Dr.K.Jaiganesh, MD

Professor of Physiology

MGMCRI

Objectives

1. Complete transection of spinal cord

2. Incomplete transection of spinal cord

Spinal Cord Injuries

Causes (in order of frequency)

Motor Vehicle Accidents

Gunshot wounds/acts of violence

Falls

Sports injuries

Classification of SCI

1. Flexion: Head is suddenly & forcefully accelerated forward causing extreme flexion of the neck “Kiss the Chest

Classification of SCI

2. Hyperextension

Automobile accidents

Classification of SCI

3. Vertical compression

Blow to the top of the head

Often begins with a sudden, traumatic force

Classification of SCI

4. Excessive Rotation (either flexion- or extension-rotation)

Classification of SCI

5. Penetrating injuries

Types of Cord Injury

1. Concussion

Similar to cerebral concussion

Temporary and transient disruption of cord function

2. Contusion

Bruising of the cord

Tissue damage, vascular leakage, and swelling

3. Compression - Secondary to:

Displacement of the vertebrae

Herniation of inter vertebral disk

Displacement of vertebral bone fragment

Swelling from adjacent tissue

4. Laceration

Direct damage to cord with associated bleeding, swelling and potential disruption of cord

5. Hemorrhage

Associated with contusion, laceration, or stretching

6. Transection

Partial or complete severing of cord

Common sites of Spinal Injury

C-1/C-2: Delicate vertebrae

C-7: Transition from flexible cervical spine to thorax

T-12/L-1: Different flexibility between thoracic and lumbar regions

Complete spinal cord injury

Most severe form of injury

All sensations & motor functions will be lost beneath the level of the injury

Depend on the level of the injury!

Tetraplegia (formerly quadriplegia)occurs with C-1 to C-8 injuries.

Paraplegia occurs with T-1 to L-4

Complete Cord Transection

Complete spinal cord injury

Stages

1. Stage of spinal shock

2. Stage of reflex activity

3. Stage of reflex failure

Spinal shock:

Begins within hour of injury & Lasts from few minutes up to several months & Ends with return of reflex activity: Hyper reflexia, Muscle spasticity, Reflex bladder emptying.

Reflex activity

Stage of spinal shock

1.Spinal Shock - Temporary loss of reflex function (a reflexia) below level of injury beginning immediately after complete transection of spinal cord

Temporary insult to the cord

Affects body below the level of injury

Cramp like pains at the level of lesion

Loss of all sensations below the lesion

Muscles are paralyzed

Muscle tone is lost

Reflexes are lost

Bladder & the rectum are paralyzed

Sphincters paralyzed but recover their activity faster

Vasomotor tone lost, so BP falls

Skin becomes cold & blue- bed sores may develop

Effects of section at various levels

At C1 segment level

Quadriplegia

Maximum fall in BP

Anaesthesia

Paralysis of respiratory muscles

Death

At C5 segment level

Quadriplegia

Maximum fall in BP

Anaesthesia below the lesion

Diaphragm is not paralysed. So, respiration is maintained

Horner’s syndrome develops

Effects of section at various levels

At C8

Miosis

No sweating on the face and the neck

Ptosis due to paralysis of the Muller’s muscle

Enophthalmos

Loss of ciliospinal reflex – (stimulation of skin over the neck produces reflex dilatation of the pupil)

Other features remain the same

At upper thoracic level

Paraplegia

Maximum fall in BP

Anaesthesia below the lesion

No Horner’s syndrome

Effects of section at various levels

At lower thoracic level

BP fall is less

Other features remain the same

At or below 2nd lumbar

Minimum or no fall in BP

Paraplegia

Anaesthesia below the lesion

Other features remain the same

Site Sensory Motor BP RS Other

C1 Anaesthesia Quadriplegia Max Fall Paralysis

of RS

muscles

Death

C5 Anaesthesia

below

Quadriplegia Max Fall No Horner‘s

develops

C8 SAME Full

Horner‘s

Upper

Thoracic

Anaesthesia

below

Paraplegia Max fall No

Horner”s

Lower

thoracic

SAME Less BP

fall

At or

below II

lumbar

SAME No BP fall

Stage of reflex activity

Sensations remain lost

Voluntary movements absent

Skeletal muscle tone increases in flexors first then in extensors

Functional activity of smooth muscle returns

Reflexes appear – Babinski reflex positive

Micturition & Defaecation reflex reappear

Mass reflex - Stroking the inner thigh – flexor spasm,contraction of abdominal muscles & evacuation of bladder

BP increases & skin sweats

Stage of reflex failure

Reflexes become functionless

Loss of muscle tone

Muscle wasting (degenerative changes)

General infection – bedsores, UTI, sepsis ----Death

Incomplete (partial transection)

Mixed loss of voluntary motor activity and sensation below level of injury as pathways are only partially interrupted

Four patterns or syndromes

Central cord syndrome

Anterior cord syndrome

Posterior cord syndrome

Brown-Sequard syndrome

Cord Syndrome

Brown-Sequard syndrome

Central cord syndrome

Anterior cord syndrome

Posterior cord syndrome

Brown-Sequard’s Syndrome

Incomplete Transection Cord Injury

Brown-Sequard’s Syndrome

Damage to one half of the cord on either side

Penetrating injury that affects one side of the cord

Ischemia,infectious or inflammatory diseases (tuberculosis,multiplesclerosis)& spinal cord tumor

Ipsilateral sensory and motor loss

Contralateral pain and temperature sensation loss

Brown Sequard Syndrome

Below the level of lesion:

Impairment of ipsilateral light touch, proprioception and vibration (dorsal columns) from site of lesion, caudally

Impairment of contralateral pain and temperature (spinothalamictract) below level of lesion

Impairment of ipsilateral voluntary movements (UMN type of paralysis) below level of lesion

Temporary loss of vasomotor tone

Brown Sequard Syndrome

Above the lesion

Small area of cutaneous hyperaesthesia on the same side

No motor involvement on both sides

At the level of lesion

Complete sensory loss on the same side

LMN paralysis – same side

Vasomotor paralysis – same side

No sensory motor & vasomotor involvement on the opposite side

Brown Sequard’s Syndrome

Site Function Same side Opp. side

Above the level Sensory

Motor

Vasomotor

Normal

Normal

Normal

Normal

Normal

Normal

At the level Sensory

Motor

Vasomotor

Total sensory loss

LMN type palsy

Vaso dilatation

Normal

Normal

Normal

Below the level Sensory

Motor

Vasomotor

Dorsal column lost

UMN type palsy

Vaso dilatation

Spino thalamic lost

Normal

Normal