1. Dr Mohamed abdul jalil altamimi Consultant neurosurgeon
Spinal Cord Injuries
Dr Mohamed abdul jalil altamimi
Consultant neurosurgeon
Department of surgery

2. Basic Anatomy and Physiology
On cross section

3. What is the anatomy of the spinal cord on cross section?
On cross section; ascending (conveying information to the brain) and descending (conveying information from the brain) tracts.

4. What is the anatomy of the spinal cord on cross section?
On cross section; breathing and voiding.

5. From a surgeon’s perspective, the layers to get to the spinal cord.

6. From a surgeon’s perspective, the layers to get to the spinal cord.

7. What are the clinically important ascending tracts and where do they cross over?
Explain Brown Sequard if somebody stabs you in the Right hemicord: pain is abolished in the left leg (pin prick), fine touch is abolished in the right leg (light touch).

8. What are the clinically important descending tracts and where do they cross over?
Paralysis on the same side in Brown Sequard example (right leg)

9. At what level does the spinal cord end and why is it important?
Can a cauda equina syndrome give you complete paralysis of the legs? Only if it is at L2!

10. What are the differences between UMN and LMN. (e. g. , cauda equina vs
What are the differences between UMN and LMN? (e.g., cauda equina vs. myelopathy)

11. SPINAL TRAUMA

12. Acute vs. chronic injuries; complete vs. incomplete injuries
“Acute”=sudden onset of symptoms
“Complete” ?

13. What is a complete spinal cord injury?
“Complete” = absence of sensory and motor function in the perianal area (S4-S5)

14. Terminology Plegia = complete lesion
Paresis = some muscle strength is preserved
Tetraplegia (or quadriplegia)
Injury of the cervical spinal cord
Patient can usually still move his arms using the segments above the injury (e.g., in a C7 injury, the patient can still flex his forearms, using the C5 segment)
Paraplegia
Injury of the thoracic or lumbo-sacral cord, or cauda equina
Hemiplegia
Paralysis of one half of the body
Usually in brain injuries (e.g., stroke)

15. Motor: how do you test each segment?

16. Motor: how do you grade the strength?

17. Sensory: how do you determine the level?

18. What are the important vegetative functions and when are they affected?

19. Reflexes Deep Tendon Reflexes Pathological reflexes Arm Leg
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)

20. 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

21. Case scenario 25 y/o white male Fell off the roof (20 feet)
Had to be intubated at the scene by EMS
Consciousness regained shortly thereafter
Could not move arms or legs
Could close and open eyes to command
Not able to breathe by himself–totally dependent on mechanical ventilation

22. High cervical injuries (C3 and above)
Motor and sensory deficits involve the entire arms and legs
Dependent on mechanical ventilation for breathing (diaphragm is innervated by C3-C5 levels)

23. Case scenario 19 y/o white male Diving accident (shallow water)
No loss of consciousness
Could not understand why he could not move his legs, forearms and hands (he could shrug shoulders and elevate arms)
BP 75/40, HR 54/’
Had difficulties breathing and required intubation a few hours after the accident

24. Midcervical injuries (C3-C5)
Varying degrees of diaphragm dysfunction
Usually need ventilatory assistance in the acute phase
Shock

25. What is the difference between spinal shock and neurogenic shock?
Hypovolemic
Etiology
Loss of sympathetic outflow
Loss of blood volume
Blood pressure
Hypotension
Heart rate
Bradycardia
Tachycardia
Skin temperature
Warm
Cold
Urine output
Normal
Low

26. 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

27. Low cervical injuries (C6-T1)
Usually able to breathe, although occasionally cord swelling can lead to temporary C3-C5 involvement (need mechanical ventilation)
The level can be determined by physical exam

28. So what do you expect with a cervical lesion?
Quadriplegia or quadriparesis
Bowel/bladder retention (spastic)
Various degrees of breathing difficulties
Neurogenic and/or spinal shock

29. Case scenario 22 y/o female
Motor vehicle accident (hit a pole at 60mph)
Short term loss of consciousness (10’)
Not able to move or feel her legs
No bladder / bowel control or sensation
Sensory level at the umbilicus

30. Thoracic injuries (T2-L1)
Paraparesis or paraplegia
UMN (upper motor neuron) signs

31. Case scenario 22 y/o female Motor vehicle accident
Not able to move or feel her legs below the knee
Could flex thighs against gravity
No bladder / bowel control or sensation
Sensory level above the knee on L, below the knee on R

32. Cauda equina injuries (L2 or below)
Paraparesis or paraplegia
LMN (lower motor neuron) signs
Thigh flexion is almost always preserved to some degree

33. What is the difference between cauda equina and conus medullaris syndrome?

34. What is an incomplete lesion?

35. Anterior cord syndrome
Loss of motor, pain and temperature
Preserved propioception and deep touch

36. What is the central cord syndrome?
Cervical spinal cord involvement with arms more affected than legs
May occur with trauma, tumors, infections, etc
Traumatic lesions tend to improve in 1-2 weeks
Surgical decompression may be indicated if there is spinal stenosis

37. Brown-Sequard syndrome

38. Goal of spine trauma care
Protect further injury during evaluation and management
Identify spine injury or document absence of spine injury
Optimize conditions for maximal neurologic recovery

39. Suspected Spinal Injury
High speed crash
Unconscious
Multiple injuries
Neurological deficit
Spinal pain/tenderness
Up to 15% of spinal injuries have a second (possibly non adjacent) fracture elsewhere in the spine

40. Initial Management Immobilization Prevent hypotension
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 neckAdvance Trauma Life Support (ATLS) guidelines

41. 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

42. Radiolographic evaluation
X-ray Guidelines (cervical)
AABBCDS
Adequacy, Alignment
Bone abnormality, Base of skull
Cartilage
Disc space
Soft tissue

43. Adequacy Must visualize entire C-spine
A film that does not show the upper border of T1 is inadequate
Caudal traction on the arms may help
If can not, get swimmer’s view or CT

44. Alignment
The anterior vertebral line, posterior vertebral line, and spinolaminar line should have a smooth curve with no steps or discontinuities
Malalignment of the posterior vertebral bodies is more significant than that anteriorly, which may be due to rotation
A step-off of >3.5mm is
significant anywhere

45. Lateral Cervical Spine X-Ray
Anterior subluxation of one vertebra on another indicates facet dislocation
< 50% of the width of a vertebral body  unilateral facet dislocation
> 50%  bilateral facet dislocation

46. Bones

47. Disc Disc Spaces Assess spaces between the spinous processes
Should be uniform
Assess spaces between the spinous processes

48. Soft tissue Nasopharyngeal space (C1) 10 mm (adult)
Retropharyngeal space (C2-C4)
5-7 mm
Retrotracheal space (C5-C7)
14 mm (children)
22 mm (adults)

49. AP C-spine Films Spinous processes should line up
Disc space should be uniform
Vertebral body height should be uniform. Check for oblique fractures.

50. Open mouth view
Adequacy: all of the dens and lateral borders of C1 & C2
Alignment: lateral masses of C1 and C2
Bone: Inspect dens for lucent fracture lines

51. CT scan Good in acute situations Shows bone very well
Sagittal reconstruction is mandatory
Soft tissues (discs, spinal cord) are poorly visualized
Do NOT give contrast in trauma patients (contrast is bright, mimicking blood)

52. MRI Almost never an emergency
Exception: cauda equina syndrome
Shows tumors and soft tissues (e.g., herniated discs) much better than CT scan
May be used to clear c-spine in comatose patients

53. Lumbar Puncture Sedate the patient and make your life easier
Measure opening pressure with legs straight
Always get head CT prior to LP to r/o increased ICP or brain tumor

54. Cervical Spine Clearance
Occiput to T1 need to be cleared
ER, Neurosurgery or Orthopedics physician
If the patient
Is awake and oriented
Has no distracting injuries
Has no drugs on board
Has no neck pain
Is neurologically intact
then the c-spine can be cleared clinically, without any need for XRays
CT and/or MRI is necessary if the patient is comatose or has neck pain
Subluxation >3.5mm is usually unstable

55. Cervical Traction Gardner-Wells tongs
Provides temporary stability of the cervical spine
Contraindicated in unstable hyperextension injuries
Weight depends on the level (usually 5lb/level, start with 3lb/level, do not exceed 10lb/level)
Cervical collar can be removed while patient is in traction
Pin care: clean q shift with appropriate solution, then apply povidone-iodine ointment
Take XRays at regular intervals and after every move from bed

56. Jefferson Fracture Burst fracture of C1 ring Unstable fracture
Increased lateral ADI on lateral film if ruptured transverse ligament and displacement of C1 lateral masses on open mouth view
Need CT scan

57. Burst Fracture Fracture of C3-C7 from axial loading
Spinal cord injury is common from posterior displacement of fragments into the spinal canal
Unstable

58. Clay Shoveler’s Fracture
Flexion fracture of spinous process
C7>C6>T1
Stable fracture

59. Flexion Teardrop Fracture
Flexion injury causing a fracture of the anteroinferior portion of the vertebral body
Unstable because usually associated with posterior ligamentous injury

60. Bilateral Facet Dislocation
Flexion injury
Subluxation of dislocated vertebra of greater than ½ the AP diameter of the vertebral body below it
High incidence of spinal cord injury
Extremely unstable

61. Hangman’s Fracture Extension injury Bilateral fractures of C2 pedicles
(white arrow)
Anterior dislocation of C2 vertebral body (red arrow)
Unstable

62. Odontoid Fractures Complex mechanism of injury Generally unstable
Type 1 fracture through the tip
Rare
Type 2 fracture through the base
Most common
Type 3 fracture through the base and body of axis
Best prognosis

63. Odontoid Fracture Type II

64. Odontoid Fracture Type III

65. Gardner-Wells tongs

66. Surgical Decompression and/or Fusion
Indications
Decompression of the neural elements (spinal cord/nerves)
Stabilization of the bony elements (spine)
Timing
Emergent
Incomplete lesions with progressive neurologic deficit
Elective
Complete lesions (3-7 days post injury)
Central cord syndrome (2-3 weeks post injury)

67. Soft and hard collars

68. Minerva vest and halo-vest

69. Long term care Rehab for maximizing motor function
Bladder/bowel training
Psychological and social support