SPINAL CORD INJURIES

RIZKY NUR AMALIA KASUN

2014010098
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
Statistics:
 Occurs primarily in young males (> 75% of
cases)
 Half of these injuries result from MVAs
 2/3 of patients are < 30 years old
 Other sources of SCI: Falls, sporting and
industrial accidents, gunshot wounds.
 Most common vertebrae involved are C5, C6,
C7, T12, and L1 because they have the greatest
ROM
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!
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%
Other causes:
 Vascular disorders
 Tumours
 Infectious conditions
 Spondylosis
 Iatrogenic
 Vertebral fractures secondary to
osteoporosis
 Development disorders
Anatomy :
Anatomy :
Anatomy :
 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
National Spinal Cord Injury Association dan The
Christopher & Dana Reeve Foundation

a. High Cervical Nerves ( C1-C4)

b. Low Cervical Nerves (C5 – C8)
c. Thoracic Nerves (T1-T5)
d. Thoracic Nerves (T6 – T12)
e. Lumbar Nerves (L1-L5)
f. Sacral Nerves ( S1-S5)
Spinal Cord Injury
Classification
 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 Cord Injury
Classification

a.Paraplegia incomplete (torakal

incomplete)
b.Paraplegia complete (torakal
complete)
c.Tetraplegia incomplete (servikal
complete)
d.Tetraplegia complete (cedera
servikal complete)
Injury either:
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
Spinal Cord Injury
Classification
 A. Complete transaction
Spinal Cord Injury
Classification
b. Incomplete transaction : Central cord syndrome
Spinal Cord Injury
Classification
c. Incomplete transection : Anterior Cord Syndrome
Spinal Cord Injury
Classification
d. Incomplete transaction : Brown Sequard Syndrome
Spinal Cord Injury
Classification
E. Incomplete transaction : 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
Management of Spinal Cord
Injuries
 Immediate management at the scene is critical.
 Improper handling can cause further damage and loss of functioning
 Always assume there is a spinal cord injury until it is ruled out
 Immobilize
 Prevent flexion, rotation or extension of neck
 Avoid twisting patient
 If conscious, patients will usually mention acute pain in back or neck
which may radiate along the involved nerve.
 Management is aimed at preventing further injury and observing for
progression of neuro deficits
 Consists of emergency treatment following an A-B-C-D-E sequence.
 Breathing circularion
Airway
• Lesions above C5 level • Cardiac output is
will cause partial to affected by external or
complete internal hemorrhage
• First priority.
diaphragmatic and neurogenic shock.
• Open airway with
paralysis (the • Two signs of internal
jaw-thrust maneuver.
diaphragm is bleeding from
• Use bag-valve-mask
innervated at C3-5 abdominal trauma are
devise initially for
levels). abdominal pain and
airway compromise
• Any lesion above T12 muscular rigidity.
and if necessary to
may cause some However, these signs
prepare for
airway compromise. may be masked in a
intubation.
• Lesions at C5 and patient with sensory
• High concentration of
below will allow full and motor deficits.
02 will prevent
diaphragmatic • Other usual signs of
bradycardia or
movement, but shock from internal
asystole for patients
intercostal muscles bleeding are absence
exhibiting signs of
(innervated at T1) and of urine and/or classic
neurogenic shock.
abdominal muscles signs of shock
(innervated at T12) are (decreased BP and
affected. increased HR)
 Exposure management
Dissability
• Lesions above C5 level
will cause partial to
• Neurological complete High dose corticosteroids
Examination diaphragmatic (Methylprednisolone) -
• Lateral C-Spine X-ray paralysis (the improves the prognosis
• CT scan diaphragm is and decreases disability
• MRI innervated at C3-5 if initiated within 8 hours
• ECG - bradycardia levels). of injury. Patient receives
and asystole are • Any lesion above T12 a loading dose and then a
common with acute may cause some continuous drip.
cervical injury airway compromise. High dose steroids,
• Search for other • Lesions at C5 and Mannitol, Dextran
injuries - spinal below will allow full Naloxone - has shown
trauma is often diaphragmatic promise in use on
accompanied by movement, but humans, minimal side
other injuries, intercostal muscles effects, may promote
particularly of the (innervated at T1) and neurological
head and chest. abdominal muscles improvement
(innervated at T12) are
affected.
Spinal Shock vs Neurogenic
Shock
Spinal Shock :

 Transient reflex depression of cord function

below level of injury
 Initially hypertension due to release of
catecholamines
 Followed by hypotension
 Flaccid paralysis
 Bowel and bladder involved
 Sometimes priaprism develops
 Symptoms last several hours to days
Neurogenic shock:
 Triad of i) hypotension
ii) bradycardia
iii) hypothermia
 More commonly in injuries above T6
 Secondary to disruption of sympathetic outflow from T1 – L2

• Loss of vasomotor tone – pooling of blood

• Loss of cardiac sympathetic tone – bradycardia
• Blood pressure will not be restored by fluid infusion
alone
• Massive fluid administration may lead to overload and
pulmonary edema
• Vasopressors may be indicated
• Atropine used to treat bradycardia
Spinal Shock
 Management:
 monitor patient for respiratory difficulty, bladder and bowel management,
abrupt onset of fever (as patient loses ability to perspire in areas of
paralysis).
 May last from weeks to months. When it ends, flaccid muscles become
spastic.
 Neurological/Orthopedic
Management
 Neurological/orthopedic management includes methods a surgeon
may use to treat unstable spinal cord injuries:

Reduction
Fixation
Fusion
Reduction

With reduction, the spine is

realigned through the
application of a skeletal traction
devise, such as Gardner-Wells
tongs or Halo traction.
Fixation and Fusion

 Fusion involves
 Fixation
involves attaching injured
stabilizing vertebrae to uninjured
vertebral vertebrae with bone
fractures with grafts, and steel rods
wires, to help maintain
plates,screws structural integrity.
and other types
of hardware.
Complications of SCI -
Pulmonary
 Pulmonary complications - Function
compromise, Airway compromise,
infection, decreased vital capacity,
atelectasis, retention of secretions,
respiratory failure, pulmonary edema
 Acute respiratory failure is the leading
cause of death in high cervical injuries.
Deep Vein Thrombosis
(DVT)
 The incidence of DVT is extremely high in SCI patients due to pressure
on their calf muscles, loss of the skeletal muscle pump, and the
hypercoagulability of their blood.
 Treatment :DVT prophylaxis - pneumatic compression hose, low dose
Heparin, and vena cava filters.
Orthostatic Hypotension

 Caused by venous pooling in the legs and

abdomen, loss the skeletal muscle pump, and
impaired sympathetic nervous system control of
BP.
 May occur with position changes and can result in
syncope, bradycardia, or asystole.
 Treatment consists of quickly returning the patient
to a supine position, administering oxygen, and if
necessary, atropine to increase heart rate.
thank you
References:
1. Andrew T Raftery, et al. Applied Basic
Science for Basic Surgical Training. Second
edition 2008;8:219-223
2. ATLS, et al. Student Course Manual. 7th
Edition 2004;7:177-204
3. Keith L Moore et al. Clinically Orientated
Anatomy. 3rd Edition1992;4:359-369
4. Segun T Dawodu et al. eMedicine
Specialities. March 2009
5. K Frielingsdorf, R N Dunn et al. SAMJ. March
2007,Vol. 97,No. 3