. logo-LF_red_1500 Injury of spinal cord logo Traumacentrum Definition — — Insult to spinal cord resulting in a change, — in the normal motor, sensory or autonomic function. This change is either temporary or permanent. —Mechanisms: — i)Direct trauma ii)Compression by bone fragments / haematoma / disc material iii)Ischemia from damage / impingement on the spinal arteries —Other causes: —Vascular disorders —Tumours —Infectious conditions —Spondylosis —Iatrogenic —Vertebral fractures secondary to osteoporosis —Development disorders — Anatomy : —Spinal cord: — —Extends from medulla oblongata – L1 —Lower part tapered to form conus medullaris IMG —On the surface : —Deep anterior median fissure —Shallower posterior median sulcus — —Spinal cord segment : —Section of the cord from which a pair of spinal nerves are given off —On the surface : —Deep anterior median fissure —Shallower posterior median sulcus — —Spinal cord segment : —Section of the cord from which a pair of spinal nerves are given off image664[1] — Dorsal root – sensory fibres — —Ventral root – motor fibres — —Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve IMG_0001 Physiology and function —Grey matter – sensory and motor nerve cells — —White matter – ascending and descending tracts —Divided into - dorsal — - lateral — - ventral — M28454-040-f021a Tracts : — — —1) Posterior column: — —Fine touch —Light pressure —Proprioception — — — —2) Lateral corticospinal tract : — —Skilled voluntary movement — —3) Lateral spinothalamic tract : — —Pain & temperature sensation —Posterior column and lateral corticospinal tract crosses over at medulla oblongata — —Spinothalamic tract crosses in the spinal cord and ascends on the opposite side — —NB to understand this as it helps to understand the clinical features of injury patterns and the neurological deficit 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 M28454-040-f020a Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM) © 2007 Elsevier M28454-040-f020b Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM) © 2007 Elsevier 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 Classification —Quadriplegia : — injury in cervical region — all 4 extremities affected — —Paraplegia : — injury in thoracic, lumbar or sacral segments — 2 extremities affected —Injury either: — 1)Complete 2) 2) 2)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 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 Types of incomplete injuries i)Central Cord Syndrome ii) ii)Anterior Cord Syndrome iii) iii)Posterior Cord Syndrome iv) iv)Brown – Sequard Syndrome v) v)Cauda Equina Syndrome i)Central Cord Syndrome : — —Typically in older patients —Hyperextension injury —Compression of the cord anteriorly by osteophytes and posteriorly by ligamentum flavum — —Also associated with fracture dislocation and compression fractures —More centrally situated cervical tracts tend to be more involved hence — flaccid weakness of arms > legs —Perianal sensation & some lower extremity movement and sensation may be preserved 305143-321651-321907-321988[1] IMG_0008 —ii) Anterior cord Syndrome: —Due to flexion / rotation —Anterior dislocation / compression fracture of a vertebral body encroaching the ventral canal —Corticospinal and spinothalamic tracts are damaged either by direct trauma or ischemia of blood supply (anterior spinal arteries) —Clinically: —Loss of power —Decrease in pain and sensation below lesion —Dorsal columns remain intact IMG_0002 —ii) Posterior Cord Syndrome: — Hyperextension injuries with fractures of the posterior elements of the vertebrae — — Clinically: — Proprioception affected – ataxia and faltering gait — Usually good power and sensation IMG_0006 —iv) Brown – Sequard Syndrome: —Hemi-section of the cord —Either due to penetrating injuries: — i) stab wounds — ii) gunshot wounds —Fractures of lateral mass of vertebrae — —Clinically: —Paralysis on affected side (corticospinal) —Loss of proprioception and fine discrimination (dorsal columns) —Pain and temperature loss on the opposite side below the lesion (spinothalamic) IMG_0009 —v) Cauda Equina Syndrome: — Due to bony compression or disc protrusions in lumbar or sacral region — — Clinically —Non specific symptoms – back pain — - bowel and bladder dysfunction — - leg numbness and weakness — - saddle parasthesia