1. Disease of Spine and Spinal Cord

2. THE SPINAL CORD
The Spinal Cord is an extension of the brain; a thick bundle of nerve fibres.
takes a message from the brain, to the muscles to communicate movement
messages to the brain, communicating the sense of touch, pain, pressure of heat and cold

4. anterior spinothalamic tract (or ventral) transmits crude touch.
lateral corticospinal tract controls movement of contralateral limbs

5. Lateral spinothalamic tract Pain and Temperature
Lateral corticospinal
tract: Movement

6. General view
Spinal Cord Injury is damage to the spinal cord that results in a loss of function such as mobility or feeling. Frequent causes of damage are trauma and disease.
Spinal Cord is the major bundle of nerves that carry impulses to/from the brain to the rest of the body.
Spinal Cord is surrounded by rings of bone-vertebra. They function to protect the spinal cord.

7. Prognosis
Patients with a complete cord injury have a less than 5% chance of recovery. If complete paralysis persists at 72 hours after injury, recovery is essentially zero.
The prognosis is much better for the incomplete cord syndromes.
If some sensory function is preserved, the chance that the patient will eventually be able walk is greater than 50%.
Ultimately, 90% of patients with SCI return to their homes and regain independence.
In the early 1900s, the mortality rate 1 year after injury in patients with complete lesions approached 100%. Much of the improvement since then can be attributed to the introduction of antibiotics to treat pneumonia and urinary tract infection.
Currently, the 5-year survival rate for patients with a traumatic quadriplegia exceeds 90%. The hospital mortality rate for isolated acute SCI is low.

8. Upper vs. Lower Motor Neuron
Upper motor neuron lesion
Motor cortex
internal capsule
brainstem
spinal cord
Lower motor neuron lesion
Anterior horn cell
nerve root
plexus
peripheral nerve
neuromuscular junction and muscle
spasticity, muscle weakness, exaggerated reflexes, and an out toeing of toes and extensor plantar response known as the Babinski sign.
decreased tone, decreased strength and decreased reflexes in affected areas

9. Basic Features of Spinal Cord Disease
UMN findings below the lesion
Hyperreflexia and Babinski’s
Sensory and motor involvement that localizes to a spinal cord level
Bowel and Bladder dysfunction common

10. Scale of Motor Strength in SCI
The American Spinal Injury Association:
0 - No contraction or movement
1 - Minimal movement
2 - Active movement, but not against gravity
3 - Active movement against gravity
4 - Active movement against resistance
5 - Active movement against full resistance
Assessment of sensory function helps to identify the different pathways for light touch, proprioception, vibration, and pain. Use a pinprick to evaluate pain sensation

11. Types of Spinal Cord Paralysis
Depending on the location and the extent of the injury different forms of paralysis can occur.
Monoplegia- paralysis of one limb
Diplegia- paralysis of both upper or lower limbs
Paraplegia- paralysis of both lower limbs, Injury in the the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris
Hemiplegia- paralysis of upper limb, torso and lower leg on one side of the body
Tetraplegia (Quadraplegia)- paralysis of all four limbs

12. History Acute, subacute, chronic Pain Weakness Sensory Autonomic Onset
Symptoms
Pain
Weakness
Sensory
Autonomic
Past history
Family history

13. Motor Exam Strength - helps to localize the lesion Upper cervical
Quadriplegia with impaired respiration
Lower cervical
Proximal arm strength preserved
Hand weakness and leg weakness
Thoracic T1
Paraplegia
Can also see paraplegia with a midline lesion in the brain
Tone
Increased distal to the lesion

14. Sensory Exam Dermatomes Vibration
Establish a sensory level
Dermatomes
Nipples: T4-5
Umbilicus: T8-9
Posterior columns
Vibration
Joint position sense (proprioception)
Spinothalamic tracts
Pain
Temperature

15. Autonomic disturbances
Neurogenic bladder
Urgency, incontinence, retention
Bowel dysfunction
Constipation more frequent than incontinence
With a high cord lesion, loss of blood pressure control
Alteration in sweating

16. Investigation of Spinal Cord Disease
Radiographic exams
Plain films
Myelography
CT scan with myelography
MRI
Spinal tap
If you suspect: inflammation, MS, rupture of a vascular malformation

17. Etiology of Spinal Cord Disease

18. Traumatic Spinal Cord Disease
10,000 new spinal cord injuries per year
MVA, sports injuries the most common
Victims under 30 yrs old, male>>females
Fx/dislocation of vertabrae most likely to occur at:
C5,6
T12, L1
C1,2

19. Vertebral column injury, with or without neurological deficits, must always be sought and excluded in a patient with 􀂄Multiple trauma.
􀂄Any injury above the clavicle
􀂄Spine injury
􀂄Cervical spine 55%
􀂄Thoracic spine 15%
􀂄Thoracolumbar junction 15%
􀂄Lumboscaral spine 15%

20. 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.

21. Excessive manipulation and inadequate immobilization of a patient with a spinal cord injury can cause additional neurological damage and worsen the patient’s outcome.

22. SPINAL CORD INJURIES
Caused by sudden trauma

23. Incidence:
Race
Whites at 66.4%, African Americans at 21.1%, Hispanics at 8.8%, Asians at 1.6%, Native Americans at 1.1%, and others at 1%.
Sex
The male-to-female ratio of individuals with SCI is 4:1
Age
50% ,aged years.
Traumatic SCI < 40 years,
Nontraumatic SCI > 40 years.

24. Associated injuries Bone fractures (29.3%),
Loss of consciousness (17.8%),
Traumatic brain injury affecting emotional/cognitive functioning (11.5%).

25. Mechanism: 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. The different clinical presentations of the above causes of tissue damage are explained further below.

26. Spinal Shock
An immediate loss of reflex function, called areflexia, below the level of injury
Signs:
Slow heart rate
Low blood pressure
Flaccid paralysis of skeletal muscles
Loss of somatic sensations
Urinary bladder dysfunction
Spinal shock may begin within an hour after injury and last from several minutes to several months, after which reflex activity gradually returns

27. Neurogenic shock
Neurogenic shock is manifested by the triad of hypotension, bradycardia, and hypothermia.
Shock 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 decrease in vascular resistance with associated vascular dilatation.
Neurogenic shock needs to be differentiated from spinal and hypovolemic shock. Hypovolemic shock tends to be associated with tachycardia

28. Spinal Shock
An immediate loss of reflex function, called areflexia, below the level of injury
Signs:
Slow heart rate
Low blood pressure
Flaccid paralysis of skeletal muscles
Loss of somatic sensations
Urinary bladder dysfunction
Spinal shock may begin within an hour after injury and last from several minutes to several months, after which reflex activity gradually returns

29. Classification
The extent of injury is defined by the ASIA Impairment Scale (modified from the Frankel classification), using the following categories:
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 - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3.
D - Incomplete: 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.

30. Spinal Cord Syndromes can be classified into either complete or incomplete categories
Complete – characterized as complete loss of motor and sensory function below the level of the traumatic lesion
Incomplete – characterized by variable neurological findings with partial loss of sensory and/or motor function below the lesion

31. Injuries by ASIA classification
Incomplete tetraplegia %
Complete paraplegia %
Incomplete paraplegia %
Complete tetraplegia %
The most common neurologic level of injury is C5. In paraplegia, T12 is the most common level.

32. Functional outcome measures
Several functional-outcome measures are reliable and valid for use in SCI. A common scale for the measurement of functional ability is the Functional Independence Measure (FIM), which uses a 7-point scale to measure 18 items in the following 6 categories:
Mobility
Locomotion
Self-care
Continence of the bowel and/or bladder
Communication
Social cognition
On the FIM scale, a score of 1 indicates total dependence on a caregiver, and a score of 7 indicates independence. Numbers between 1 and 7 represent different levels of assistance required from a caregiver or assistive device to perform a specific skill

33. Clinical syndromes
Central cord syndrome often is associated with a cervical region injury leading to greater weakness in the upper limbs than in the lower limbs with sacral sensory sparing.
Brown-Séquard syndrome often is associated with a hemisection lesion of the cord, causing a relatively greater ipsilateral proprioceptive and motor loss with contralateral loss of sensitivity to pain and temperature.
Anterior cord syndrome often is associated with a lesion causing variable loss of motor function and sensitivity to pain and temperature, while proprioception is preserved.
Conus medullaris syndrome is 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 is due to injury to the lumbosacral nerve roots in the spinal canal leading to areflexic bladder, bowel, and lower limbs.

34. Central Cord Syndrome Usually involves a cervical lesion
May result from cervical hyperextension causing ischemic injury to the central part of the cord
Motor weakness is more present in the upper limbs then the lower limbs
More commonly seen in older patients with cervical arthritis or narrowing of the spinal cord

35. Brown-Sequard Syndrome
Results from an injury to only half of the spinal cord and is most noticed in the cervical region
Motor loss is evident on the same side as the injury to the spinal cord
Sensory loss is evident on the opposite side of the injury location (pain and temperature loss)
Bowel and bladder functions are usually normal

36. Anterior Spinal Cord Syndrome
Compression of the artery that runs along the front of the spinal cord
Patients have a variable amount of motor function below the level of injury
Sensation to pain and temperature are lost while sensitivity to vibration and proprioception are preserved

37. Conus Medullaris vs. Cauda Equina Lesion
Finding Conus CE
Motor Symmetric Asymmetric
Sensory loss Saddle Saddle
Pain Uncommon Common
Reflexes Increased Decreased
Bowel/bladder Common Uncommon

38. Scale of Motor Strength in SCI
The American Spinal Injury Association:
0 - No contraction or movement
1 - Minimal movement
2 - Active movement, but not against gravity
3 - Active movement against gravity
4 - Active movement against resistance
5 - Active movement against full resistance
Assessment of sensory function helps to identify the different pathways for light touch, proprioception, vibration, and pain. Use a pinprick to evaluate pain sensation.

41. 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/extremity and a total possible score of 100
Sensory level - Most caudal dermatome with a normal score of 2/2 for both 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)
Neurologic level of injury - Most caudal level at which both motor and sensory levels are intact, with motor level as defined above and sensory level defined by a sensory score of 2

42. Zone of partial preservation - This index is used only when the injury is complete. All segments below the neurologic level of injury with preservation of motor or sensory findings
Skeletal level of injury - Level of greatest vertebral damage on radiograph
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 score of 20 or less indicates patients are likely to be limited ambulators. A LEMS of 30 or more suggests that patients are likely to be community ambulators.

43. Spinal Cord Paralysis Levels
C1-C3
All daily functions must be totally assisted
Breathing is dependant on a ventilator
Motorised wheelchair controlled by sip and puff or chin movements is required C4
Same as C1-C3 except breathing can be done without a ventilator

44. C5
Good head, neck, shoulder movements, as well as elbow flexion
Electric wheelchair, or manual for short distances C6
Wrist extension movements are good
Assistance needed for dressing, and transitions from bed to chair and car may also need assistance
C7-C8
All hand movements
Ability to dress, eat, drive, do transfers, and do upper body washes

46. T1-T4 (paraplegia)
Normal communication skills
Help may only be needed for heavy household work or loading wheelchair into car
T5-T9
Manual wheelchair for everyday living
Independent for personal care
T10-L1
Partial paralysis of lower body

47. L2-S5
Some knee, hip and foot movements with possible slow difficult walking with assistance or aids
Only heavy home maintenance and hard cleaning will need assistance

48. Complications after SCI

49. DVT

50. Orthostatic Hypotension sustained decrease in blood pressure exceeding 20 mmHg systolic or 10 mmHg diastolic occurring within 3 minutes of upright tilt.

51. Severe pounding headache Sweating above the level of the injury
Patients that are most at risk for autonomic hypererflexia are those with spinal cord injuries above T6. This tends to occur after the spinal shock phase. Autonomic hyperreflexia occurs because nerve messages that were once able to go up the spinal cord to the brain are blocked.
High blood pressure
Low heart rate
Anxiety
Severe pounding headache
Sweating above the level of the injury
Nasal stuffiness

53. Neurogenic bladder: inability to pass urine without use of a catheter or other method

54. Heterotopic ossification: Occurs when calcium lost from the bones build up in muscles, tendons, or joints. This usually begins between 2 weeks to 4 months after injury. The most common places where this process may occur in the body are in the hips, knees, shoulders, and elbows. It can lead to pain, spasms, and a reduced ability to function.

58. Treatment
Fifty years ago, a spinal cord injury was usually fatal. At that time, most injuries were severe, complete injuries and little treatment was available.
Today, there's still no way to reverse damage to the spinal cord. But modern injuries are usually less severe, partial spinal cord injuries.
And advances in recent years have improved the recovery of people with a spinal cord injury and significantly reduced the amount of time survivors must spend in the hospital.
Researchers are working on new treatments, including innovative treatments, prostheses and medications that may promote nerve cell regeneration or improve the function of the nerves that remain after a spinal cord injury.
In the meantime, spinal cord injury treatment focuses on preventing further injury and enabling people with a spinal cord injury to return to an active and productive life within the limits of their disability. This requires urgent emergency attention and ongoing care.

59. Emergency actions
Urgent medical attention is critical to minimizing the long-term effects of any head or neck trauma. So treatment for a spinal cord injury often begins at the scene of the accident.
Attend to three immediate concerns:
Maintaining the ability to breathe
Keeping the patient from going into shock
Immobilizing the neck to prevent further spinal cord damage

60. Three procedures are crucial in treating spinal cord injuries:
Treatment with the steroid medication methylprednisolone to reduce swelling. Used within 8 hours after an injury, this medication may help prevent nerve damage.
Relief of pressure on the spine using surgery or traction (a mechanical system of weights).
Treatment to stabilize the spine using screws, metal plates, and other devices. This is often done during an operation. Sometimes, traction may be used instead.

61. Ongoing care Medications: To control pain and muscle spasticity,
İmprove bladder control, bowel control and sexual functioning.
Short-term medications from time to time, such as antibiotics for urinary tract infections.

62. SCI Rehabilitation:
Physiotherapy for patients with spinal cord injuries can include;
exercises and stretches
joint care
pain control
breathing exercises and chest clearance techniques
anticipating and minimising secondary complications

63. Rehabilitation provision of equipment, orthoses, and wheelchairs
advice on handling techniques
teaching how to use specialised exercise equipment
teach transfers (getting in and out of a wheelchair, bed, car, shower/bath and onto and off a toilet).
teaching wheelchair skills
hydrotherapy treatment
referral to appropriate health professionals

64. The effects of physiotherapy can be:
increased quality of life
increased independence
increased muscle strength
increased energy levels
reduced pain and muscle spasms
reduced stiffness
reduced risk of chest infections

65. Tumors Metastatic or primary Extramedullary Extradural - most common
Bony - breast, prostate
Intradural - very rare
Meninges - meningioma
Nerve root - schwannoma
Intramedullary - very rare
Metastatic
Primary - astrocytoma or ependymoma

66. Transverse myelitis Inflammation of the spinal cord
Post-infectious
Post-vaccinial
Multiple sclerosis
Pain at level of lesion may preceed onset of weakness/sensory change / b&b disturbance

67. B12 Deficiency Subacute combined degeneration of the cord
malabsorption of B12 secondary to pernicious anemia or surgery
insufficient dietary intake - vegan
Posterior columns and CST involvement with a superimposed peripheral neuropathy

68. Infections Involving the Spinal Cord
Polio
only the anterior horn cells are infected
Tabes dorsalis
dorsal root ganglia and dorsal columns are involved
tertiary syphillis
sensory ataxia, “lightening pains”
HIV myelopathy
mimics B12 deficiency
HTLV-1 myelopathy - tropical spastic paraparesis

69. Multiple Sclerosis Demyelination is the underlying pathology
Cord disease can be presenting feature of MS or occur at any time during the course of the disease
Lesion can be at any level of the cord
Patchy
Transverse
Devic’s syndrome or myelitis optica
Transverse myelitis with optic neuritis

70. Vascular Diseases of the Spinal Cord
Infarcts
Anterior spinal artery infarct

71. Vascular Diseases of the Spinal Cord
Arteriovenous malformation (AVM) and venous angiomas
Both occur in primarily the thoracic cord
May present either acutely, subacutely or chronically (act as a compressive lesion)
Can cause recurrent symptoms
If they bleed
Associated with pain and bloody CSF
Notoriously difficult to diagnose
Hematoma - trauma, occasionally tumor

72. Other Disease of the Spinal Cord
Hereditary spastic paraparesis
Usually autosomal dominant
Infectious process of the vertabrae
TB, bacterial
Herniated disc with cord compression
Most herniated discs are lateral and only compress a nerve root
Degenerative disease of the vertabrae
Cervical spondylosis with a myelopathy
Spinal stenosis

73. Syringomyelia Fluid filled cavitation in the center of the cord
Cervical cord most common site
Loss of pain and temperature related to the crossing fibers occurs early
cape like sensory loss
Weakness of muscles in arms with atrophy and hyporeflexia (AHC)
Later - CST involvement with brisk reflexes in the legs, spasticity, and weakness
May occur as a late sequelae to trauma
Can see in association with Arnold Chiari malformation

74. Syringomyelia