Damage to the spinal cord
may result from direct injury to the cord itself or indirectly from damage to surrounding bones, soft tissues, and blood vessels.
Spinal cord trauma can be caused by
any number of injuries to the spine. They can result from motor vehicle accidents, falls, sports injuries (particularly diving into shallow water), industrial accidents, gunshot wounds, assault, and others
Cervical Injuries are
More vulnerable to trauma due to poor mechanical stability, with
C1 and C2 injuries result in death because it interrupts the diaphragm's innervation
Cervical Flexion Injuries
Result of rapid deceleration as occurs in head on collision,
Vertebral column subjected to compression force anteriorly and distraction force posteriorly
Cervical Flexion with Rotation Injuries
Flexion and rotation forces can result in the dislocation and locking of a single facet joint, and
Can cause Brown Sequard syndrome or nerve root damage
Cervical Vertical Compression Injuries
Axial loading through a straight cervical spine results in burst fracture (ex. Jumping into swallow water),
and Most often occurs at C4 or C5.
Cervical Extension Injuries
Occurs when someone strikes his chin or forehead in a fall or is struck from behind while riding in a car,
this results in Distraction force anteriorly and compression forces posteriorly
Cervical Lateral Flexion Injuries
Compression on one side of the vertebral column and distraction on the other side
Thoracic Injuries
Rib cage provides support for T1 through T10 spine,
Less likely than cervical but more likely to be complete,
Often associated with gunshot wounds, vehicular accidents, and falls,
Most often occur at T12 and L1
Thoracic Flexion Injuries
Most fractures are caused by compression of the anterior aspects of the vertebral bodies,
Thoracic region is prone to this type of injury because of natural kyphotic position.
Thoracic Flexion with Rotation
Injuries
Can lead to fracture dislocations with anterior compression of the vertebral body, damage to the anterior, longitudinal ligament, disruption of disk, fractures of posterior arch
Thoracic Vertical Compression Injuries
Occurs when a person is struck by a falling object of falls and lands on his upper thoracic spine, buttocks, or feet,
Falls result in burst fractures of T10, T11, or T12
Thoracic Extension and Lateral Flexion Injuries
Rarely occur with thoracic spine,
Disruption of anterior ligaments and, lateral wedging of vertebral body
Lumbar Injuries
Lumbar region has intermediate stability; More flexible than thoracic region but less flexible than cervical region,
Supported by strong paraspinal and abdominal musculature,
Common causes of injury include falls, MVA, GSW, and direct impact of heavy obje
Lumbar Flexion Injuries
Vertebral column subjected to compression forces anteriorly and distraction forces posteriorly
Lumbar Flexion with Rotation Injuries
Can lead to fracture dislocations with anterior compression of the vertebral body, damage to the anterior, longitudinal ligament, disruption of disk, fractures of posterior arch
Lumbar Flexion with Distraction Injuries
Seat Belt Injuries,
Lumbar spine is flexed violently about a fulcrum located at the anterior abdominal wall,
Results in extreme distractive forces of the middle and posterior columns of the spine.
Lumbar Shear Injuries
Horizontally directed force such as when a person is struck from behind with a heavy object or falls on uneven ground
Lumbar Vertical Compression Injuries
Results in burst fracture
Neuropathology
Initial trauma occurs,
Can lead to any of the following,
Interruption of blood flow,
Disruption of ionic concentration,
Inflammation,
Apoptosis: Programmed cell death that occurs during embryonic development and following CNS damage
Tetraplegia:
Partial or complete paralysis of all four extremities and trunk; including respiratory muscles, and results from lesions in the cervical region
Paraplegia:
Partial or complete paralysis of all or part of the trunk and both lower extremities, resulting from lesion of the thoracic and lumbar spinal cord or sacral roots
Complete Lesions:
No sensory or motor function below the level of lesion
Incomplete lesions:
preservation of some sensory or motor function below the level of lesion
Brown Sequard Syndrome
Occurs from hemisection of the spinal cord (damage to one side) and is typically associated with stab wounds
Effects of Brown Sequard are
Ipsilateral side as the lesion, loss of sensation in the dermatome corresponding to the level of the lesion, with decreased reflexes, lack of superficial reflexes, clonus, and a positive Babinski sign. Loss of, proprioception, kinesthesia, and vibration s
Hemi-section injury of the spinal cord
produces greater ipsilateral proprioceptive & motor loss with contralateral loss of pin & temperature sensation
Brown Sequard Overall best prognosis for recovery
Ambulation 75%(40% if >50 yo)
ADLs 70%
Bowel 82%
Bladder 89%
2-4% of all traumatic SCI
Anterior Cord Syndrome
Frequently related to flexion injuries of the cervical region,
Typically compression of the anterior cord from fracture, dislocation, or cervical protrusion
Anterior Cord Syndrome is
Characterized by
Loss of motor function (corticospinal tract damage),
Loss of sense of pain and temperature (spinothalamic tract damage)
Anterior Cord Syndrome is an
Injury involving anterior 2/3 of spinal cord with variable loss of motor function, pain & temperature, with preserved proprioception and light touch,
Poor prognosis for recovery only 10 - 20% have any motor recovery and it's almost always non-functional A
Central Cord Syndrome is
Most commonly occurs from hyperextension injuries to the cervical region,
Characterized by:,
Severe neurological involvement of the UE than the LE,
Normal sexual, bladder, and bowel function will be retained,
Most learn to walk again with some residual UE
Central Cord Syndrome has Good prognosis for recovery but age a predictor
<50 yo >50 yo
Ambulation 97% 41%
ADLs 77% 12%
Bowel 63% 24%
Bladder 83% 29%
Posterior Cord Syndrome
Extremely rare,
Characterized by,
Preservation of motor function, sense of pain, and light touch,
Loss of proprioception and combined cortical sensation,
Wide base step gait pattern,
Least frequent,
Preserves pain, temperature, and light touch with varyin
Sacral Sparing
An incomplete lesion in which the centrally located sacral tracts are spared,
Clinical signs include perianal sensation, rectal spincter contraction, cutaneous sensation in the saddle area, and active contraction of the sacrally innervated toe flexors,
Fi
Cauda Equina Injuries
Spinal cord tapers distally to form the conus medullaris at the lower border of the first lumbar vertebra,
This is typically the termination of the spinal cord,
Below this level is the collection of long nerve roots known as the cauda equina,
Cauda equina
Reasons why cauda equina injuries usually don't regenerate
Large distance between the lesion and point of innervation,
Axonal regeneration may not occur along the original nerve,
Axonal regeneration may be blocked by scarring,
The end organ may no longer be functioning once reinnervation occurs,
Rate of regenerat
Spinal Shock has a
Period of areflexia immediately following spinal cord injury,
Characterized by absence of all reflex activity, flaccidity, and loss of sensation below the level of lesion,
One of the first indications that spinal shock may be resolving is a positive Bulbo
Autonomic dysreflexia, also known as hyperreflexia,
is a state that is unique to patients after spinal cord injury at a T-5 level and above. Patients with spinal cord injuries at Thoracic 5 (T-5) level and above are very susceptible. Patients with spinal cord injuries at Thoracic 6 - Thoracic 10 (T6-T10) m
Autonomic dysreflexia can develop suddenly,
and is a possible emergency situation. If not treated promptly and correctly, it may lead to seizures, stroke, and even death.
Autonomic dysreflexia means an over-activity of the
Autonomic Nervous System. It can occur when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. The stimulus sends nerve, impulses to the spinal cord, where they travel upward until they are
Symptoms of Autonomic Dysreflexia
Pounding headache (caused by the elevation in blood pressure),
Goose Pimples,
Sweating above the level of injury,
Nasal Congestion,
Slow Pulse,
Blotching of the Skin,
Restlessness
Causes of Autonomic Dysreflexia
� The most common cause seems to be overfilling of the bladder. This could be due to a blockage in the urinary drainage device, bladder infection (cystitis), inadequate bladder emptying, bladder spasms, or possibly stones in the bladder. The second most c
Prevention of Autonomic Dysreflexia
If you have an indwelling catheter:
� Keep the tubing free of kinks
� Keep the drainage bags empty
� Check daily for grits (deposits) inside of the catheter.
� If you are on an intermittent catheterization program, catheterize yourself as often as necessa
ASIA Impairment Scale � A =
Complete: no motor or sensory function preserved in the sacral segments S4-5 (ie. NO perianal sensation, deep anal sensation, or voluntary anal contraction)
ASIA Impairment Scale � B =
Incomplete: Sensory but no motor function preserved in the sacral segments (may not be normal, but is present!)
ASIA Impairment Scale � C =
Incomplete: Motor function is preserved below the neurologic level, & > � of the key muscles below the NLI have a muscle grade of < than 3
ASIA Impairment Scale � D =
Incomplete: Motor function is preserved below the neurologic level, & ? � of the key muscles below the NLI have a muscle grade of ? than 3
Facilitation of a tenodesis grasp should be done during
range of motion of the hand, particularly for patients with injuries at the C6 and C7 levels. The wrist is maintained in an extended position while the fingers are flexed, and the wrist is flexed while the fingers are extended
Multiple Sclerosis is
A chronic, disabling, demylinating disease of the CNS,
� Affects mostly young adults 20 to 40
� Characterized by periods of exacerbation (relapse or periods of symptom flare ups) and remission (periods free of evolving symptoms)
� Caused by autoimmune dis
Sensory Impairments Associated with MS
Paresthesias: numbness of the face, body, or extremities,
Anesthesia is rare (complete loss of any single sensation),
Disturbances in proprioception,
Dysesthesias: abnormal burning or aching,
Hyperpathia: hypersensitivity EX. Light touch, elicits extreme
Visual Impairments Associated with MS
Optic Neuritis: Inflammation of the optic nerve causing blurred or grayed vision,
Scotoma: Dark spot in the center of the visual field,
Nystagmus: Involuntary oscillations of the eye
Diplopia: double vision
Motor Impairments Associated with MS
Upper Motor Neuron (UMN) Syndrome: Due to secondary damage of the corticospinal tracts or motor cortex,
Characteristics of UMN syndrome: Paresis, Spasticity, hypertonicity, Involuntary flexor or extensor synergy patterns, Clonus (+ babinski sign), exagger
Cognitive and Behavioral Dysfunction
Depression is common
� Euphoria: exaggerated sense of well being; sense of optimism inconsistent with the pt's incapacitating disability
� Emotional dysregulation syndrome: lack of control with uncontrollable laughing or crying
Bladder and Bowel Dysfunction with MS
Bladder deficits include a small, spastic bladder (a failure to store problem), a flaccid or big bladder (failure to empty problem), or dyssynergic bladder,
� Dyssynergic bladder is caused by incoordination between the bladder contraction and sphincter re
Benign MS:
defined as disease in which the pt remains fully functional in all neurological systems 15 years post onset
Malignant MS:
Relatively rare disease course that is rapidly progressing, leading to significant disability in multiple neurological systems and death in a short time
Exacerbating Factors for MS
Viral or bacterial infections,
� Disease of major organ systems (Ex. Hepatitis, Pancreatitis, Asthma Attacks)
� Major life stress events (Divorce, Marriage, Death, Losing a job)
� Minor stresses
Diagnosis of MS
Cerebrospinal Fluid Examination: abnormal protein composition in spinal tap,
� MRI: scattered areas of abnormal nerve tissue
� CT Scan: scattered areas of increased density
Prognosis of MS
Life expectancy is not decreased in most patients,
� Death can occur early if pt gets pneumonia, bladder infection, decubitus ulcers, etc