1) The document discusses spinal cord injuries, including common causes, anatomy, types of fractures, classifications, and neurological examination. It provides details on the anatomy of the spine, vertebrae, and spinal cord as well as classifications of spinal fractures.
2) Key points include that most spinal injuries are from traffic accidents and result in no associated spinal cord injury. It also notes that at least 5% of patients with spinal cord injuries worsen neurologically in the hospital.
3) The document covers neurological examination techniques including assessing sensory function using dermatomes, muscle strength grading, and determining motor function for different spinal levels. It also summarizes spinal cord tracts and classifications of spinal cord injuries.
1) The document discusses spinal cord injuries, including common causes, anatomy, types of fractures, classifications, and neurological examination. It provides details on the anatomy of the spine, vertebrae, and spinal cord as well as classifications of spinal fractures.
2) Key points include that most spinal injuries are from traffic accidents and result in no associated spinal cord injury. It also notes that at least 5% of patients with spinal cord injuries worsen neurologically in the hospital.
3) The document covers neurological examination techniques including assessing sensory function using dermatomes, muscle strength grading, and determining motor function for different spinal levels. It also summarizes spinal cord tracts and classifications of spinal cord injuries.
1) The document discusses spinal cord injuries, including common causes, anatomy, types of fractures, classifications, and neurological examination. It provides details on the anatomy of the spine, vertebrae, and spinal cord as well as classifications of spinal fractures.
2) Key points include that most spinal injuries are from traffic accidents and result in no associated spinal cord injury. It also notes that at least 5% of patients with spinal cord injuries worsen neurologically in the hospital.
3) The document covers neurological examination techniques including assessing sensory function using dermatomes, muscle strength grading, and determining motor function for different spinal levels. It also summarizes spinal cord tracts and classifications of spinal cord injuries.
1) The document discusses spinal cord injuries, including common causes, anatomy, types of fractures, classifications, and neurological examination. It provides details on the anatomy of the spine, vertebrae, and spinal cord as well as classifications of spinal fractures.
2) Key points include that most spinal injuries are from traffic accidents and result in no associated spinal cord injury. It also notes that at least 5% of patients with spinal cord injuries worsen neurologically in the hospital.
3) The document covers neurological examination techniques including assessing sensory function using dermatomes, muscle strength grading, and determining motor function for different spinal levels. It also summarizes spinal cord tracts and classifications of spinal cord injuries.
fibers Motor fibers = anterior or ventral root Sensory fibers = posterior or dorsal root
Anatomy and Physiology
Components of Vertebrae Spinal Canal Opening in the vertebrae that the spinal cord passes through
Pedicles Thick, bony structures that connect the vertebral body to the spinous and transverse processes
Anatomy Spinal cord ends below lower border of L1 Cauda equina is below L1 Mid dorsal spinal cord & neural canal space are of same diameter hence prone for complete lesion Mechanical injury - early ischaemia, cord edema cord necrosis Neurological recovery unpredictable in cauda equina ie. peripheral nerves
OVERVIEW LOOK inspection
FEEL palpation
MOVE active & passive movements
EXAMINATION :STANDING
Feel : Tenderness: may be bony,
intervertebral or paravertebral Bony prominence or steps spinous processes using C7 &/or L4-5 as landmarks
facet joints approx. 2cm lateral to spinous processes
EXAMINATION : STANDING
Feel : assess alignment, mobility & tenderness of: transverse processes of vertebrae lateral to spinous processes
Signs of nerve root
compression Standard full neurological examination of both lower limbs : tone, power (MRC grading) sensation (light touch, pinprick & proprioceptive if indicated) reflexes (physiologic and patologic) an anatomical distribution [dermatome(s) or myotome(s)]
Neurological Examination Objectives : Determine if defect is present Localize the level of the deficit
Include : Sensory Motor Reflex
Neurological Examination Sensory examination Explain, eyes closed Examine : touch, 2 point discrimination, proprioceptive. Sensory dermatomes, compare each opposite
Sensory Dermatome
Muscle Power Grading
0 - complete paralysis 1 - flicker of contraction possible 2 - movement is possible when gravity is excluded 3 - movement is possible against gravity 4 - movement is possible against gravity + some resistance 5 - normal power
Neurological Examination Motor examination Muscle grading Compare each side
Cervical : Scapular
C4
Deltoid & Biceps
C5
Wrist extension & supination
C6
Wrist flexion & Pronation
C7
Neurological Examination Motor examination Lumbo-sacral Hip flexor Hip extensor
L 1,2,3 S1
Knee flexor Knee extensor
L 4,5, S1,2 L 2,3,4
Ankle flexor Ankle extensor
S1 L5
Denis 3 Column Theory
Denis, F.: The Three-Column Spine and its Significance in the
Classification of Acute Thoracolumbar Spinal Injuries. Spine, 8:1983.)
Cervical spine anatomy
Anterior column - Anterior longitudinal ligament+ Anterior annular ligament and anterior half of VB. Middle column Posterior long. Lig. + Posterior annular ligament +Posterior half of VB. Posterior Column Lig flavum + superior & Interspinous lig + intertransverse capsular lig + neural arch + pedicle & spinous process.
Location : 1. Jefferson fracture 2. Dens fracture 3. Hangmans fracture 4. Clay shovelers fracture 5. SCIWORA
Compression fracture
Failure of the anterior column
Mechanism anterior or lateral flexion Normally Stable or unstable fracture Rarely involved neurologic comprimise
Criteria unstable Loss of 50% of vert body height Angulation of thoracolumbar junct > 20 deg Mutiple adjacent column of spine Failure of 2/3 of column of spine
Chance fracture Anterior column falls in tension (along w/ the middle and posterior columns) Three columns rupture in distraction (tension) Seldom assc w/ neurologic comprimise unless Unstable
Burst fracture Compressive failure of vert body both anteriorly & posteriorly , w/ failure of both anterior & middle columns Axial loading applied to intravertebral disc results in increased nuclear pressure and hoop stresses in the annulus
Classification : Stable frx - neurologically intact - poterior arch remains intact : pedicl widening implies post arch disruption - less than 50% anterior body height - compression fracture
Unstable frx - neurologic defisit - loss of 50% vertebral body height - fracture dislocation - thoracolumbar burst frx
Jefferson Fracture Pediatric frx - frx proceeds thru open synchondroses, and may occur w/ minimal trauma/ - posterior synchondroses fuses at age 4 - anterior synchondroses fuses at age 7
Mechanism - original description in 1920 noted role of axial compression - may also be caused by hyperextension, causing a posterior arch fracture
Associated injuries - approx 1/3 of these fractures are associated with a axis fracture - approx 50% chance that some other C-spine injury is present - low rate of neurologic deficits is due to large breadth of C1 canal
Dens Fracture Odontoid fractures are the most common upper cervical spine fratures Remember rule of thirds cervical cord occupies a 1/3 of canal, dens occupies a 1/3 and the remaining 1/3 is empty Mechanism Flexion loading Extension loading
Hangmans frx/Traumatic Spondylolisthesis of the Axis Fix of pars interarticularis of C2 & disruption of C2-C3 junction Type of traumatic spondylolisthesis Hangmans frx Term Hangmans fracture is not accurate for the majority of cases, because mechanism of injury for clinically encountered frx often lacks large traction force present in judicial hangings
In cases in which there is neurologic
injury, there will usually be significant horizontal translation w/ accompanying damage to the posterior longitudinal ligament w/ or w/o damage of the C2 C3 interspace
Mechanism of injury in adults
Judical lesion : hyperextension and distraction Hyperextension w/ vertical compression of posterior column, & translation of C2 and C3 Forceful extension of already extended neck is most commonly described mech of injury, but other causes include flexion of flexed neck & compression of an extended neck A blow on the forehead forcing the neck into extension is a classic mechanism of injury producing fractures thru the
SCIWORA Syndrome Occurs may often in pediatric population Accounts for up to 2/3 of severe cervical injuries in children < 8 years of age Inherent elasticity in pediatric cervical spine can allow severe spinal cord injury to occur in absence of xray findings
Clasification spinal cord
injury
Complete Incomplete Anterior cord syndrome Central cord syndrome Brown sequad Cauda equina
Anatomy crossection spinal cord Ascending Tract Tracts of Goll and Burdach (fasc gracilis and cuneatus
Proprioception,vibration ,discrimination
uncrosssed
Dorsal and ventral
spinocerebellar tract
Proprioception, light touch
uncrossed
Lateral spinothalamic tract
Pain, temperature
crossed
Spinal olivary tract
Tendon and muscle
proprioception
crossed
Ventral spinothalamic tract
Deep tactile and
pressure sensation
crossed
Lateral corticospinal tract
(pyramidal)
Motor control
uncrossed
Rubrospinal tract
Cerebellar reflexes
crossed
Lateral reticulospinal Vestibulospinal tracttract
Inhibits locomotor Postural control conytrol
crossed Uncrossed
Reticulospinal tract Tectospinal tract
Facilittes locomotor control
Eye and ear reflleces
uncrossed crossed
Descending Tract
Complete / incomplete Spinal Cord
Lession Complete cord injury : there is complete loss of sensation and muscle function in the body below the level of the injury An injury to the upper portion of the spinal cord in the neck can cause quadriplegiaparalysis of both arms and both legs. If the injury to the spinal cord occurs lower in the back it can cause paraplegiaparalysis of both legs only.
Incomplete lesion : there is some
remaining function below the level of the injury. In most cases both sides of the body are affected equally. Present when there is any distal sparing of motor or sensory function along with sparing of perirectal sensation
Diff dx of incomplete lesions
Central cord syndrome Brown sequard syndrome Anterior cord syndrome Posterior cord syndrome Isolated nerve root injury Cauda equina syndrome (w/ or w/o root escape) Conus medullaris injury
Anterior Cord Syndrome
Damage is primarily in the
anterior 2/3 of cord and is related to vascular insuffiency There is sparing the posterior columns Syndrome is manisfested by complete motor paralysis (corticospinal func) and sensory anesthesi (spinothalamic func) Patient demonstrates greater motor loss in the legs than arms
Prognosis anterior cord syndrome has the worst prognosis of all cord syndromes prognosis is good if recovery is evident & progressive during first 24 hours after 24 hrs, if no signs of sacral sensibility to pinprick or temp are present, prognosis for further functional recovery are poor; only 10 to 15% of patients demonstrate functional recovery;
Central Cord Syndrome
most common incomplete cord lesion frequently associated w/ extension injury to osteoarthritic spine (cervical spondylosis )in middle aged person who sustains hyperextension injury cord is injured in central gray matter, & results in proportionally greater loss of motor functionto upper extremities than lower extremities w/ variable sensory sparing;
Anatomy: fibers responsible for lower extremity motor and sensory functions are located in the most peripheral part of the cord whereas fibers controlling the upper extremity and voluntary bowel and bladder function are more centrally located sacral tracts are positioned on the periphery of the cord & are usually
Mechanism of Injury: hyperextension injury central cord injury and hemorrhage occur with compression of adjacent white-matter tracts more peripheral positioning of lower extremity axons within the spinal cord tracts accounts for the injury pattern
damage tocentral portion of
corticospinal and spinothalamic long tracts in white matter produces upper motor neuron spastic paralysis of trunk and lower extremity
Examination central cord syndrome is remarkable for more cord involvement in the upper extremities than in the lower extremities manifests w/ loss of distal upper extremity pain & temperature sensation and strength, w/ relative preservation of lower extremity strength & sensation
upper extremities: mixed upper and lower-motor-neuron lesion, w/ partial flaccid paralysis of upper extremities (indicativeof involvement of lower motor neurons) prognosis is variable w/ poor hand function lower extremities: spastic paralysis of lower extremities (indicative of involvement of upper motor neurons) bladder and bowel function may also be
Brown Sequard Syndrome
type of incomplete cord syndrome injury to either side of spinal cord produces ipsilateral muscle paralysis (fromcorticospinal tract injury) and contralateral hypersthesia to pain and temperature (from spinothalamic injury)
syndrome results from
hemitransection of spinal cord w/ unilateral damage to the spinothalamic & corticospinal tracts and resultant loss of ipsilateral motor & dorsal column function & of contralateral pain and temperature sensation often due to penetrating trauma or unilateral facet fracture or dislocation
Prognosis: this syndrome has a good prognosis for recovery more than 90% of pts regain bladder & bowel control & ability to walk most patients will regain some strength in lower extremities and most will regain functional walking ability;;
Cauda Equina Syndrome
urinary retention is the most consistent finding in spinal cord injuries, the caudal equina may sustain considerable initial trauma in any potential cauda equina syndrome it is important to examine for saddle anesthesia, rectal tone, bulbocaverosus reflex, and sacral sparing;
Significance Unstable if middle column + either Anterior or Posterior column is damaged Rupture of interspinous ligament is : - associated with avulsion of spinous process - Unstable spine - Further flexion increases neurological injury
Level of Spinal injury
Neurological level is at the most lowest segment with normal motor & sensory function Difficult to determine : - as most muscle efferents receive fibres from more than one level - Closed cord lesions may extend over several cms. - Dermatomes have imprecise boundaries.
Instant ebooks textbook Atlas of Interventional Orthopedics Procedures: Essential Guide for Fluoroscopy and Ultrasound Guided Procedures 1st Edition Christopher J. Williams Md (Editor) download all chapters
Instant ebooks textbook Atlas of Interventional Orthopedics Procedures: Essential Guide for Fluoroscopy and Ultrasound Guided Procedures 1st Edition Christopher J. Williams Md (Editor) download all chapters
