1. Neurologic Assessment for Spinal Pathologies
Sunil Jeswani, MD

2. Incidence of spinal injury
12,000 new cases of spinal cord injury in the US per year
Average age of injury is 41 years
80.6% of spinal cord injury are males
40% are due to MVAs
20% of patients with a major spine injury may have a second spinal injury at another level
Often have other non-spinal simultaneous injuries

3. Definitions Spinal Stability White and Punjabi definition
Ability of the spine under physiological loads to resist:

4. Definitions Spinal Stability White and Punjabi definition
Ability of the spine under physiological loads to resist:
Displacement resulting in injury of spinal cord or spinal nerves

5. Definitions Spinal Stability White and Punjabi definition
Ability of the spine under physiological loads to resist:
Displacement resulting in injury of spinal cord or spinal nerves
Spinal deformity

6. Definitions Spinal Stability White and Punjabi definition
Ability of the spine under physiological loads to resist:
Displacement resulting in injury of spinal cord or spinal nerves
Spinal deformity
Incapacitating pain

7. Definitions Level of Injury Lowest level of normal neurological level
Lowest level with motor function at least 3 out 5 with pain/temperature sensation present
Not necessarily the same level as the level of the fracture dislocation

8. Definitions Completeness of Lesion Incomplete lesion:
Any residual motor or sensory function more than 3 segments below level of injury
Look for sensation/voluntary movement in lower extremities
Sensation around anus
Voluntary rectal sphincter contraction

9. Definitions Completeness of Lesion Incomplete lesion: Complete lesion:
Any residual motor or sensory function more than 3 segments below level of injury
Look for sensation/voluntary movement in lower extremities
Sensation around anus
Voluntary rectal sphincter contraction
Complete lesion:
No motor/sensory function in S4-5 level
Poor prognosis
3% of patients will recover some function within 24 hours

10. Definitions Spinal shock
Transient loss of all spinal cord function including reflexes below the level of injury
May last days to weeks to even months

11. Definitions Spinal shock Neurogenic shock
Transient loss of all spinal cord function including reflexes below the level of injury
May last days to weeks to even months
Neurogenic shock
Hypotension
Dysfunction of sympathetic outflow from sympathetic fibers descending from hypothalamus and exiting thoracic spinal cord
Decreased vascular tone
Unopposed parasympathetic activity resulting in bradycardia
Loss of muscle tone secondary to paralysis
Results in venous pooling

12. Examination Palpation of: Point tenderness “Step off”
Widening of interspinous space

13. Examination
The purpose of the neurological exam in spinal cord injury is to determine level and completeness of injury

14. Examination Motor exam Grading scale 5: normal strength
4: movement against resistance
4- : slight resistance
4: moderate resistance
4+ : strong resistance
3: movement against gravity
2: movement with gravity eliminated
1: flicker or trace contraction
0: no contraction

15. Examination Motor Exam Upper extremities Deltoids Biceps Triceps
Wrist extensors
Wrist flexors
Hand grip
Hand intrinsics

16. Examination Motor Exam Upper extremities Lower extremities Deltoids
Biceps
Triceps
Wrist extensors
Wrist flexors
Hand grip
Hand intrinsics
Lower extremities
Iliopsoas (hip flexion)
Quadriceps (knee extension)
Hamstring (knee flexion)
Gastrocnemius (foot plantar flexion)
Tibialis anterior (foot dorsiflexion)
Extensor hallicus longus (big toe dorsiflexion)

17. Examination Motor Exam Upper extremities Lower extremities Rectal exam
Deltoids
Biceps
Triceps
Wrist extensors
Wrist flexors
Hand grip
Hand intrinsics
Lower extremities
Iliopsoas (hip flexion)
Quadriceps (knee extension)
Hamstring (knee flexion)
Gastrocnemius (foot plantar flexion)
Tibialis anterior (foot dorsiflexion)
Extensor hallicus longus (big toe dorsiflexion)
Rectal exam
Voluntary anal sphincter contraction

18. Examination
Assessment of motor level based on motor exam

19. Examination
Sensory exam

20. Examination Sensory exam Sensation to pinprick
Tests lateral spinothalamic tract
Also test pinprick sensation in face as spinal trigeminal tract can descend down to C4

21. Examination Sensory exam Sensation to pinprick
Tests lateral spinothalamic tract
Also test pinprick sensation in face as spinal trigeminal tract can descend down to C4
Sensation to light touch
Tests anterior spinothalamic tract

22. Examination Sensory exam Sensation to pinprick
Tests lateral spinothalamic tract
Also test pinprick sensation in face as spinal trigeminal tract can descend down to C4
Sensation to light touch
Tests anterior spinothalamic tract
Propioception/vibration sense
Tests posterior columns
Cuneate/Gracilis fasciculi

23. Examination
Identification of the sensory level of injury based on sensory exam

24. Examination Reflex exam Muscle stretch reflexes Biceps (C5,6)
Triceps (C7)
Brachioradialis (C5,6)
Patellar (L3,4)
Achilles (S1)
*May be absent in spinal shock

25. Examination Reflex exam Muscle stretch reflexes Grading scale Biceps
Triceps
Brachioradialis
Patellar
Achilles
*May be absent in spinal shock
*Hypereflexivia in delayed onset
Grading scale
0: absent
1+: hypoactive
2+: normal
3+: hyperactive without clonus
4+: hyperactive with clonus

26. Examination Reflex exam Abdominal cutaneous reflex Cremasteric reflex
Involves stroking/scratching abdominal skin near umbilicus
Normal response will cause abdominal muscle contraction resulting in deviation of umbilicus in direction of stimulation
Cremasteric reflex
Light stroking of medial thigh results in contraction of cremasteric muscle and causes testis to rise on ipsilateral side
Bulbocavernosus reflex
Tugging of foley catheter results in contraction of anal sphincter
Anal cutaneous reflex (anal wink)
Pinprick to skin in anal region resulting in involuntary anal contraction

27. Examination Other signs Loss of perspiration below level of injury
Bowel/bladder incontinence
Priapism
Clonus (delayed finding)
Babinski sign (delayed finding)

28. Examination American Spinal Injury Association (ASIA) Classification
Used to assess prognosis for recovery after spinal cord injury

29. Examination American Spinal Injury Association (ASIA) Classification
Used to assess prognosis for recovery after spinal cord injury
ASIA Grade A
Complete: No motor or sensory function preserved in sacral segments S4-5
3% chance of any recovery within 24 hours

30. Examination American Spinal Injury Association (ASIA) Classification
Used to assess prognosis for recovery after spinal cord injury
ASIA Grade A
Complete: No motor or sensory function preserved in sacral segments S4-5
3% chance of any recovery within 24 hours
ASIA Grade B
Incomplete: Sensory but no motor function preserved below level of injury (includes sacral segments S4-5)
10-30% chance of significant improvement

31. Examination American Spinal Injury Association (ASIA) Classification
Used to assess prognosis for recovery after spinal cord injury
ASIA Grade A
Complete: No motor or sensory function preserved in sacral segments S4-5
3% chance of any recovery within 24 hours
ASIA Grade B
Incomplete: Sensory but no motor function preserved below level of injury (includes sacral segments S4-5)
10-30% chance of significant improvement
ASIA Grade C
Incomplete: Motor function preserved below level of injury (more than half the muscles below level of injury are < 3)

32. Examination American Spinal Injury Association (ASIA) Classification
Used to assess prognosis for recovery after spinal cord injury
ASIA Grade A
Complete: No motor or sensory function preserved in sacral segments S4-5
3% chance of any recovery within 24 hours
ASIA Grade B
Incomplete: Sensory but no motor function preserved below level of injury (includes sacral segments S4-5)
10-30% chance of significant improvement
ASIA Grade C
Incomplete: Motor function preserved below level of injury (more than half the muscles below level of injury are < 3)
ASIA Grade D
Incomplete: Motor function preserved below level of injury (more than half the muscles below level of injury are >3)

33. Examination American Spinal Injury Association (ASIA) Impairment Scale
Used to assess prognosis for recovery after spinal cord injury
ASIA Grade A
Complete: No motor or sensory function preserved in sacral segments S4-5
3-5% chance of progressing to an incomplete injury
If complete >72 hrs, then that chance drops to 0
ASIA Grade B
Incomplete: Sensory but no motor function preserved below level of injury (includes sacral segments S4-5)
10-30% chance of significant improvement
ASIA Grade C
Incomplete: Motor function preserved below level of injury (more than half the muscles below level of injury are < 3)
ASIA Grade D
Incomplete: Motor function preserved below level of injury (more than half the muscles below level of injury are >3)
ASIA Grade E
Sensory and motor function normal

34. Clinical Syndromes of Incomplete Injuries
Central cord syndrome
More pronounced weakness in upper extremites than lower extremities
Hyperpathia in proximal upper extremities
Usually from hyperextension injury
Usually in older patients with pre-exisiting spinal stenosis
Lower extremity and bowel/bladder dysfunction recover earlier than upper extremity function
Relatively good prognosis
50% will ambulate independantly

35. Clinical Syndromes of Incomplete Injuries
Anterior Cord Syndrome
Also known as anterior spinal artery syndrome
Due to infarction of spinal cord in territory of anterior spinal artery
Motor paralysis below level of injury
Loss of pain/temperature sensation below level of injury
Proprioception/vibration sense preserved
Worst prognosis of incomplete injuries
10-20% recover functional motor control

36. Clinical Syndromes of Incomplete Injuries
Brown-Sequard Syndrome
Hemisection of spinal cord
Usually result of penetrating trauma
Motor paralysis on same side of lesion
Loss of proprioception/vibration sense on same side of lesion
Loss of pain/temperature sensation on opposite side of lesion
Best prognosis
90% will regain ability to ambulate independantly

37. Management
1. Stabilization of patient

38. Management 1. Stabilization of patient
2. Assessment of spinal stability

39. Management 1. Stabilization of patient
2. Assessment of spinal stability
3. Treatment

40. Management Stabilization of patient
ABC’s
Avoid hypotension!
Phenylephrine not recommend due to reflex bradycardia
Have atropine available for bradycardia
Data shows improved outcome if MAPs kept > 85-90mmHg for first 7 days after spinal cord perfusion*
Maintain adequate oxygenation
NG tube to suction to prevent aspiration from paralytic ileus (lasts for several days)
* “Blood pressure management after acute spinal cord injury.” Neurosurgery. 50 Supplement(3). S

41. Management Maintain immobilization of spine Supportive care
C-collar/head rolls
Backboard for patient transfers
Supportive care
Foley catheter to prevent distention for urinary retention
DVT prophylaxis
9% mortality from DVTs in spinal cord injury patients
SCDs/compression stockings/rotating beds
Anticoagulation/IVC filters
Temperature control due to loss of vasomotor control of temperature
Avoid fluid overload since prone to pulmonary edema
Monitor for electrolyte disturbances
Increased aldosterone activity -> hypokalemia, metabolic alkalosis

42. Management STEROIDS??? NASCIS Trial
Improved outcomes at 6 weeks, 6 months, and 1 year
Administration of methylprednisolone within 8 hours of injury x hours
Not intended for penetrating injuries to spine
CONTROVERSIAL
Other studies have not able to duplicate their results
Morbidity from steroid adminstration

43. Case #1 16 yo male fell from a tire swing
Neurologically intact in the ER
5/5 strength in all muscle groups
No sensory deficits
Neck pain

44. Case #1 16 yo male fell from a tire swing
Neurologically intact in the ER
5/5 strength in all muscle groups
No sensory deficits
Neck pain

45. Case #1 16 yo male fell from a tire swing
Neurologically intact in the ER
5/5 strength in all muscle groups
No sensory deficits
Neck pain
LEVEL OF INJURY?

46. Case #1 16 yo male fell from a tire swing
Neurologically intact in the ER
5/5 strength in all muscle groups
No sensory deficits
Neck pain
LEVEL OF INJURY?
COMPLETE VS INCOMPLETE?

47. Case #1 16 yo male fell from a tire swing
Neurologically intact in the ER
5/5 strength in all muscle groups
No sensory deficits
Neck pain
LEVEL OF INJURY?
COMPLETE VS INCOMPLETE?
ASIA GRADE?

48. Case #1
Halo vest applied for cervical stabilization x 2-3 months

49. Case #2 65 yo male s/p mechanical fall
Came to ER with 3 to 4-/5 strength in upper extremities
4+/5 strength lower extremities
Voluntary anal sphincter contraction intact
Sensation intact

50. Case #2 65 yo male s/p mechanical fall
Came to ER with 3 to 4-/5 strength in upper extremities
4+/5 strength lower extremities
Voluntary anal sphincter contraction intact
Sensation intact
LEVEL OF INJURY?

51. Case #2 65 yo male s/p mechanical fall
Came to ER with 3 to 4-/5 strength in upper extremities
4+/5 strength lower extremities
Voluntary anal sphincter contraction intact
Sensation intact
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?

52. Case #2 65 yo male s/p mechanical fall
Came to ER with 3 to 4-/5 strength in upper extremities
4+/5 strength lower extremities
Voluntary anal sphincter contraction intact
Sensation intact
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?
ASIA GRADE?

53. Case #2 65 yo male s/p mechanical fall
Came to ER with 3 to 4-/5 strength in upper extremities
4+/5 strength lower extremities
Voluntary anal sphincter contraction intact
Sensation intact
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?
ASIA GRADE?
CLINICAL SYNDROME?

54. Case #2 65 yo male s/p mechanical fall
Came to ER with 3 to 4-/5 strength in upper extremities
4+/5 strength lower extremities
Voluntary anal sphincter contraction intact
Sensation intact
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?
ASIA GRADE?
CLINICAL SYNDROME?

55. Case #2 65 yo male s/p mechanical fall
Came to ER with 3 to 4-/5 strength in upper extremities
4+/5 strength lower extremities
Voluntary anal sphincter contraction intact
Sensation intact
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?
ASIA GRADE?
CLINICAL SYNDROME?

56. Case #3 84 yo old male fell into an empty pool
Arrived in ER unable to move extremities

57. Case #3 84 yo old male fell into an empty pool
Arrived in ER unable to move extremities

58. Case #3 84 yo old male fell into an empty pool
Arrived in ER unable to move extremities
Gardner-Wells tongs fixed to skull
Traction applied to tongs

59. Case #3 84 yo old male fell into an empty pool
Arrived in ER unable to move extremities
Gardner-Wells tongs fixed to skull
Traction applied to tongs

60. Case #3 84 yo old male fell into an empty pool
Arrived in ER unable to move extremities
Gardner-Wells tongs fixed to skull
Traction applied to tongs

61. Case #3 Exam: Left bicep 3/5, tricep 2/5 No movement in right arm
No movement in lower extremities
No voluntary anal sphincter contraction
Sensation to pinprick/light touch intact including S4-5
Muscle reflexes present
Bulbocavernosus reflex present
Bradycardic/hypotensive

62. Case #3 Exam: Left bicep 3/5, tricep 2/5 No movement in right arm
No movement in lower extremities
No voluntary anal sphincter contraction
Sensation to pinprick/light touch intact including S4-5
Muscle reflexes present
Bulbocavernosus reflex present
Bradycardic/hypotensive
LEVEL OF INJURY?

63. Case #3 Exam: Left bicep 3/5, tricep 2/5 No movement in right arm
No movement in lower extremities
No voluntary anal sphincter contraction
Sensation to pinprick/light touch intact including S4-5
Muscle reflexes present
Bulbocavernosus reflex present
Bradycardic/hypotensive
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?

64. Case #3 Exam: Left bicep 3/5, tricep 2/5 No movement in right arm
No movement in lower extremities
No voluntary anal sphincter contraction
Sensation to pinprick/light touch intact including S4-5
Muscle reflexes present
Bulbocavernosus reflex present
Bradycardic/hypotensive
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?
ASIA GRADE?

65. Case #3 Exam: Left bicep 3/5, tricep 2/5 No movement in right arm
No movement in lower extremities
No voluntary anal sphincter contraction
Sensation to pinprick/light touch intact including S4-5
Muscle reflexes present
Bulbocavernosus reflex present
Bradycardic/hypotensive
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?
ASIA GRADE?
NEUROGENIC SHOCK VS. SPINAL SHOCK?

66. Case #3 Exam: Taken to OR for stabilization/fixation of fracture…
Left bicep 3/5, tricep 2/5
No movement in right arm
No movement in lower extremities
No voluntary anal sphincter contraction
Sensation to pinprick/light touch intact including S4-5
Muscle reflexes present
Bulbocavernosus reflex present
Bradycardic/hypotensive
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?
ASIA GRADE?
NEUROGENIC SHOCK VS. SPINAL SHOCK?
Taken to OR for stabilization/fixation of fracture…

67. Case #3 Exam: Taken to OR for stabilization/fixation of fracture…
Left bicep 3/5, tricep 2/5
No movement in right arm
No movement in lower extremities
No voluntary anal sphincter contraction
Sensation to pinprick/light touch intact including S4-5
Muscle reflexes present
Bulbocavernosus reflex present
Bradycardic/hypotensive
LEVEL OF INJURY?
COMPLETE VS. INCOMPLETE?
ASIA GRADE?
NEUROGENIC SHOCK VS. SPINAL SHOCK?
Taken to OR for stabilization/fixation of fracture…

68. Thank You!