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SPINAL CORD INJURY

REVIEW OF ANATOMY, PATHOPHYSIOLOGY, MECHANISM ,VARIOUS SYNDROMES OF SPINAL CORD INJURY

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SPINAL CORD INJURY

  1. 1.  Partial or complete disruption of spinal cord resulting in paralysis, sensory loss, altered autonomic and reflex activities.
  2. 2.  CNS: Brain & spinal cord  Base of the skull ( foramen magnum) to lower margin of the L1 vertebral body as conus medullaris.  Cauda equina:  Below L1  Lumbar, Sacral & Coccygeal spinal nerves  Filum terminale
  3. 3. Two enlargements:  Cervical: C3 to T1 segments innervates arm via brachial plexuses  Lumbar: L1 to S3 segments innervates leg via lumbosacral plexuses
  4. 4.  3 layers: › Pia › Arachnoid › Dura matter
  5. 5. Segments: (31) Cervical - C1- C8 Thoracic - T1- T12 Lumbar - L1- L5 Sacral - S1- S5 Coccygeal - 1 pair of spinal nerves (mixed)  ventral (motor)  dorsal (sensory)
  6. 6.  1 anterior and 2 posterior spinal arteries which arise from the vertebral arteries.  Various radicular arteries branch off the thoracic and abdominal aorta to provide collateral flow.  Venous drainage is usually by 3 anterior and 3 posterior spinal veins.  Spinal veins join the veins draining the vertebral bodies to form the internal vertebral venous plexus.
  7. 7.  Spinal cord injury is a mortal condition and has been recognised as such since antiquity.  Spinal cord injuries cause previously normal people to become handicapped. Furthermore, most common affected age group being 20-29 signifying higher incidence in young, active and productive population of the society.  In India, fall from height is the leading cause for spinal cord insult. Road traffic accident is the commonest cause in the younger age group i.e. 18-<25 years.  Traumatic lesions are common in men and non-traumatic lesions are common in women.  Majority of the cases are illiterate, poor villagers who are involved in high risk jobs.  Lumbar level (T 10 and below) is the commonest level of lesion in individuals with paraplegia.
  8. 8.  Tetraplegia refers to complete paralysis of all four extremities and trunk, including the respiratory muscles and resulting from lesions of the cervical cord.  Paraplegia refers to complete paralysis of all or part of the trunk and both lower extremities, resulting from lesions of the thoracic or lumbar spinal cord or cauda equina.
  9. 9.  COMPLETE INJURY- Having no sensory/ motor function in lowest sacral segments(S4- S5). Sensory function- anal sensations Motor function- voluntary anal sphincter contraction  INCOMPLETE INJURY- Having motor/ sensory function below the neurological level of lesion including sensory and/or motor function at S4-S5.
  10. 10. ASIA Impairment Scale Type of Injury Description 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 neurological level and includes the sacral segment S4-S5. C=Incomplete Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3. Sensory function is present below the neurological level and includes sacral segments S4-S5. D=Incomplete Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more. Sensory function is present below the neurological level and includes sacral segments S4-S5. E=Normal Motor and sensory function is normal
  11. 11.  Spinal cord transection and spinal shock:  Immediately following SCI, there is a period of areflexia- SPINAL SHOCK  Transient reflex depression- not clearly understood  Withdrawal of connections between higher centers and spinal cord  Clinical features- Areflexia, flaccidity, loss of sensory and motor function below the level of lesion  Lasts for days to weeks  First reflex to suggest withdrawal from spinal shock- Bulbocavernous reflex
  12. 12. Complete Cord Transection Syndrome:  Complete cord transection syndrome results in complete loss of all sensibility and voluntary movement below the level of the lesion.  Clinical features: 1. Bilateral lower motor neuron paralysis and muscular atrophy in the segment of the lesion. 2. Bilateral spastic paralysis below the level of the lesion.  A bilateral Babinski sign is present, and  depending on the level of the segment of the spinal cord damaged, bilateral loss of the superficial abdominal and cremaster reflexes occurs.
  13. 13. 4. Bilateral loss of all sensations below the level of the lesion. The loss of tactile discrimination and vibratory and proprioceptive sensations is due to bilateral destruction of the ascending tracts in the posterior white columns. The loss of pain, temperature, and light touch sensations is caused by section of the lateral and anterior spinothalamic tracts on both sides. 5. Bladder and bowel functions are no longer under voluntary control, since all the descending autonomic fibers have been destroyed.
  14. 14. Anterior cord syndrome  Clinical features: 1. Bilateral lower motor neuron paralysis in the segment of the lesion and muscular atrophy. 2. Bilateral spastic paralysis below the level of the lesion. The bilateral paralysis is caused by the interruption of the anterior corticospinal tracts on both sides of the cord. 3. Bilateral loss of pain, temperature, and light touch sensations below the level of the lesion. These signs are caused by interruption of the anterior and lateral spinothalamic tracts on both sides. 4. Tactile discrimination and vibratory and proprioceptive sensations are preserved because the posterior white columns on both sides are undamaged.
  15. 15. POSTERIOR CORD SYNDROME  It is an extremely rare syndrome resulting in deficits of function served by the posterior cord. This was seen in tebes dorsalis, a condition found in late stage of siphylis.  Clinical features:  Preservation of motor function, sense of pain and light touch  Loss of proprioception and epicretic sensation (two point discrimination, graphesthesia, stereognosis) below the level of lesion  A wide base step gait
  16. 16. Central Cord Syndrome  It is most often caused by hyperextension of the cervical region of the spine.  Clinical features:  Bilateral lower motor neuron paralysis in the segment of the lesion and muscular atrophy.  Bilateral spastic paralysis below the level of the lesion with characteristic sacral “sparing.”  The lower limb fibers are affected less than the upper limb fibers because the descending fibers in the lateral corticospinal tracts are laminated, with the upper limb fibers located medially and the lower limb fibers located laterally.
  17. 17.  Bilateral loss of pain, temperature, light touch, and pressure sensations below the level of the lesion with characteristic sacral “sparing.”  The sparing of the lower part of the body may be evidenced by (1) the presence of perianal sensation, (2) good anal sphincter tone, and (3) the ability to move the toes slightly.
  18. 18. Brown-Sequard Syndrome or Hemisection of the Cord:  Incomplete hemisection is common; complete hemisection is rare.  Clinical features:  Ipsilateral lower motor neuron paralysis in the segment of the lesion and muscular atrophy. These signs are caused by damage to the neurons on the anterior gray column and possibly by damage to the nerve roots of the same segment.
  19. 19.  Ipsilateral spastic paralysis below the level of the lesion. An ipsilateral Babinski sign is present, and depending on the segment of the cord damaged, an ipsilateral loss of the superficial abdominal reflexes and cremasteric reflex occurs. All these signs are due to loss of the corticospinal tracts on the side of the lesion.  Ipsilateral loss of tactile discrimination and of vibratory and proprioceptive sensations below the level of the lesion. These signs are caused by destruction of the ascending tracts in the posterior white column on the same side of the lesion.
  20. 20.  Contralateral loss of pain and temperature sensations below the level of the lesion. This is due to destruction of the crossed lateral spinothalamic tracts on the same side of the lesion. Because the tracts cross obliquely, the sensory loss occurs two or three segments below the lesion distally.
  21. 21.  M:F = 3:1  Age: > 50% of SCI occur in – age between16-30 years Traumatic SCI is more common in <40 years, Non-traumatic SCI is more common in > 40 years  Only about 5% of spinal cord injuries occur in children, but usually complete injury.  Incidence: 30-60 cases / million population / year.
  22. 22.  Common causes of SCI : Motor vehicle accidents (44.5%) Falls (18.1%) especially in persons aged 45 years or older Violence (16.6%) Sports injuries (12.7%)  Other causes : Vascular disorders Tumors Infectious conditions Spondylosis Iatrogenic injuries, especially after spinal injections and epidural catheter placement Vertebral fractures secondary to osteoporosis Developmental disorders
  23. 23.  Level and type of injury: The most common levels are C4, C5 and C6 then thoracolumbar junction T12  July, Saturday
  24. 24.  Injuries by ASIA classification Incomplete tetraplegia - 29.5% Complete paraplegia - 27.9% Incomplete paraplegia - 21.3% Complete tetraplegia - 18.5%  Leading cause of death in patients following SCI : - pneumonia and other respiratory conditions, - bed sore - by heart disease, subsequent trauma, and septicemia
  25. 25.  Common mechanism of injury are;  Flexion  Compression  Hyperextension  Flexion-rotation

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