Spinal Cord InjuryVitya Chandika 2013-061-060Priscila Stevanni 2013-061-066Pricilia Nicholas 2013-061-070

DefinitionSpinal cord injury (SCI) An insult to the

spinal cord resulting in a change, either temporary or permanent, in the cord’s normal motor, sensory, or autonomic function.

Anatomy

Ligamentous Anatomy

a = Ligamentum flavumb = Interspinous

ligamentsc = Supraspinous

ligament

ANATOMY• Spinal cord is divided into 31 segments

• Each with a pair of anterior (motor) and dorsal (sensory) spinal nerve roots

• The spinal cord extends from the base of the skull to the lower margin of L1 vertebral body

• Injuries below L1 are not considered spinal cord injuries

NEUROPATHWAYS

1 anterior and 2 posterior spinal arteries.Anterior supplies 2/3 of the cordPosterior primarily supply the dorsal columns

SPINAL CORD INJURIES• 3 common mechanism :

Destruction from direct trauma Compression by bone fragments,

hematoma, or disk material Ischaemia from damage on the spinal

arteries

INCOMPLETE SPINAL CORD INJURIES• Any residual motor or sensory function more than 3 segments

below the level of the injury

• Signs of incomplete lesion: sensation (including position sense) or voluntary movement in

the Lower Extremities “sacral sparing”: preserved sensation around the anus,

voluntary rectal sphincter contraction, or voluntary toe flexion an injury does not qualify as incomplete with preserved sacral

reflexes alone

Complete spinal cord injuries• No preservation of any motor and/or sensory

function more than 3 segments below the level of the injury.

• Recovery is essentially zero if the spinal cord injury remains complete beyond 72 hours.

Spinal Cord Injury1. Complete Spinal Cord Injuries

Bulbar-cervical dissociation

2. Incomplete Spinal Cord Injuries Central cord syndrome Anterior cord syndrome Brown-sequard syndrome Posterior cord syndrome

Central Cord Syndrome

Anterior Cord Syndrome

Brown Sequard Syndrome

BULBAR-CERVICAL DISSOCIATION• Occurs as a result of spinal

cord injury at or above ≈ C3

• Bulbar-cervical dissociation produces immediate pulmonary and, often, cardiac arrest

Central cord syndrome• Central cord syndrome (CCS) is the most common type of incomplete

spinal cord injury syndrome. Usually seen following acute hyperextension injury in an older patient with pre-existing anterior spurs

• Presentation Motor: weakness of upper extremities with lesser effect on lower

extremities Sensory: varying degrees of disturbance below level of lesion may

occur Myelopathic findings: sphincter dysfunction (usually urinary

retention)

Anterior cord syndrome• Also known as anterior spinal artery syndrome

• Cord infarction in the territory supplied by the anterior spinal artery

• May result from occlusion of the anterior spinal artery, anterior cord compression, e.g. by dislocated bone fragment, or by traumatic herniated disc

• Presentation paraplegia, or (if higher than ≈ C7) quadriplegia dissociated sensory loss below lesion:

loss of pain and temperature sensation (spinothalamic tract lesion) preserved two-point discrimination, joint position sense, deep pressure

sensation (posterior column function)

Brown-sequard syndrome Classical findings (rarely found in this pure form):

• ipsilateral findings: motor paralysis (due to corticospinal tract lesion) below lesion loss of posterior column function (proprioception & vibratory

sense)

• contralateral findings: dissociated sensory loss loss of pain and temperature sensation inferior to lesion beginning

1-2 segments below (spinothalamic tract lesion) preserved light (crude) touch due to redundant ipsilateral and

contralateral paths (anterior spinothalamic tracts)

Posterior cord syndrome• Also known as contusio cervicalis posterior

• condition caused by lesion of the posterior portion of the spinal cord. It can be caused by an interruption to the posterior spinal artery

• Relatively rare

• Produces pain and paresthesias (often with a burning quality) in the neck, upper arms, and torso. There may be mild paresis of the Upper Extremities.

ComplicationsNeurogenic Shock = autonomic dysfunction,

interruption of sympathetic nervous system. Common above T6.vasomotor disruption: vasodilatation Flush,warmHeart problem :bradicardia hypotension

Spinal Shock = complete loss of all neurologic function Flaccid + areflexia

Who? Any of the following patients should be treated as having a SCI until

proven otherwise:

1. All victims of significant trauma

2. Trauma patients with loss of consciousness

3. Minor trauma victims with complaints referable to the spine (neck or back pain or tenderness)or spinal cord (numbness or tingling in an extremity, weakness)

4. Associated findings suggestive of SCI include

A.Abdominal breathing

B.Priapism (autonomic dysfunction)

Initial assessment• The major cause of death in SCI are aspiration and shock

• A B C and brief neurologic exam

• Clinical criteria to rule-out cervical spine instability Awake, alert, oriented (no mental status changes,

including no alcohol or drug intoxication) No neck pain (with no distracting pain) No neurologic deficits

Initial management • Imobillization: prevent active and passive movement of the spine

Log roll Back-board Cervical collar

• Maintain blood pressure Pressors : dopamine, etc Fluids Military anti-shock trousers (MAST) : immobilizes lower spine, compensates for

loss of muscle tone in cord injuries (prevent venous pooling)

• Maintain oxygenation

• Brief motor exam to identify deficits move arms, hands, legs, toes

ManagementHypotension maintain SBP ≥ 90 mm HgOxygenationNG tube to suction prevents vomiting and aspirationTemperature regulationElectrolytes Neuro evaluation American Spinal Injury AssociationSpinal-Dose SteroidsInjury < 8 hours: metilprednisolone 30 mg/kgBB IV bolus in 15 min. 45 minute pause, then continue with 5,4 mg/kgBB/jam for 23 hInjury >8 hours : steroid IV for 48 hSurgery: decompression and stabilize

Post Injury AssessmentGoals are to

Sustain life Prevent further cord damage

Thank you