Case of the Month #38 Spinal Cord Injury

The key priorities in this situation are: 

• Initial assessment by the trauma team with a CABC (C-spine, Airway, Breathing, Circulation) primary survey 

• Accurate assessment of any neurological deficit  

• Management and prevention of any secondary injuries (further injury due to an unstable injury, hypoperfusion and subsequent hypoxia of the cord, or compression due to localised haemorrhage or oedema)  

Urgent imaging is required to identify the extent of the patient’s injuries. The National Institute for Health and Care Excellence (NICE) guideline 41 details when patients should be imaged and with what modality: 

• Apply the Canadian C-spine criteria (99% sensitive in identifying patients with a spinal injury).  In patients who are awake, with no neurological deficits identified, and without distracting injuries, a cervical spine X-Ray may be sufficient.  

• In patients identified as having a high risk of injury the preferred initial modality is CT, with an MRI to be considered if the patient remains symptomatic with no injury visible on CT. An individual is high risk if they fulfil one or more the criteria below: 

• Age ≥ 65 years 

• Dangerous mechanism1 

• Paraesthesia in the upper or lower limbs 

• In children under 16, the primary imaging modality should be MRI 

Over the next 30 mins, the patient becomes hypotensive (80/40mmHg) and bradycardic (50 beats per minute). Primary survey has revealed no obvious cause of hypovolaemia. On examination the patient has no lower limb motor or sensory function and has upper limb power of 3/5 for elbow and wrist flexion with abnormal sensation in C6 dermatome and no sensation distally.  The patient undergoes an urgent trauma CT which reveals fractures of C6 and C7 with spinal cord impingement, but no other injuries.