1. Spinal Cord Injuries S4S

2. Definition ❖ Trauma or damage to the spinal cord resulting in complete or partial loss of sensorimotor function; dependant on the level of injury.

3. Aetiology & Epidemiology ❖ Trauma: ❖ ~50% due to traffic-related incidents ❖ ~20% fall related ❖ ~15% violence related ❖ ~10% sports/recreation related ❖ ~5% other causes ❖ Non-traumatic: ❖ Transverse Myelitis ❖ Polio ❖ Spina Bifida ❖ Friedreich’s Ataxia

4. Pathophysiology ❖ Acute impact or compression ❖ Acute impact injury: ❖ initiated by hypoperfusion of grey matter ❖ cellular injury due to increased intracellular calcium and reperfusion injury occur soon after injury ❖ Compression injury: ❖ mass impinges on the cord, causing increased pressure ❖ leads to gliosis, demyelination and axonal loss in white matter ❖ grey matter is preserved, whilst white matter diminishes

5. Red Flag Signs ❖ Gait disturbance ❖ Clumsy/weak hands ❖ Loss of sexual/bladder/bowel function ❖ Lhermitte’s sign (electric shock feeling with neck flexion) ❖ Babinski’s sign ❖ Upper limb atrophy or hyperreflexia ❖ Loss of proprioception

6. Signs and Symptoms ❖ Dependant on level of damage ❖ Dependant on severity and type: ❖ Complete SCI ❖ Central Cord Syndrome ❖ Anterior Cord Syndrome ❖ Posterior Cord Syndrome ❖ Brown Sequard Syndrome

8. Anterior Cord Syndrome ❖ Which tracts will be affected? ❖ Corticospinal and spinothalamic ❖ Bilateral paraplegia ❖ Bilateral pain and temperature sensation loss ❖ Sphincter dysfunction: urinary retention ❖ Causes? ❖ infarction of the anterior spinal artery ❖ disc hernition ❖ radiation myelopathy

9. Posterior Cord Syndrome ❖ Rare ❖ Which tracts will be affected? ❖ Dorsal Column Medial Lemniscal ❖ Bilateral proprioception loss ❖ Bilateral vibration sensation loss ❖ Possible bladder dysfunction ❖ Causes? ❖ Freidrich’s ataxia ❖ AIDS myelopathy ❖ Epidural metastases ❖ MS

10. Central Cord Syndrome ❖ More common in elderly ❖ Which tracts will be affected? ❖ Mainly grey matter damage ❖ Bilateral motor weakness (arms>legs) ❖ Sensation above and below preserved ❖ Causes? ❖ Fall leading to impaired blood supply ❖ Intramedullary tumour ❖ Syringomyelia

11. Brown-Séquard Syndrome ❖ Which tracts will be affected? ❖ All on one side ❖ Ipsilateral voluntary motor loss ❖ Ipsilateral Proprioception and vibration sensation loss ❖ Contralateral pain and temperature sensation loss 2-3 levels below the level of the damage ❖ Causes? ❖ Knife injury ❖ Bullet injury ❖ MS

12. Other Syndromes ❖ Cauda equina: ❖ lesion compressing the CE nerve roots ❖ more vulnerable due to poorly developed epineurium ❖ results in low back pain, sciatica, saddle sensory disturbances, bladder & bowel dysfunction, lower extremity sensorimotor loss ❖ Conus medullaris: ❖ similar but without lower extremity sensorimotor loss ❖ effects specific to the level of the conus medullaris (L2-L3)

13. Complete injury ❖ Complete transection of motor AND sensory tracts ❖ No sensation and flaccid paralysis ❖ Initially areflexia ❖ days/months later there is hyperreflexia and spasticity ❖ <5% chance of recovery if there is no improvement within 24 hours

14. What would you expect ❖ With complete injury at the level of… ❖ L1 ❖ T4 ❖ C6 ❖ C4 ❖ Waist down paralysis ❖ Chest down paralysis ❖ Partial neck down paralysis (arm sparing) ❖ Neck down paralysis

15. Investigations ❖ Haemoglobin and haematocrit monitoring ❖ in trauma to monitor blood loss ❖ Renal function and electrolytes ❖ to assess level of dehydration ❖ Radiography ❖ Diagnostic of vertebral damage ❖ Cervical radiography; 3 views: Anteroposterior, lateral and odontoid ❖ CT scan is more sensitive ❖ CT brain if patient is unconscious ❖ MRI ❖ multilevel injuries or Cauda Equina ❖ to evaluate soft tissue lesions

16. Complications ❖P❖Pressure sores ❖H❖Hypothermia ❖C❖Chronic musculoskeletal pain ❖A❖Autonomic dysreflexia ❖R❖Respiratory complications ❖D❖Depression ❖N❖Neurogenic bladder and bowel

17. ❖A❖Autonomic dysreflexia ❖U❖Uninhibited sympathetic nervous activation seen in SCI at or above T6 ❖h❖hypertension ❖s❖severe headache ❖p❖profuse sweating above level of injury ❖c❖cold and clammy skin below level of injury ❖r❖restlessness ❖d❖dilated pupils ❖b❖bradycardia ❖c❖chest tightness

18. Respiratory Complications ❖ Diaphragm controlled by C5 ❖ All injuries above L1 will likely have some respiratory dysfunction ❖ Reduced respiratory muscle strength > reduced vital capacity ❖ Tetraplegic patients benefit from supine positioning ❖ Atelectasis and infection common

19. Management – Initial ❖ Immobilisation: prevent further injury and stabilise fracture ❖ ABCs: Ensure patient can breathe and remove obvious obstruction ❖ Manage shock, ensure haemodynamic stability ❖ Prevent complications: thromboprophylaxis, gastroprotection, pressure area care (move from spinal board early)

21. Management – After Assessment ❖ Neurosurgery referral ❖ Emergency decompression of exradural lesions ❖ Surgery to stabilise and repair vertebral damage ❖ Catheter for bladder dysfunction ❖ Breathing exercises and suction to clear secretions ❖ Psychological care ❖ Analgesia as required ❖ Patient and carer education and support

22. Specific Respiratory Management ❖ Supine positioning ❖ Non-invasive ventilation ❖ Regular arterial blood gases ❖ Humidified oxygen ❖ Vital capacity monitoring is the most important measure of ventilatory status in SCI patients

23. Prognosis ❖ Very low chance of recovery if paralysis persists for over 72 hours ❖ 40-80% of patients with SCI die of pulmonary complications within 1 year of injury ❖ Most recovery will occur in the first 9-12 months, with a relative plateau beyond 12-18 months post injury