SPINAL INJURY

MOHD ROSLEE BIN ABD GHANI

LEARNING OBJECTIVE

 Define spinal injury

 Explain two types of spinal injury

 State the signs and symptoms of spinal cord injury

 Describe the management of spinal cord injury

 State the complications of spinal injury

FUNCTION OF SPINE
 The spine has many functions, the main ones are listed below-
1. To provide protection of the spinal cord and associated nerves
2. To allow for movement
3. To support our body frame in an upright position
4. To allow for flexibility
5. To provide a structural foundation for the shoulder girdle and the pelvic
girdles
6. To act as shock absorbers from load- bearing
7. To provide a structural base for rib attachments which protect the heart and
lungs.
Definition Of Spinal Injury

 “ Spinal injury” may be defined as- Injury to the Spinal column

(Bony Column)/Spinal Cord, or both of them.
 Spinal injury can be divided into-

1. Spinal Column(Bony)Injury.

2. Spinal Cord injury.

3. Combined (Both Column & Cord) Injury.

Definition Of Spinal Injury…

 Bony spinal injuries may or may not be associated with spinal cord injury

 These bony injuries include:

1. Compression fractures of the vertebrae

2. Comminuted fractures of the vertebrae

3. Subluxation (partial dislocation) of the vertebrae

4. Sprains- over-stretching or tearing of ligaments

5. Strains- over-stretching or tearing of the muscles.

INCIDENCE

 SCI is highest among persons age 16-30, in whom 53.1 percent of injuries.

 Males represent 81.2 percent of all reported SCIs and 89.8 percent of all sports-
related SCIs.

 Among both genders, auto accidents, falls and gunshots are the three leading
causes of SCI.

 Sports and recreation-related SCI injuries primarily affect people under age 29.
ETIOLOGI
1. Traumatic
 damage to the vertebrae, ligaments or disks of the spinal column or to the spinal cord itself.
 may stem from a sudden, traumatic blow to your spine that fractures, dislocates, crushes or
compresses one or more of your vertebrae.
 it may also result from a gunshot or knife wound that penetrates and cuts your spinal cord.

2. Nontraumatic
 may be caused by arthritis, cancer, inflammation, infections or disk degeneration of the spine.
CAUSES…
1. Motor vehicle accidents.
 Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for almost half of new
spinal cord injuries each year.
2. Falls.
 A spinal cord injury after age 65 is most often caused by a fall. Overall, falls cause about 31% of spinal cord
injuries.
3. Acts of violence.
 Over 13% of spinal cord injuries result from violent encounters, most commonly involving gunshot wounds.
Knife wounds also are common.
4. Sports and recreation injuries.
 Athletic activities, such as impact sports and diving in shallow water, cause about 10% of spinal cord injuries.
5. Alcohol.
 Alcohol use is a factor in about 1 out of every 4 spinal cord injuries.
6. Diseases.
 Cancer, arthritis, osteoporosis and inflammation of the spinal cord also can cause spinal cord injuries.
TYPES OF SPINAL CORD INJURY(SCI)

 Spinal cord injury (SCI) is damage to the spinal cord that results in a loss of function such
as mobility or feeling.
 Symptoms may include loss of muscle function, sensation, or autonomic function in the
parts of the body served by the spinal cord below the level of the injury.
 2 types of injury;
 Complete. If all feeling (sensory) and all ability to control movement (motor function) are lost
below the spinal cord injury, your injury is called complete.
 Incomplete. If you have some motor or sensory function below the affected area, your injury is
called incomplete. There are varying degrees of incomplete injury.
COMPLETE SCI

 Tetraplegia
 Paraplegia
Complete Spinal Cord Injuries

 Tetraplegia(Quadriplegia)
 Spinal cord injury above the first thoracic vertebra, or within the cervical sections of C1-C8.
 result is some degree of paralysis in all four limbs—the legs and arms.
 Paraplegia:
 Spinal cord injuries below the first thoracic spinal levels (T1-L5).
 Paraplegics are able to fully use their arms and hands, but the degree to which their legs are
disabled depends on the injury.
 Complete paraplegia:
 It is described as permanent loss of motor and nerve function at T1 level or below, resulting in
loss of sensation and movement in the legs, bowel, bladder, and sexual region.
Incomplete SCI

1. Central Cord Syndrome

2. Anterior Cord Syndrome

3. Posterior Cord Syndrome

4. Brown- Sequard Syndrome

5. Conas Medularis Syndrome

6. Cauda Equina Syndrome

 CENTRAL CORD SYNDROME

 Cause:

 Injury or edema of the central cord, usually

of the cervical area and cervical lesions . •

 Characteristics:

 Motor deficits (in the upper extremities

sensory loss varies in the upper extremities).
 ANTERIOR CORD SYNDROME

 Cause:
 acute disk herniation associated with fracture-
dislocation of vertebra and also occur injury
to anterior spinal Artery and lesion. •
 Characteristics:
 Loss of pain, temperature, and motor function
is noted below the level of the lesion or
injury; light touch, position, and vibration
sensation remain intact.
 POSTERIOR CORD SYNDROME

 Cause:

 an infarct in the posterior spinal artery and is

caused by lesions on the posterior portion of
the spinal cord,

 Characteristics:

 loss of proprioceptive sensation, fine touch,

pressure, and vibration below the lesion; deep
tendon areflexia.
 BROWN-SEQUARD SYNDROME

 Known as Lateral Cord Syndrome.

 Cause:
 The lesion is caused by a transverse hemisection
of the cord, as a result of a knife or missile
injury, fracture dislocation of a unilateral
articular process.
 Characteristics:
 Ipsilateral paralysis or paresis is noted, together
with ipsilateral loss of touch, pressure, and
vibration and contralateral loss of pain and
temperature.
 CONAS MEDULARIS SYNDROME

 Known as Lateral Cord Syndrome.

 Cause:
 blow to the back- such as Gunshot and
spinal tumor.
 Characteristics:
 Bowel and bladder dysfunction, Flaccid
lower extremities. Sexual dysfunction.
 CAUDA EQUINA SYNDROME

 Known as Horse tail Syndrome.

 Cause:
 Injury or lesion at the lumbosacral nerve
root below the conus medulararis.
 Characteristics:
 Areflexia loss of reflexes(Lower
Extremities). Leg weakness •
Bladder/bowel dysfunction
SIGNS AND SYMPTOMS
• Loss of movement

• Loss or altered sensation, including the ability to feel heat, cold and touch

• Loss of bowel or bladder control

• Exaggerated reflex activities or spasms

• Changes in sexual function, sexual sensitivity and fertility

• Pain or an intense stinging sensation caused by damage to the nerve fibers in your
spinal cord

• Difficulty breathing, coughing or clearing secretions from your lungs

Level Patient Function
C1-C3 - Ventilator dependent with limited talking.
- Electric wheelchair with head or chin control
C3-C4 - Initially ventilator dependent, but can become independent
- Electric wheelchair with head or chin control
C5 - Ventilator independent
- Has biceps, deltoid, and can flex elbow, but lacks wrist extension and supination needed to
feed oneself
- Independent ADL’s; electric wheelchair with hand control, minimal manual wheelchair
function 
C6 - C6 has much better function than C5 due to ability to bring hand to mouth and feed oneself
(wrist extension and supination intact)
- Independent living; manual wheelchair with sliding board transfers, can drive a car with
manual controls
C7 - Improved triceps strength
- Daily use of a manual wheelchair with independent transfers
C8-T1 - Improved hand and finger strength and dexterity
- Fully independent transfers
T2-T6 - Normal UE function
- Improved trunk control
- Wheelchair-dependent
T7-T12 - Increased abdominal muscle control
- Able to perform unsupported seated activities; with extensive bracing walking may be possible
L1-L5 - Variable LE and B/B function
- Assist devices and bracing may be needed
S1-S5 - Various return of B/B and sexual function
- Walking with minimal or no assistance
LUMBOSACRAL

 The effects of injuries at or above the lumbar or sacral regions of the spinal cord
(lower back and pelvis) include decreased control of the legs and hips,
genitourinary system, and anus.

 People injured below level L2 may still have use of their hip flexor and knee
extensor muscles.

 Bowel and bladder function are regulated by the sacral region.

 It is common to experience sexual dysfunction after injury, as well as dysfunction

of the bowel and bladder, including fecal and urinary incontinence.
THORACIC

 In addition to the problems found in lower-level injuries, thoracic (chest height) spinal
lesions can affect the muscles in the trunk.
 Injuries at the level of T1 to T8 result in inability to control the abdominal muscles. Trunk
stability may be affected; even more so in higher level injuries.
 The lower the level of injury, the less extensive its effects. Injuries from T9 to T12 result in
partial loss of trunk and abdominal muscle control.
 Thoracic spinal injuries result in paraplegia, but function of the hands, arms, and neck are
not affected.
 One condition that occurs typically in lesions above the T6 level is autonomic dysreflexia
(AD), in which the blood pressure increases to dangerous levels, high enough to cause
potentially deadly stroke.
THORACIC…

 Signs and symptoms of AD include anxiety, headache, nausea, ringing in the ears, blurred
vision, flushed skin, and nasal congestion.
 It can occur shortly after the injury or not until years later.
 Other autonomic functions may also be disrupted.
 Another serious complication that can result from lesions above T6 is neurogenic shock,
which results from an interruption in output from the sympathetic nervous system
responsible for maintaining muscle tone in the blood vessels.
 Without the sympathetic input, the vessels relax and dilate.
 Neurogenic shock presents with dangerously low blood pressure, low heart rate, and blood
pooling in the limbs—which results in insufficient blood flow to the spinal cord and
potentially further damage to it.
CERVICAL

 Spinal cord injuries at the cervical (neck) level result in full or partial tetraplegia (also
called quadriplegia).

 Depending on the specific location and severity of trauma, limited function may be
retained.

 Additional symptoms of cervical injuries include low heart rate, low blood pressure,
problems regulating body temperature, and breathing dysfunction.

 If the injury is high enough in the neck to impair the muscles involved in breathing, the
person may not be able to breathe without the help of an endotracheal tube and mechanical
ventilator.
DIAGNOSIS

 History taking
 MVA
 Sports
 Fall
 Physical examination
 Neurological examination
 Grading
 Investigation
 Muscle strength ASIA Impairment Scale for classifying spinal cord injury
Grade Muscle function Grade Description
Complete injury. No motor or sensory function is
0 No muscle contraction A
preserved in the sacral segments S4 or S5.
Sensory incomplete. Sensory but not motor
1 Muscle flickers B function is preserved below the level of injury,
including the sacral segments.
Motor incomplete. Motor function is preserved
below the level of injury, and more than half of
2 Full range of motion, gravity eliminated C muscles tested below the level of injury have a
muscle grade less than 3 (see muscle strength
scores, left).
Motor incomplete. Motor function is preserved
below the level of injury and at least half of the key
3 Full range of motion, against gravity D
muscles below the neurological level have a muscle
grade of 3 or more.
Normal. No motor or sensory deficits, but deficits
4 Full range of motion against resistance E
existed in the past.
5 Normal strength
INVESTIGATION

• X-rays.
• Medical personnel typically order these tests on people who are suspected of having a spinal cord injury after
trauma.
• X-rays can reveal vertebral (spinal column) problems, tumors, fractures or degenerative changes in the spine.
• Computerized tomography (CT) scan.
• A CT scan may provide a better look at abnormalities seen on an X-ray.
• This scan uses computers to form a series of cross-sectional images that can define bone, disk and other
problems.
• Magnetic resonance imaging (MRI).
• MRI uses a strong magnetic field and radio waves to produce computer-generated images.
• This test is very helpful for looking at the spinal cord and identifying herniated disks, blood clots or other
masses that may be compressing the spinal cord.
EMERGENCY MANAGEMENT
 Initial care must include a rapid assessment, immobilization, extrication, stabilization or
control of life threating injuries & transportation to the most appropriate medical facility.
 At the scene of injury, the patient must be immobilized on a spinal (back) board with head
& neck in a neutral position, to prevent an incomplete injury from becoming complete.
 If possible, at least four people should slide the patient carefully onto a board for transfer
to the hospital.
 During treatment in the emergency & x-ray department, the patient is kept on the transfer
board.
 The patient must always be maintained in an extended position.
 No part of the body should be twisted or turned, nor should the patient be allowed to sit.
 Once the extent of injury has been determined the patient may be placed on a rotating bed
or in a cervical collar.
MANAGEMENT OF ACUTE PHASE
 The goals of management are to prevent further SCI & to observe for symptoms of
progressive neurologic deficits.
 Maintain vital function: oxygen therapy is administered to maintain high partial pressure of
oxygen.
 Respiratory compromise occur & if the client develops diaphragmatic fatigue mechanical
ventilation may be needed.
 ABGs are monitored closely.
 The client may be transferred to a kinetic bed to reduce risk of pressure ulcer development
& minimize complication of immobility.
 Aspiration is also risk for clients who must remain flat while in tongs & traction because
this immobilize the head.
 They should be encouraged to take small bites, eat slowly & concentrate on swallowing.
PHARMACOLOGICAL THERAPY
 Vasoactive agents are commonly used to support BP immediately after injury.
 Short term high dose methylprednisone therapy (improve motor & sensory
outcomes) is started in people with SCI < 8 hrs old.
 A bolus does of 30 mg/kg infused over 1 hour followed by 5.4 mg/kg infused
over 23 hours.
 Neuropeptide & thyrotropin- releasing hormone may induce some reversal of
lesions by decreasing post traumatic ischemia.
 Long term pharmacologic therapy include urinary antiseptics, anticoagulants,
laxatives & antispasmodics.
 SKELETAL FRACTURE REDUCTION & TRACTION

 Cervical fractures are reduced & the

cervical spine is aligned with some form
of skeletal traction such as skeletal tongs
or calipers or with use of halo device.
 Skeletal tongs involves fixation in the
skull.
 Garderner-wells tongs requires no
predrilled holes in the skull, cruth-field
tongs are inserted through holes made in
the skull with a special drill under local
anesthesia.
 SURGICAL MANAGEMENT

 A laminectomy (excision of the posterior aches &

spinous process of a vertebrae) for a patient with
progressive neurologic deficit, suspected epidural
hematomas.
 Surgical debridement: bony fragments &
penetrating injuries.
 Stabilization by surgical fusion can be done by
insertion of metal plates & screws or use of bone
grafts alone or in combination.
 COMPLICATIONS
1. Pulmonary Edema,
2. Respiratory Failure,
3. Neurogenic Shock,
4. Paralysis Below The Injury Site.
5. Muscle Atrophy
6. Pressure Sores,
7. Spasticity, The Uncontrollable Tensing Of
Muscles Below The Level Of Injury, Occurs In
65–78% Of Chronic Sci.[
8. Pneumonia
9. Deep Venous Thrombosis (Dvt),
 REHABILITATION

1. Occupational Therapist

2. Physiatrist.

3. Physical Therapist:

4. Rehabilitation Nurse.

5. Speech and Language Pathologist.

6. Therapeutic Recreational Specialist.

7. Vocational Rehabilitation Therapist.

8. Rehab Psychologist