Central nervous system

Neurological assessment is often difficult in patients who are under the influence of alcohol/drugs or who have a head injury.

Whenever possible sensory and motor assessment together with reflex changes should be documented. Involuntary, reflex withdrawal of extremities to stimulus should be distinguished from voluntary, repeatedly reproducible movements of extremities. Ill-defined observations such as “moving periphery”, “moving all four limbs” is inadequate to make a meaningful assessment of the extent of the neurological deficit. If examination is difficult, documentation should reflect this. If examination is incomplete, documentation should reflect this.

Sensory assessment particularly around the perineum has significant prognostic value and should always be performed. In the unconscious patient the presence of priapism may suggest neurological deficit due to SCI. A proportion of patients seen soon after SCI in the A&E Department may exhibit involuntary fasciculation of lower extremity muscles and rarely in the upper extremity muscles. These do not represent preservation of true motor function.

The use of a sensory chart is strongly recommended (appendix A).

The use of a spinal injury motor chart may be of value in certain centres (appendix B).

Neurological assessment should be repeated at least once after transfer to an appropriate receiving ward during the first 24 hours. Neurological assessment should be carried out following each increment of traction weight if a reduction is being attempted. Daily neurological charting during the first week and weekly charting thereafter is strongly recommended. Occasionally patients with thoraco-lumbar spinal column injury may suffer a gradual but progressive neurological deterioration over several hours or days. This could be related to a spinal cord oedema or vascular insult to the spinal cord.