Spinal Cord Injury

Anugrah onie w, dr, Neurosurgeon

Basic Anatomy and Physiology
What is the anatomy of the spinal cord on
cross section?
What is the anatomy of the spinal cord on
cross section?
What are the clinically important ascending tracts and where do they
cross over?
What are the clinically important descending tracts and where do they
cross over?
At what level does the spinal cord end and
why is it important?
What are the differences between UMN and LMN? (e.g., cauda equina
vs. myelopathy)
Spinal Cord Injuries
Whos at risk?
ADULT MEN BETWEEN 15 AND 30 YEARS
Anyone in a risk-taking occupation or lifestyle
SCI in older clients increasing largely due to MVAs
Spinal Cord Injuries
Causes (in order of frequency)
MVA
Gunshot wounds/acts of violence
Falls
Sports injuries
Spinal and Neurogenic Shock
Below site of injury:
Total lack of function
Decreased or absent reflexes and flaccid paralysis
Lasts from a week to several months after onset.
End of spinal shock signaled by muscular spasticity, reflex
bladder emptying, hyperreflexia
What is the difference between spinal shock
and neurogenic shock?
Spinal shock is mainly a loss of reflexes (flaccid paralysis)
Neurogenic shock is mainly hypotension and bradycardia due
to loss of sympathetic tone
Neurogenic shock
Seen in cervical injuries
Due to interruption of the sympathetic input from
hypothalamus to the cardiovascular centers
Hallmark: hypotension (due to vasodilation, due to loss of
sympathetic tonic input) is associated with bradycardia (not
tachycardia, the usual response), due to inability to convey
the information to the vasomotor centers in the spinal cord
Classification of SCI
Mechanism of injury
Flexion (bending forward)
Hyperextension (backward)
Rotation (either flexion- or extension-rotation)
Compression (downward motion)
Pathophysiology
of SCI
Classification of SCI
Level or Injury
Cervical (C-1 through ??)
Thoracic (T-1through ??)
Lumbar (L-1through ??)
Degree of Injury
Complete
Total paralysis and loss of sensory and motor function
although arms or rarely completely paralyzed
Incomplete or partial
Motor: how do you test each segment?
Motor: how do you grade the strength?
Sensory: how do you determine the level?
What are the important vegetative functions
and when are they affected?
Reflexes
Deep Tendon Reflexes
Arm
Bicipital: C5
Styloradial: C6
Tricipital: C7
Leg
Patellar: L3, some L4
Achilles: S1
Pathological reflexes
Babinski (UMN lesion)
Hoffman (UMN lesion at or above cervical spinal cord)
Clonus (plantar or patellar) (long standing UMN lesion)
What is and how do you determine the level
of injury?
Motor level = the last level with at least 3/5
(against gravity) function
NB: this is the most important for clinical purposes
Sensory level = the last level with preserved
sensation
Radiographic level = the level of fracture on plain
XRays / CT scan / MRI
NB: spine level does not correspond to spinal cord
level below the cervical region
Degree of Injury
Complete transection
Total paralysis and loss of sensory and motor function
although arms or rarely completely paralyzed
Incomplete (partial transection)
Mixed loss of voluntary motor activity and sensation
Four patterns or syndromes
Incomplete cord patterns
Insert picture of cord here
Central cord syndrome More common in older
clients
Frequently from hyperextension of spine
Weakness in upper and lower ext, but greater in upper.
Anterior cord syndrome
Posterior cord syndrome
Brown-Sequard syndrome
Anterior cord syndrome
Compression of the ant. Cord, usually a flexion injury
Sudden, complete motor paralysis at lesion and below;
decreased sensation (including pain) and loss of
temperature sensation below site.
Touch, position, vibration and motion remain intact.
Posterior cord syndrome
Assoc with cervical hyperextension injuries
Dorsal area of cord is damaged resulting in loss of
proprioception
Pain, temperature sensation and motor function remain
intact.
Brown-Sequard syndrome
Damage to one half of the cord on either side.
Caused by penetrating trauma or ruptured disk.
ischemia (obstruction of a blood vessel), or infectious
or inflammatory diseases such as tuberculosis, or
multiple sclerosisBSS may be caused by a spinal cord
tumor, trauma (such as a puncture wound to the neck
or back),.
a rare SCI syndrome which results in
weakness or paralysis (hemiparaplegia) on one side of the
body and
a loss of sensation (hemianesthesia) on the opposite side.
Clinical manifestations of SCI
Depend on the LEVEL and DEGREE of the injury!
Quadriplegia occurs with C-1 through
C-8 injuries.
Paraplegia occurs with T-1 thru L-4.
SEE TABLE 57-3 ON PAGE 1725!
Clinical Manifestations of SCI
Respiratory
C1 C3: Absence of ability to breathe independently.
C4 poor cough, diaphragmatic breathing,
hypoventilation
C5 T6: decreased respiratory reserve
T6 or T7 L4: functional respiratory system with adequate
reserve.
Initial Management
Immobilization
Rigid collar
Sandbags and straps
Spine board
Log-roll to turn
Prevent hypotension
Pressors: Dopamine, not Neosynephrine
Fluids to replace losses; do not overhydrate
Maintain oxygenation
O2 per nasal canula
If intubation is needed, do NOT move the neck
Management in the hospital
NGT to suction
Prevents aspiration
Decompresses the abdomen (paralytic ileus is
common in the first days)
Foley
Urinary retention is common
Methylprednisolone (Solu-Medrol)
Only if started within 8 hours of injury
Exclusion criteria
Cauda equina syndrome
GSW
Pregnancy
Age <13 years
Patient on maintenance steroids