Principles of medicine and surgery L.

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‫حيدرقاسم املوسوي‬.‫د‬
The Spinal Cord:
Spinal Cord Injury:
Spinal cord injury (SCI) is a major health problem, occurs almost four times more
often in males than females. Young people aged 16 to 30 suffer more than half of the
new SCIs each year.
The most common cause of SCI is motor vehicle crashes, which account for (35%) of
the injuries, violence-related injures account for nearly as many SCIs (30%), fall from
height causing (19%) and sports-related injuries causing (8%). There is a high
frequency of associated injuries and medical complications.
The predominant risk factors for SCI include age, gender, and alcohol and drug use.
The frequency with which these risk factors are associated with SCI serves to
emphasize the importance of primary prevention.
The vertebrae most frequently involved in SCI are the 5th, 6th, and 7th cervical (neck),
the 12th thoracic, and the 1st lumbar vertebrae. These vertebrae are the most
susceptible because there is a greater range of mobility in the vertebral column in
these areas.
Damage to the spinal cord ranges from transient concussion (from which the patient
fully recovers) to contusion, laceration, and compression of the cord substance (either
alone or in combination), to complete transection of the cord (which renders the
patient paralyzed below the level of the injury).

SCIs can be classified into two categories:

1. Primary SCIs: are the result of the initial direct insult or trauma and are usually
permanent.

2. Secondary SCIs: are usually the result of a contusion or tear injury, in which the
nerve fibers begin to swell and disintegrate. A secondary chain of events produces
ischemia, hypoxia, edema, and hemorrhagic lesions, which in turn result in
destruction of myelin and axons. These secondary reactions, believed to be the
principal causes of spinal cord degeneration at the level of injury, are now thought
to be reversible 4 to 6 hours after injury. Therefore, if the cord has not suffered
irreparable damage, some method of early treatment is needed to prevent partial
damage from developing into total and permanent damage.

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Causes of Non-traumatic spinal cord injuries (NTSCIs):
1. Spinal tumour: primary tumour (intradural or extradural) and metastasis
(from lung, breast, bowel and prostate)
2. Degenerative disorders: degenerative disc disease, herniated disc and spinal
stenosis.
3. Vascular disorders: spinal ischemia, aneurysm, haematoma and spinal AVM.
4. Inflammatory: Vasculitis and sarcoidosis
5. Autoimmune/ demyelinating: Transverse myelitis (TM), multiple sclerosis
(MS)
6. Infections: Herpes, HIV and TB

Clinical Manifestations of SCIs:

Clinical Manifestations of SCIs depend on the type and level of SCIs. The type of
injury refers to the extent of injury to the spinal cord itself. Incomplete spinal cord
lesions are classified according to the damaged area of spinal cord: central, lateral,
anterior, or peripheral.
The American Spinal Injury Association (ASIA) provides another standard
classification of SCI according to the degree of sensory and motor function present
after injury. “Neurologic level” refers to the lowest level at which sensory and motor
functions are normal. Below the neurologic level, there is total sensory and motor
loss, loss of control of the urinary bladder and the bowel (usually patient presents
with urine retention and bladder distention), loss of sweating and vasomotor tone, and
marked reduction of blood pressure as a result from loss of peripheral vascular
resistance. ‫ﺷﻠﻞ ﺳﻔﻠﻲ‬
Complete spinal cord damage can result in paraplegia (paralysis of the lower body) or
quadriplegia (paralysis of all four extremities). If conscious, the patient usually
complains of acute pain in the back or neck, which may radiate along the involved
nerve. Absence of pain, however, does not rule out spinal cord injury, and a careful
assessment of the spine should be done in the face of any significant mechanism of
injury. Often the patient speaks of fear that the neck or back is broken. Respiratory
dysfunction is related to the level of injury, the muscles contributing to respiration are
the abdominals and intercostals (T1 to T11) and the diaphragm. In high cervical cord
injury, acute respiratory failure is the leading cause of death.

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Assessment and Diagnostic Findings:
A detailed neurologic examination is performed. Diagnostic x-rays (lateral cervical
spine x-rays) and CT scanning are usually performed initially. An MRI scan may be
ordered as a further workup if a ligamentous injury is suspected, since significant
spinal cord damage may exist even in the absence of bony injury.
A search is made for other injuries, because spinal trauma often is accompanied by
concomitant injuries, commonly to the head and chest.
Continuous electrocardiographic (ECG) monitoring may be indicated if a cord injury
is suspected since bradycardia (slow heart rate) and asystole (cardiac standstill) are
common in acute spinal injuries.

SPINAL CORD TUMOURS:

A spinal tumor is an abnormal mass of tissue within or surrounding the spinal
cord and/or spinal column. These cells grow and multiply uncontrollably, seemingly
unchecked by the mechanisms that control normal cells. Spinal tumors can be benign
or malignant. Primary tumors originate in the spine or spinal cord, and metastatic or
secondary tumors result from cancer spreading from another site to the spine.

Spinal cord tumors are referred to in two ways:

A. By the region of the spinal cord in which they occur. These basic areas
are cervical, thoracic, lumbar and sacrum.

B. By their location within the spinal cord:-

1. Intradural-extramedullary – The tumor is located inside the thin covering of

the spinal cord (the dura), but outside the actual spinal cord. Frequency of
occurrence in this location is 40%. The most common of these types of tumors
develop in the spinal cord's arachnoid membrane (meningiomas), in the nerve
roots that extend out from the spinal cord (schwannomas and neurofibromas), or
at the spinal cord base (filum terminale ependymomas). Although meningiomas
are often benign, they can be difficult to remove and may recur. Nerve root
tumors are also generally benign, although neurofibromas may become
malignant over time. Ependymomas at the end of the spinal cord can be large,
and the delicate nature of fine neural structures in that area may make removal
difficult.

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 2. Intramedullary – These tumors grow inside the spinal cord. They typically
derive from glial or ependymal cells (a type of glial cell) that are found
throughout the interstitium of the spinal cord. Frequency of occurrence in this
location is approximately 5%. Astrocytomas and ependymomas are the two most
common types. Astrocytomas are more common in the thoracic region followed
by the cervical. Ependymomas are most common in the filum (bottom region of
the spinal cord), followed by the cervical region. They are often benign
(compared to intracranial), but can be difficult to remove.
Intramedullary lipomas are rare congenital tumors most commonly located in the
cervicothoracic spinal cord.

3. Extradural – The tumor is located outside the dura, which is the thin covering
surrounding the spinal cord. Frequency of occurrence in this location to the ones
above is approximately 55%. These lesions are typically attributed to metastatic
cancer or less commonly schwannomas derived from the cells covering the nerve
roots. Occasionally, an extradural tumor extends through the intervertebral
foramina, lying partially within and partially outside of the spinal canal.

Tumors occurring within the spinal cord or exerting pressure on it cause symptoms
ranging from localized or shooting pains and weakness and loss of reflexes above the
tumor level to progressive loss of motor function and paralysis. Usually, sharp pain
occurs in the area innervated by the spinal roots that arise from the cord in the region
of the tumor. In addition, increasing sensory deficits develop below the level of the
lesion.

Assessment and Diagnostic Findings of Spinal Cord Tumors:

Helpful imaging diagnostic studies include x-rays, radionuclide bone scans, and MRI.
MRI is the most sensitive diagnostic tool and is particularly helpful in detecting
epidural spinal cord compression and vertebral bone metastases.