1. SPINAL CORD INJURY

2. SPINAL CORD INJURY

3. Definition Insult to spinal cord resulting in a change,
in the normal motor, sensory or autonomic function. This change is either temporary or permanent.

4. Mechanisms: Direct trauma
Compression by bone fragments / haematoma / disc material
Ischemia from damage / impingement on the spinal arteries

5. Statistics: National Spinal Cord Injury Database { USA Stats }
MVA %
Falls %
Violence %
Sports %
55% cases occur in 16 – 30yrs of age
81.6% are male!

6. Other causes:
Vascular disorders
Tumours
Infectious conditions
Spondylosis
Iatrogenic
Vertebral fractures secondary to osteoporosis
Development disorders

7. Anatomy : Spinal cord: Extends from medulla oblongata – L1
Lower part tapered to form conus medullaris

8. On the surface :
Deep anterior median fissure
Shallower posterior median sulcus
Spinal cord segment :
Section of the cord from which a pair of spinal nerves are given off

9. Hence: 31 pairs of spinal nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal

10. Basic Anatomy and Physiology
On cross section

11. Ventral root – motor fibres
Dorsal root – sensory fibres
Ventral root – motor fibres
Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve

13. Physiology and function
Grey matter – sensory and motor nerve cells
White matter – ascending and descending tracts
Divided into - dorsal
- lateral
- ventral

15. Tracts :
1) Posterior column:
Fine touch
Light pressure
Proprioception

16. 2) Lateral corticospinal tract :
Skilled voluntary movement
3) Lateral spinothalamic tract :
Pain & temperature sensation

17. Posterior column and lateral corticospinal tract crosses over at medulla oblongata
Spinothalamic tract crosses in the spinal cord and ascends on the opposite side
NB to understand this as it helps to understand the clinical features of injury patterns and the neurological deficit

18. Dermatomes
Area of skin innervated by sensory axons within a particular segmental nerve root
Knowledge is essential in determining level of injury
Useful in assessing improvement or deterioration

19. Myotomes : Segmental nerve root innervating a muscle
Again important in determining level of injury
Upper limbs: C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C Long finger flexors
T Small hand muscles
Lower Limbs : L Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion

20. Spinal Cord Injury Classification
Quadriplegia :
injury in cervical region
all 4 extremities affected
Paraplegia :
injury in thoracic, lumbar or sacral segments
2 extremities affected

21. Injury either: Complete Incomplete
Loss of voluntary movement of parts innervated by segment, this is irreversible
Loss of sensation
Spinal shock
Incomplete
Some function is present below site of injury
More favourable prognosis overall
Are recognisable patterns of injury, although they are rarely pure and variations occur

22. Spinal Shock vs Neurogenic Shock
Transient reflex depression of cord function below level of injury
Initially hypertension due to release of catecholamines
Followed by hypotension
Flaccid paralysis
Bowel and bladder involved
Sometimes priaprism develops
Symptoms last several hours to days

23. Neurogenic shock: Triad of i) hypotension ii) bradycardia
iii) hypothermia
More commonly in injuries above T6
Secondary to disruption of sympathetic outflow from
T1 – L2

24. Loss of vasomotor tone – pooling of blood
Loss of cardiac sympathetic tone – bradycardia
Blood pressure will not be restored by fluid infusion alone
Massive fluid administration may lead to overload and pulmonary edema
Vasopressors may be indicated
Atropine used to treat bradycardia

25. What is the difference between spinal shock and neurogenic shock?
Spinal shock is mainly a loss of reflexes (flaccid paralysis)
Neurogenic shock is mainly hypotension and bradycardia due to loss of sympathetic tone

26. Types of incomplete injuries
Central Cord Syndrome
Anterior Cord Syndrome
Posterior Cord Syndrome
Brown – Sequard Syndrome
Cauda Equina Syndrome

27. Central Cord Syndrome :
Typically in older patients
Hyperextension injury
Compression of the cord anteriorly by osteophytes and posteriorly by ligamentum flavum
Also associated with fracture dislocation and compression fractures
More centrally situated cervical tracts tend to be more involved hence
flaccid weakness of arms > legs
Perianal sensation & some lower extremity movement and sensation may be preserved

29. ii) Anterior cord Syndrome:
Due to flexion / rotation
Anterior dislocation / compression fracture of a vertebral body encroaching the ventral canal
Corticospinal and spinothalamic tracts are damaged either by direct trauma or ischemia of blood supply (anterior spinal arteries)
Clinically:
Loss of power
Decrease in pain and sensation below lesion
Dorsal columns remain intact

30. iii) Posterior Cord Syndrome:
Hyperextension injuries with fractures of the posterior elements of the vertebrae
Clinically:
Proprioception affected – ataxia and faltering gait
Usually good power and sensation

31. iv) Brown – Sequard Syndrome:
Hemi-section of the cord
Either due to penetrating injuries:
i) stab wounds
ii) gunshot wounds
Fractures of lateral mass of vertebrae

34. 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 neck

35. 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

36. 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)

37. 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

38. 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

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

40. THANK YOU