1. SPINAL CORD INJURY
ÖZNUR MOLLA

2. Anatomy Review A major component of the Central Nervous System
It is cm long,
1cm to 1.5 cm diameter
It extends from the brain stem
to the level of the first or second
lumbar vertebrae and at the end called caude equina, or “horses tail”

3. Anatomy Review
There are 31 spinal cord segments , each with a pair of ventral and dorsal spinal nerve roots, which mediate motor and sensory function.
The ventral and dorsal nerve roots combine on each side to form the spinal nerves as they exit from the vertebral column through the neuroforamina

6. SPINAL CORD INJURY
Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in the cord’s normal motor, sensory, or autonomic function.
Patients with SCI usually have permanent and often devastating neurologic deficits and disability.

7. EPIDEMIOLOGY
In the United States, the incidence of TSCI in 2010 was about 40 per million persons per year, or about 12,400 annually 
Males are 4 times more likely than females
50% of SCI years
3.5% years and younger
11.5% older than 60 years(greater mortality)

8. ETIOLOGY TRAUMATIC NON-TRAUMATIC Most frequent cause of adult SCI
Motor vehicle accidents
Falls
Violence (especially gunshot wounds)
Sports accidents
Other
NON-TRAUMATIC
Approx 30% of all SCI
Result from disease or pathological influence
Cervical spondylosis
Atlantoaxial instability
Congenital conditions, eg, tethered cord
Osteoporosis
Spinal arthropathies, including ankylosing spondylitis or rheumatoid arthritis 
MS, ALS

10. PATHOPHYSIOLOGY
The primary injury refers to the immediate effect of trauma which includes forces of compression, contusion, and shear injury to the spinal cord.
This is followed by the delayed onset of a secondary injury phase involving  ischemia, hypoxia, inflammation, edema, excitotoxicity, disturbances of ion homeostasis and apoptosis.

11. SPINAL STABILITY
3 Column theory Two or more column injury is unstable ( or middle column alone)

12. The injury reflects the force and direction of the traumatic event and subsequent fall, which produces pathologic flexion, rotation, extension, and/or compression of the spine

13. CLINICAL PRESENTATION
Pain and numbness, or burning sensation
Inability to move the extremities or walk
Inability to feel pressure, heat, or cold
Muscle spasms
Loss of bladder or bowel control
Difficulty breathing

14. Symptoms by Region
Cervical (C1-C8) - Damage to the spinal cord in the cervical spine is considered the most severe because it can be life-threatening.
Symptoms of cervical spinal cord damage may affect the arms, legs, mid-body, and even the ability to breathe on one’s own.
The higher up in the cervical spine the damage occurs, the worse the injury.
Symptoms may be felt on one or both sides of the body.

15. Thoracic (T1-T12) - Damage to the spinal cord in the thoracic spine typically affects the legs.
Thoracic spinal cord damage high up in the area may affect blood pressure.
Lumbar (L1-L5) - Damage to the spinal cord in the lumbar spine typically affects one or both legs.
Patients with lumbar spinal cord damage may also have trouble controlling their bladder and/or bowel function. 

16. Most common type is cervical %55

18. Complete cord injury (ASIA grade A)
No sensory or motor function below the level of the lesion.
In the acute stage, reflexes are absent, there is no response to plantar stimulation, and muscle tone is flaccid.
Urinary retention and bladder distension occur. 
The bulbocavernosus reflex and anal tonus are usually absent.
Caused by a complete transection (or severing), severe compression, or extensive vascular impairment to the spinal cord

19. Incomplete injury
Preservation of some sensory or motor function below the level of injury
Usually sensation is preserved to a greater extent than motor function because the sensory tracts are located in more peripheral.
The bulbocavernosus reflex and anal sensation are often present.
Often result from contusions produced by pressure on the cord or swelling within the spinal canal

21. Specific Incomplete Lesions
1. Anterior Cord Syndrome 2. Brown-Sequard’s Syndrome 3. Cauda Equina Injuries 4. Central Cord Syndrome 5. Posterior Cord Syndrome

22. Anterior Cord Syndrome
Usually caused by cervical flexion, which compresses and damages the anterior part of the spinal cord or anterior spinal artery
Motor function is lost bilaterally
Pain and temperature sensation are lost bilaterally

23. Brown-Sequard’s Syndrome
Result of hemisection of spinal cord (gunshot or stab wound)
Ipsilateral paralysis, loss of proprioception & vibration
Contralateral loss of pain & temperature sense

24. Central Cord Syndrome Hyperextension injuries
It is marked by a disproportionately greater impairment of motor function in the upper extremities than in the lower ones, as well as by bladder dysfuntion and a variable amount of sensory loss below the level of injury
CCS has been reported to occur with particular frequency among older persons with cervical spondylosis

25. Posterior Cord Syndrome
Very rare
Compression by tumor or infarction of the posterior spinal artery
Proprioception, vibration sense, two-point discrimination and light touch are lost below the lesion
Motor function is preserved

26. Cauda Equina Injuries Injuries below the L1 vertebral level
Results in a LMNL (lower motor neuron lesion)
Usually incomplete; can be complete
Results in flaccidity, areflexia, and impairment of bowel & bladder function
Caused by a central lumbar disk herniation

28. Conus Medullaris Syndrome
Severe back pain
Saddle anaesthesia
Bowel and bladder dysfunction
Sexual dysfunction
Weakness, numbness, or tingling in your lower limbs
Causes include disc herniation, spinal fracture, and tumors 

30. Spinal Shock
Immediately following SCI there is a period of areflexia called spinal shock
Characterized by absence of all reflex activity, flaccidity, and loss of sensation below the level of the lesion
Can last hours to weeks, but typically subsides within 24 hours

31. Spinal Shock
1) Motor paralysis or paresis 2) Sensory loss 3) Respiratory dysfunction 4) Impaired temperature control 5) Spasticity 6) Bowel and bladder dysfunction 7) Sexual dysfunction

32. Neurogenic Shock
 Insufficient blood flow is caused by the sudden loss of signals from the sympathetic nervous system that maintain the normal muscle tone in blood vessel walls.
The blood vessels relax and become dilated, resulting in pooling of the blood in the venous system and an overall decrease in blood pressure.

34. INITIAL EVALUATION AND TREATMENT
ABCD prioritization scheme: Airway, Breathing, Circulation, Disability (neurologic status)
Shock (Hemorrhagic or neurogenic?) Traumatic spinal injury should be assumed
Immobilizing your neck to prevent further spinal cord damage.
Transportation

35. TREATMENT IN SPINAL TRAUMA
Prioritize assessment and stabilization following the ABCD scheme
Vital signs including heart rate, blood pressure, respiratory status, and temperature require ongoing monitoring
Respiratory mechanical support may be needed
May need traction to stabilize your spine, to bring the spine into proper alignment or both. A special bed also may help immobilize your body.

36. Intravenous (IV) methylprednisolone is a treatment option for an acute spinal cord injury.
If methylprednisolone is given within eight hours of injury, some people experience mild improvement.
It appears to work by reducing damage to nerve cells and decreasing inflammation near the site of injury.
Often surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity.
Most penetrating injuries require surgical exploration to ensure that there are no foreign bodies imbedded in the tissue, and also to clean the wound to prevent infection.

37. IMAGING
Plain x-rays : Plain x-rays provide a rapid assessment of alignment, fractures, and soft tissue swelling
Computed tomography: CT is more sensitive than plain films, patients who are suspected to have a spinal injury and have normal plain films should also undergo CT
Magnetic resonance imaging  It provides a detailed image of the spinal cord as well as spinal ligaments, intervertebral discs, and paraspinal soft tissues that is superior to CT

38. PROGNOSIS
The potential for recovery from SCI is directly related to the extent of damage to the spinal cord and/or nerve roots
Formulation of a prognosis is initiated only after spinal shock has subsided, once it is known if the injury is complete or incomplete