Approach to Spinal Cord Injury 
Habib Emil Rafka, Dr. Paul Shu, and Dr. Fraser Henderson Jr. 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Background:  
The best outcomes from management of 
traumatic spinal cord injury are achieved with 
expedient and appropriate management. These 
patients, predominantly young and male, present 
after traumatic events such as motor vehicle 
collisions and falls. A spinal column injury might be 
one aspect of poly-trauma and its management must 
be prioritized as soon as cardiopulmonary stability is 
achieved.  
Current understanding of spinal cord injury 
recognizes both the primary injury (the trauma itself) 
and the secondary injury (damage occurring after the 
trauma itself). Primary spinal cord injury is the initial 
damage done to the spinal cord, most commonly due 
to physical, traumatic stress. Secondary spinal cord 
injury is understood to occur from the delayed and 
harmful inflammatory response that can itself cause 
further neurological damage. Decades of research 
have sought to block this cascade, though sadly no 
definitive treatment has been found. High-dose 
steroid protocols have helped in occasional 
situations, though clinical trials have largely 
remained disappointing. Steroid use is no longer 
standard for spinal cord injuries in most management 
guidelines.  
Primary spinal cord injuries might result 
from impact, laceration, hyper-flexion or -extension, 
or ongoing compression. An efficient but thoughtful 
neurological exam remains critical for the managing 
surgeon because the clinical presentation will result 
from the specific level and the specific part of the 
spinal cord that is involved. There are several 
syndromes of paraplegia, hemiplegia, quadriplegia, 
sensory deficits, loss of bowel control, sexual 
dysfunction, and others that will be recognized by an 
astute surgeon and can localize to the level of injury. 
Imaging can then confirm the diagnosis. 
Because international guidelines generally 
assume a high-resource setting, we must often 
modify our approach in lower resource settings. In 
this chapter we will aim to address:  
● Inconsistent availability of advanced imaging 
● Shortage of material resources such as cervical 
neck braces, ventilators, halo reduction vests, 
Wells-Gardner tongs, etc. 
● Delayed presentation  
● Patients without funds 
● Theater and nursing staff limitations, team 
fatigue and burnout 
 
Anatomy:  
 
A cross-sectional image of the spinal cord, highlighting 
important anatomical structures. Source: 
https://doi.org/10.53347/rID-53264 
 
A stable spine is one that can protect the 
neural elements (cord and nerve roots) within the 
physiologic range of normal human motion. An 
unstable spine, therefore, has lost the ability to 
protect and encase the neural elements in their 
journeys from the skull to the vertebral foramina at 
each level.  
33 vertebrae occur in the human spine: 7 
cervical, 12 thoracic, 5 lumbar, 5 sacral and about 4 
coccygeal. The Greek root for vertebra is 
“spondylo” which explains why we often refer to 
spondylosis or spondylo-listhesis (vertebral slip). 
The vertebral bodies anteriorly stack upon one 
another, held in place by interlocking portions called 
facets. Facets articulate to permit some movement; 
the cervical spine is relatively mobile in flexion and 
rotation, the thoracic spine is limited mostly to 
rotation, and the lumbar spine is limited mostly to 
flexion. The pars is the portion of bone connecting 
superior facets to inferior facets. Transverse 
processes extend posterolaterally, forming joints 
with the rib cage in the thoracic spine. Pedicles 
separate the anterior bodies from the posterior bony 
Approach to Spinal Cord Injury 
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surfaces called laminae, and thereby forming the 
spinal canal, a hollow channel in which the tube-like 
dura runs. Posteriorly a spinous process protrudes at 
the midline, forming the part we can palpate as when 
performing lumbar punctures or massage. Over these 
spinous processes runs the supraspinous ligament 
which contributes to stability. Damage to any part of 
this anatomy that permits non-physiologic extension, 
stretch, compression, etc. will lead to a neurologic 
deficit in the affected territory.  
 
Superior (Top) and posterolateral (Bottom) views of the 
components of the  vertebrae. Source: Jmarchn, CC BY-SA 3.0 
via Wikimedia Commons 
https://commons.wikimedia.org/w/index.php?curid=45613313  
 
The vertebral column has a natural lordosis in 
the cervical and lumbar region and a natural kyphosis 
in the thoracic region. Between each vertebra is a 
cartilaginous, poorly vascularized intervertebral disk 
that acts as a natural cushion to distribute forces 
evenly. 
 
The Human Spine, aka, Vertebral Column. Note the natural 
cervical and lumbar lordosis and thoracic kyphosis. When 
intact, the many articulating joints allow the complex mobility 
of the spinal column.  
 
Approach to Spinal Cord Injury 
Habib Emil Rafka, Dr. Paul Shu, and Dr. Fraser Henderson Jr. 
 
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Left: Image of the extradural spinal cord with nerve roots. 
Right: intradural view of the spinal cord with associated nerve 
roots piercing the dura. The cauda equina, a collection of 
nerves described below, is seen below the conus medullaris, the 
inferior most extent of the spinal cord. Source:CC BY 4.0  
https://creativecommons.org/licenses/by/4.0  via Wikimedia 
Commons 
 
The spinal cord emerges from the brainstem 
and continues down through the cervical and thoracic 
vertebrae to ultimately end at the L1/L2 vertebrae 
where it is called the conus medullaris. Below the 
level of L1/L2, a collection of nerve roots called the 
cauda equina (because the many nerve roots 
resemble the fibers of a horse’s tail) float in 
cerebrospinal fluid within the thecal sac (aka, dura).  
Each spinal level has its own paired spinal 
nerves exiting below the pedicle of that respective 
level (L2 spinal nerve exits below the L2 pedicle), 
except for the cervical level, where the spinal nerves 
exit above the respective vertebrae. Note: although 
there is no C8 vertebra, the C8 nerve exits between 
the C7 and T1 vertebra. 
The spinal cord is surrounded by three 
meningeal layers: dura, arachnoid, and pia. Blood, 
pus, or external penetrating foreign bodies typically 
cause meningeal inflammation which can be quite 
painful. Infection within these layers can travel up 
from the spine to the brain; meningitis should be 
considered after penetrating trauma with a dural leak 
if prompt infectious precautions have not been taken.  
The spinal cord is a complex organ with a plethora of 
functions at each level – hence the various 
presentations of spinal cord injury. Given the 
structure of the anatomy and the tight space in which 
the spinal cord resides, a spinal cord with ongoing 
compression 
and 
some 
preserved 
neurologic 
function 
should 
be 
surgically 
decompressed 
emergently. If there are spinal injuries, a specialist 
should make an assessment of “stable” versus 
“unstable.” Stabilization of the unstable spine with 
internal or external bracing is essential to maximize 
the opportunity for a good outcome.  
Although spinal cord and column anatomy 
can be complex and overwhelmingly intricate, there 
are simple fundamentals that every surgeon can 
remember.  
 
A cross section view of the spinal cord within the vertebral 
canal, ventral is anterior in this picture. 1. the central canal, 2. 
posterior median sulcus, 3. gray matter, 4. white matter, 5. Left 
dorsal root and dorsal root ganglion 6. Left ventral root 7. 
Right fascicles 8. Anterior spinal artery 9. Arachnoid mater 10. 
Dura mater. Source: Tomáš Kebert & umimeto.org, 
https://creativecommons.org/licenses/by-sa/4.0 
Approach to Spinal Cord Injury 
Habib Emil Rafka, Dr. Paul Shu, and Dr. Fraser Henderson Jr. 
 
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via Wikimedia Commons 
 
The anterior spinal artery runs midline from 
the junction of vertebral arteries at the foramen 
magnum and travels down the entirety of the spinal 
cord before ending at the conus medullaris. The 
vertebral arteries pass through the transverse 
processes of the cervical spine at C6 - C2 and can be 
injured during neck trauma.  
 
An illustration showing the relationship of important 
vasculature of the spinal cord, ventral is anterior in this picture. 
Injury to any of these arteries can cause a stroke at the 
respective spinal level. Anastomoses in the mid- and lower-
thoracic spine make it vulnerable to ischemia from hypotension 
or aortic dissection. Source: Hapugoda S, Spinal cord 
(illustrations). Case study, Radiopaedia.org 
https://doi.org/10.53347/rID-54777  
 
Principles:  
Begin your evaluation of the injured patient 
with a primary survey. The goal of this is to identify 
rapidly 
life-threatening 
injuries 
to 
ensure 
cardiopulmonary stabilization. Like the brain, the 
spinal cord can suffer irreversible damage with 
prolonged hypoxia.  
A. Airway and Cervical spine immobilization: 
Confirm airway patency. Assign a quick 
Glasgow Coma Score (GCS) and alert the team 
to intubate the patient with GCS of 8 and below. 
Immobilize the cervical spine in all patients in 
whom you cannot clearly rule out a cervical spine 
injury. Though airway management can be the 
primary concern, do not exacerbate a concurrent 
cervical spine injury by careless manipulation. 
B. Breathing: Ensure adequate ventilation and air 
entry in the chest to rule out hemothorax, 
pneumothorax, 
tamponade, 
and 
other 
immediately life-threatening thoracic injuries. 
C. Circulation: Obtain hemodynamic stability. 
Note that hypotension may not always be 
associated with bleeding. Spinal cord injury 
could present with neurogenic shock which 
presents as hypotension from loss of sympathetic 
tone. Recognizing hypotension caused by spinal 
cord injury is discussed further below.  
D. Disability: To test for disability, you must 
complete a neurologic exam as discussed below.  
E. Exposure/Environment: 
Evaluate 
other 
potential injuries, taking note of the environment 
from which the patient came, and taking note of 
any other hazardous exposures.  
 
After the primary survey, move on to the 
secondary survey. The mnemonic for secondary 
survey is AMPLE: Allergies, Medications, Past 
illness, Last meal, and Events. This history is usually 
taken from the patient’s caretaker if the patient is 
unconscious. 
 
Neurologic examination consists of checking 
strength, assessing sensation at each limb and if 
necessary, discerning the particular level where 
sensation is lost, and examining reflexes. Motor 
strength is graded by muscle group from 0 (no 
strength) to 5 (full strength); a grade of 3 indicates 
only anti-gravity strength, 4 means there is some 
resistance. Unilateral motor deficits affecting both 
arm and leg on one side should point towards a brain 
injury. Note that hemiplegia refers to complete 
weakness 0/5 whilst hemiparesis implies some 
strength is preserved. Conversely, bilateral leg 
weakness (paraplegia or paraparesis) as well as the 
combination of bilateral arm and leg weakness 
(quadriplegia or quadriparesis) are more likely to be 
associated 
with 
spinal 
cord 
injury.  
 
Spinal shock is loss of all or most of motor 
and sensory function immediately following a severe 
spinal cord injury. Flaccid paralysis, anesthesia, and 
loss of reflexes all occur, including loss of the 
bulbocavernosus reflex. The management is usually 
nonoperative. Neurogenic shock occurs in the same 
Approach to Spinal Cord Injury 
Habib Emil Rafka, Dr. Paul Shu, and Dr. Fraser Henderson Jr. 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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population but refers to the vascular phenomenon of 
peripheral vasodilation resulting from the loss of 
sympathetic tone (such as lesions above T6) and 
unopposed parasympathetic activity. Neurogenic 
shock 
is 
characterized 
by 
hypotension, 
bradyarrhythmia, and temperature dysregulation. 
This life-threatening condition requires intensive 
care for volume support and often pressors. Because 
phenylephrine may incite reflex bradycardia, 
norepinephrine is the preferred agent to maintain the 
mean arterial pressure of patients with neurogenic 
shock at 85-90mmHg for at least the first seven days. 
 
Syndrome: Complete Cord Transection 
Causes:  
● Trauma 
● Infection 
● Transverse Myelitis 
● Abscess 
● Tumor 
Clinical Findings: 
● Complete loss of 
sensation below 
level 
● Complete paralysis 
below level 
 
Syndrome: Cord Hemisection 
Causes:  
● Trauma 
● Multiple Sclerosis 
● Tumor  
● Abscess 
Clinical Findings: 
● Ipsilateral loss of 
motor, 
proprioception 
● Contralateral loss of 
pain, temperature 
 
Syndrome: Central Cord Syndrome 
Causes:  
● Neck 
hyperextension 
● Spinal Stenosis 
● Osteoarthritis 
● Syringomyelia 
● Tumor 
Clinical Findings: 
● Motor impairment 
> sensory 
impairment 
● Upper extremities > 
lower extremities 
● Distal > Proximal 
● Bladder dysfunction 
● “Cape-like” 
distribution of pain 
and sensory loss 
 
Syndrome: Anterior Cord Syndrome 
Causes:  
● Hyperflexion 
● Disc protrusion 
● Anterior spinal 
artery occlusion 
● Abdominal aortic 
aneurysm 
Clinical Findings: 
● Motor function loss 
● Pain and 
temperature loss 
● Proprioception 
spared 
 
Cauda Equina Syndrome 
Causes:  
● Disc prolapse 
● Tumor 
● Infection 
Clinical Findings: 
● Bladder and bowel 
dysfunction 
● Saddle anesthesia 
● Sexual dysfunction 
 
 
Spinal cord injury diagnosis can be made from clinical 
examination and confirmed on imaging. The most thorough tool 
is called the ASIA Impairment Scale. The ASIA “level” refers 
to the lowest spinal cord segment with preserved/normal 
function. A full-size copy of this worksheet is provided at the 
end of this chapter. Source: 
https://asia-spinalinjury.org/wp-
content/uploads/2019/04/ASIA-ISCOS-
IntlWorksheet_2019.pdf 
 
 
Sensation travels to the thalamus of the brain 
through several types of nerves bundled into 
different parts of the spinal cord. Therefore, 
examination should include testing for both light 
touch/vibration (posterior columns) and also 
pain/temperature as with a safety pin or sharp object 
(anterior and lateral spinothalamic tracts). Presence 
or absence of sensation, whether temperature, fine 
touch, or position and vibration sense can help you 
determine the type of incomplete spinal cord 
syndrome as shown above. Sensation from the sacral 
area is the most likely to be preserved because it 
travels in the most lateral part of the sensory tract 
Approach to Spinal Cord Injury 
Habib Emil Rafka, Dr. Paul Shu, and Dr. Fraser Henderson Jr. 
 
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(“sacral sparing”) and is therefore most resistant to 
traumatic stretch injury which affects central fibers 
foremost. 
Reflexes must be examined. Levels below a 
spinal cord injury will exhibit increased reflexes, 
whereas reflexes will be decreased if the respective 
nerve root is injured. This is because in a normal 
patient the brain is constantly sending inhibitory 
signals to reflex synapses; if the brain signal is 
interrupted along its path down the spinal cord, the 
reflex synapse is no longer tonically inhibited, and 
the reflex becomes more brisk or even clonic. 
However, a peripheral nerve root injury will decrease 
the reflex because the reflex arc is directly injured. 
Recall that a patient in spinal shock will have loss of 
all reflexes: this condition may persist hours to days 
and rarely for weeks. 
Cervical spine injuries are more associated 
with mortality especially if the C3-C5 cervical 
vertebrae are involved; this is where the phrenic 
nerve arises, supplying the diaphragm.  
Some basic landmarks for sensory loss are:  
● Loss of sensation below the umbilicus indicates 
a lesion at the T10 level. 
● Loss of sensation below the nipple in men, or the 
inframammary fold in women, indicates a lesion 
at the T4 level. 
In the absence of “spinal shock,” if complete 
loss of sensation and motor function is found, 
recovery is unlikely, and therefore emergent surgery 
may be a waste of resources as recovery of function 
is unlikely even after surgery; long term external 
bracing may be a better use of resources depending 
on the context.  
Cauda equina syndrome refers to an injury 
pattern. Consider it with patients who present with 
some of the following components, especially if the 
symptoms are progressing:  
● Bilateral leg weakness  
● Urinary incontinence  
● Loss of sphincter control  
● Sensory loss around the perineum and anus  
Refer these patients promptly for imaging to 
assess for severe compression of the lumbar nerve 
roots and the need for emergent decompression. 
The pre-hospital management of these 
patients is universal- it begins with immobilization 
of the neck and primary and secondary surveys as 
described above. The neck should be immobilized 
with a hard collar at the scene and the patient should 
be maintained supine. Transportation to the hospital 
should be done with a hard board unto which the 
patient is logrolled. 
 
Ideally, a cervical collar is applied at the scene before the 
patient is moved, and the patient is transported on a backboard. 
Source: Baedr-9439, CC0, via Wikimedia Commons 
 
If a neck collar is not available at the scene 
but a hard board is, the patient’s head can be secured 
to the board using tape to prevent movement of the 
head, hence immobilizing the spine. 
Imaging is an important adjunct to the 
diagnosis of spinal cord injury. This is especially true 
for unconscious patients. These include plain x-rays, 
CT scan and/or MRI. Contrast is usually unnecessary 
for trauma situations. The National Emergency X-
Radiography Utilization Study (NEXUS) criteria and 
the Canadian C-Spine Rules are important concepts 
to keep in mind when contemplating imaging for 
spinal cord injury.  
 
According to the NEXUS criteria, cervical 
spine injury should be considered if there is: 
● Neurological deficit 
● Spinal tenderness 
● Alternated mental status 
● Intoxication 
● Distracting injury. 
This can be remembered with the mnemonic 
“NSAID.” Traumatic patients that would not need 
spine imaging require all of the following:  
● Alert and stable 
Approach to Spinal Cord Injury 
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● No focal neurological deficit  
● No altered level of consciousness 
● No intoxication  
● No midline spinal tenderness 
● No distracting injury  
 
The Canadian C-Spine Rule, shown below, also 
offers an intuitive algorithm to think through whether 
imaging is required.  
 
 
A flow-chart highlighting the Canadian C-spine rule Source: 
https://www.physio-pedia.com/Canadian_C-Spine_Rule  
 
Any unconscious or intoxicated patient with 
a mechanism of injury suggestive of neck injury 
should get imaging studies. In resource-rich settings, 
a CT scan of both the head and the cervical spine 
without contrast is usually performed. For conscious 
patients, a midline tenderness, focal neurological 
deficit, and any distracting injury is an indication for 
imaging. In areas where there is no CT scan, an Xray 
series should be ordered even though it is more likely 
to miss non-bony injuries compared to a CT scan.  
In-hospital management includes medical 
and sometimes surgical management. Triage patients 
and diagnose neurogenic shock versus hemorrhagic 
shock. Hemorrhagic shock is usually associated with 
tachycardia and hypotension, unlike neurogenic 
shock which has just hypotension and sometimes 
bradycardia. Support the cardiovascular system with 
fluid resuscitation and then pressors for neurogenic 
shock as necessary to adequately maintain mean 
arterial pressure 85-90. Guidelines no longer support 
high dose steroids for acute spinal cord injury 
because of the adverse side effects, even though it 
may improve recovery in younger patients with some 
motor preservation. Immobilize the neck if 
ligamentous or bony injury (not requiring surgery) is 
suspected. Halo traction, when available, may 
prevent the need for open internal fixation of the 
spine in some cases. Surgery may apply an anterior 
or posterior approach depending on the pathology 
and the instrumentation available. Chronic spinal 
cord compression can be relieved by simple 
laminectomy provided that the neck retains a natural 
lordosis and not a kyphosis, in which case 
instrumented fusion would be warranted. 
 
Laminectomy decompresses the spinal canal by removing its 
“roof,” the lamina and spinous process. Essential structures 
such as the intervertebral facet joints (Red arrows) are 
preserved. Diskectomy can also be performed if disc rupture 
and herniation passes beyond the dotted Red line and 
compresses the spinal canal or the nerve roots passing through 
the neural foramina (Blue arrow.)  
 
Approach to Spinal Cord Injury 
Habib Emil Rafka, Dr. Paul Shu, and Dr. Fraser Henderson Jr. 
 
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A halo vest provides complete immobilization of the neck during 
the healing period. Source: BruceBlaus, CC BY-SA 4.0 via 
Wikimedia Commons 
 
In-hospital management also involves the 
prevention of complications associated with spinal 
cord injuries. Complete spinal cord injuries of the 
cervical spine ultimately lead to death because of the 
many complications that can occur including 
respiratory failure, pneumonia, urosepsis, pulmonary 
embolism, and pressure sores. Intensive nursing 
measures like turning the patient, clean intermittent 
catheterization, aggressive respiratory toilet, and 
prevention of deep venous thrombosis can be taught 
to family/caregivers. 
Rehabilitation including the above measures 
will be a patient’s best chance to regain function. 
Exercises 
can 
be 
started 
in-hospital 
and 
physiotherapy should be involved with spinal cord 
injury from the first day of hospitalization. 
 
Decision Making:  
The decision making of these patients starts 
with first contact. After ruling out or addressing all 
life-threatening conditions and the pattern of injury 
determined, referral is a key decision in the 
management of these patients. Patients with 
incomplete spinal cord injuries with no other life-
threatening condition, those with worsening spinal 
cord injury on repeated exams or those with cauda 
equina syndrome should be referred to a spine 
specialized center immediately since early surgery is 
associated with better recovery compared to those 
with complete injury. Cervical spine injuries are 
more delicate to handle. Patients with cervical 
fractures especially C1 and/or C2 fractures with 
greater than 7mm displacement should be referred 
for operative management. Others may benefit from 
halo traction or rigid neck collar. A decision to 
operate or not depends on the availability of a 
competent surgeon and the patient’s overall status. 
 
Complication Avoidance and Considerations 
Specific to Low Resource Settings 
Surgeons in low resource settings must 
occasionally develop and apply unique solutions for 
spinal cord injury patients. The authors recognize the 
absurdity of applying the same standard of care 
across all global settings. In the authors' experience, 
however, the spine injury patient population in low-
resource settings are otherwise young and previously 
healthy, meaning that remarkable recoveries can be 
observed. This is particularly true when injuries are 
addressed promptly and when complications are 
avoided. For example, tuberculosis infection of the 
spine remains rampant and presents late in the 
disease, but it can often be treated successfully with 
a 
combination 
of 
medications 
and 
surgical 
decompression and fusion or bracing.  
In settings without available instrumentation, 
plaster casting of the cervical spine or thoracolumbar 
junction can brace fractures while they heal or while 
a patient is transported to a facility for definitive 
treatment: https://www.neurosurgeryglobal.com/cases-
videos/cervical-spine-injuries 
Centers without the equipment for spinal 
instrumentation should search for international 
partners to help expand the scope of their services. 
Institutional competition or a surgeon's pride should 
never prevent a physician from seeking external 
advice in patient management, or from transferring a 
patient who would be better served at another 
institution.  
When surgery is undertaken, complications 
must be fastidiously avoided because in low-
resource settings, patients can rarely afford the first 
surgery, much less a second surgery for resolving a 
Approach to Spinal Cord Injury 
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complication. 
Appropriate 
infection 
control 
measures must include complete sterile technique, 
double-gloving, 
and 
copious 
intraoperative 
irrigation. For example, the authors utilize a diluted 
solution of povidone to irrigate wounds before 
closure in every case, and vancomycin powder can 
be sprinkled in wounds.  
Fusion surgeries require three properties for 
bones to fuse properly: osteoinduction, osteogenesis, 
and osteoconduction. If you do not have bone 
allograft options for osteoconduction, fusion cases 
must rely on autograft from separate incisions for 
harvesting of rib or iliac crest bone. Bone marrow 
aspiration through a sterile Jamshidi needle from the 
iliac 
crest 
can 
enhance 
osteogenesis 
and 
osteoinduction. Gentle decortication should be 
performed using a drill on adjacent surfaces of bone 
where a fusion is desired. Antibiotics must be given 
at the time of anesthesia induction and re-dosed 
accordingly during the surgery. Placement of a sub-
fascial surgical drain at the end of surgery can 
decrease postoperative fluid accumulation, thereby 
relieving pressure on the healing wound and 
providing further insurance against a post operative 
infection. The drain is tunneled to exit at least 5 cm 
from the surgical incision and removed promptly 
when the drainage decreases. Data from high income 
countries remains mixed on the use of routine drains 
for spinal surgery. However, in our experience the 
lack of robust hemostatic agents, occasional lapses in 
sterility, and higher ratio of patients to nurses 
inhibiting administration of pain medication favor 
routine use of a subfascial drain. Of course, this must 
be weighed against the expense and availability of 
surgical suction drains at a particular institution. And 
drains should never be put to suction when the dura 
has been compromised or a cerebrospinal fluid 
fistula will develop. Compressive stockings can be 
obtained cheaply and may be a cost-effective method 
for deep venous thrombosis prevention in high-risk 
patients, 
especially 
where 
pharmacological 
prophylaxis is unavailable. 
The importance of close follow-up must be 
explained 
to 
patients 
so 
that 
postoperative 
complications can be recognized and addressed 
quickly. For conservatively managed injuries, close 
clinical and radiological follow-up can also 
recognize when an unstable kyphosis starts to 
progress or when a neurologic deficit is worsening.  
Finally, all surgeons of the spine must keep 
excellent records of their cases and outcomes to 
facilitate their internal reviews and as a source of 
future research. By sharing experiences and 
outcomes in journals and at conferences, surgeons 
will find that many of their challenges have been 
similar to those of their colleagues, and the data will 
indicate the superior treatment algorithms. 
 
 
 
Habib Emil Rafka 
Medical University of South Carolina 
USA 
 
Paul Shu MD 
Mbingo Baptist Hospital 
Cameroon 
 
Fraser Henderson Jr MD 
Tenwek Hospital 
Kenya 
 
February 2024 
 
 
Resource-Rich Settings 
Spinal cord stimulation (SCS) involves implantation of a pulse-
generating battery pack connected to epidural electrodes 
overlying the dorsal horns of the spinal cord. The Gate Control 
Theory of pain presumes that stimulation of the dorsal sensory 
columns inhibits perception of pain in the brain. 
 
Neural Stem Cell transplantation is an unproven but exciting 
area of research that might harness a patient's own neural stem 
cells and inject them into sites of injury to promote healing, 
reduce scarring, and decrease painful inflammation. 
 
Approach to Spinal Cord Injury 
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REV 04/19
Page 1/2
This form may be copied freely but should not be altered without permission from the American Spinal Injury Association.
NEUROLOGICAL 
LEVELS
Steps 1- 6 for classific
a
t ion  
as on reverse
1. SENSORY 
2. MOTOR
  R         L
 3. NEUROLOGICAL 
LEVEL OF INJURY
(NLI)
4. COMPLETE OR INCOMPLETE?
Incomplete = Any sensory or motor function in S4-5
5. ASIA IMPAIRMENT SCALE (AIS)
(In injuries with absent motor OR sensory function in S4-5 only)
6. ZONE OF PARTIAL
PRESERVATION
Most caudal levels with any innervation
SENSORY 
MOTOR
  R         L
MOTOR SUBSCORES  
SENSORY SUBSCORES  
UER
+UEL
= UEMS TOTAL
LER
+ LEL
= LEMS TOTAL
PPR
+ PPL
= PP TOTAL
LTR
+ LTL
= LT TOTAL
MAX (25)
(25)
(50)
(25)
(25)
(50)
(56)
(56)
(112)
MAX
MAX (56)
(56)
(112)
MAX
(50)
(56)
(56)
RIGHT TOTALS
          (MAXIMUM)
(56)
(56)
(50)
LEFT TOTALS
(MAXIMUM)
(VAC) Voluntary Anal Contraction 
(Yes/No)
(DAP) Deep Anal Pressure 
(Yes/No)
C5
C6
C7
C8
T1
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1
L2
L3
L4
L5
S1
C2
C3
C4
S2
S3
S4-5
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
C2
C3
C4
S2
S3
S4-5
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
RIGHT
LEFT
UER
(Upper Extremity Right)
LER
(Lower Extremity Right)
UEL
(Upper Extremity Left)
LEL
(Lower Extremity Left) 
Elbow fle
x
or s
Wrist extensors
Elbow extensors
Finger fle
x
or s
Finger abductors (little fin
g
er )
Hip fle
x
or s
Knee extensors
Ankle dorsifle
x
or s
Long toe extensors
Ankle plantar fle
x
or s
Elbow fle
x
or s
Wrist extensors
Elbow extensors
Finger fle
x
or s
Finger abductors (little fin
g
er )
Hip fle
x
or s
Knee extensors
Ankle dorsifle
x
or s
Long toe extensors
Ankle plantar fle
x
or s
    Pin Prick (PPR)
Light Touch (LTR)
Pin Prick (PPL)
Light Touch (LTL)
SENSORY 
KEY SENSORY POINTS
MOTOR
KEY MUSCLES
MOTOR
KEY MUSCLES
0 = Absent
1 = Altered
2 = Normal
NT = Not testable
0*, 1*, NT* = Non-SCI 
                     condition present
SENSORY
(SCORING ON REVERSE SIDE)
 0 = Total paralysis
 1 = Palpable or visible contraction
 2 = Active movement, gravity eliminated
 3 = Active movement, against gravity
4 = Active movement, against some resistance 
5 = Active movement, against full resistance
NT = Not testable 
0*, 1*, 2*, 3*, 4*, NT* = Non-SCI condition present
MOTOR
(SCORING ON REVERSE SIDE)
Comments (Non-key Muscle? Reason for NT? Pain?
Non-SCI condition?):
C2
C2
C3
C4
T3
S4-5
S3
S2
S1
L5
L
4
L
3
L
2
C3
C4
T2
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
C8
C7
C6
Dorsum
Palm
Key Sensory
Points
Patient Name
Date/Time of Exam
Examiner Name 
Signature
INTERNATIONAL STANDARDS FOR NEUROLOGICAL 
CLASSIFICATION OF SPINAL CORD INJURY
(ISNCSCI)
 
Approach to Spinal Cord Injury 
Habib Emil Rafka, Dr. Paul Shu, and Dr. Fraser Henderson Jr. 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
  
