An understanding of the issues related to chronic spinal cord injury should commence from an appreciation of the events that caused the primary injury.
Primary injury results from acute mechanical trauma, compression by a space-occupying lesion, or a vascular insult. The injury may be exacerbated by ischaemia or inflammation.
The aim of diagnosis is to carefully assess the extent of neurological injury, the degree of residual sensory and motor function, and to identify complications.
Common associated problems include bladder or bowel dysfunction, constipation, neurogenic pain, gait disturbance, contractures, sexual dysfunction, autonomic dysreflexia, and development of a syrinx.
Management involves intensive rehabilitation to optimise mobility and hand function, prevention of complications, bladder and bowel management, and analgesia. Surgical decompression may be required for progressive neurological deficits.
Full recovery of neurological function is unlikely, and the outcome depends on the residual function and the success of rehabilitation. Patients have a decreased life expectancy compared with the general population.
Complications include dysphagia, DVT, contractures, pressure sores, orthostatic hypotension, heterotopic ossification, dependent oedema, and osteoporosis.
Chronic spinal cord injury refers to a permanent and/or progressive interruption in the conduction of impulses across the neurons and tracts of the spinal cord. It may be due to mechanical distortion or vascular ischaemia of the spinal cord arising from trauma, tumour, infection or other space-occupying lesions. The term is generally used when elements of spinal cord injury have been present for at least 1 year. Commensurate neurological deficits occur that may be stable or progressive and lead to disability with spasticity, joint contractures, sensory changes, and sphincter and locomotion abnormalities.
History and exam
Key diagnostic factors
- presence of risk factors
- motor weakness
- loss of fine motor coordination
- paraesthesia, numbness, dysaesthesia
- hyperreflexia and ankle clonus
- pathological reflexes
- loss of perianal sensation, voluntary anal contraction, and anal tone
- autonomic dysreflexia
Other diagnostic factors
- central (midline) pain
- girdle pain
- musculoskeletal or visceral pain
- unsteady gait
- urinary incontinence or retention
- sexual dysfunction
- non-specific malaise
- radicular pain
- spinal cord trauma or ischaemia
- higher-level spinal cord lesion
- extremes of age
- narrow spinal canal
- male sex
Investigations to consider
- MRI spine
- urodynamic studies
- bladder ultrasound
- micturition cysto-urethrogram
progressive neurological deficit
stable neurological status
Kenneth Casey, MD, FACS
Clinical Associate Professor of Surgery (Neurosurgery)
Michigan State University School of Medicine
Clinical Associate Professor of Physical Medicine and Rehabilitation
Wayne State University School of Medicine
Surgical Director Intensive Care
Oakwood Southshore Medical Center
KC declares that he has no conflicts of interest.
Dr Kenneth Casey would like to gratefully acknowledge Dr Jwalant S. Mehta, a previous contributor to this topic. JSM declares that he has no competing interests.
Steven Kirshblum, MD
Medical Director and Director of Spinal Cord Injury Services
Kessler Institute for Rehabilitation
University of Medicine and Dentistry of New Jersey/New Jersey Medical School
SK declares that he has no competing interests.
Deborah Short, MRCP
Consultant in Rehabilitation Medicine
Robert Jones and Agnes Hunt Hospital
DS declares that she has no competing interests.
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