Spinal Cord Injuries Lecture Notes PDF

# Spinal Cord Injuries ## Importance of spine: * **Stability:** "Backbone" * **Protection of spinal cord** (Sc) * "Good Trunk control" is the most important, even if someone is amputated they can walk, but with SCI they cannot walk * A large injury is needed for SCI where it has passed a...

# Spinal Cord Injuries ## Importance of spine: * **Stability:** "Backbone" * **Protection of spinal cord** (Sc) * "Good Trunk control" is the most important, even if someone is amputated they can walk, but with SCI they cannot walk * A large injury is needed for SCI where it has passed all bodily limits * The injury has to extend past the skin, muscles, ligament and bone * **Protection of nerves:** between superior and inferior articular facet + sheath * **Allow movements:** 33 joint with their IVD * L4-L5: most mobile segment * L4-L5: most liable to injury ## Bony Anatomy: There are 33 vertebrae: * 7 Cervical * 12 Thoracic * 5 Lumbar * 5 Sacral (fused) * 4 Fused Coccyx **Painful fender area between glutei:** * May be fracture coccyx * Most cases are coccydynia * Fused vertebrae are spread out in x-ray ### Cervical: * **Atlas** form: * Atlantoaxial with the occipital * Allows free motion - flexion, extension, rotation * **Typical Cervical Vertebrae** * **Intervertebral foramen** * Two vertebral arteries * Vertebrobasilar insufficiency occurs in a vertebral arterial insufficiency (VA) in the intervertebral foramen * It runs in parallel from C6 to C2 * Basilar art joins together to form basilar groove that then runs through pons * The arteries then divide into two posterior cerebral arteries ### Typical Cervical vs. Typical Thoracic vs. Typical Lumbar * **Vertebral body:** * Typical thoracic has more stability. * Typical lumbar is bigger. * **Transverse process:** angle of lamina and lamina gives more stability. * **Spinous process:** angle of pedicle with lamina. * **Most prominent spinous process:** C7 * **Facet Joint:** articulation of superior articular facet and inferior articular facet: * Has capsule * Disc Prolapse causes osteophytes, no manipulation is allowed as they can be paralyzed. ## IVD Anatomy: * **Annulus Fibrosus:** * Tough fibrous dense strong network of fibers * Anterior is thicker posterior. * At 60 Loss of water + degeneration of content * **Nucleus Pulpous:** * Gelatinous material * 60-80% water * Dehydrates through the day and rehydrates through the night. * With age, a shorter height is seen. * **Function:** * Shock absorber to allow movement between segments. * Cushion between bodies of each vertebra ## Ligamentous Anatomy: * **Anterior Longitudinal ligament:** prevent hyperextension * **Posterior Longitudinal ligament:** * **Ligamentum Flavum:** * **Interspinous ligament:** between spinous process above and below * **Supraspinous ligament:** * **Intertransverse ligament:** between transverse process above and below ## Anatomy of the Cord: * Give 31 pairs of spinal nerves (mixed) * Sensory motor * **Extend From Foramen Magnum to L1, L2 junction** * **Cervical Enlargement:** Brachial Plexus - Support UL * **Lumbar Enlargement:** Lumbosacral Plexus - Supply LL * **End with:** * **Epiconus:** L4,L5, S1, S2 segments * **Conus medullaris:** S3, S4, S5 * **Cauda Equina:** * Emerges from foramen * Origin of spinal nerves extending inferiorly from conus medullaris * Post dorsal- lateral - ventral * **Gray matter:** divides into horns: anterior ventral, lateral, dorsal * **White matter:** divides into 3 columns: anterior, lateral, dorsal * **Commisures:** Connect between left and right halves. * **Roots** * **Dorsal Root:** sensory - ascends * **Ventral Root:** motor - descends * **Merge laterally** to form spinal nerve * **Connect** opposite side (siccles) * **Dorsal root ganglion:** DSG ## Spinal Cerebellum: * **Tract:** spino cerebellum * **Tract:** spino olivary * **Tract:** spino tectal **Cutting of these tracts does not affect sensation.** * Even though they are ascending, they do not impact sensation * **Spino Cerebellar:** they detect certain position, trunk, UL, LL position in the cerebellum * **Unconscious sensation:** always running, does not need stimulus * **Proximal joint problem:** mainly proximal, extra articular lesion, shoulder girdle, ms. - they send information to the spin. * **Distal:** usually, it refers to pyramidal * **Spinal Cord Protection:** Integument: Ligaments + Dura + Meninges + CSF in the subarachnoid space. * **Choroid Plexus** In ventricle below L2 to vent 4th level * **CSF:** motor, sensory function, temporary (according to cause) * **SCI:** * motor * sensory * autonomic * National SCI Database: * MVA: 44.5% * Falls: 18.1% * Violence: 16.6% * Sports: 12,790 * Age: 16-30 years: 55% cases * Male: 81.6% cases ## Causes of SCI: **Traumatic:** * Motor vehicles most frequent. * Falls recreational in adults * Sports injuries * Diving accidents * Falling down **Non Traumatic:** * Vascular malformation * Ischemia "supply areas" * Transverse Myelitis * Infection * Tumor * Central lobula ## Classifications of SCI: - **Skeletal and neurologic level** - **Mechanism of injury** - **Completeness (degree) of injury** ### According to level of injury: - **Quadriplegia** * Injury from C1 to T1 * All 4 extremities are affected. * Complete transection (phrenic nerve - link to death). * Incomplete C1, C2, C3 lesion may be able to live. - **Paraplegia** * Injury in thoracic, lumbar, sacral segments * 2 extremities are affected. * T1-T7: High level para * T8 - T12: Mid level para * T12 - L1: Low level para * Spastic - **Tetraplegia:** injury in C1, C6 "cervical" * Quadriplegia but lower affected more than upper. * MS spared in shoulder girdle. - **Paraplegia:** lesion in lower extremity, no trunk. * "Low" * MS spared in shoulder girdle. * Good prognosis - the lower the lesion the easier they can resume life. * "Good function" - their function is not as good - they can still participate life. ### According to mechanism of injury: * **Cervical flexion and rotation injuries** (most common) * Rupture of posterior spinal ligament- stretch PLL * Rupture of anterior longitudinal ligament- rupture ALL * Uppermost cervical vertebrae displaced over the lower * Rupture of IVD - rupture IVD * Spinal cord transection * **Cervical hyperflexion injuries** * Anterior compression fracture of vertebral body * Wedge type fracture * Affect anterior spinal artery. * **Cervical hyperextension injuries** * Stretch long ligament, fracture of vertebrae, spinal cord compressed between ligamentum flavum, vertebral body. * Cause central cord injury * Nuclues pulposus moves into the vertebral body (central cord). * Bone fragments * **Compression injuries:** * Individual chin displaced outward * Strike stationary object * Diving accidents - whiplash * Permanent or transient lesion in the spinal cord * Post spinal artery ischemia, eclema * Common in older adults * Falls * Osteoporosis * OA, RA * "Compressed flexion" - car hitting the head. ### According to severity of injury: - **Complete:** * Loss of voluntary movement of parts innervated by the segments below. * "Irreversible" * Loss of sensation * Spinal shock - neurogenic shock * Flaccid * A neurogenic shock stage is to be passed by the patient no matter what- "Quick pain" * Bad prognosis. - **Incomplete** * Some function is presented below the site of injury. * More favorable prognosis overall * Recognizable pattern of injury, although they are rarely pure and variations occur. ## Spinal and Neurogenic Shock: * **Spinal Shock:** * Flaccid stage * Last days to months * Loss of * Sensation * Motor "Flaccid paralysis" * Sensory "touch, pressure, pain, proprioception" * **Neurogenic Shock** * Due to the loss of vasomotor tone. * Sympathetic nervous system loss * Parasympathetic dominates "Vasomotor failure" * Cause peripheral pooling and decreased COP * Hypertonia * Bradycardia * Orthostatic hypotension - "poor temperature control" (Poikilothermia) * Below level of injury * Do not leave patient with muscles at zero tone, we must use electro-stimulation in order to improve muscle tone. * Do not move a patient too quickly, too much weight, or too early, this will cause injury. * Do not have a patient sit up all at once. ## Common types of incomplete SCI: 1. **Anterior cord syndrome** - UMNL 2. **Posterior cord syndrome** - UMNL 3. **Central cord syndrome** - UMNL 4. **Brown Sequard syndrome** - UMNL 5. **Conus medullaris syndrome** 6. **Cauda Equina syndrome** ### 1. Central Cord Syndrome: * Tumor intramedullary - extends laterally - affects lateral spinothalamic tract - affects upper more than lower. * Affects pyramidal tract. * Hyperextension injury. * Compression of cord - anteriorly by osteophytes - posteriorly by ligamentum flavum. * Associated with fracture dislocation and compression fracture. * "More centrally" - cervical tract tends to be more involved - weakness of arms > legs - perianal sensation and some lower limb movement and sensation preserved. ### 2. Anterior Cord Syndrome: * Due to flexion and rotation. * Corticospinal and spinothalamic tracts are damaged. * Either by direct trauma - ischemia (anterior spinal arteries) * Clinically: * Loss of power. * Decrease in pain/sensations below lesion * Dorsal column remains intact "deep sensations, gracile and cuneate" * Dissociated sensory loss - loss of pain, temp - preservation of deep "fine touch" ### 3. Posterior Cord Syndrome: * Hyperextension injury. * Fracture of posterior elements of vertebrae. * Proprioception affected - deep * Good power and sensation * Sensory ataxia * Base - sway - difficult to walk * Wide base- deviation to the affected side * Zigzag gait- "drunk-like," slurring ### 4. Brown Sequard Syndrome: "Spinal Cord Hemisection" * Injury up to C8 * Half of cord * Symptoms: * Ipsilateral * UMNL below level * LMN at level * Loss of fine, touch, conscious proprioception below the level * Contralateral * Loss of pain, temperature, deep sensation below the level. * Same side of lesion: * Medulla - motor - ipsilateral weakness - UMN * Deep sensations, ipsilateral loss - vibratory, proprioception * Opposite side of lesion * Superficial - contralateral loss ### 5. Cauda Equina Syndrome: * Due to bony compression. * Disc protrusion in: * Lumbar * Sacral