Traumatic spinal cord injury

Last revised by Khalid Alhusseiny on 7 Jun 2024

Traumatic spinal cord injury can manifest as a wide variety of clinical syndromes resulting from damage to the spinal cord or its surrounding structures. It can result from minor injury if the spine is weakened from disease such as ankylosing spondylitis or if there is pre-existing spinal stenosis. It is an emergency which can require urgent surgical intervention to prevent long-term neurological complications of spinal cord injury.

Clinical presentation is very variable ranging from minor neurological dysfunction to complete paralysis (e.g. in spinal cord transection). Damage to the cord not only can vary in severity but also only affect certain tracts and result in incomplete cord syndromes 6

In addition to neurological signs (e.g. altered sensation, limb weakness, autonomic dysfunction, and sphincter disruption) there is usually pain due to related injury to the musculoskeletal components of the spine.

There are several types of traumatic spinal cord injury 3-5:

  • spinal cord swelling
  • spinal cord contusion/edema
    • cord edema only: most favorable prognosis
    • cord edema and contusion: intermediate prognosis
    • cord contusion only: worse prognosis
  • intramedullary hemorrhage
  • extrinsic compression, e.g. from fracture fragment or disc herniation
  • spinal cord transection

The mechanism of injury varies and can include:

  • road traffic accidents
  • sports injuries
  • assault or gunshot injury
  • falls

Injuries can be complete or incomplete at a specified level. The most common system is the American Spinal Injury Association (ASIA) Impairment Scale 2.

These have no real role in traumatic cord injury in patients with significant trauma as they have limited sensitivity for detecting spinal cord trauma and bony injuries associated with it.

This is best for assessing the associated bony injuries which may need concomitant treatment consideration but does not assess the cord itself.

Apart from routine axial and sagittal T1 and T2 imaging additional sequences should be considered depending on the clinical concern. T2* sequences (e.g. gradient echoSWI) are more sensitive to hemorrhage, while STIR sequences are more sensitive to associated ligamentous injury.

  • spinal cord swelling
    • focal cord enlargement at the level of trauma without signal change 5 best seen on sagittal T1
  • spinal cord edema
    • as per swelling but with additional increased T2 signal 
  • spinal cord contusion
    • thick high T2 signal rim around small central low T1 signal above or below the level of trauma 5
    • blooming on T2* sequences
  • intramedullary hemorrhage
    • thin high T2 signal rim around large central low T1 signal 5
    • blooming on T2* sequences
    • see aging blood on MRI for other timescales
  • spinal cord transection
    • discontinuity of cord best seen on sagittal sequences 8

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