Neurologic Assessment for Spinal Pathologies Sunil Jeswani, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

Examination Assessment of motor level based on motor exam

Examination Sensory exam

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

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

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

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

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

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

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

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

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

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

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

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)

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)

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

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

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

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

Management 1. Stabilization of patient

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

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

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). S58-60. 2002.

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

Management STEROIDS??? NASCIS Trial Improved outcomes at 6 weeks, 6 months, and 1 year Administration of methylprednisolone within 8 hours of injury x 24-48 hours Not intended for penetrating injuries to spine CONTROVERSIAL Other studies have not able to duplicate their results Morbidity from steroid adminstration

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

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

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?

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?

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?

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

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

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?

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?

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?

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?

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?

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?

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

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

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

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

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

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

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?

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?

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?

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?

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…

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…

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