SPINAL CORD INJURY
ANATOMY OF THE SPINAL CORD
• The brain and spinal cord together make up the central
nervous system (CNS).
• The spinal cord is the long, thin, tubular bundle of nervous
tissue and support cells.
• It begins at the occipital bone and extends downward to
the first and second lumbar vertebral.
• It extends from the foramen magnum and continues
through to the conus medullaris near the second lumbar
vertebral, terminating in a fibrous extension known as the
filum terminale.
ANATOMY OF THE SPINAL CORD CONTD
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The length of spinal cord is varies in
individual.
It is around 45cm in men and 43cm in women
The spinal cord is surround by connective
tissue membrane called the meninges. They
are;
The dura mater
The arachnoid mater
The pia mater
CROSS SECTION OF THE SPINAL
• Spinal cord consist of peripheral white portion and
central gray portion
• The white mater consist of the myelinated axons
forming nerve tracts.
• The gray mater consist of neuron cell bodies, dendrite
and axons.
• Spinal cord is separated into two equal halfs by;
Anterior median fissure and Posterior median sulcus
• The white mater subdivided three columns;
• Ventral column
• Lateral column
• Dorsal column
CROSS SECTION OF THE SPINAL CORD
CONTD
• The nerve cell bodies of the grey matter are
contained in the three grey columns of the
spinal cord that give the butterfly-shaped
central region its shape.
• The central region surrounds the central canal
which is an extension of the fourth ventricles
and contains cerebrospinal fluid.
• The cord has grooves in the dorsal and ventral
sides
SPINAL CORD SEGMENTS
• The human spinal cord can be anatomically
divided into 31 spinal segment in spinal cord:
• 8 cervical segments forming 8 pairs of cervical
nerves
• 12 thoracic segment forming 12 pairs of
thoracic nerves
• 5 lumbar segment forming 5 pairs of lumbar
nerves
• 5 sacral segment forming 5 pairs of sacral
nerves
• 1 coccygeal segment
ANATOMY OF THE SPINAL CORD CONTD
• The spinal cord functions primarily in the
transmission of neural signals between the
brain and rest of the body
• conduit for motor information in the reverse
direction, and
• finally as a center for coordinating certain
reflexes.
SPINAL CORD INJURY
INTRODUCTION
• Spinal cord injury (SCI) is a complete or
partial lesion to the spinal cord.
• The result of SCI is functional loss (sensory
motor and autonomic dysfunction); severity
depends on the level and completeness of the
lesion.
INTRODUCTION CONTD
• Common categories are
Paraplegia (SCI affecting T2 and below, trunk
and lower extremities involved) and
Quadriplegia/ tetraplegia (SCI affecting level
of T1 or above, all four extremities and trunk
involved).
INTRODUCTION CONTD
• During trauma the spinal cord is crushed and deprived of
its blood supply resulting in loss of function, (paralysis)
and loss of sensation below the point of injury (example
of causes of trauma injuries; car accident, gunshot, fall,
sports) or disease (tranverse polio mylitis, spina bifida,
Fiedeich’s ataxia etc.).
INTRODUCTION CONTD
• Damage to spinal cord can also occur through illness (referred
to as non-traumatic SCI) such as tumours, infections or
circulatory disorders such as haemorrhage or clot formation
within the spinal cord.
Spinal Cord Injuries (Cont’d)
Spinal Cord Injuries (Cont’d)
Prevalence in Nigeria
• One study in a tertiary health institution showed a traumatic
SCI prevalence of 5.2% among trauma patients between 2015
and 2019.
• Another study over four years in a different institution found a
SCI prevalence rate of 15.5% among admitted patients.
• (read entire article by Oyediran et al, 2022)
EPIDEMIOLOGY
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!
EPIDEMIOLOGY CONTD
South African Statistics (GSH Acute Spinal Cord
Injury Unit 2007)
• MVA
56%
• Falls
16%
• Gunshot Injuries
11%
• Blunt Assault
6%
• Diving Accidents
5%
• Stab Wounds
4%
• Sport Injuries
3%
Spinal Cord Injury Classification
• Spinal cord injuries are classified by:
a. the Mechanism of injury
b. Skeletal and neurologic level of injury
c. Completeness or degree of injury.
Mechanisms of injury: the major mechanisms of injury are:
I. Flexion
II. Hyperextension
III. Flexion-rotation
IV. extension-rotation
V. compression
Flexion and extension injuries to the spinal cord occur when the spinal column is bent forward (flexion) or backward
(extension) beyond its normal range of motion, potentially damaging the spinal cord and surrounding structure
Spinal cord injury Classification Cont’d
• Level of injury: The level of the injury may be
• cervical
• thoracic
• lumbar.
• The vertebrae most frequently involved in SCI are the 5th,
6th, and 7th cervical (neck), the 12th thoracic, and the 1st
lumbar vertebrae.
• These vertebrae are the most susceptible because they are
associated with the greatest flexibility and movement.
Spinal cord injury Classification Cont’d
• Quadriplegia :
injury in cervical region
all 4 extremities affected
• Paraplegia :
injury in thoracic, lumbar or sacral segments
2 extremities affected
• Degree of injury: The degree of spinal cord
injury may be either;
• Complete
• Incomplete
Complete:
i) Loss of voluntary movement of parts innervated
by segment, this is irreversible
ii) Loss of sensation
iii) Spinal shock
Incomplete:
i) Some function is present below site of injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury, although they are
rarely pure and variations occur
Types of incomplete injuries
i)
Central Cord Syndrome
ii) Anterior Cord Syndrome
iii) Posterior Cord Syndrome
iv) Brown – Sequard Syndrome
v) Cauda Equina Syndrome
Common Spinal Cord Syndromes (Cont’d)
Anterior Cord Syndrome
• Damage to the anterior portion of both
gray and white matter of the spinal cord
• Usually a result of decreased blood
supply
• Motor function and pain and
temperature lost below the level of the
injury (neurologic level)
• Sensations of touch, position, and
vibration remain intact
Posterior Cord Lesion
• Damage to the posterior gray and white
matter of the spinal cord
• Motor function remains intact
• Patient experiences loss of vibratory
sense, touch, and position sensation
Brown-Séquard Syndrome
• Results from penetrating injuries that cause
hemisection of the spinal cord, or injuries
that affect half of the spinal cord.
• Motor function, proprioception, vibration,
deep touch sensations are lost on the same
side (ipsilateral) of the body as the lesion.
• Opposite side (contralateral) of the body
sensations of pain, temperature, light touch
are affected.
Central Cord Syndrome
• Lesions of the central portion of the
spinal cord.
• Loss of motor function is more
pronounced in the upper extremities
than in the lower extremities.
• Varying degrees and patterns of
sensation remain intact.
Injury defined by ASIA Impairment Scale
• A Complete: No motor or sensory function is preserved in the
sacral segments S4-S5.
• B Incomplete: Sensory (but not motor function) is preserved below
the neurologic level, and includes the sacral segments S4-S5.
• C Incomplete: Motor function is preserved below the neurologic
level, and more than half of key muscles below the neurologic level
have a muscle grade less than 3.
• D Incomplete: Motor function is preserved below the neurologic
level, and at least half of key muscles below the neurologic level
have a muscle grade of 3 or greater.
• E Normal: Motor and sensory function are normal.
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
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
Spinal and neurologic shock
• spinal shock: is characterized by decreased reflexes, loss of
sensation, and flaccid paralysis below the level of injury.
• This syndrome last days to months and may mask postinjury
neurologic function.
• Active rehabilitation may begin in the presence of spinal shock
• Neurogenic shock, is due to the loss of vasomotor tone caused
by injury and is characterized by hypotension, and bradycardia
CAUSES OF SPINAL CORD INJURY
Traumatic and non-traumatic
• Causes of SCI include; Trauma.
• Motor vehicle crashes accounts for 42%;
• falls, 27%;
• violence, 15%;
• sports injuries, 7%; and
• other miscellaneous causes, 8%
Other causes:
• Vascular disorders
• Tumours
• Infectious conditions
• Spondylosis
• Iatrogenic
• Vertebral fractures secondary to osteoporosis
• Development disorders
Pathophysiology of SCI
Pathophysiology of SCI
• Blood flow into the subarachnoid spaces of the spinal cord
• Oedema and disintegration of nerve fibres
• Blood circulation to the gray matter of the spinal cord is
impaired
• Secondary chain of event: ischaemia, hypoxia
• Destruction of axons
• These secondary reactions are believed to be the principal
cause of SC degeneration
General Signs and Symptoms
• Extremity paralysis
• Pain with and without movement
• Tenderness along spine
• Impaired breathing
• Spinal deformity
• Priapism
• Posturing
• Loss of bowel or bladder control
• Nerve impairment to extremities
The consequence of SCI depends on:
• The type of injury
• The neurologic level (the lowest level at which sensory and
motor functions are normal)
Diagnosis of spinal cord injury
• History taking
• Physical examination including complex neurologic
examination
• CT scan
• MRI
• X-rays of spine
Management of SCI
• Collaborative care
• Nursing care
Pre-hospital Care
• Most pre-hospital care providers recognize the
need to stabilize and immobilize the spine on the
basis of mechanism of injury, pain in the vertebral
column or neurological symptoms.
• Patients are usually transported to the hospital
with a cervical hard collar on a hard backboard.
Basic Life Changes
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Eating
Dressing
Bowel/Bladder function
Weight Management- nutrition and fitness
Respiratory Issues
Pain
Psychosocial Issues
Sex and Pregnancy
Independence
Equipment / Accessibility
• Kinesiologist should plan with client
ways to improve personal mobility:
• Homes
• Vehicles
• Public Access
• Types of wheelchairs, mobility devices,
splinting and seating available
Psychosocial Issues
• These topics should be covered with the client, but will most likely be
referred to another professional for:
• Aging
• Education/Employment
• Family/Relationships
• Psychosocial Adjustments
• Rehabilitation
• Sex
• Substance Abuse
Treatment Fields
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Occupational Therapy
Physiotherapy
Physicians
Social Workers
Therapeutic Recreation
Rehabilitation
Psychologists
Vocational Counsellors
Nutrition Assistance
Telemedicine-employing a SCI
caregiver
Partners to Consult
• Neurosurgery
• Neurology
• Urology
• Orthopedics
• Plastic Surgery
• Neuropsychology
• Internal Medicine
• Gynecology
• Driver Education
• Rehabilitation Engineering
• Chaplaincy
• Pulmonary Medicine
• General Surgery
• Psychiatry
• Speech Pathology