could be reached.39 In the same year Frankel published the Frankel's classification in which the density of the neurological lesion could be described as complete or incomplete depending on the absence or presence of sensation and motor power below the level of the lesion. Patients with incomplete injuries could be further subdivided into three groups depending on the degree of sensory and motor sparing. On the basis of this classification, Frankel published the outcome of postural reduction and conservative management of a large series of patients with spinal injuries at all levels. Using Frankel's grid, Frankel et al demonstrated in 1969 for the first time that the neurological progress of groups of patients could be easily described by the assessor and easily understood by the reader.10 Since 1980 a number of classifications have subsequently been proposed. In 1982, based on the Frankel classification, the American Spinal Injuries Association (ASIA) developed the Standards for Neurological Classification of spinal injured patients. Since 1992 the ASIA standards have become internationally accepted.40

The ASIA classification was revised and updated on four occasions (the last being in the year 2000).41

Frankel's Classification

This method of classification was developed as a system to evaluate and document the neurological progress of an individual patient, large numbers of patients, or subgroups of patients with spinal injuries following a full neurological examination. The Frankel classification is still the most commonly used classification by clinicians from all disciplines.10

Patients are grouped into five categories, based on their clinical neurological presentation. These categories range from patients with complete sensory and motor loss below the level of the injury (Frankel A), to patients with no somatosensory loss and no sphincter disturbance; however, abnormal reflexes may be present (Frankel E). The three categories in between describe various degrees of sparing below the level of the lesion. Frankel B describes sensory sparing only including sacral sparing, however, with complete absence of motor power. Frankel C describes sensory and motor sparing below the level of the lesion, however, the motor power is poor and of no practical use to the patient. Frankel D describes sparing of sensation and motor power below the level of the lesion which many patients could use to walk, with or without aids. Frankel E patients have normal motor power, sensation, and sphincter functions.

The advantage of the Frankel classification is that with one letter of the alphabet (from A to E) one is able to describe and/or understand in general terms both the density of neurological damage at a particular level, the presence or absence of sparing, the modality(ies) spared, and the usefulness of the motor functions spared, if any, below the level of the injury. Furthermore, any significant influence of treatment and/or time resulting in a significant change of density and function can easily be documented by repeating the assessment for the individual patient or the group of patients and documenting the findings in the Frankel grid.

The sphincter functions are not described in Frankel group A, B, C, or D. They are presumed to be undisturbed in Frankel E. Similarly, the quality of ambulation and the requirements of lower limb orthosis and/ or arm support are not specified in Frankel D. Although the Frankel classification is good at measuring significant changes in neurology and function, it is not, however, sensitive enough to elicit small changes in neurology when the patient has not improved or deteriorated sufficiently to move from one Frankel grade to another. As a tool of measurement it is good at measuring most of what matters to the patient and the clinician but not necessarily what is required for the rigors of research and accurate comparison between methods of treatment. The Frankel classification, however, remains the most practical method for describing the progress of a patient or a group of patients in the clinical situation.

For research purposes the Frankel classification or its modified version by ASIA requires combination with a method to quantify loss and gain of both sensation and motor power numerically, quantitatively, and in percentage terms.42,43 The method of percentage of loss from normal and percentage of recovery or loss following treatment were described and recommended by El Masry et al as an alternative to simple numerical calculations in order to avoid the problems of parametric measurements.42,43

Ambulation and sphincter functions will also require additional specific documentation.

The ASIA/IMSOP Classification

Some advantages of the ASIA classification include the limitation of motor power testing to five groups of muscles in each limb representing the myotomal distribution in each limb. It also includes a scoring system for motor power, as well as pin prick and touch sensation. This gives a total numerical score for each modality separately for both sides of the body. Progress can be monitored through repeated examination.

El Masry et al in 1996 tested the validity of testing the chosen muscles by the ASIA and the National Acute Spinal Cord Injury Study (NASCIS) group in representing the standard motor examination.42 The assessment of the individual patient was carried out by the same examiner. Using a quantitative formula of motor deficit percentage (loss) and motor recovery percentage (gain) they concluded that the chosen muscles recommended by both ASIA and NASCIS were representative of the conventional motor scoring in the population of patients examined. It is important, however, not to miss movements in muscles other than those recommended by ASIA, such as the hip adductors that may be spared in an ASIA C patient or which may be the first to reappear.

The current guidelines, definitions, precautions, and methods of classification based on the last revision (2000) are summarized by Jonsson et al.41

Clinical Syndromes

The various known patterns of identifiable sparing (syndromes) in incomplete traumatic spinal injuries have been incorporated into the documentation of the ASIA classification.44

Management of the Spinal Injury

It is logical to suggest that since all the problems, medical and nonmedical, are caused by the cord injury; anything that can be done to reverse or minimize the pathology would in turn reduce the neurological impairment and magnitude of the effects of the spinal injury. It is also attractive to extrapolate from the results of the experimental laboratory animal and believe that certain pharmacological agents and/or surgical procedures can alter the course of the secondary injury and improve the outcome of the spinal cord injury in humans.

The Secondary Injury

Opinion is divided as to the contribution of the initial impact on the final neurological outcome following a spinal cord injury. Frankel et al and many others believe that the fate of the neurological injury is largely determined at the time of the accident.45 Freeman and Wright in 1953 did, however, suggest that the definitive cord damage could result from the changes that occur in the spinal cord following injury rather from the initial impact.46

Scientists and clinicians have for a number of decades tried to direct treatment to the changes (vascular, cellular, electrophysiological, enzymatic, electrolytic, and metabolic) that occur in and around the spinal cord lesion in the hope of improving the neurological outcome. Unfortunately, the interpretation of the clinical significance of some of these changes in the spinal cord are not agreed upon.47 In the laboratory animal, attempts at manipulating the secondary changes following sub-threshold impact within a window of opportunity can possibly be beneficial. Beyond a certain threshold of impact, however, these secondary changes cannot be manipulated successfully and neurological improvement cannot be demonstrated.48,49 In other words, there is a threshold of magnitude of impact above which attempts at manipulating the secondary changes by surgery or other means fail and no improvement can be achieved nor demonstrated in the experimental animal.

In humans the force of the impact cannot be measured, the secondary changes cannot be directly observed nor measured; the window of opportunity could be at least theoretically different from the laboratory animal and practically difficult to take advantage of (because of associated life threatening injuries). The results from surgery and pharmacological agents such as high-dose methyl prednisolone are, therefore, more difficult to evaluate and have yet to be convincingly demonstrated in humans to parallel the experimental findings in the laboratory situation.50

Biomechanical Instability of Injuries to the Spinal Column

Biomechanical instability (BI) causes concern because of the potential displacement of the fractured elements at the site of the injury which can damage or further damage neural tissue. The diagnosis of BI is usually based on radiological investigations at the time of the presentation of the patient. Unfortunately, the function of the soft tissues (muscles and ligaments) and the natural history of the repair process that follows are not always taken into account. It is perhaps worthwhile noting that most vertebral fractures heal within 6-12 weeks from injury. Ligamentous injuries, however, can take much longer to heal.

In the majority of patients the biomechanical stability (BS) of the spine is usually restored once the healing of bone and/or ligament occurs. In other words, biomechanical instability is time related