1. Spinal Cord lesions

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

3. Anatomy
Spinal cord lies within protective covering of vertebral column.
Begins just below foramen magnum of the skull.
Ends opposite 2nd lumbar vertebra.
Below L2 continue as a leash of nerve roots known as cauda equina.
Prolongation of the pia matter forms filum terminale

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

5. Spinal cord structure

6. Spinal cord structure
The spinal cord consists of central core of grey matter containing nerve cell bodies, and outer layer of white matter of nerve fibers.
Within the grey matter, the dorsal horn contains sensory neurons, the ventral horn contains motor neurons and the lateral horn contains preganglionic sympathetic neurons.
Within the white matter run ascending and descending nerve fiber tracts, which link the spinal cord to the brain.

7. The principle ascending tracts are the spinothalamic tracts, spinocerebellar tracts and dorsal columns. The coticospinal tracts is an important descending tract.
The spinal cord receives information from, and controls the trunk and limbs.
This is achieved through 31 pairs of spinal nerves which join the cord at intervals along its length and contain afferent and efferent nerve fibers connecting with the structures at the periphery.

8. Spinal cord compression

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

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

11. Normal Spinal Cord Reflex Arc Involuntary response to a stimulus
Where sensory and motor nerves arise from cord
Sensory fibers enter posterior
Synapse in the grey matter
Motor fibers leave anterior
Once outside cord join form spinal nerve

13. Spinal Cord Protection
Bones- vertebral column
7 Cervical
12 Thoracic
5- Lumbar
5- Sacral
Discs-
between
vertebra

14. Tracts : 1) Posterior column: Fine touch Light press Proprioception
2) Lateral corticospinal tract :
Skilled voluntary movement
3) Lateral spinothalamic tract :
Pain & temperature sensation

15. 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

17. 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

18. Spinal Cord Injury Primary Secondary Ischemia Hypoxia Microhemorrhage
Initial mechanism of injury
Secondary
Ongoing progressive damage
Ischemia
Hypoxia
Microhemorrhage
Edema

19. Mechanism of Injury Flexion Hyperextension Compression
Flexion /Rotation

20. Flexion (hyper flexion)
Most common because of natural protection position.
Generally cause neck to be unstable because stretching of ligaments

21. Hyperextension
Caused by chin hitting a surface area, such as dashboard or bathtub
Usually causes central cord syndrome symptom

22. Hyperextension

23. Compression Caused by force from above, as hit on head
Or from below as landing on butt
Usually affects the lumbar region

24. Flexion/Rotation Most unstable
Results in tearing of ligamentous structures that normally stabilize the spine
Usually results in serious neurologic deficits

25. Classifications of SCI Completeness (Degree) of Injury
Incomplete
Central cord syndrome
Anterior Cord syndrome
Brown-Sequard Syndrome
Posterior Cord Syndrome
Cauda Equina and Conus Medullaris

26. Complete Motor deficits- Sensory- Autonomic deficits-
Loss of voluntary movement of parts innervated by segment, this is irreversible
Loss of sensation
Spinal shock
Motor deficits-
spastic paralysis below level of
injury
Sensory-
loss of all sensation perception
Autonomic deficits-
vasomotor failure and spastic bladder

27. Incomplete: Some function is present below site of injury
More favourable prognosis overall
Are recognizable patterns of injury, although they are rarely pure and variations occur

28. Central cord syndrome
Injury to the center of the cord by edema and hemorrhage
Motor weakness and sensory loss in all extremities
Upper extremities affected more

30. Anterior cord Syndrome:
Injury to anterior cord
Loss of voluntary motor, pain and temperature perception below injury
Retains posterior column function (sensations of touch, position, vibration, motion)

32. Posterior Cord Syndrome
Least frequent syndrome
Injury to the posterior (dorsal) columns
Loss of proprioception
Pain, temperature, sensation and motor function below the level of the lesion remain intact
Proprioception affected – ataxia and faltering gait
Usually good power and sensation

34. Brown – Sequard Syndrome:
Hemisection of cord
Ipsilateral paralysis
Ipsilateral superficial sensation, vibration and proprioception loss
Contralateral loss of pain and temperature perception

36. Cauda Equina and Conus Medullaris
Injury to the sacral cord (conus) and lumbar nerve roots
Cauda Equina
Injury to the lumbosacral nerve roots
Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs

37. Cervical injuries
- When spinal cord injuries occur near the neck, symptoms can affect both the arms and the legs:
Breathing difficulties (from paralysis of the breathing muscles).
Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms).
Numbness.
Sensory changes.
Spasticity (increased muscle tone).
Pain.
Weakness, paralysis.

38. Thoracic injuries
When spinal injuries occur at chest level, symptoms can affect the legs:
Breathing difficulties (from paralysis of the breathing muscles)
Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms).
Numbness.
Sensory changes.
Spasticity (increased muscle tone).
Pain.
Weakness, paralysis.
Injuries to the cervical or high-thoracic spinal cord may also result in blood pressure problems, abnormal sweating, and trouble maintaining normal body temperature

39. Lumbosacral injuries
When spinal injuries occur at the lower-back level, varying degrees of symptoms can affect the legs:
Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms).
Numbness.
Pain.
Sensory changes.
Spasticity (increased muscle tone).
Weakness and paralysis

40. 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
Hemiplegic- paralysis of upper limb, torso and lower leg on one side of the body
Quadriplegia- paralysis of all four limbs

41. 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 C5
Good head, neck, shoulder movements, as well as elbow flexion
Electric wheelchair, or manual for short distances

43. 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

44. 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
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

46. Injury defined by ASIA Impairment Scale
ASIA – American Spinal Injury Association :
A – Complete: no sensory or motor function preserved in sacral segments S4 – S5
B – Incomplete: sensory, but no motor function in sacral segments

47. ASIA – American Spinal Injury Association
C – Incomplete: motor function preserved below level and power graded < 3
D – Incomplete: motor function preserved below level and power graded 3 or more
E – Normal: sensory and motor function normal

48. Investigation X ray. CT scan. MRI. Myelogram. Biopsy. Bone scan.
Blood and spinal fluid studies.

49. Muscle Strength Grading:
5 – Normal strength
4 – Full range of motion, but less than normal strength against resistance
3 – Full range of motion against gravity
2 – Movement with gravity eliminated
1 – Flicker of movement
0 – Total paralysis

50. Therapeutic Interventions
Stabilization/
Immobilization
Traction-
Gardner-wells tongs
Halo
Casts
Splints
Collars
Braces

51. Management of Spinal Cord Injuries
Immediate management at the scene is critical.
Improper handling can cause further damage and loss of functioning
Always assume there is a spinal cord injury until it is ruled out
Immobilize
Prevent flexion, rotation or extension of neck
Avoid twisting patient
If conscious, patients will usually mention acute pain in back or neck which may radiate along the involved nerve

52. Management of Spinal Cord Injuries
Consists of emergency treatment following an A-B-C-D-E sequence.
Airway Management
Use bag-valve-mask devise initially for airway compromise and if necessary to prepare for intubation.
Breathing
Circulation
Disability
Exposure

53. Breathing
Lesions above C5 level will cause partial to complete diaphragmatic paralysis (recall the diaphragm is innervated at C3-5 levels).
Any lesion above T12 may cause some airway compromise.
Lesions at C5 and below will allow full diaphragmatic movement, but intercostal muscles (innervated at T1) and abdominal muscles (innervated at T12) are affected

54. Circulation
Cardiac output is affected by external or internal hemorrhage.
To determine external bleeding, turn the patient in log-roll fashion and quickly note the site of injury.
Two signs of internal bleeding from abdominal trauma are abdominal pain and muscular rigidity. However, these signs may be masked in a patient with sensory and motor deficits.

55. Exposure
Patients with SCI become poikilothermic, meaning that their body temperature will increase and decrease with the temperature of the environment.
Because they lose the ability to regulate core body temperature through vasodilatation and vasoconstriction, they can become dangerously hyperthermic or hypothermic.

56. Neurological/Orthopedic Management
Reduction
Fixation
Fusion
Fixation involves stabilizing vertebral fractures with wires, plates, and other types of hardware.

57. Rehab and Long-Term Issues
Mobility - initially may require a brace or halo. Needs to bear weight as soon as possible because it helps decrease disuse atrophy, decrease the opportunity for osteoporosis, decrease the possibility of renal calculi, and enhances metabolic processes
self-care
Skin Integrity - needs to be taught the importance of being responsible for own skin integrity
Exercise - to strengthen unaffected parts and promote

58. Bed mobility Pressure relief Wheel chair transfer
Prevent and Manage Complications
Spastic Muscles - maximum spastic activity is usually 2 years out and then minimizes some. May require long-term use of anti-spasmodic drugs such as valium, baclofen or dantrium.
Contractures - Needs to understand the importance of exercise and maintaining function
Bed mobility
Pressure relief
Wheel chair transfer