Spinal Cord Injury Diagnosis: a Step by Step Guide

By Scihealthhub – December 12, 2024

A spinal cord injury (SCI) can have devastating consequences, making timely and accurate diagnosis essential for effective treatment and improved outcomes.

The human spinal cord is the body’s communication highway, transmitting signals between the brain and the rest of the body. Any damage to this system can lead to serious complications, including paralysis or loss of vital functions. 

Road traffic accidents are the most common causes of spinal cord injuries, accounting for nearly up to 40% of new cases. Other causes of spinal cord injuries include falls, gunshot wounds, sports accidents, work-related accidents and diseases (e.g., tumors, infections) (1).

Timely diagnosis of spinal cord injury allows healthcare providers to take immediate steps to stabilize the injury, prevent further damage, and map out a treatment plan tailored to the patient’s needs.

In contrast, delays or inaccuracies in diagnosis can worsen the injury, prolong recovery, and reduce the chances of regaining lost functions.

This makes understanding the diagnostic process important, not just for medical professionals but also for patients and their loved ones.

In this step-by-step guide, we’ll break down the key stages involved in diagnosing a spinal cord injury. 

Step 1: Suspecting a Spinal Cord Injury

The first step in spinal cord injury diagnosis is knowing when to suspect the condition. 

Timely suspicion is crucial because immediate actions taken at the scene of an incident can significantly impact recovery outcomes. 

For instance, improper handling or transportation of a person with a potential spinal cord injury can lead to further damage to the spinal cord and worsen the condition.

Rescuers should suspect a spinal cord injury in cases of trauma if any of the following key signs are observed:

• Severe neck or back pain: The individual reports intense discomfort in these areas.
• Weakness, numbness, or loss of movement: They experience difficulty moving or feeling their limbs.
• Loss of or reduced consciousness: The person appears drowsy, unresponsive, or disoriented.
• Abnormal body alignment: Their neck or body is twisted or positioned unnaturally.

When these signs are present, it’s essential to handle the individual with extreme caution and get professional help immediately. 

You might like to see what immediate actions should taken if you suspect a spinal cord injury in our article Spinal Cord Injury Treatment (Current and Future). 

Step 2: Recognizing Symptoms of Spinal Cord Injury

The next step in spinal cord injury diagnosis is to recognize the common signs and symptoms. 

These can be classified into two – Immediate and delayed symptoms and signs.

Immediate Symptoms and Signs

These symptoms appear right after the injury (0 to 48 hours post-injury):

• Severe back or neck pain: Persistent and intense pain in the spine area.
• Loss of or change in sensation: Numbness, tingling, or loss of feeling below the injury site.
• Loss of movement: Partial or complete inability to move certain parts of the body, especially the arms and legs.
• Difficulty breathing: Trouble catching a breath or shallow breathing, which may signal an injury to the cervical spinal cord.
• Loss of bladder control: Inability to control urination, leading to incontinence.
• Loss of bowel control: Difficulty controlling bowel movements, often accompanied by constipation or incontinence.

Delayed Symptoms and Signs

These symptoms often develop over time (48 hours to weeks/months post-injury):

• Muscle spasms: sudden, involuntary contraction in one or more muscles causing the affected body part to move uncontrollably. 
• Spasticity: abnormal, uncontrolled tightening of muscles causing the limb to become stiff, heavy, and difficult to move.
• Muscle atrophy: Gradual muscle wasting due to disuse.
• Changes in reflexes: Exaggerated or diminished reflex responses in affected areas.
• Changes in sexual function. 

Step 3: Initial Assessment at the Scene or Emergency Room

Once a spinal cord injury is suspected, the initial assessment performed by first responders and emergency medical teams is critical in ensuring the patient’s safety and improving their prognosis. 

This step focuses on stabilizing the injured person, identifying the potential severity of the injury, and minimizing any further harm.

Role of First Responders

First responders are often the first to evaluate and assist the individual at the scene of the incident. Their responsibilities include:

• Securing the Scene: Ensuring the environment is safe for both the patient and the rescuers to prevent additional injuries.
• Call emergency services: Get professional help immediately.
• Immobilizing the Spine: Using cervical collars, backboards, or other spinal immobilization tools to prevent movement that could worsen the injury.
• Assessing Vital Signs: Monitoring breathing, pulse, and level of consciousness to determine if life-saving measures are needed.
• Gathering Information: Asking witnesses about the incident and the patient’s symptoms, if possible, to help inform further medical care.

Role of Emergency Medical Teams in the ER

Once the patient arrives at the emergency room, the medical team continues the assessment and stabilization process:

• Triage and Prioritization: Evaluating the patient’s condition and prioritizing care based on the severity of the injury.
• Primary Survey: Conducting a rapid evaluation focusing on identifying life-threatening conditions using the ABC approach (Airway, Breathing, Circulation). 
• Initial Neurological Assessment: Checking for signs of spinal cord damage, such as weakness, numbness, or loss of sensation, and documenting these findings.

Step 4: Medical History and Physical Examination

After the initial stabilization, the next step in spinal cord injury diagnosis involves a detailed medical history and physical examination. This process helps the healthcare provider understand the circumstances surrounding the injury, identify potential risk factors, and evaluate the extent of neurological damage.

Besides identifying the location and extent of the injury, this step also provides essential information to guide the next stages of care and rehabilitation. 

Medical History

A comprehensive medical history helps the healthcare team gather vital information about the injury and the individual’s overall health. Key aspects include:

• Injury Details: The cause and mechanism of the injury (e.g., a car accident, fall, or sports injury) and the time elapsed since the incident.
• Symptoms: Any symptoms experienced, such as loss of sensation, muscle weakness, or difficulty breathing.
• Pre-existing Conditions: Prior medical conditions, such as degenerative spine disease, osteoporosis, or past spinal injuries, which may influence the injury’s severity and recovery.
• Medications: Current medications that could affect treatment options or recovery, such as blood thinners or immunosuppressants.

Physical Examination

The physical examination involves a thorough evaluation of the patient’s neurological status and general health to determine the location and severity of the spinal cord injury. This may include:

1. Neurological Assessment:

The American Spinal Injury Association (ASIA) Impairment Scale is often used to classify the injury level and severity.

Key elements include:

Sensory Function Testing: Involves evaluating light touch and pinprick sensation at specific points on the body. 

Motor Function Testing: Checks muscle strength and the ability to move specific muscle groups. Strength is graded on a scale from 0 (no movement) to 5 (normal strength).

Impairment Grading: Based on ASIA Impairment Scale, the extent of the injury is classified from Grade A to E:

• A (Complete): No sensory or motor function in the sacral segments (S4-S5).
• B (Sensory Incomplete): No motor function, but sensory function is preserved below the injury level, including sacral segments.
• C (Motor Incomplete): Motor function is preserved below the injury level, with more than half of key muscles having a grade less than 3 (unable to move against gravity).
• D (Motor Incomplete): Motor function is preserved, with at least half of key muscles graded 3 or higher.
• E (Normal): Sensory and motor functions are normal.

2. Reflex Testing:

Reflexes, such as the deep tendon reflex, are assessed to identify abnormal responses that may indicate spinal cord dysfunction.

3. Autonomic Function Testing:

Evaluations for bladder, bowel, and blood pressure control, which are often affected by spinal cord injuries.

4. Observation of Other Signs:

Checking for deformities, bruising, or tenderness in the spine.

Assessing for complications like respiratory difficulty or signs of shock.

Step 5: Imaging Tests

Imaging tests are vital for confirming the diagnosis of spinal cord injury, assessing its severity, and planning further treatment. 

These techniques provide detailed views of the spinal column and surrounding structures, enabling healthcare providers to pinpoint the location and extent of damage. 

A combination of imaging modalities is often used to gather comprehensive information about the injury.

1. X-rays

X-rays are typically the first imaging study performed, especially in emergency settings. They are quick, widely available, and effective for detecting:

• Fractures: Broken vertebrae or cracks in the spinal bones.
• Dislocations: Misalignment of vertebrae caused by trauma.
• Degenerative Changes: Conditions like osteoporosis or spondylosis that may predispose an individual to spinal cord injury.

However, X-rays have limitations as they primarily visualize bones and may not provide sufficient detail about soft tissue or nerve damage.

2. CT (Computed Tomography) Scans

CT scans offer a more detailed, cross-sectional view of the spine compared to X-rays. They are especially useful for:

• Identifying Small Fractures: CT scans can detect fractures that might be missed on X-rays.
• Assessing Bone Alignment: They help in evaluating complex fractures and dislocations.
• Visualizing Soft Tissues: While not as detailed as MRI, CT scans can provide some insight into soft tissue injuries, including muscle or ligament damage.

CT is often used when X-rays reveal abnormalities or when a more detailed evaluation is required.

3. MRI (Magnetic Resonance Imaging)

MRI is the gold standard for evaluating spinal cord injuries due to its superior ability to visualize soft tissues. It is particularly valuable for:

• Detecting Spinal Cord Damage: MRI can reveal bruising (contusion), swelling, or bleeding within the spinal cord.
• Assessing Ligament and Muscle Injuries: Critical for understanding the stability of the spine.
• Herniated Discs or Compressed Nerves: MRI can identify disc material pressing on the spinal cord or nerve roots.
• Diagnosing Secondary Conditions: Such as hematomas, abscesses, or tumors affecting the spinal cord.

Although MRI provides the most detailed images, it is more time-consuming and may not always be available in emergency situations.

4. Ultrasound

Rarely used but may assist in bedside evaluations in specific situations, such as assessing blood flow to the spine.

5. Myelography

This is an advanced imaging technique that is sometimes employed for a more comprehensive assessment. It is basically an X-ray or CT scan performed after injecting contrast dye into the spinal canal. It can help identify blockages in the flow of cerebrospinal fluid, often caused by herniated discs or tumors.

Step 6: Laboratory Tests and Additional Investigations

While imaging studies and clinical assessments provide critical information about the physical damage to the spine, laboratory tests and related evaluations help detect complications or underlying conditions, monitor overall health, and guide treatment strategies.

1. Routine Laboratory Tests

These tests are commonly performed in most cases of spinal cord injury. They include:

Complete Blood Count (CBC):

Identifies anemia, infections, or blood loss associated with trauma.

Elevated white blood cell (WBC) count may indicate infection or inflammation.

Electrolyte Levels:

Monitors imbalances in sodium, potassium, calcium, and other electrolytes that can arise from trauma, medications, or immobility.

Blood Urea Nitrogen (BUN) and Creatinine:

Evaluates kidney function, particularly if there is urinary retention or catheter use is involved.

Blood Glucose Levels:

Assesses metabolic status. 

2. Additional Tests 

These tests  may be considered by your healthcare provider under certain circumstances. 

Urinalysis and Urine Culture: Detects signs of UTIs, which are common due to impaired bladder function.

Blood Cultures: Identifies systemic infections (sepsis), which can complicate recovery.

Wound Cultures: Taken if there are pressure sores or surgical wounds.

Coagulation Studies: Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) can be ordered to assess clotting function, especially if the individual is at risk of deep vein thrombosis (DVT) or pulmonary embolism.

Inflammatory Markers: Tests like C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) can indicate inflammation or infection.

Cerebrospinal Fluid (CSF) Analysis: If an infection, bleeding, or neurological disorder is suspected, a lumbar puncture (spinal tap) may be performed to analyze CSF. 

Cardiac and Pulmonary Evaluations: EKG and chest X-ray may be ordered for individuals with potential cardiovascular or respiratory complications.

Step 7: Formulating a Diagnosis

This is the final step in spinal cord injury diagnosis. Once all the necessary evaluations are complete, the healthcare provider integrates the findings from clinical examinations, imaging studies, and laboratory tests to confirm the diagnosis, determine the level of the injury and whether it is complete or incomplete, and identify any co-existing health condition or complications. 

After the diagnosis is confirmed, the provider discusses the treatment options, prognosis and possible outcomes with the patient and their family. 

The provider will give an honest but empathetic explanation of the current condition, potential recovery trajectory, and any anticipated challenges.

Conclusion

Diagnosing spinal cord injury involves a combination of clinical assessments, imaging, and laboratory testing. Early and accurate diagnosis is vital to prevent further damage and initiate appropriate treatment.