Ghavam Tavallaee Neurosurgeon

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

Mechanisms: i) Direct trauma ii) Compression by bone fragments / haematoma / disc material iii) Ischemia from damage / impingement on the spinal arteries

National Spinal Cord Injury Database ( USA )  MVA44.5%  Falls 18.1%  Violence 16.6%  Sports 12.7%  55% cases occur in 16 – 30yrs of age  81.6% are male!

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

Spinal cord:  Extends from medulla oblongata – L 1  Lower part tapered to form conus medullaris

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

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

 Grey matter – sensory and motor nerve cells  White matter – ascending and descending tracts  Divided into - dorsal - lateral - ventral

1) Posterior column:  Fine touch  Light pressure  Proprioception

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

 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

 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

Downloaded from: Rosen's Emergency Medicine (on 29 April :34 PM) © 2007 Elsevier

Downloaded from: Rosen's Emergency Medicine (on 29 April :34 PM) © 2007 Elsevier

 Segmental nerve root innervating a muscle  Again important in determining level of injury  Upper limbs: C 5 - Deltoid C 6 - Wrist extensors C 7 - Elbow extensors C 8 - Long finger flexors T 1 - Small hand muscles

 Lower Limbs : L 2 - Hip flexors L 3,4 - Knee extensors L 4,5 – S 1 - Knee flexion L 5 - Ankle dorsiflexion S 1 - Ankle plantar flexion

 Quadriplegia : injury in cervical region all 4 extremities affected  Paraplegia : injury in thoracic, lumbar or sacral 2 extremities affected

Injury either : 1) Complete 2) Incomplete

Complete: i) Loss of voluntary movement of parts innervated by segment, this is irreversible ii) Loss of sensation iii) Spinal shock

Spinal shock i) Transient physiological reflex depression of cord function – ‘concussion of spinal cord’ ii) Loss anal tone, reflexes, autonomic control within 24-72hr iii) Flaccid paralysis bladder & bowel and sustained Priapism iv) Lasts even days till reflex neural arcs below the level recovers

Incomplete: i) Some function is present below site of injury ii) More favourable prognosis overall iii) Are recognisable patterns of injury, although they are rarely pure and variations occur

 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

Spinal 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

Neurogenic shock:  Triad of i) hypotension ii) bradycardia iii) hypothermia  More commonly in injuries above T 6  Secondary to disruption of sympathetic outflow from T 1 – L 2

 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 …Neurogenic shock

i) Central Cord Syndrome ii) Anterior Cord Syndrome iii) Posterior Cord Syndrome iv) Brown – Sequard Syndrome v) Cauda Equina Syndrome

i) 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

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 (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

ii) 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

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

Clinically:  Paralysis on affected side (corticospinal)  Loss of proprioception and fine discrimination (dorsal columns)  Pain and temperature loss on the opposite side below the lesion (spinothalamic)

v) Cauda Equina Syndrome :  Due to bony compression or disc protrusions in lumbar or sacral region

… Cauda Equina Syndrome : Clinically  Non specific symptoms – back pain - bowel and bladder dysfunction - leg numbness and weakness - saddle parasthesia

ABCDE – Logroll and remove the spinal board Look for markers of spinal injury Secondary survey Adequate Xray’s Emergency treatment Surgery Definitive care & rehab Assessment & Managemnt

Pain in the neck or back radiating due to nerve root irritation Sensory disturbance distal to neurological level Weakness or flaccid paralysis below the level Clinical features

Diaphragmatic breathing Neurological shock (Low BP & HR) Spinal shock - Flaccid areflexia Flexed upper limbs (loss of extensor innervation below C5) Responds to pain above the clavicle only Priapism – may be incomplete. Signs in an Unconscious patients

Forehead wounds – think of hyperextension injury Localized bruise Deformities of spine - Gibbus, feel a step & Priapism Beevors sign – tensing the abdomen umbilicus moves upwards in D10 lesions Signs of spinal injury

- Sudden hyperextension and flexion - Increasing neck pain for the first 24hours - Associated headache, pain radiating to both shoulders and paraesthesia in hands - Reduced lateral flexion - Anterior longitudinal ligaments are torn causes dysphagia - Forward flexion against resistance is painful - 90% are asymptomatic after 2years - 10% still have pain - Some still claim money hence the need for proper documentations. Whiplash injury

Document the level of injury Rule out other injuries – DPL in abdominal injuries as there is paralytic ileus and absent peritioneal irritation. Associated injuries in dorsal spine fracture are : - Renal injuries - Chest and Sternal injuries - Wide Mediatinum due to fracture haematoma. - Retroperitoneal injuries Assessment

Be thorough – Adequacy, Alignment,Bones, Cartilages and soft tissues and distances SCIWORA in kids Low threshold for xray in rheumatoid & Ankylosing spond Flexion injury common in lower cervical spine Extension injury in upper cervical Spine Junction of mobile & fixed part are prone to injury eg. C7 T1 & T12,L1. Radiology

- Cervical XR : AP/Lat - Thoracic XR : AP/Lat - Thoracolumbar XR : AP/ Lat - Lumbosacral XR :AP/Lat Radiographs in spinal injuries

- ABCDE - Keep warm - Treat if BP<100mmHg - H2 Antagonists - Methylprednisolone 30mg/kg iv bolus over 15min immediately - 45minutes after the bolus a 5.4mg/kg/h infusion over 23 hrs in first 3 hours after the injury mg/kg/hr for 47hrs if 4 - 8hrs following the injury. Emergency treatment

GOOD LUCK