The cause of neurologic deterioration after acute cervical spinal cord injury

Study Design: A retrospective review was performed to identify patients at risk for secondary neurologic deterioration after complete cervical spinal cord injury. Objective: To examine the causes of early neurologic deterioration in patients with complete spinal cord injury at a regional spinal cord injury center. Summary of Background Data: After complete spinal cord injury, neurologic deterioration occurs in a subgroup of patients. Despite anecdotal reports, no study has clearly identified the subgroups at highest risks. Methods: One hundred eighty-two patients with complete spinal cord injury were identified among 1904 consecutive patients with acute spinal trauma evaluated from March 1993 through September 1999. Parameters analyzed included demographics, mechanism of injury, American Spinal Cord Injury Association (ASIA) level on admission and during hospital stay, onset of ascension, blood pressure, hemoglobin, febrile episode, heparin administration, and the timing of operation and traction. Radiographs of patients with ascending complete spinal cord injury were reviewed with attention to fracture type and neurologic and vascular injuries. Results: Twelve of 186 patients with ASIA Grade A (6.0%) complete spinal cord injury had neurologic deterioration during the first 30 days after injury. No patients With penetrating injuries had deterioration. A significant association between death and ascension was observed. The onset of ascension of the injury could be categorized into three discrete temporal subsets. Early deterioration (less than 24 hours) was typically related to traction and immobilization. Delayed deterioration (between 24 hours and 7 days) was associated with sustained hypotension in patients with fracture dislocations. Late deterioration (more than 7 days) was observed in a patient with vertebral artery injuries. Conclusion: Delayed neurologic deterioration in complete spinal cord injury (ASIA A) is not rare. Specific causes were identified among discrete temporal subgroups. Management of complete spinal cord injury can be improved with recognition of these temporal patterns and earlier intervention.