Traumatic spinal cord injury

Disease Description (Causes and Symptoms)

Traumatic spinal cord injury is a condition in which the spinal cord is damaged by trauma such as traffic accidents, falls, sports injuries, gunshot or stab wounds. Approximately 70% of all spinal cord injuries are caused by trauma, and the pattern of occurrence varies by age (trauma is more common before age 40, while falls increase after age 45). Major traumatic causes: automobile accidents approximately 45%, falls approximately 41%, and direct impact (such as from a heavy object) approximately 10%.

Pathophysiology: Physical impact causes direct spinal cord injury (compression, transection) and consecutive secondary injuries (edema, bleeding, inflammation, ischemia), blocking nerve transmission. Depending on the level of injury, it is classified as quadriplegia (at or above the cervical spinal cord) or paraplegia (at or below the thoracolumbar region), and as complete injury (loss of all motor and sensory function below the injury) or incomplete injury (preservation of some function).

Main symptoms:

• Loss of motor and sensory function (paralysis, numbness)
• Urinary and bowel dysfunction (bladder and bowel paralysis)
• Autonomic nervous system abnormalities: hypotension (sympathetic paralysis), bradycardia (relative parasympathetic predominance), autonomic dysreflexia
• Difficulty breathing (especially when a high cervical or upper thoracic spinal cord injury causes weakness of the intercostal muscles/diaphragm)
• Acute pain followed by chronic neuropathic pain

Main diagnostic methods: Neurological examination (including the ASIA classification) is the most sensitive method, while imaging (spinal X-ray, CT, MRI) and neurophysiological tests (electromyography, evoked potentials) are used to determine the location and extent of the lesion.

Treatment Methods (Standard Treatment, Medications, Procedures/Surgery, Lifestyle Management and Precautions)

The initial goals are to maintain vital functions (airway, breathing, circulation), prevent further spinal cord injury, and preserve and restore as much neurological function as possible.

Emergency and Initial Management

• Spinal immobilization (including cervical immobilization), according to ATLS principles (airway, breathing, circulation)
• Airway and respiratory management: Mechanical ventilation may be necessary in high spinal cord injuries
• Neurological assessment (ASIA) and early imaging (MRI/CT)

Surgical Treatment

• In cases of acute neurological deterioration, persistent spinal cord compression, or unstable fractures, early decompression and spinal stabilization surgery should be considered (if possible, within 24 hours; there is evidence that early surgery is beneficial for neurological recovery).
• Surgical treatment when there is an open wound, infection, or a need for alignment correction

Medication Treatment

• Steroids (high-dose methylprednisolone): Previously used based on NASCIS studies, but are not currently recommended as standard treatment or are considered only in limited circumstances because of adverse effects and limitations in the evidence. There is no blanket recommendation in the latest guidelines (the risks and benefits should be discussed with the treatment team).
• Thromboprophylaxis: Early prevention of DVT (such as low-molecular-weight heparin)
• Gastrointestinal mucosal protection: In patients with injuries at or above the upper thoracic spinal cord (T5), medications (PPI/H2 blockers) may be considered to prevent stress ulcers and bleeding
• Pain and spasticity: Gabapentin/pregabalin for neuropathic pain, and baclofen/tizanidine for spasticity, etc.

Nonsurgical and Conservative Treatment

• External fixation (traction, braces) for bone alignment and stabilization
• Bladder management with an indwelling urinary catheter or intermittent self-catheterization
• Initial management of bowel paralysis, such as gastric tube decompression and fasting

Rehabilitation and Lifestyle Management

• Respiratory physical therapy (airway management, sputum clearance techniques)
• Physical and occupational therapy to restore and maintain function (standing, gait training, wheelchair transfers)
• Prevention of pressure sores (regular repositioning, pressure relief)
• Osteoporosis management (exercise, calcium and vitamin D, osteoporosis medication if necessary) and fracture prevention
• If heterotopic ossification develops, consider medication, exercise, or surgery

Precautions and Complication Management

• Prevention and early treatment of respiratory complications (atelectasis, pneumonia)
• Management of orthostatic hypotension (changing position slowly, compression stockings, fluid and salt supplementation, medication)
• Prevention of deep vein thrombosis and pulmonary embolism
• In cases of autonomic hyperactivity (autonomic dysreflexia), immediately remove the cause (such as minor urinary tract irritation) and control blood pressure
• Monitoring and treatment of long-term complications such as pain, pressure sores, joint contractures, and heterotopic ossification

Checklist Before an Outpatient Visit (Including Items to Bring, Records, and Example Questions)

Items/materials to bring

• List of currently used medications and supplements (including doses and administration times)
• Timing and course of the accident (initial emergency treatment and surgical history)
• Copies of existing imaging (CT, MRI) and test results (blood tests, neurophysiological tests)
• Records of urinary and bowel patterns (urine leakage, urination intervals, residual urine volume, etc.)
• Records of the location, characteristics, and intensity of pain (pain diary)
• Whether respiratory support is being used (mechanical ventilator, oxygen), and whether pressure sores are present and where

Symptom change checklist

• Muscle strength (upper and lower limbs), and sensory changes (decreased sensation, abnormal sensations)
• Changes in fever, difficulty breathing, or sputum (suspected pneumonia)
• Leg swelling or sudden pain (suspected deep vein thrombosis)
• Urine color and frequency, and difficulty urinating (urinary tract infection or bladder problems)

Examples of materials and questions to show the doctor during an outpatient visit (to help the doctor quickly understand the patient's condition)

• Timing and details of major treatments during and after the accident (surgery, intubation, etc.)
• Summary and files of recent test results (MRI/CT)

Examples of General Questions to Ask the Doctor

• What is the prognosis for this injury (based on the injury level and ASIA classification)? What is the range of possible recovery?
• What treatments (surgery, medication, rehabilitation) are currently recommended for me, and what are their expected benefits and risks?
• How should pain and spasticity be managed? What are the side effects of the medications?
• What should I do to prevent complications such as DVT (deep vein thrombosis), pneumonia, and pressure sores?
• When might I be able to return to daily activities (work, driving, sexual activity, etc.), and what preparations are needed?

Examples of Disease-Specific Questions

• What are my injury level (e.g., C4, T6, etc.) and ASIA grade, and to what level might the expected functions (breathing, transfers, independent walking, etc.) recover?
• Current imaging (MRI/CT) shows spinal cord compression or an unstable fracture. Is early surgery necessary, and what degree of neurological improvement can be expected from surgery?

(If necessary, please prepare recent imaging files and a list of your current medications when you visit, so the doctor can refer to them.)