Spinal Cord Injury Presentation and Treatment

Spinal cord injury is term used for spectrum of insults to the spinal cord which results in either temporary or permanent loss of function of the affected area of the cord.

Spinal cord works to relay motor and sensory signals to the peripheral organs. Therefore the function affected are sensation, proprioreception, activity of smooth and striated muscles.

The profile of the injury and region affected would determine the functions affected. This motor and sensory loss pattern in fact guides the clinicians to reach at the diagnosis of the levels of injury.

At any level, the  injury to spinal cord could be complete[ a total loss of sensation and muscle function at and below the level of injury] incomplete [sparing of some functions distal to level of injury indicating the signal transmission]

The prognosis of the spinal cord injury depends on the severity of the injury and may range from complete recovery to permanent quadriplegia [cervical injuries]  and complete paraplegia in lower injuries.

Physical trauma like motor vehicle injury, gunshots, falls, or sports injuries are most common causes of injury to spinal cord. But the cord injury can also occur due to non-traumatic causes like  infection, insufficient blood flow, and tumors.

In every trauma patient, unless confirmed otherwise, spinal injury is presumed and patient is handled accordingly. That means following spinal precautions in the field and transit.

Males suffer from spinal cord injuries about 4 times more than females. Most of these injuries occur in men under 30 years of age.

The general perception of a cure for spinal cord injury is the loss of motor function. But injury to the spinal cord affects many systems and functions of the body including neural control of motor, sensory, autonomic, bowel and bladder.

The goal of treatment of spinal cord injuries is

• Preventing the loss of function
• Restoring lost functions—including sensory, motor, bowel, bladder, autonomic, and sexual functions
• Elimination of complications- pain, spasticity, pressure sores (decubitus ulcers) and depression

Relevant Anatomy

Spine consists of many vertebrae stacked and articulating with one another to form a vertebral column. Spinal canal occupies the vertebral or spinal canal.

At each level of the spinal column, spinal nerves branch off from either side and exit through intervertebral foramina to supply different regions of body.

The area of skin innervated by a specific spinal nerve is called a dermatome, and the group of muscles innervated by a single spinal nerve is called a myotome. [see the table below for motor functions of different segments].

[ Read more about spinal nerves]

Following are links to detailed anatomy of the spine and spinal cord.

• Spine Anatomy Overview
• Anatomy of Upper Cervical Spine
• Thoracic Spine Anatomy
• Lumbar Spine Anatomy
• Vertebral Canal Anatomy and Contents
• What are Spinal Nerves

 Classification of Spinal Cord Injury

Spinal injuries could be classified according to causation which broadly could be traumatic or non-traumatic.

Another way to classify is complete or incomplete injuries.

A complete injury results in loss of  all functions below the injured area  whereas incomplete spinal injury preserves some motor or sensory function. American spinal injury association (ASIA) suggests that if the person does not  have motor and sensory function in the anal and perineal region representing the lowest sacral cord (S4-S5), it should be classified as complete spinal injury. These segments represent the last spinal nerves of the cord and if the injury has occurred to the lowest segments, it is a complete injury.

Spinal cord injury can also be classified by  the degree of impairment. ASIA score is used for measuring degree of impairment.

More on ASIA score.

Biomechanics of Spine injury

Physical injuries include hyperflexion, hyperextension , lateral stress, rotation (twisting of the head) and compression or distraction.

Traumatic spinal cord injury can result in contusion, compression, or stretch injury.

Nontraumatic injury can occur due to mechanical pressure, toxicity or ischemia.

[Read Flexion Distraction Injuries of Spine]

In this scenario there could be primary and secondary injury. [primary injury is the cell death that occurs immediately in the original injury, and secondary injury occurs due to  biochemical cascades that are initiated by the original insult and cause further tissue damage.

Motor vehicle injury is most common cause of spinal cord injury followed by falls. Gunshot wounds and sports injuries are other important causes.

Nontraumatic causes include tumors, degenerative diseases and infections like tuberculosis.

Intervertebral disc prolapse,  compromise of blood supply due to arteriovenous malformation or intervertebral disks can herniate. Diseases of spinal cord such as multiple sclerosis can also cause the injury.

Clinical Presentation

Non-traumatic orthopedic causes are discussed elsewhere. From here on we would concentrate on traumatic injuries and their management.

[Read about tuberculosis of spine]

After an injury, every patient is deemed to have a spinal injury and is treated like one unless spinal injury has been ruled out. That means right from initial contact with patient in the field the patients is handled with a protocol that protects the spine as well.

Because the spinal cord has got sensory and motor function, the injury to spinal cord would present with loss of sensation, motor weakness or paresthesiae.

The  specific parts of the body affected by loss of function are determined by the level of injury.

Sometimes, there may not be signs of spinal cord injury. But patient may have injured spinal cord and not considering protection of the spine is fraught with risk of injury to spinal cord during handling of patient in extrication, transport and shifting. Therefore, it becomes important to protect spine in all cases.

Following are gross region wise affection of spinal cord injury. The severity of loss of function is dictated by the severity of injury. As  a rule higher level of injury affects more functions than lower.

Cervical Injuries

Depending upon level of injury, the functions affected are motor and sensory functions of all the four limbs, abdominal and trunk muscles, visceral muscles [loss of bladder and bowel functions], respiratory muscles and neck muscles.

Upper cervical muscles are more severe and require ventilator support.

Low heart rate, low blood pressure, problems regulating body temperature can also be present.

Thoracic Injury

Thoracic spinal injuries result in paraplegia, but function of the hands, arms, and neck are not affected. Higher injuries [T1 to T8] affects function of the abdominal muscles and trunk muscles in addition. Injuries to the level T9 to T12 result in partial loss of trunk and abdominal muscle control.

Autonomic dysreflexia, neurogenic shock and temperature regulation may be affected.

Lumbosacral

Loss of  control of the legs and hips, bladder, bowel and genital function system, and anus. Different levels may spare different functions.

It may be reiterated again that a higher complete lesion would include all the deficits of lower level in addition to addition of other neural deficits.

Care of Injured Spine at the Site of Accident

It must be kept into the mind that all trauma patients are at risk for spinal cord injury. The principle of spinal care in all trauma patient is based on the possibility that all trauma patients may have an unstable spine injury definitively excluded.

In any trauma setting the treatment priorities are preserving life, limb, and function. The spine must be protected as these priorities are addressed.

Extrication

Proper extrication of the patient and immobilization of the cervical spine at the accident scene are critical to avoid further neurologic injury. The neck movements are to be avoided when taking out the person out of the car or shifting the person. For this, the head and neck need to be aligned with the long axis of the trunk and immobilized in this position.

Immobilization and Transport

The cervical spine needs to be immobilized to prevent further movements that can cause damage to the spinal cord. Immobilization with cervical collar, sandbags, tape, and spine board. The spine is usually kept in neutral position irrespective of type of injury.

Neutral flexion-extension head and neck alignment is optimal during prehospital transport of cervical spine injury patients .

Helmet and shoulder gear should be left in position until personnel trained in safe removal techniques are available.

Determination of gross neurologic status in the field helps prioritize subsequent treatment interventions.

Suspicion of neurologic injury should be conveyed to the hospital to prepare for subsequent evaluation and management.

Initial Examination

When the patient arrives in hospital a brief over must be taken from the prehospital care team. This helps to get an idea about the scene of injury and circumstances in which patient had been. Also relevant information about treatment along the way must be sought.

There are lot of possibilities in this scenario. In some countries, the prehospital care is excellent and by the time patient arrives in hospital, all the relevant information had been passed by prehospital care team over radio or phone and the hospital is ready to receive the patients.

On the other extreme patient might be brought to the hospital by police van or some good Samaritan and the physician is first person to look at the patient.

Sometimes there is no information available about the circumstances of the injury as the patient was found roadside and brought to the hospital.

In either case, initial evaluation of the patient must include spinal injury evaluation which might go concurrent with resuscitative measures.

Initial evaluation at the hospital arrival must include

• Gross neurological assessment with movement and sensation in all extremities [This might have been done already if prehospital care was extended]
• Assessment of gross neurological function. This again might be based on by report from field personnel, direct observation, or initial examination
• Direct examination to get a a clinical idea of level of injuries
• Cervical spine x-ray, anteroposterior chest x-ray and x-ray of any other injured part
• Analysis of hemodynamic parameters

Any condition which needs immediate treatment should be part of the side by side ongoing resuscitation.

Hypotension, bradycardia, warm extremities in presence of normal urine output must raise the suspicion of neurogenic shock and it needs to be differentiated from hemorrhagic shock shock as the treatment is different. Treatment of neurogenic shock is pharmacologic intervention to augment peripheral vascular tone and may be essential for effective resuscitation. Fluid overload from excessive fluid volume administration, as appropriate for hemorrhagic shock, can result in pulmonary edema in the setting of neurogenic shock.

Spinal cord injury also increases the risk of multiple organ system failure in polytrauma patients. The presence of severe hemodynamic parameter abnormalities in the initial phases of resuscitation is associated with a poor prognosis for neurologic recovery but normal hemodynamics, however, do not predict neurologic recovery.

After the patient has been resuscitated, a detailed examination of the patient follows.

This detail examination follows a different sequence in unresponsive and awake (cooperative) patients and awake sequence of evaluation and intervention steps differs in both the cases.

Detailed Clinical Examination after Stabilization of  Patient

If patient is responsive, a detailed history is obtained regarding acute symptoms and past history.

For unresponsive patients, a past history is obtained from family members or available previous medical records.

The patient must be rolled on his or her side using a log-rolling maneuver. For this, The patient’s head and neck are supported by one person and the trunk by two to three other assistants. The head and trunk are then rolled in unison to facilitate the examination of spine by physician.

Following things are noted –

• Areas of hemorrhage
• Abrasion
• Laceration
• Alignment of the spine
• Gross deformity
• Palpable gap in the spinous processes
• Tenderness

Trunk and abdomen are also examined for injury.

After local examination of the spine neurological examination is performed.

The neurological examination would vary in awake-cooperatibve and unresponsive patients.Awake and cooperative patients require a complete neurological examination. There are many methods and gradings to assess the neurological deficit whose basic purposes are following

• Presence of spinal shock
• Localization of the lesion level
• To determine whether injury is complete or in complete
• To determine if the injury fits into a particular pattern [see below]

Initial care in the hospital, as in the prehospital setting, aims to ensure adequate airway, breathing, cardiovascular function, and spinal immobilization. Acute spinal cord injury should be treated in intensive care unit, especially injuries to the cervical spinal cord

This is achieved by detailed motor and sensory examination.

Following  reflexes must be seen in patients of spinal injury

Reflexes of Spinal Cord and Conus Medullaris

In case of unresponsive patient, radiographic studies are the primary modalities for identifying a spine injury. Spine injury precautions must be observed until the spine is cleared. If a spinal column injury is identified, the neurological deficit should be assessed. This can be done by serial neurological examinations, magnetic resonance imaging and sensory- or motor-evoked potentials.

[More on cervical spine clearance]

Investigations

• Haemoglobin and haematocrit levels should be measured initially and monitored serially to monitor blood loss.
• Renal function and electrolytes: dehydration.
• Perform urinalysis to detect associated genitourinary injury.

 Imaging

 Spinal column injury is trauma that causes fracture of the bone or instability of the ligaments in the spinal column. this can coexist with or cause injury to the spinal cord, but each injury can occur without the other.

Spinal cord injury without radiographic abnormality (SCIWORA) exists when spinal cord injury is present but there is no evidence of spinal column injury on radiograph.

Abnormalities might show up on MRI, but the term was coined before MRI was in common use.

A radiographic evaluation using an X-ray, CT scan, or MRI can determine if there is damage to the spinal column and where it is located.

Radiographs (X-ray)

Following xrays are essential in a patient who has multiple injuries

• Chest x-ray anteroposterior view
• Pelvis x-ray anteroposterior view
• Lateral cervical spine x-ray.

Rest of the imaging for spine is done after patient has been stabilized.

Cervical Spine

After patient is stabilized, a complete imaging of cervical spine views should be obtained. Following views are generally ordered.

• Open mouth view
• Anteroposterior
• Right and left oblique.

Flexion-extension views may be done in case there is doubt of instability.

To avoid further injury the patient is not moved to position for the various views. Instead, the x-ray beam and film position is adjusted.

Lateral radiograph allows visualization of the spine from the occiput to C6 vertebra and C7 if shoulders are pulled during the xray. A swimmer’s lateral view or a CT scan may be needed if lower cervical spine cannot be visualized. Following things are noted in a cervical spine x-ray.

Lateral View

• Alignment of the cervical vertebrae- Assessed by examining longitudinal lines along vertebral bodies, lamina, and spinous processes.
• The prevertebral soft tissues are also examined for swelling related to acute hemorrhage. If increased, it suggests acute cervical spine injury.

Anteroposterior View

Shows the C3 to T4 segments. A change in alignment of the uncovertebral joints (Small synovial joints between adjacent lateral lips of the bodies of the lower cervical vertebrae) and spinous processes can indicate an acute injury.

Open mouth view

It is essential for excluding a C1 arch or odontoid process fracture.

Oblique views

To identify injuries of the facet joints, pedicles, and lateral masses.

Flexion-extension views

To identify any occult cervical ligamentous injury if the patient has pain and tenderness but other xrays are normalThese are dangerous in settings of injury and should be performed in alert patients, under supervision, and with voluntary unassisted positioning by the patient.

Thoraccic, Lumbar and Sacral Spine

Anteroposterior and lateral thoracic and lumbar radiographs and a pelvis AP view are standard xrays. Alignment, destruction of vertebrae or reduction in height of vertebra, vertebral fractures are signs of injury.

Computed Tomography

CT scans are done for

• Patients with suspected spinal fracture and/or dislocation
• Difficult visualization of their spinal column on radiographs.
• Preoperative planning
• substitute for the open mouth view in unresponsive person
• Junctional injuries – Cervicothoracic area, Thoracolumbar junction

CT is superior to MRI in demonstrating bony injury.

MRI

It is done in patients with cervical level spinal cord injury, incomplete spinal cord injury, and for assessment of disk or ligament injuries. The purpose of MRI is to look for integrity of the cord and severity of injury to the cord.

Treatment of Spinal Cord Injury

Initial management

Following cautions should be taken

• Management of airway, respiration, and circulation as the first priority.The cervical spine must be maintained in a neutral alignment at all times.
• Treatment of hypotension if present
• Urinary output monitoring via Foley’s catheterization
• Maintain adequate warmth as temperature control may be poor

All trauma patient must be provided protection and immobilization of the spine until spinal injury has been ruled out or treated definitively.

This general principle and implications are commonly referred to as spine precautions. These precautions include

• All trauma patients should be maintained in the supine position at strict bed rest with the bed flat;
• Transfers should be done with a spine board
• Patients with cervical injury must be stabilized with hard cervical collar
• Log rolling maneuver should be done to turn the patients

Further course of events depend upon the clinical and radiological assessment of the injury.

In case of cervical spine

• Patients with abnormal radiographs/CT with or without deficit are to remain immobilized in a cervical collar till definitive evaluation by the specialist. An MRI may be sought in next 72 hours
• Patients with complaints of neck pain and no radiographic abnormality will remain immobilized in a cervical collar and will undergo flexion/extension radiographic examination at a later time.
• In patients who remain comatose or cannot be clinically evaluated at 48 hours, a computerized tomography of the cervical spine may be asked for.
• Cervical injuries may require skull traction but it should not be applied in distractive injuries. In such cases it may worsen the injury further or may lead to fatal iatrogenic neurologic and vascular injury. These patients are better immobilized with sandbags and tape or a halo apparatus . In non-distractive injuries a skull traction is applied by inserting the tongs in the skull.

In case of injury to rest of spine

• Patients with abnormal thoracic, lumbar and/or sacral spine radiographs should be put on strict bed rest and regular log roll turning should be carried to avoid bed sores. An MRI and/or CT is sought to define the injury better and plan the treatment.

• Patients with complaints of thoracic, lumbar or sacral spine pain and no radiographic abnormality should undergo observation. More radiographs/computerized tomography/ MRI of suspected areas may be obtained .

Patients under intoxication and normal total spine radiographs/computerized tomography should remain in bed until a clinical exam can be performed to reliably.

Definitive Treatment

After initial care of the patient with spinal injury, decision is made about the definitive care. A definitive care aims at making the injured spine stable and removing any decompression on the spinal cord.

Because not all patients would have neural injury and not all patients would have instability of the spine, the definitive treatment has a spectrum from immobilization with a collar to surgery. There are indications for each method and one treatment cannot treat all kind of injuries.

Following are the ways of treating a spinal injury

• Non operative Treatment
• Operative treatment
• Closed reduction with or without surgery (in cervical spine only)

Non Operative Treatment

Non operative treatment remains the standard of care for spinal injuries. Barring few types. Most of injuries can be treated with these methods.

Closed treatment options are

• Traction – In case of cervical spine injuries
• Bed rest with regular periodic turning to avoid bed sores.
• Halo apparatus, external orthosis, or cast.

Bed rest is advised for the initial few weeks and is followed by bracing. This option can be used in unstable injuries too. External orthosis is chosen as per level of the injury.

Bracing is continued for 8–12 weeks in cervical injuries and 12–24 weeks in thoracolumbar injuries. This is the time taken for the fracture to heal sufficiently to bear the load.

Prolonged bed rest as definitive treatment may be advised in rare cases of patients unwilling to undergo bracing or surgery or are unsuitable for that treatment because of severe preexisting deformity, morbid obesity, or medical problems etc.

In some patients, non operative treatment of may lead to chronic pain at a later date.

Operative Treatment

Surgical stabilization of the spinal column aims at

• Prevention of further mechanical injury
• Decompress spinal cord by removing the structures causing compression e.g. bone fragments pressing on the spinal cord

Following patients should be considered for surgery

• Skeletal instability with a neurologic deficit.
• Unstable ligamentous injury in adult patient where non operative treatment does not restore sufficient strength for stability
• Patients with multiple injuries
• Multiply injured patients

The surgery of injured spine varies as per level of the injury but the principles followed are

• Decompression
• Fixation of the injured segment with implant
• Fusion of the segment with bone graft

Read more about lumbar Spine Surgery

The purpose of the implant is to hold the segment in the position till the time fusion occurs. If not fused, implant would fail some day and spine would again become unstable.

There are various gadgets available for spine surgery and each has its own advantages and disadvantages.

Closed Reduction in Spine Injuries

This method is used in cervical spine dislocations. The principle behind this is to use heavy weights to distract the injured area so that a slow maneuver can be performed to reduce the spine. It is quite safe method. Neurologic deterioration during reduction is a risk but is quite rare if done meticulously.

This needs insertion of Crutchfield tongs or Gardner-Wells tongs.

• In alert cooperative patients, imaging is not necessary prior to reduction
• An unconscious patient should be undergo an MRI scan before reduction.
• Injuries such as craniocervical dissociation or a cervical injury that shows distraction should not be put on traction.

Benefits of closed reduction

• Decreases the need for complicated surgical procedures
• Improves stability, prevent neurologic deterioration or can improve neurologic status
• Reduction within the first few hours of injury may lead to dramatic improvement in neurologic status.

There is no effective closed reduction technique for thoracolumbar spine.

Rehabilitation of Spinal Cord Injuries

Spinal cord injuries  patients often require extended treatment in specialized unit or which typically begins in the acute care setting.

Spinal rehabilitation is a multidisciplinary approach and requires Physical therapists, occupational therapists, recreational therapists, nurses, social workers, psychologists and other health care professionals

Orthopedic devices such as ankle-foot orthoses can aid in walking.

Complications of Spinal Cord Injuries

• pulmonary edema
• Respiratory failure
• Neurogenic shock
• Paralysis
• Muscle atrophy
• Pressure sores,
• Neuropathic pain
• Immobility led demineralization of bones
• Heterotopic ossification
• Deep vein thrombosis
• Urinary tract infection and its complications
• Depression

Different Incomplete Patterns of Spinal Cord Injury

Bell’s cruciate paralysis

The lesion is at the level of decussation of motor fibers in brainstem. the patient would present with variable cranial nerve involvement. Weakness of upper is greater than lower limbs and weakness is more pronounced tin proximal part of the limb than distal.

Wallenberg’s hemiplegia

The injury is in one side of brainstem. the picture might also occur in upper cervical spine injury. The clinical picture includes weakness od upper arm on one side and lower limb of the opposite side. there might be cranial nerve cranial nerve and brainstem involvement.

Anterior Cord Syndrome

The lesion is in anterior gray matter of spinal cord which affects descending corticospinal motor tract and spinothalamic tract. The dorsal column is preserved.

The patient presents with loss of motor power below affected level of spine. There is loss of pain and temperature sensation.

However because dorsal column is not injured, there is preservation preservation of proprioception  and deep pressure sensation.

Central Cord Syndrome

It is associated with cervical injuries where central part of the cord is more affected.

Central cord syndrome is characterized by weakness in the arms with relative sparing of the legs, and spared sensation in regions served by the sacral segments. There is loss of sensation of pain, temperature, light touch, and pressure below the level of injury.

The spinal tracts that serve the arms are more affected due to their central location in the spinal cord, while the corticospinal fibers destined for the legs are spared due to their more external location.

Central cord syndrome usually results from neck hyperextension in older people with spinal stenosis. In younger people, it most commonly results from neck flexion.

Motor vehicular accidents are most common cause.

Brown-Sequard Syndrome

The lesion is in lateral half of the cord and there is preservation of contralateral half. Clinical Presentation includes motor weakness on the same side including proprioception loss and contralateral pain and temperature sensory loss.

Conus Medullaris Syndrome

Lesion Injury to the sacral cord (conus) and lumbar nerve roots within the spinal canal. Clinical presentation is of areflexic bladder, bowel, and lower limbs resulting in paralysis and incontinence of bladder and bowel. Bulbocavernosus and micturition reflexes are preserved.

Cauda Equina Syndrome

There is an injury to the lumbosacral nerve roots within the spinal canal and is considered a surgical emergency. The patient presents with areflexic bladder, bowel, anaesthesia in perineum and medial aspect of thigh and lower motor neuron weakness in lower limbs

Root Injury Syndrome

The lesion consists avulsion or compression injury to single or multiple nerve roots (brachial plexus, sacral plexus injury). the patient presents with dermatomal sensory loss, myotomal motor loss, and absent deep tendon reflexes supplied by the affected roots.

Posterior cord syndrome

Posterior cord syndrome, in which just the dorsal columns of the spinal cord are affected, is usually seen in cases of chronic myelopathy but can also occur with infarction of the posterior spinal artery. It causes the loss of proprioception and sense of vibration below the level of injury while motor function and sensation of pain, temperature, and touch remain intact. Usually posterior cord injuries result from insults like disease or vitamin deficiency rather than trauma. Tabes dorsalis, due to injury to the posterior part of the spinal cord caused by syphilis, results in loss of touch and proprioceptive sensation.

Prognosis of Spinal Cord Injury

Prognosis is predicted by  the level and completeness of injury. The neurological score at the initial Most people with ASIA scores of A (complete injuries) do not have functional motor recovery, but improvement can occur. Most patients with incomplete injuries recover at least some function.

People with residual deficits  may need to use specialized devices and to make modifications to their environment in order to handle activities of daily living and to function independently.

In general, most individuals regain some motor function, mostly within the first 6 months, although there may be further improvement observed years later.

People who survive a spinal cord injury often have medical complications, e.g. chronic pain, bladder and bowel dysfunction, and increased susceptibility to lower respiratory tract infections.

References

• American Spinal Injury Association. International Standards for Neurological Classifications of Spinal Cord Injury. revised ed. Chicago, Ill: American Spinal Injury Association; 2000. 1-23.
• Yucesoy K, Yuksel KZ. SCIWORA in MRI era. Clin Neurol Neurosurg. 2008 May. 110(5):429-33.
• Rhee P, Kuncir EJ, Johnson L, Brown C, Velmahos G, Martin M, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. 2006 Nov. 61(5):1166-70.
• Furlan JC, Fehlings MG. Cardiovascular complications after acute spinal cord injury: pathophysiology, diagnosis, and management. Neurosurg Focus. 2008. 25(5):E13.
• Harris MB, Sethi RK. The initial assessment and management of the multiple-trauma patient with an associated spine injury. Spine. 2006 May 15. 31(11 Suppl):S9-15; discussion S36.
• Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma. 2005 May. 58(5):890-5; discussion 895-6.
• Sansam KA. Controversies in the management of traumatic spinal cord injury. Clin Med. 2006 Mar-Apr. 6(2):202-4.
• Hadley MN, Walters BC, Grabb PA, et al. Pharmacological therapy after acute spinal cord injury. Neurosurgery. 2002. 50 Suppl:63-72.
• Mirza SK, Krengel WF 3rd, Chapman JR, Anderson PA, Bailey JC, Grady MS. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop Relat Res. 1999 Feb. (359):104-14.
• Vaccaro AR, Daugherty RJ, Sheehan TP, et al. Neurologic outcome of early versus late surgery for cervical spinal cord injury. Spine. 1997 Nov 15. 22(22):2609-13.

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