25 Complete and Incomplete Thoracic Spinal Cord Injuries Abstract Thoracic spinal injuries include complete and incomplete injuries, and are a major cause of morbidity and mortality resulting from either destabilization of the bony spine or neurological injury to the spinal cord or spinal nerves. Prompt medical and surgical treatment is essential to minimizing chronic functional disability. Major nonoperative issues are immobilization and management of hypoxia and hypotension to reduce secondary neurological damage to the spinal cord. Accurate diagnosis of the injury requires careful neurological examination and imaging. Optimal surgical decisions depend on the need for decompression, reduction of any induced deformity, and maintenance and/or restoration of spinal stability. This report reviews the commonly used criteria, guidelines, and approaches for operative management of thoracic spinal cord injury. Keywords: spinal injury, spinal cord damage, vertebral fractures, spinal fusion, spinal stability Clinical Pearls • The goals of surgery in thoracic spinal cord injury include decompression of the spinal cord, correction of deformity, reduction of fractures, and the restoration of stability. • Patients with incomplete thoracic spinal cord injuries often present with deficits that localize to specific areas of spinal cord injury, such as Brown–Sequard syndrome. • Patients with Brown–Sequard syndrome have the best prognosis among patients with spinal cord injury. Most patients recover enough motor function to maintain ambulatory status. • The thoracolumbar injury classification and severity score (TLICS) is based on morphology of the injury, integrity of the posterior ligamentous complex, and neurological status of the patient to provide prognosis and treatment guidelines. About 12,000 Americans sustain an acute spinal cord injury (SCI) every year, and in 2013 there existed a nationwide population of 273,000 who were living with the chronic consequences of SCI.1 Patient with SCI comprise only 10 to 20% of all patients with spinal fractures.2 For each patient with SCI many more suffer from bony or ligamentous injury. Common causes of SCI include motor vehicle accidents (MVA, 37%), falls (29%), violence (14%), and sports (9%).1 SCIs are often life changing for the patient and his or her family. They can cause great anxiety in the acute phase and substantial disability in the long term. Despite many refinements in the medical management and technological innovations in the surgical treatment, more than 99% of hospitalized patients with SCI are left with residual neurological dysfunction. The nature of residual neurological disability ranges complete tetraplegia (12%), incomplete tetraplegia (41%), complete paraplegia (18%), and incomplete paraplegia (19%).1,3 Spinal injuries without SCI have more favorable outcomes but correct diagnosis and treatment is necessary to limit chronic disability. The immediate effect of the injury is direct disruption of the neurological tissue by pressure or laceration from the spinal bones or foreign bodies. Simultaneous disruptions of blood vessels may cause bleeding in the spinal cord and result in a hematoma with potential to cause further pressure damage. Starting immediately and evolving over weeks, a number of vascular, eurohumoral, and cellular mechanisms are activated that cause secondary neurological injury. Vascular effects include hypotension from hemorrhagic or neurogenic shock leading to vasoconstriction and ischemic-reperfusion injury. Cellular effects include tissue hypoxia, free radical activation, cytokine release, lipid peroxidation, and apoptosis.4,5 About 3 to 25% of damage to the spinal cord is estimated to occur after the initial injury. Hence, it is important to optimize care and minimize further loss of neurological function after the primary injury.5 In addition to consideration of spinal cord injury, the decision between operative and nonoperative management of spinal trauma depends on whether the spine is considered stable or unstable. Multiple theoretic models have been developed to assess spinal stability. The most commonly used model is the three-column model of Denis6 consisting of an anterior column (anterior longitudinal ligament, the anterior two-thirds of the vertebral body, and the anterior annulus fibrosis), a middle column (posterior one-third of the vertebral body, the posterior longitudinal ligament, and posterior annulus fibrosis), and a posterior column (the posterior ligamentous complex connecting the neural arches and consisting of facet capsules, ligamentum flavum, and the interspinous and supraspinous ligaments). Failure of two or more columns results in spinal instability. More recent criteria for stability will also be discussed in this chapter. For 48 to 72 hours after SCI, the patient may be in spinal shock, a transient state of neurological unresponsiveness below the level of injury due to injury-induced hyperpolarization of spinal cord neurons. This stage is recognized by the loss of the bulbocavernosus reflex (contraction of anal sphincter in response to squeezing of the glans penis or tugging on the urinary catheter). Prognostication about permanent neurological loss should be postponed till the resolution of spinal shock. Table 25.1 International standards for neurological classification of spinal cord injury by the American Spinal Injury Association (ASIA): ASIA Impairment Scale (AIS), 20117
25.1 Introduction
25.2 Pathophysiology of Spinal Cord Injury
25.3 Spinal Stability
25.4 Emergency Room and Intensive Care Management
25.4.1 Neurological Assessment
A = Complete | No sensory or motor function is preserved in the sacral segments S4–S5 |
B = Sensory incomplete | Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4–S5, and no motor function is preserved more than three levels below the motor level on either side of the body |
C = Motor incomplete | Motor function is preserved below the neurological level,a and more than half of key muscle functions below the single neurological level of injury have a muscle grade < 3 (grades 0–2) |
D = Motor incomplete | Motor function is preserved below the neurological level,a and at least half (half or more) of key muscle functions below the neurological level of injury have a muscle grade > 3 |
E = Normal | If sensation and motor function as tested with the International Standards for Neurological Classification of Spinal Cord Injury are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without a spinal cord injury does not receive an AIS grade |
Table 25.2 Spinal Cord Independence Measure8
Self-care (subscore 0–20) | Feeding: 0–5 |
Bathing: 0–5 | |
Dressing: 0–5 | |
Grooming: 0–5 | |
Respiration and sphincter management (subscore 0–40) | Respiration: 0–10 |
Sphincter management—bladder: 0–15 | |
Sphincter management—bowel: 0–10 | |
Use of toilet: 0–5 | |
Mobility (subscore 0–40) | Mobility in bed and action to prevent pressure sores: 0–6 |
Transfers: bed–wheelchair: 0–2 | |
Transfers: wheelchair–toilet–tub: 0–2 | |
Mobility indoors (short distances): 0–8 | |
Mobility for moderate distances: 0–8 | |
Mobility outdoors: 0–8 | |
Stair management: 0–4 | |
Transfers: wheelchair–car: 0–2 | |
Mobility in bed and action to prevent pressure sores: 0–6 | |
Transfers: bed–wheelchair: 0–2 | |
Transfers: wheelchair–toilet–tub: 0–2 |
Neurological examination should include an inspection of face, head, and spine for lacerations, ecchymosis, and angular or rotational deformities. Patient should be log-rolled to palpate the entire spine. Absence of posterior, midline, and spinal tenderness in an awake and alert patient makes cervical SCI unlikely.
The American Spinal Injury Association (ASIA) recommended International Standards for Neurological Classification of Spinal Cord Injury in 1997 and last revised them in 2011 (
Table 25.1).7
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