This document provides an overview of spinal cord injury, including relevant anatomy, classifications, mechanisms of injury, and clinical presentations. Key points include:
- Spinal cord injuries can result in partial or complete disruption leading to paralysis and sensory loss below the level of injury. Injuries are classified based on preservation of functions below the neurologic level.
- Common mechanisms of injury include motor vehicle accidents, falls, violence, and sports. Flexion injuries commonly cause complete injuries while hyperextension often results in central cord syndrome.
- Clinical assessment involves determining the neurologic level and grade of motor function below the level using a motor index. Incomplete injuries may present as central cord syndrome with relatively greater upper extremity
This document provides an overview of spinal cord injury, including relevant anatomy, classifications, mechanisms of injury, and clinical presentations. Key points include:
- Spinal cord injuries can result in partial or complete disruption leading to paralysis and sensory loss below the level of injury. Injuries are classified based on preservation of functions below the neurologic level.
- Common mechanisms of injury include motor vehicle accidents, falls, violence, and sports. Flexion injuries commonly cause complete injuries while hyperextension often results in central cord syndrome.
- Clinical assessment involves determining the neurologic level and grade of motor function below the level using a motor index. Incomplete injuries may present as central cord syndrome with relatively greater upper extremity
This document provides an overview of spinal cord injury, including relevant anatomy, classifications, mechanisms of injury, and clinical presentations. Key points include:
- Spinal cord injuries can result in partial or complete disruption leading to paralysis and sensory loss below the level of injury. Injuries are classified based on preservation of functions below the neurologic level.
- Common mechanisms of injury include motor vehicle accidents, falls, violence, and sports. Flexion injuries commonly cause complete injuries while hyperextension often results in central cord syndrome.
- Clinical assessment involves determining the neurologic level and grade of motor function below the level using a motor index. Incomplete injuries may present as central cord syndrome with relatively greater upper extremity
This document provides an overview of spinal cord injury, including relevant anatomy, classifications, mechanisms of injury, and clinical presentations. Key points include:
- Spinal cord injuries can result in partial or complete disruption leading to paralysis and sensory loss below the level of injury. Injuries are classified based on preservation of functions below the neurologic level.
- Common mechanisms of injury include motor vehicle accidents, falls, violence, and sports. Flexion injuries commonly cause complete injuries while hyperextension often results in central cord syndrome.
- Clinical assessment involves determining the neurologic level and grade of motor function below the level using a motor index. Incomplete injuries may present as central cord syndrome with relatively greater upper extremity
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SPINAL CORD INJURY o Artery of Adamkiewicz (Radularis
Magna) – arise from T9-L2 from the
Paraplegia – complete paralysis of all or part of the trunk and (B) LE; lesions of the thoracic or Partial/complete disruption of the SC (L) side of 70% of the population lumbar cord or cauda equina Paralysis, sensory loss, altered autonomic Veins of the SC – drain mainly into internal Complete – absence of sensory and motor in activity BELOW the level of the injury venous plexus lowest sacral segments (S4 and S5) Relevant Anatomy: Spinal Cord Zone of Partial Preservation – dermatomes Extends from the foramen magnum – L1 in Spinal Cord Tracts and myotomes caudal to neurologic level adults and up to L3 in newborns Ascending of injury c partial innervation Nearly cylindrical, 1 cm in diameter, with Lateral Spinothalamic – conveys superficial Incomplete – Partial preservation of functions cervical and lumbar enlargements sensations (pain, temperature, light below neurologic level including lowest sacral (plexuses) touch); decussates at the SC, ascends 2-3 segments Vertebral Level Spinal segments Sacral Sparing – voluntary anal sphincter (Radiographic) Segment/s Dorsal Column Medial Lemniscus – contraction/sensory function in lowest (Neurologic) conveys deep sensations (vibration, sacral segments; indicates possibility of SC Cervical +1 proprioception, 2-point discrimination, recovery Upper Thoracic +2 light touch); decussates at the brainstem Mechanisms of Injury (T1-T6) Descending Flexion – common in MVA/head-on collisions Lower Thoracic +3 Corticospinal – controls fine movement of Vertebral body > 50% displaced on x-ray (T7-T9) ipsilateral limbs; decussates at the Both facets dislocate, unstable (both T10 L1 - L2 medulla oblongata ligaments are torn) T11 L3 – L4 Corticobulbar – innervates several cranial Common in C5-C6 T12 L5 nerves; terminates at the brainstem 85% suffer neurologic injuries, likely to be L1 Sacral and Etiology a complete injury coccygeal Attachments Traumatic – most frequent cause of injury Hyperextension – common in acceleration- Denticulate Ligaments – extensions of the Vehicular Accidents – major cause; >45 deceleration injuries, rear-end collision pia mater; stabilizes the SC y/o Stable, only ALL is disrupted Filum Terminale – extension of the pia Violence – commonly by gunshot wounds Can be seen in hyperextension of the C- mater; extends from the apex of the conus Falls – occurs in >45 y/o spine, appearing as Central Cord medullaris to the coccyx to anchor SC Diving – m/c sports-related cause Syndrome (Walking SCI), which commonly Non-traumatic – account for ~39% of SCIs spares the LE Spinal nerve roots Blood Supply Vascular diseases – spinal cord infarction, Commonly occurs in older persons c AVM degenerative changes in the neck Anterior Spinal Artery – arise from the vertebral arteries; narrowest at T8, prone Infections – syphilis, transverse myelitis, UE more commonly involved than LE, with to damage during HTN (watershed area) Pott’s disease bowel, bladder, and sexual dysfunction at Tumors/neoplastic diseases various degrees Posterior Spinal Artery – arise from either the vertebral arteries directly or the PICA Classification Common in C4-C5 Tetraplegia – complete paralysis of all four Compression Radicular Arteries – branches of local arteries from the aorta (deep cervical, extremities and trunk, including respiratory M/c in C5 intercostal, and lumbar), enter the muscles; lesions of the cervical cord Wedge-shaped vertebra on x-ray, may vertebral canal through the IV foramina involve injury to nerve roots/SC Stable, ligaments intact Most caudal key muscle group c at least C Incomplete Motor function Flexion-Rotation 3/5 with segments above graded 5/5 preserved below Unilateral facet jt dislocation Possible score of 100 (25 pts per neurologic level, more Vertebral body displacement > 50% on x- extremity) than half of key muscles Key Myotomes: below neurologic level ray, narrowing of the spinal canal and have < 3/5 MMT neural foramen Myoto Index Muscle Action D Incomplete At least half of key Unstable if PLL is disrupted me muscles below Common in C5-C6 C5 Biceps, brachialis Elbow flexion neurologic level > 3/5 May disrupt the IV disc, facet jt, and C6 Extensor carpi radialis Wrist extension MMT interspinous ligament s vertebral fx C7 Triceps brachii Elbow extension E Normal Sensory and motor C8 Flexor digitorum Finger flexion functions ~75% s neurologic symptoms, likely profundus (of middle incomplete injury finger) Incomplete SCI Syndromes Other Fx of the Spine T1 Abductor digiti minimi Small finger Jefferson – burst fx of the C1 ring, usually Central Cord Syndrome (Schneider) – m/c abduction no neurologic findings if pt survives incomplete SCI syndrome L2 Iliopsoas Hip flexion Hangman – burst fx of C2, body separated L3 Quadriceps Knee extension An acute cervical SCI from posterior element, no SCI L4 Tibialis anterior Ankle Greater impairment of motor function of Odontoid – fx of C2 odontoid process at dorsiflexion the UE than LE, typically recover ability to base L5 Extensor hallucis Big toe ambulate but with weakness of distal UE Chance – m/c seen in pts wearing lap seat longus extension and loss of fine motor skills belts, transverse fx of lumbar spine S1 Gastrocnemius Ankle Hyperextension injury on an individual c through bodies and pedicles plantarflexion long-standing cervical spondylosis, from Assessment pinching of post cord by ligamentum According to sensory, motor, and Neurologic flavum/ant compression by osteophytes neurologic level of injury Most caudal segment c intact motor and Brown-Sequard Syndrome – hemisection of the Sensory sensory on both sides of the body SC, typically by GSW or stab wounds Most caudal segment of the SC c normal Recommended to record each side Ipsilateral: Motor and proprioception (2/2) sensation of pinprick and light touch separately deficits on (B) sides of the body Skeletal Contralateral: Pain and temperature deficit 28 key sensory dermatomes Where greatest vertebral damage is several dermatome segments below level recorded through radiographic evaluation of injury Face used as normal control point ASIA Impairment Scale Anterior Cord Syndrome (Beck’s) – d/t 2 Normal American Spinal Cord Injury Association ischemia/infarct of the ant 2/3 of the SC; related 1 Impair Gra Impairment Description to flexion injuries of the cervical cord ed de Loss of motor function (corticospinal 0 Absent A Complete No motor/sensory tracts) and pain and temperature Key Dermatomes: function in sacral sensation (lateral spinothalamic tracts) segments Posterior Cord Syndrome (Posterior Spinal Artery) Motor B Incomplete Sensory but no motor – least frequent syndrome; lesions of the function below posterior 1/3, occlusion of the post spinal artery, neurologic level infection e.g. syphilis (Tabes Dorsalis), or pernicious anemia (vitamin B12 deficiency) Proprioceptive loss with intact pain, temperature, light touch, and motor function spared in varying degrees Conus Medullaris Syndrome – injury to conus medullaris and lumbar nerve roots; L1 fx, tumar, gliomas, vascular injury, spina bifida, tethered cord Common in injuries at level of T12 - L2 Good prognosis for walking Cauda Equina Syndrome – injury to lumbosacral nerve roots c/in neural canal; L2 fx or below, sacral fx, pelvic ring fx, associated c spondylosis Areflexive bladder, bowel, and LE, saddle anesthesia, paralysis of the sphincters Treatment Wheelchair Prescription C1 - C4 – chin control C5 – manual c projection C6 - C7 – friction hand rim C8 – normal manual Orthotic Prescription Neurologic Level Expected Outcomes Mid-thoracic (T6-T9) (B) KAFO, crutches, swing-to gait High Lumbar (T12- (B) KAFO, crutches, L3) reciprocating gait orthosis c walker Low Lumbar (L4-L5) Community ambulation: (B) AFO c crutch/cane Complications and Associated Conditions o Seizures, cardiac arrest, Rostral SCI results in loss of sympathetic Spinal Shock subarachnoid hemorrhage, stroke, communication while parasympathetic Areflexia below level of injury immediately death remains intact p injury Symptoms: Orthostatic hypotension can be Believed to result from very abrupt o HTN, bradycardia, headache, experienced during early transitions of withdrawal of connections between higher profuse sweating, spasticity, posture, usually only significant in pts c centers and the SC restlessness, vasoconstriction below SCI above T6 Absence of DTR, impaired autonomic level of lesion, vasodilation above o Blurred vision, ringing in the ears, regulation (hypotension, loss of control of level of lesion, piloerection, blurred light-headedness, fainting sweating and piloerection), vision Tx: bulbocavernosus, cremasteric, and Diagnosis: 20-30 mmHg rise in BP (250- o Gradual progression to the vertical Babinski reflexes, and a delayed plantar 300/200-220 mmHg) position response Tx: o Pharmacologic agents – ephedrine, Initial period lasts ~24 hrs, longest time in o Place pt in an upright position. low-dose diuretics 1-6 mos o Eliminate triggers Impaired Temperature Control Motor and Sensory Impairments o Pharmacologic: D/t cut-off of hypothalamic control Autonomic Dysreflexia Nifedipines – calcium-channel No control of cutaneous blood flow and Potentially life-threatening pathological blocker level of sweating, loss of ability to shiver autonomic reflex Nitrates – vasodilators below level of lesion Typically appears in pts c lesions above Captopril – ACE inhibitor Initially, hypothermia may occur, but T6 (sympathetic splanchnic outflow in T1- Spastic Hypertonia hyperthermia is a more common L1) Velocity-dependent increase in resistance complication later Pt’s BP can reach a systolic of 220 to passive stretch Pulmonary Impairment Produces autonomic activity from noxious Part of the UMN Syndrome (spasticity, Leading cause of death in pts c high stimuli (triggers): muscle spasms, abnormally high muscle tetraplegia (C1-C2) o Distended/irritated bladder/bowel – tone, hyperactive stretch reflexes, clonus) Level Respiratory m/c Emerges below level of lesion p spinal of Intervention Muscles Distended bladder shock evolves; gradual increase in first 6 Injury Blocked catheter mos, plateau 1 yr p injury Artificial UTI Occurs in most SCIs except cauda equina C1 – SCM, upper traps, ventilator, Kidney stones syndrome C2 cervical extensors phrenic nerve o Noxious cutaneous stimuli below stimulation Tx: level of lesion Partial diaphragm, Acute, o Muscle relaxants – baclofen, C3 – scalenes, levator mechanical o Pressure sores botulinum neurotoxin C4 scapulae ventilation o Kidney malfunction Adverse effects: weakness, Diaphragm, o ES below level of lesion drowsiness, dizziness Assistance C5 – pectorals, SA, o Labor o Myotomy, tenotomy, rhizotomy – with airway C8 rhomboids, clearance o Fx cutting of the nerve roots latissimus dorsi HTN triggered by AD can cause: Cardiovascular Impairment T1 – Some intercostals, T5 erector spinae T6 – Intercostals, o Psychogenic – cognitive activity e.g. T10 abdominals sexual fantasy Injuries below T10 are likely to have near- Ejaculation – greater capacity in LMNL and normal respiratory function incomplete lesions Paradoxical breathing pattern – o Orgasm – cognitive, psychogenic paralysis/paresis of scalenes and o Ejaculation – physical occurrence intercostals Female o Flattening of upper chest wall, Menstrual cycle – interrupted for 4-5 mos decreased chest wall expansion, but returns dominant epigastric rise during Secondary Medical Complications inspiration Pressure Sores – unrelieved pressure, shearing Bladder and Bowel Dysfunction forces Bladder Especially common in the sacral area, Alteration of micturition (S2-S4) heels, and ischium o Spastic/Hyperreflexive/UMN Bladder Evaluated and predicted using Braden – occurs in lesions above the conus scale medullaris Deep Vein Thrombosis – from development of a Empties in response to filling thrombus within a vein pressure (detrusor muscle is Leads to thrombophlebitis: local swelling, hyperreflexive) erythema, heat Failure to store urine More likely to occur in acute stages o Flaccid/Areflexive/LMN Bladder – Tx: lesion of sacral segments/conus o Early mobilization, pneumatic medullaris compression sleeves No reflex action of the o IVC filter detrusor muscle o Prophylactic anticoagulant drug Failure to empty urine therapy (heparin, warfarin) for 2-3 Tx: Catheterization mos Bowel Pain Spastic/Reflex/UMN Bowel – lesions above Nociceptive – musculoskeletal/visceral in S2 nature Flaccid/Areflexive/LMN Bowel – S2-S4 or Neuropathic – central pain, damage to the cauda equina lesions nervous system and can be below, at, or Sexual Dysfunction above level of injury, treated with Males Pregabalin (Lyrica) Erection – greater capacity in UMNL and Heterotopic Ossification – osteogenesis usually incomplete lesions near jts below level of the lesion o Reflexogenic – external physical Often occurs in the hip and knee stimulation, mediated through S2- S4