DEFINITION
Insult to spinal cord resulting in a change,
in the normal motor, sensory or autonomic
function. This change is either temporary or
permanent.
Anatomy
Spinal cord lies within protective
covering of vertebral column.
Begins just below foramen
magnum of the skull.
Ends opposite 2nd lumbar
vertebra.
Below L2 continue as a leash of
nerve roots known as cauda equina.
Prolongation of the pia matter
forms filum terminale
Hence:
31 pairs of
spinal nerves:
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
Spinal cord structure
Spinal cord structure
The spinal cord consists of central core of grey matter
containing nerve cell bodies, and outer layer of white
matter of nerve fibers.
Within the grey matter, the dorsal horn contains
sensory neurons, the ventral horn contains motor
neurons and the lateral horn contains preganglionic
sympathetic neurons.
Within the white matter run ascending and
descending nerve fiber tracts, which link the spinal
cord to the brain.
The principle ascending tracts are the
spinothalamic tracts, spinocerebellar tracts and
dorsal columns. The coticospinal tracts is an
important descending tract.
The spinal cord receives information from, and
controls the trunk and limbs.
This is achieved through 31 pairs of spinal nerves
which join the cord at intervals along its length and
contain afferent and efferent nerve fibers
connecting with the structures at the periphery.
Spinal cord compression
Spinal Cord Compression in Three Main Areas
Thoracic
70%
Lumbosacral
20%
Cervical
10%
Statistics
National Spinal Cord Injury Database
{ USA Stats }
 MVA
44.5%
 Falls
18.1%
 Violence
16.6%
 Sports
12.7%
 55% cases occur in 16 – 30yrs of age
 81.6% are male!
Physiology and function
 Grey matter – sensory and motor nerve cells
 White matter – ascending and descending
tracts
 Divided into - dorsal
- lateral
- ventral
Normal Spinal Cord
Reflex Arc
Involuntary response
to a stimulus
Where sensory and
motor nerves arise from
cord
Sensory fibers enter
posterior
Synapse in the grey
matter
Motor fibers leave
anterior
Once outside cord join
form spinal nerve
Spinal Cord
Protection
• Bones- vertebral
column
• 7 Cervical
• 12 Thoracic
• 5- Lumbar
• 5- Sacral
• Discs• between
• vertebra
Tracts :
1) Posterior column: Fine touch
Light press
Proprioception
2) Lateral corticospinal tract :
Skilled voluntary movement
3) Lateral spinothalamic tract :
Pain & temperature sensation
Dermatomes
 Area of skin innervated by sensory axons within a
particular segmental nerve root
 Knowledge is essential in determining level of injury
 Useful in assessing improvement or deterioration
Myotomes
 Segmental nerve root innervating a muscle
 Again important in determining level of injury
 Upper limbs:
C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Small hand muscles
 Lower Limbs :
L2 - Hip flexors
L3,4 - Knee extensors
L4,5 – S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion
Spinal Cord Injury
 Primary
 Initial mechanism of injury
 Secondary
 Ongoing progressive damage




Ischemia
Hypoxia
Microhemorrhage
Edema
Mechanism of Injury
Flexion
Hyperextension
Compression
Flexion /Rotation
Flexion (hyper flexion)
•Most common
because of natural
protection
position.
•Generally cause
neck to be
unstable because
stretching of
ligaments
Hyperextension
Caused by chin
hitting a surface
area, such as
dashboard or
bathtub
Usually causes
central cord
syndrome
symptom
Hyperextension
Compression
Caused by force
from above, as hit
on head
Or from below
as landing on butt
Usually affects
the lumbar region
Flexion/Rotation
Most unstable
Results in tearing of
ligamentous structures that
normally stabilize the spine
Usually results in serious
neurologic deficits
Classifications of SCI
Completeness (Degree) of Injury
 Complete
 Incomplete
 Central cord syndrome
 Anterior Cord syndrome
 Brown-Sequard Syndrome
 Posterior Cord Syndrome
 Cauda Equina and Conus Medullaris
Complete


Loss of voluntary movement of parts innervated by
segment, this is irreversible
Loss of sensation
Spinal shock

Motor deficits-

 spastic paralysis below level of
injury

Sensory loss of all sensation perception
Autonomic deficitsvasomotor failure and spastic bladder
Incomplete:
i)
ii)
iii)
Some function is present below site of injury
More favourable prognosis overall
Are recognizable patterns of injury, although they are
rarely pure and variations occur
Central cord syndrome
Injury to the center
of the cord by edema
and hemorrhage
Motor weakness and
sensory loss in all
extremities
Upper extremities
affected more
Anterior cord Syndrome:
Injury to anterior cord
Loss of voluntary motor,
pain and temperature
perception below injury
Retains posterior
column function
(sensations of touch,
position, vibration,
motion)
Posterior Cord Syndrome
Least frequent syndrome
Injury to the posterior
(dorsal) columns
Loss of proprioception
Pain, temperature,
sensation and motor
function below the level of
the lesion remain intact
Proprioception affected –
ataxia and faltering gait
Usually good power and
sensation
Brown – Sequard Syndrome:
Hemisection of cord
Ipsilateral paralysis
Ipsilateral superficial
sensation, vibration
and proprioception
loss
Contralateral loss of
pain and temperature
perception
Cauda Equina and Conus Medullaris
Conus Medullaris
Injury to the sacral cord
(conus) and lumbar
nerve roots
Cauda Equina
Injury to the
lumbosacral nerve roots
Result- areflexic
(flaccid)bladder and
bowel, flaccid lower limbs
Cervical injuries
- When spinal cord injuries occur near the neck,
symptoms can affect both the arms and the legs:
 Breathing difficulties (from paralysis of the
breathing muscles).
 Loss of normal bowel and bladder control (may
include constipation, incontinence, bladder
spasms).
 Numbness.
 Sensory changes.
 Spasticity (increased muscle tone).
 Pain.
 Weakness, paralysis.
Thoracic injuries
When spinal injuries occur at chest level, symptoms can affect
the legs:
 Breathing difficulties (from paralysis of the breathing
muscles)
 Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms).
 Numbness.
 Sensory changes.
 Spasticity (increased muscle tone).
 Pain.
 Weakness, paralysis.
 Injuries to the cervical or high-thoracic spinal cord may also
result in blood pressure problems, abnormal sweating, and
trouble maintaining normal body temperature
Lumbosacral injuries
When spinal injuries occur at the lower-back level,
varying degrees of symptoms can affect the legs:
 Loss of normal bowel and bladder control (may
include constipation, incontinence, bladder
spasms).
 Numbness.
 Pain.
 Sensory changes.
 Spasticity (increased muscle tone).
 Weakness and paralysis
Types of Spinal Cord Paralysis
 Depending on the location and the extent of the injury





different forms of paralysis can occur.
Monoplegia- paralysis of one limb
Diplegia- paralysis of both upper or lower limbs
Paraplegia- paralysis of both lower limbs
Hemiplegic- paralysis of upper limb, torso and lower
leg on one side of the body
Quadriplegia- paralysis of all four limbs
Spinal Cord Paralysis Levels
C1-C3
 All daily functions must be totally assisted
 Breathing is dependant on a ventilator
 Motorised wheelchair controlled by sip and puff or chin
movements is required
C4
 Same as C1-C3 except breathing can be done without a
ventilator
C5
 Good head, neck, shoulder movements, as well as elbow
flexion
 Electric wheelchair, or manual for short distances
C6
Wrist extension movements are good
Assistance needed for dressing, and transitions from bed to
chair and car may also need assistance
C7-C8
All hand movements
Ability to dress, eat, drive, do transfers, and do upper body
washes
T1-T4 (paraplegia)
Normal communication skills
Help may only be needed for heavy household
work or loading wheelchair into car
T5-T9
Manual wheelchair for everyday living
Independent for personal care
T10-L1
Partial paralysis of lower body
L2-S5
Some knee, hip and foot movements with possible
slow difficult walking with assistance or aids
Only heavy home maintenance and hard cleaning
will need assistance
Injury defined by ASIA Impairment
Scale
ASIA – American Spinal Injury Association :
A – Complete: no sensory or motor function preserved in
sacral segments S4 – S5
B – Incomplete: sensory, but no motor function in sacral
segments
ASIA – American Spinal Injury
Association
C – Incomplete: motor function preserved below level and
power graded < 3
D – Incomplete: motor function preserved below level and
power graded 3 or more
E – Normal: sensory and motor function normal
Investigation
 X ray.
 CT scan.
 MRI.
 Myelogram.
 Biopsy.
 Bone scan.
 Blood and spinal fluid studies.
Muscle Strength Grading:
 5 – Normal strength
 4 – Full range of motion, but less than
normal strength against resistance
 3 – Full range of motion against gravity
 2 – Movement with gravity eliminated
 1 – Flicker of movement
 0 – Total paralysis
Therapeutic Interventions
 Stabilization/
 Immobilization
 Traction Gardner-wells tongs
 Halo




Casts
Splints
Collars
Braces
Management of Spinal Cord
Injuries
 Immediate management at the scene is critical.
 Improper handling can cause further damage
and loss of functioning
 Always assume there is a spinal cord injury until
it is ruled out
 Immobilize
 Prevent flexion, rotation or extension of neck
 Avoid twisting patient
 If conscious, patients will usually mention acute
pain in back or neck which may radiate along the
involved nerve
Management of Spinal Cord Injuries
Consists of emergency treatment following an
A-B-C-D-E sequence.
Airway Management
Use bag-valve-mask devise initially for airway compromise
and if necessary to prepare for intubation.
Breathing
Circulation
Disability
Exposure
Breathing
 Lesions above C5 level will cause partial to
complete diaphragmatic paralysis (recall the
diaphragm is innervated at C3-5 levels).
 Any lesion above T12 may cause some airway
compromise.
 Lesions at C5 and below will allow full
diaphragmatic movement, but intercostal
muscles (innervated at T1) and abdominal
muscles (innervated at T12) are affected
Circulation
 Cardiac output is affected by external or internal
hemorrhage.
 To determine external bleeding, turn the patient
in log-roll fashion and quickly note the site of
injury.
 Two signs of internal bleeding from abdominal
trauma are abdominal pain and muscular rigidity.
However, these signs may be masked in a
patient with sensory and motor deficits.
Exposure
 Patients with SCI become poikilothermic,
meaning that their body temperature will
increase and decrease with the temperature of
the environment.
 Because they lose the ability to regulate core
body temperature through vasodilatation and
vasoconstriction, they can become dangerously
hyperthermic or hypothermic.
Neurological/Orthopedic
Management
 Reduction
 Fixation
 Fusion
 Fixation involves stabilizing vertebral fractures with
wires, plates, and other types of hardware.
Rehab and Long-Term Issues
 Mobility - initially may require a brace or halo. Needs
to bear weight as soon as possible because it helps
decrease disuse atrophy, decrease the opportunity
for osteoporosis, decrease the possibility of renal
calculi, and enhances metabolic processes
 self-care
 Skin Integrity - needs to be taught the importance of
being responsible for own skin integrity
 Exercise - to strengthen unaffected parts and
promote
Prevent and Manage Complications
Spastic Muscles - maximum spastic activity is usually 2
years out and then minimizes some. May require longterm use of anti-spasmodic drugs such as valium,
baclofen or dantrium.
Contractures - Needs to understand the importance of
exercise and maintaining function
Bed mobility
Pressure relief
Wheel chair transfer