High Cervical Spinal Cord Injury without Respiratory or Cardiovascular Compromise: A Rare Event and Its Management

Abstract

High cervical spinal cord injuries (SCIs) resulting from road traffic accidents (RTAs) often lead to serious respiratory and cardiovascular issues. This case report details an unusual instance of a C3-C4 SCI that did not present these complications and discusses its management. A 50-year-old man experienced a C3-C4 SCI in an RTA. Even though he was completely quadriplegic (American Spinal Injury Association grade A), he maintained normal respiratory function and stable cardiovascular readings. A magnetic resonance imaging revealed a contusion at the C3-C4 level. He was treated with injection methylprednisolone and underwent a C3-C4 laminectomy. After the surgery, he showed remarkable improvement in both motor and sensory functions. Throughout his hospital stay, there were no signs of respiratory or cardiovascular distress. This unique case underscores the diverse presentations of SCI, particularly high SCI without respiratory and cardiovascular issues, and suggests that early intervention and rehabilitation can lead to positive outcomes. Additionally, this report sheds light on the importance of early diagnosis, treatment, physiotherapy, and rehabilitation, which can facilitate significant recovery with minimal morbidity or mortality. More research is needed to better understand such atypical cases.

Keywords

ASIA grade - cardiovascular system - cervical spinal cord - quadriplegia - respiratory system - road traffic accidents

Introduction

Road traffic accidents (RTAs) causing spinal cord injury (SCI) is a well-known entity.[1] India is one of the top countries in deaths caused by RTA; SCI is around 40% in those cases. High cervical cord injuries are associated with paraplegia (51%) more than quadriplegia, and respiratory paralysis (26%). Along with respiration, cardiovascular and other systems are also affected in these cases. Many cases end up with prolonged hospital stays. We found a case of RTA presented with American Spinal Injury Association (ASIA) grade A injury, having an injury at the C3-C4 level but without respiratory or cardiovascular compromise. Hence, we wanted to report this case as a rare occurrence and given a glimpse of its management.

Case Presentation

A 50-year-old male with no known comorbidities met with RTA, treated in local hospital, and was referred to our center for further management.

On Examination

He was conscious, alert, and oriented.

• Vitals were stable, SpO2: 98% at room air.

• Breath holding time: normal (> 22 seconds), normal respiratory rate.

• Below the C5 dermatome level, there was a complete loss of motor, sensory, and autonomic functions. Abrasion was noted on the back of the neck.

Hospital Course

Rigid cervical collar was applied. Vitals were monitored and there was no drop in saturation, respiratory rate, or rhythm. He maintained a stable blood pressure (BP) throughout the course. Magnetic resonance imaging (MRI) cervical spine with brain was done. His MRI scan showed C3-C4 cord contusion along with disc osteophyte complex from C3 to C5 level; no other injury was noted ([Fig. 1]). He was given injection methylprednisolone and was continued for 24 hours. He underwent surgery.

Fig. 1 Magnetic resonance imaging (MRI) T2 phase sagittal cervical spine shows cervical cord edema and cord compression from both sides due to osteophyte disc complex.

Intraop

Under C-arm guidance, C3-C4 laminectomy was done. Surgery was uneventful ([Fig. 2]).

Fig. 2 Intraop picture shows post-laminectomy cord, which was tense, bulged out, and pulsatile.

Postop

On postoperative day 1, he had spontaneous breathing, hence was extubated, and he had no respiratory compromise, which was a surprise. He maintained a stable BP and pulse, with no drop in saturation. His power in lower limbs improved to Medical Research Council grade ⅗ and in upper limbs it was ⅖. Tone also improved in all the limbs. He also started recognizing sensory perceptions. Regular physiotherapy was given. On follow-up, he had no respiratory or cardiac issues.

Discussion

RTA causing SCI is one of the leading causes of morbidity and mortality. Young adults are the most common to involve.[1] The cervical cord is more commonly injured vertebral region than other parts in the spine. The most common age group involved is between 30 and 40 years, with a male-to-female ratio of 5.9:1.[1] Among the causes of spinal injury, RTA is the most common, with 45%, followed by a fall from height of 39.63%.[1]

Clinically, traumatic cervical cord injury resulting in complete paraplegia is seen in 51.94% and incomplete paraplegia in 14.72%, with the rest having various ranges of neurological deficits.[2] SCIs have a high risk of mortality, ranging from 4 to 18%.[2] The principal causes include respiratory dysfunction (36–83%) and cardiovascular disorders (41%). Rest include sepsis and multiorgan failures.[2] The prevalence of respiratory failure above C4 was 26.92% and below C4 vertebrae was 11.71%.[2] According to the ASIA spinal injury grading, the prevalence of respiratory failure in patients with grade A, B, C, and D injuries was 39.34, 15, 5.56, and 1.59%, respectively.[2]

Our patient had RTA with C3-C4 cord contusion and presented with ASIA grade A spinal injury. He had loss of sensations below the C5 dermatomal level. At admission, he had no breathing problems, had normal breath-holding time, had good respiratory reserve, and completely stable cardiovascular parameters, which is very rare and were not mentioned in the literature. He was examined and had findings as noted above. MRI identified cord contusion at the C3-C4 level. He arrived within 8 hours of injury, and hence, he was given injection methylprednisolone and was continued for 24 hours.[3] Looking into his clinical status, he underwent C3-C4 laminectomy.

When coming to treatment for SCI, the prevalence of respiratory failure with the surgical intervention was 6.98%, and in nonsurgical patients, it was 39.22%.[3] Our patient had no respiratory insufficiency or compromise. Hence, was extubated. His clinical condition gradually improved.

Other parameters that get affected in high SCIs were the cardiovascular system; with high cervical spine injury, ejection fraction would reduce by 10% and cardiac output decrements by 27%.[4] But our patient had stable BP and pulse from the day of admission to the day of discharge.

He had improved stage-by-stage, with motor power improving first, followed by sensory, bowel functions, tone, and refluxes. Physiotherapy was given regularly.

We wanted to report this case because of its unique presentation, High cervical spine injury, ASIA grade A without respiratory and cardiovascular compromise, and sustained surgery and was extubated without difficulties. This type of case gives us hope in treating them and expecting good recovery without a prolonged hospital stay.

Conclusion

High cervical cord injury causes respiratory and cardiovascular compromise and is one of the leading causes of morbidity and mortality. Our patient had a cervical injury at the C3-C4 level but had normal respiratory and cardiovascular parameters, which was rare. Hence, we wanted to report this case as a unique case and wanted to give a glimpse into its management. Further studies are required for managing this kind of patients and need to formulate the principles of management.

Conflict of Interest

None declared.

Authors' Contributions

C.K.A. named the title, designed the study, provided critical reagents, and wrote the manuscript.

Patients' Consent

Informed consent for publication was obtained from the patient in this study.

• References

• 1 Chhabra HS, Arora M. Demographic profile of traumatic spinal cord injuries admitted at Indian Spinal Injuries Centre with special emphasis on mode of injury: a retrospective study. Spinal Cord 2012; 50 (10) 745-754
• 2 Song J, Shao J, Qi HH, Song DW, Zhu W. Risk factors for respiratory failure with tetraplegia after acute traumatic cervical spinal cord injury. Eur Rev Med Pharmacol Sci 2015; 19 (01) 9-14
• 3 Fehlings MG, Wilson JR, Cho N. Methylprednisolone for the treatment of acute spinal cord injury: counterpoint. Neurosurgery 2014; 61 (Suppl. 01) 36-42
• 4 Mneimneh F, Moussalem C, Ghaddar N, Aboughali K, Omeis I. Influence of cervical spinal cord injury on thermoregulatory and cardiovascular responses in the human body: literature review. J Clin Neurosci 2019; 69: 7-14

Publication History

Article published online:
09 May 2025