Spinal Cord Injuries

Definitions Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function

Definitions Spinal shock a state of transient physiologic (rather than anatomic) reflex depression of cord function below the level of injury, with associated loss of all sensorimotor functions (+) Increase in blood pressure (initially) due to the release of catecholamines, followed by hypotension (+) Flaccid paralysis, including of the bowel and bladder Symptoms last several hours to days until the reflex arcs below the level of the injury begin to function again (eg, bulbocavernosus reflex, muscle stretch reflex)

Definitions Neurogenic shock Triad of hypotension, bradycardia, and hypothermia Tends to occur more commonly in injuries above T6, secondary to the disruption of the sympathetic outflow from T1-L2 and to unopposed vagal tone, leading to a decrease in vascular resistance, with associated vascular dilatation

Mechanisims of Injury Destruction from direct trauma Compression by bone fragments, hematoma, or disk material Ischemia from damage or impingement on the spinal arteries **Edema could ensue subsequent to any of these types of damage

Causes of SCI Trauma Vascular disorders Tumors Infectious conditions Spondylosis Iatrogenic injuries, especially after spinal injections and epidural catheter placement Vertebral fractures secondary to osteoporosis Developmental disorders

History Depends on the cause of the SCI Discomfort or pain in the back, slight muscle weakness, tingling, other changes in sensation, and, in men, difficulty initiating and maintaining an erection (erectile dysfunction), pain that may radiate down a leg, sometimes to the foot If the cause is cancer, an abscess, or a hematoma, the back may be tender to the touch in the affected area

History If there is substantial compression, severe muscle weakness, numbness, retention of urine, and loss of bladder and bowel control may happen If all nerve impulses are blocked, paralysis and complete loss of sensation result

Physical Examination

Steps in Classification The following order is recommended in determining the classification of individuals with SCI: 1. Determine sensory levels for right and left sides 2. Determine motor levels for right and left sides 3. Determine the single neurological level 4. Determine whether the injury is Complete or Incomplete

Steps in Classification 5. Determine ASIA Impairment Scale (AIS) Grade If sensation and motor function is normal in all segments, AIS=E

Sensory Testing Sensory testing for light touch and pinprick is done, and is scored as follows Absent, or of the patient cannot differentiate between the a sharp point or a dull edge 1 Impaired or hyperesthesia 2 Intact

Sensory Testing C2 Occipital protuberance C3 Supraclavicular fossa C4 Top of the acromioclavicular joint C5 Lateral side of antecubital fossa C6 Thumb C7 Middle finger C8 Little finger T1 Medial side of antecubital fossa T2 Apex of axilla T3 3rd ICS T4 4th ICS at nipple line T5 5th ICS T6 6th Ics T7 7th ICS T8 8th ICS T9 9th ICS T10 10th Ics or umbilicus T11 11th Ics T12 Midpoint of inguinal ligament L1 Half the distance between T12 and L2 L2 Midanterior thigh L3 Medial femoral condyle L4 Medial malleolus L5 Dorsum of the foot at 3rd MTP joint S1 Lateral heel S2 Popliteal fossa in the midline S3 Ischial tuberosity S4-S5 Perianal area (taken as 1 level)

Sensory Testing Sensory level Sensory index scoring Most caudal dermatome with a normal score of 2/2 for pinprick and light touch Sensory index scoring Total score from adding each dermatomal score with possible total score (= 112 each for pinprick and light touch)

Muscle Strength Testing Muscle strength always should be graded according to the maximum strength attained, no matter how briefly that strength is maintained during the examination The muscles are tested with the patient supine

Muscle Strength Testing 5 active movement, full range of motion, against gravity and provides normal resistance **muscle able to exert, in examiner’s judgement, sufficient resistance to be considered normal if identifiable inhibiting factors were not present 4 active movement, full range of motion, against gravity and provides some resistance 3 active movement, full range of motion, against gravity 2 active movement, full range of motion, gravity eliminated 1 palpable or visible contraction Total paralysis

Muscle Strength Testing The following key muscles are tested in patients with SCI, and the corresponding level of injury is indicated: C5 Elbow flexors (biceps, brachialis) C6 Wrist extensors (extensor carpi radialis longus and brevis) C7 Elbow extensors (triceps) C8 Finger flexors (flexor digitorum profundus) to the middle finger T1 Small finger abductors (abductor digiti minimi) L2 Hip flexors (iliopsoas) L3 Knee extensors (quadriceps) L4 Ankle dorsiflexors (tibialis anterior) L5 Long toe extensors (extensors hallucis longus) S1 Ankle plantar flexors (gastrocnemius, soleus)

Muscle Strength Testing Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level Motor level Determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5) Motor index scoring Using the 0-5 scoring of each key muscle, with total points being 25 per extremity and with the total possible score being 100

ASIA Impairment Scale The ASIA classification system utilizes motor and sensory examination to identify the severity and level of spinal cord injury American Spinal Injury Association

ASIA Impairment Scale A Complete No sensory or motor function is preserved in sacral segments S4-S5 B Incomplete Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5 C Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3 D Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade greater than or equal to 3 E Normal Sensory and motor functions are normal Note: AIS E is used in follow up testing when an individual with a documented SCI has recovered normal function. If at initial testing no deficits are found, the individual is neurologically intact; the ASIA Impairment Scale does not apply

ASIA Impairment Scale Perform a rectal examination to check motor function or sensation at the anal mucocutaneous junction—the presence of either is considered sacral-sparing Definitions of complete and incomplete SCI are based on the above ASIA definition with sacral-sparing Complete - Absence of sensory and motor functions in the lowest sacral segments ((-) voluntary anal contraction AND all S4-S5 sensory scores is 0) Incomplete - Preservation of sensory OR motor function below the level of injury, including the lowest sacral segments

Other Classifications of SCI Conus medullaris syndrome Associated with injury to the sacral cord and lumbar nerve roots leading to areflexic bladder, bowel, and lower limbs, while the sacral segments occasionally may show preserved reflexes (eg, bulbocavernosus and micturition reflexes) Cauda equina syndrome Due to injury to the lumbosacral nerve roots in the spinal canal, leading to areflexic bladder, bowel, and lower limbs

Muscle Strength Testing Lower extremities motor score (LEMS) Uses the ASIA key muscles in both lower extremities, with a total possible score of 50 (ie, maximum score of 5 for each key muscle [L2, L3, L4, L5, and S1] per extremity) A LEMS of 20 or less indicates that the patient is likely to be a limited ambulator A LEMS of 30 or more suggests that the individual is likely to be a community ambulator.

Other definitions of scoring Neurologic level of injury Most caudal level at which motor and sensory levels are intact, with motor level as defined above and sensory level defined by a sensory score of 2 Zone of partial preservation All segments below the neurologic level of injury with preservation of motor or sensory findings This index is used only when the injury is complete Skeletal level of injury Level of the greatest vertebral damage on imaging

Other Classifications of SCI Central cord syndrome Due to a cervical region injury and leads to greater weakness in the upper limbs than in the lower limbs, with sacral sensory sparing Brown-Séquard syndrome Associated with a hemisection lesion of the cord, causes a relatively greater ipsilateral proprioceptive and motor loss, with contralateral loss of sensitivity to pain and temperature Anterior cord syndrome Associated with a lesion causing variable loss of motor function and sensitivity to pain and temperature; proprioception is preserved