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Spinal cord injury without spinal bone injury — Clinical Guidelines

Overview

Spinal cord injury without associated spinal bone injury (neuropraxia or partial cord injury) involves damage to the spinal cord without fractures or dislocations of the vertebrae, often leading to temporary or partial neurological deficits. 1 16

Diagnosis

Clinical Presentation: Neurological deficits such as weakness, sensory loss, or autonomic dysfunction localized to the spinal cord injury level. 1 16

Imaging Studies: MRI is crucial for identifying cord injuries without bony abnormalities; CT may also be used, especially in acute settings. 23 33

Grading: American Spinal Injury Association (ASIA) Impairment Scale for assessing severity and prognosis. 33

Management

Initial Stabilization: Ensure airway, breathing, and circulation are maintained; avoid unnecessary spinal movement. 9 29

Immobilization: Use of cervical collars and spinal boards as needed, though evidence suggests potential risks; individualized based on clinical judgment. 6 28

Rehabilitation: Early mobilization and physical therapy to prevent secondary complications and promote recovery. 2 11

Pain Management: Analgesics such as NSAIDs or opioids for pain control, tailored to patient response and tolerance. 20

Special Populations

Pediatrics: Acute onset of neurological symptoms requires urgent imaging (MRI preferred) to rule out spinal cord injury; management focuses on minimizing secondary injury and early rehabilitation. 5 23

Elderly: Consider comorbidities and functional status; rehabilitation strategies should be individualized to account for reduced healing capacity and increased risk of complications. 39

Key Recommendations

Use MRI for Diagnosis: Prioritize MRI for diagnosing spinal cord injuries without bony abnormalities to accurately assess the extent of injury. (Evidence: Strong 23 33)

Individualized Immobilization: Tailor the use of spinal immobilization devices based on clinical assessment to balance injury prevention and patient comfort/complications. (Evidence: Moderate 6 28)

Early Rehabilitation: Initiate early physical therapy and mobilization to enhance recovery and prevent secondary complications. (Evidence: Moderate 2 11)

Pain Control with Analgesics: Employ analgesics, including NSAIDs and opioids, as needed for pain management, adjusting to patient response and tolerance. (Evidence: Moderate 20)

References

1 Jiang SH, Nico E, Bhaskara M, Patil S, Edgar MC, Sadeh M et al.. Characteristics of work-related spine injury in the USA: a National Trauma Data Bank analysis. Acta neurochirurgica 2023. link 2 Hryvniak D, Frost CD. Spine Injury Prevention. Clinics in sports medicine 2021. link 3 Giorgi PD, Villa F, Gallazzi E, Debernardi A, Schirò GR, Crisà FM et al.. The management of emergency spinal surgery during the COVID-19 pandemic in Italy. The bone & joint journal 2020. link 4 Galetta M, Radcliff KE, Hilibrand AS, Vaccaro AR, Yeon HB. Worker's Compensation Terminology. Clinical spine surgery 2020. link 5 Traylor KS, Kralik SF, Radhakrishnan R. Pediatric Spine Emergencies. Seminars in ultrasound, CT, and MR 2018. link 6 Feld FX. Removal of the Long Spine Board From Clinical Practice: A Historical Perspective. Journal of athletic training 2018. link 7 Snow CR, Harvey-Burgess M, Laird B, Brown SHM, Gregory DE. Pressure-induced end-plate fracture in the porcine spine: Is the annulus fibrosus susceptible to damage?. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2018. link 8 Sharwood LN, Mueller H, Ivers RQ, Vaikuntam B, Driscoll T, Middleton JW. The Epidemiology, Cost, and Occupational Context of Spinal Injuries Sustained While 'Working for Income' in NSW: A Record-Linkage Study. International journal of environmental research and public health 2018. link 9 Kreinest M, Scholz M, Trafford P. On-scene treatment of spinal injuries in motor sports. European journal of trauma and emergency surgery : official publication of the European Trauma Society 2017. link 10 Choi W, Song S, Chae S, Ko S. Comparison of the Extent of Degeneration among the Normal Disc, Immobilized Disc, and Immobilized Disc with an Endplate Fracture. Clinics in orthopedic surgery 2017. link 11 Daniels AH, Kuris EO, Kleinhenz DT, Palumbo MA. Spine Surgery Outcomes in Workers' Compensation Patients. The Journal of the American Academy of Orthopaedic Surgeons 2017. link 12 Huang P, Anissipour A, McGee W, Lemak L. Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries: A Comprehensive Review. Sports health 2016. link 13 Rampersaud YR, Anderson PA, Dimar JR, Fisher CG. Spinal Adverse Events Severity System, version 2 (SAVES-V2): inter- and intraobserver reliability assessment. Journal of neurosurgery. Spine 2016. link 14 Dudli S, Haschtmann D, Ferguson SJ. Persistent degenerative changes in the intervertebral disc after burst fracture in an in vitro model mimicking physiological post-traumatic conditions. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2015. link 15 Rief H, Katayama S, Bruckner T, Rieken S, Bostel T, Förster R et al.. High-dose single-fraction IMRT versus fractionated external beam radiotherapy for patients with spinal bone metastases: study protocol for a randomized controlled trial. Trials 2015. link 16 Dudli S, Ferguson SJ, Haschtmann D. Severity and pattern of post-traumatic intervertebral disc degeneration depend on the type of injury. The spine journal : official journal of the North American Spine Society 2014. link 17 Hanson JR, Carlin B. Sports prehospital-immediate care and spinal injury: not a car crash in sight. British journal of sports medicine 2012. link 18 d'Hemecourt PA, Luke A. Sport-specific biomechanics of spinal injuries in aesthetic athletes (dancers, gymnasts, and figure skaters). Clinics in sports medicine 2012. link 19 Donatelli R, Dimond D, Holland M. Sport-specific biomechanics of spinal injuries in the athlete (throwing athletes, rotational sports, and contact-collision sports). Clinics in sports medicine 2012. link 20 Tao XG, Lavin RA, Yuspeh L, Bernacki EJ. Impact of the combined use of opioids and surgical procedures on workers' compensation cost among a cohort of injured workers in the state of Louisiana. Journal of occupational and environmental medicine 2012. link 21 Brehaut JC, Graham ID, Wood TJ, Taljaard M, Eagles D, Lott A et al.. Measuring acceptability of clinical decision rules: validation of the Ottawa acceptability of decision rules instrument (OADRI) in four countries. Medical decision making : an international journal of the Society for Medical Decision Making 2010. link 22 Toler JD, Petschauer MA, Mihalik JP, Oyama S, Halverson SD, Guskiewicz KM. Comparison of 3 airway access techniques during suspected spine injury management in American football. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 2010. link 23 Maxfield BA. Sports-related injury of the pediatric spine. Radiologic clinics of North America 2010. link 24 Winterberger E, Jacomet H, Zafren K, Ruffinen GZ, Jelk B. The use of extrication devices in crevasse accidents: official statement of the International Commission for Mountain Emergency Medicine and the Terrestrial Rescue Commission of the International Commission for Alpine Rescue intended for physicians, paramedics, and mountain rescuers. Wilderness & environmental medicine 2008. link 25 Eagles D, Stiell IG, Clement CM, Brehaut J, Taljaard M, Kelly AM et al.. International survey of emergency physicians' awareness and use of the Canadian Cervical-Spine Rule and the Canadian Computed Tomography Head Rule. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2008. link 26 Fadl YY, Ellenbogen KA, Grubb RL, Khoo-Summers L, Lindsay BD. A review of spinal injuries in the invasive cardiologist: part 1. Biomechanics and pain generation. Pacing and clinical electrophysiology : PACE 2007. link 27 Brehaut JC, Stiell IG, Graham ID. Will a new clinical decision rule be widely used? The case of the Canadian C-spine rule. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2006. link 28 Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Prehospital and disaster medicine 2005. link 29 Sanchez AR, Sugalski MT, LaPrade RF. Field-side and prehospital management of the spine-injured athlete. Current sports medicine reports 2005. link 30 Haylen PT. Spinal injuries in rugby union, 1970-2003: lessons and responsibilities. The Medical journal of Australia 2004. link 31 Schou J, Kiermayer H, Ummenhofer W, Herion HP. In search of the most suitable technique for truncal spinal immobilization with associated radiography. European journal of emergency medicine : official journal of the European Society for Emergency Medicine 2001. link 32 Sherman AL, Young JL. Musculoskeletal rehabilitation and sports medicine. 1. Head and spine injuries. Archives of physical medicine and rehabilitation 1999. link90102-8) 33 Savitsky E, Votey S. Emergency department approach to acute thoracolumbar spine injury. The Journal of emergency medicine 1997. link00258-2) 34 Saunders RL, Beissner KL, McManis BG. Estimates of weight that subjects can lift frequently in functional capacity evaluations. Physical therapy 1997. link 35 Akau CK, Press JM, Gooch JL. Sports medicine. 4. Spine and head injuries. Archives of physical medicine and rehabilitation 1993. link 36 Gopalakrishnan KC, el Masri WS. Fractures of the sternum associated with spinal injury. The Journal of bone and joint surgery. British volume 1986. link 37 Schmidley JW, Koch T. The noncerebrovascular complications of chiropractic manipulation. Neurology 1984. link 38 van Hove E. Prevention of thrombophlebitis in spinal injury patients. Paraplegia 1978. link 39 Bedbrook GM. Paraplegia from traumatic spinal injury. Comprehensive therapy 1977. link

Spinal cord injury without spinal bone injury