Anatomy of the Spinal Cord Structure of the spinal cord Tracts of the spinal cord
CME Spinal Cord Injury
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Transcript of CME Spinal Cord Injury
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Spinal Cord Injuries
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What is the anatomy of the spinal cord on
cross section?
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What is the anatomy of the spinal cord on
cross section?
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What are the clinically important descending
tracts and where do they cross over?
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At what level does the spinal cord end and
why is it important?
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What are the differences between UMN and
LMN? (e.g., cauda equina vs. myelopathy)
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SPINAL TRAUMA
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Acute vs. chronic injuries;
complete vs. incomplete injuries
Acute=sudden onset of symptoms
Complete ?
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What is a completespinal cord injury?
Complete = absence of sensory and motor
function in the perianal area (S4-S5)
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Terminology
Plegia = complete lesion
Paresis = some muscle strength is preserved
Tetraplegia (or quadriplegia)
Injury of the cervical spinal cord
Patient can usually still move his arms using the segmentsabove the injury (e.g., in a C7 injury, the patient can still flexhis forearms, using the C5 segment)
Paraplegia
Injury of the thoracic or lumbo-sacral cord, or cauda equina
Hemiplegia
Paralysis of one half of the body
Usually in brain injuries (e.g., stroke)
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Motor: how do you test each segment?
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Motor: how do you grade the strength?
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Sensory: how do you determine the level?
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What are the important vegetative
functions and when are they affected?
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Reflexes
Deep Tendon Reflexes
Arm
Bicipital: C5
Styloradial: C6
Tricipital: C7
Leg
Patellar: L3, some L4
Achilles: S1
Pathological reflexes
Babinski (UMN lesion)
Hoffman (UMN lesion at or above cervical spinal cord)
Clonus (plantar or patellar) (long standing UMN lesion)
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What is and how do you determine the level
of injury?
Motor level = the last level with at least 3/5
(against gravity) function NB: this is the most important for clinical purposes
Sensory level = the last level with preservedsensation
Radiographic level = the level of fracture on
plain XRays / CT scan / MRI
NB: spine level does not correspond to spinal cord
level below the cervical region
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Case scenario
25 y/o male
Fell off the roof (20 feet)
Had to be intubated at the scene by EMS
Consciousness regained shortly thereafter
Could not move arms or legs
Could close and open eyes to command
Not able to breathe by himselftotallydependent on mechanical ventilation
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High cervical injuries (C3 and above)
Motor and sensory deficits involve the entire
arms and legs
Dependent on mechanical ventilation for
breathing (diaphragm is innervated by C3-C5levels)
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What is the difference between spinal shock
and neurogenic shock?
Spinal shock is mainly a loss of reflexes (flaccid
paralysis)
Neurogenic shock is mainly hypotension and
bradycardia due to loss of sympathetic tone
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Case scenario
22 y/o female
Motor vehicle accident (hit a pole at 60mph)
+ for ethanol and Tetrahydrocannabinol
Short term loss of consciousness (10)
Not able to move or feel her legs
Deep Tendon Reflexes 2+ in both upper
extremities, 0 in both lower extremities No bladder / bowel control or sensation
Sensory level at the umbilicus
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What is the difference between cauda equina and
conus medullaris syndrome?
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What is an incompletelesion?
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Lumbar Puncture
Sedate the patient and make your life easier
Measure opening pressure with legs straight
Always get head CT prior to LP to r/o
increased ICP or brain tumor
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Cervical Spine Clearance
Occiput to T1 need to be cleared ER, Neurosurgery or Orthopedics physician
If the patient Is awake and oriented
Has no distracting injuries
Has no drugs on board
Has no neck pain
Is neurologically intact
then the c-spine can be cleared clinically, without any need forXRays
CT and/or MRI is necessary if the patient is comatoseor has neck pain
Subluxation >3.5mm is usually unstable
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Cervical Traction
Gardner-Wells tongs
Provides temporary stability of the cervical spine
Contraindicated in unstable hyperextension injuries
Weight depends on the level
Cervical collar can be removed while patient is in
traction
Pin care: clean q shift with appropriate solution, then
apply povidone-iodine ointment
Take XRays at regular intervals and after every move
from bed
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Surgical Decompression and/or Fusion
Indications
Decompression of the neural elements (spinal cord/nerves)
Stabilization of the bony elements (spine)
Timing Emergent
Incomplete lesions with progressive neurologic deficit
Elective
Complete lesions (3-7 days post injury)
Central cord syndrome (2-3 weeks post injury)
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Long term care
Rehab for maximizing motor function
Bladder/bowel training
Psychological and social support
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THANK YOU!