Spinal Cord Injuries

Basic Anatomy and Physiology

What is the anatomy of the spinal cord on
cross section?
What is the anatomy of the spinal cord on
cross section?
What are the clinically important ascending
tracts and where do they cross over?
What are the clinically important descending
tracts and where do they cross over?
At what level does the spinal cord end and
why is it important?
What are the differences between UMN and
LMN? (e.g., cauda equina vs. myelopathy)

SPINAL TRAUMA
Acute vs. chronic injuries;
complete vs. incomplete injuries
Acute=sudden onset of symptoms
Complete ?
What is a complete spinal cord injury?
Complete = absence of sensory and motor
function in the perianal area (S4-S5)
Terminology
Plegia = complete lesion
Paresis = some muscle strength is preserved
Tetraplegia (or quadriplegia)
Injury of the cervical spinal cord
Patient can usually still move his arms using the segments
above the injury (e.g., in a C7 injury, the patient can still flex
his forearms, using the C5 segment)
Paraplegia
Injury of the thoracic or lumbo-sacral cord, or cauda equina
Hemiplegia
Paralysis of one half of the body
Usually in brain injuries (e.g., stroke)

Motor: how do you test each segment?
Motor: how do you grade the strength?
Sensory: how do you determine the level?
What are the important vegetative
functions and when are they affected?
Reflexes
Deep Tendon Reflexes
Arm
Bicipital: C5
Styloradial: C6
Tricipital: C7
Leg
Patellar: L3, some L4
Achilles: S1
Pathological reflexes
Babinski (UMN lesion)
Hoffman (UMN lesion at or above cervical spinal cord)
Clonus (plantar or patellar) (long standing UMN lesion)

What is and how do you determine the level
of injury?
Motor level = the last level with at least 3/5
(against gravity) function
NB: this is the most important for clinical purposes
Sensory level = the last level with preserved
sensation
Radiographic level = the level of fracture on
plain XRays / CT scan / MRI
NB: spine level does not correspond to spinal cord
level below the cervical region

Case scenario
25 y/o male
Fell off the roof (20 feet)
Had to be intubated at the scene by EMS
Consciousness regained shortly thereafter
Could not move arms or legs
Could close and open eyes to command
Not able to breathe by himselftotally
dependent on mechanical ventilation
High cervical injuries (C3 and above)
Motor and sensory deficits involve the entire
arms and legs
Dependent on mechanical ventilation for
breathing (diaphragm is innervated by C3-C5
levels)

Case scenario
19 y/o male
Diving accident (shallow water)
No loss of consciousness
Could not understand why he could not move
his legs, forearms and hands (he could shrug
shoulders and elevate arms)
BP 75/40, HR 54/
Had difficulties breathing and required
intubation a few hours after the accident
Midcervical injuries (C3-C5)
Varying degrees of diaphragm dysfunction
Usually need ventilatory assistance in the acute
phase
Shock

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
Neurogenic shock
Seen in cervical injuries
Due to interruption of the sympathetic input
from hypothalamus to the cardiovascular
centers
Hallmark: hypotension (due to vasodilation, due
to loss of sympathetic tonic input) is associated
with bradycardia (not tachycardia, the usual
response), due to inability to convey the
information to the vasomotor centers in the
spinal cord
Low cervical injuries (C6-T1)
Usually able to breathe, although occasionally
cord swelling can lead to temporary C3-C5
involvement (need mechanical ventilation)
The level can be determined by physical exam
So what do you expect with a cervical
lesion?
Quadriplegia or quadriparesis
Bowel/bladder retention (spastic)
Various degrees of breathing difficulties
Neurogenic and/or spinal shock
Case scenario
22 y/o female
Motor vehicle accident (hit a pole at 60mph)
+ for ethanol and Tetrahydrocannabinol
Short term loss of consciousness (10)
Not able to move or feel her legs
Deep Tendon Reflexes 2+ in both upper
extremities, 0 in both lower extremities
No bladder / bowel control or sensation
Sensory level at the umbilicus
Thoracic injuries (T2-L1)
Paraparesis or paraplegia
UMN (upper motor neuron) signs
Case scenario
22 y/o female
Motor vehicle accident
Not able to move or feel her legs below the knee
Could flex thighs against gravity
DTRs 2+ in BUE, 0 in BLE
No bladder / bowel control or sensation
Sensory level above the knee on L, below the
knee on R
Cauda equina injuries (L2 or below)
Paraparesis or paraplegia
LMN (lower motor neuron) signs
Thigh flexion is almost always preserved to
some degree
What is the difference between cauda equina and
conus medullaris syndrome?
What is an incomplete lesion?
What is the central cord syndrome?
Cervical spinal cord involvement with arms
more affected than legs
May occur with trauma, tumors, infections, etc
Traumatic lesions tend to improve in 1-2 weeks
Surgical decompression may be indicated if
there is spinal stenosis
Brown-Sequard syndrome
Initial Management
Immobilization
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
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
Only if started within 8 hours of injury
Exclusion criteria
Cauda equina syndrome
gunshot wound
Pregnancy
Age <13 years
Patient on maintenance steroids

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)
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
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
Cervical Spine Clearance
Occiput to T1 need to be cleared
ER, Neurosurgery or Orthopedics physician
If the patient
Is awake and oriented
Has no distracting injuries
Has no drugs on board
Has no neck pain
Is neurologically intact
then the c-spine can be cleared clinically, without any need for
XRays
CT and/or MRI is necessary if the patient is comatose
or has neck pain
Subluxation >3.5mm is usually unstable

Cervical Traction
Gardner-Wells tongs
Provides temporary stability of the cervical spine
Contraindicated in unstable hyperextension injuries
Weight depends on the level
Cervical collar can be removed while patient is in
traction
Pin care: clean q shift with appropriate solution, then
apply povidone-iodine ointment
Take XRays at regular intervals and after every move
from bed

Gardner-Wells tongs
Surgical Decompression and/or Fusion
Indications
Decompression of the neural elements (spinal cord/nerves)
Stabilization of the bony elements (spine)
Timing
Emergent
Incomplete lesions with progressive neurologic deficit
Elective
Complete lesions (3-7 days post injury)
Central cord syndrome (2-3 weeks post injury)

Soft and hard collars
Minerva vest and halo-vest
Long term care
Rehab for maximizing motor function
Bladder/bowel training
Psychological and social support
THANK YOU!