Spinal cord InjuriesStephan!du!Plessis!MDUniversity!of!Calgary!Spine!Program

April!2009

Incidence

! Varies!from!29!" 50!per!million!population!per!year!in!USA!to!9!per!million!population!per!year!in!Denmark.

! Alberta!40!" 50!cases!per!year! Peak!Incidence!for!males!is!at!20!"24!y! Peak!Incidence!for!females!is!at!25!" 29y! Second!peak!for!males!is!at!35!" 44!y! Male:!Female!=!4!:1

Causes

! MVC!=!45%! Falls!=!22%! Sports!=!14%! Violence!related!=!14%

ASIA Impairment Scale

! ASIA!A!=!No!motor!or!sensory!function!is!preserved!in!!!!the!sacral!segments!S4!and!S5.

! ASIA!B!=!Sensory!but!no!motor!function!is!preserved!below!the!neurological!level!and!extends!through!the!sacral!segments!S4!and!S5.

! ASIA!C!=!Motor!function!is!preserved!below!the!neurological!level,!and!the!majority!of!key!muscle!function!is!less!than!grade!3

! ASIA!D!=!Motor!function!is!preserved!below!the!neurological!level,!and!the!majority!of!key!muscle!function!is!greater!than!grade!3

! ASIA!E!=!Intact

Level of Injury

! The!neurological!level" is!the!most!caudal!segment!of!the!spinal!cord!with!normal!sensory!and!motor!function!on!both!sides!of!the!body.

! Zone!of!partial!preservation" is!defined!as!encompassing!those!dermatomes!and!myotomes!caudal!to!the!neurological!level!that!remain!partly!innervated!in!complete!injuries.

! Skeletal!level!of!an!injury!is!defined!as!the!level!of!greatest!vertebral!damage!on!radiology,!and!may!be!similar!or!may!differ!by!one!or!more!segments.

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Types of Neural Spinal Injuries! Complete!Injuries! Incomplete!Injuries! Conus!Injuries! Cauda!Equina!Injuries! Transient!Injuries

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Complete Spinal Cord Injury! Spinal!cord!injury!with!total!loss!of!all!modalities!of!spinal!function." Motor!function" Sensory!function" Autonomic!function

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Incomplete Spinal Cord Injury! Cervico"medullary!syndrome! Central!Cord!Syndrome! Anterior!Cord!Syndrome! Posterior!Cord!Syndrome! Brown!Sequard!Syndrome

Cervico-Medullary Syndrome! Cruciate!Paralysis:" Site!of!lesion:!Lower!medulla!and!upper!cervical!cord,!involving!the!corticospinal!tract!decussation!caudal!to!the!pyramids.

" Arms!weaker!than!legs,!flaccid!arms!acutely,!legs!normal!or!weak,!UMNL!develops!in!upper!limbs.

" May!have!Trigeminal!nerve!involvement

Central Cord Syndrome

! Traumatic!Central!Cord!Syndrome" Site!of!Lesion:!Mid!to!lower!cervical!Cord,!involves!the!anterior!horn!cells!and!medial!part!of!the!lateral!corticospinal!tract.

" Arms!weaker!than!legs,!flaccid!arms!acutely,!legs!normal!or!weak,!LMNL!deficits!percists!in!the!upper!limbs.

Anterior Cord Syndrome

! Ventral!cord!syndrome" Distribution!of!the!anterior!spinal!artery" Complete!paralysis!with!loss!of!spinothalamic!tract!sensation!(pain!and!temperature)!with!preservation!of!dorsal!column!sensation,!intact!position!and!vibration!sense

Posterior Cord Syndrome

! Loss!of!corticospinal!tract!function!and!loss!of!dorsal!column!sensation!with!preservation!of!spinothalamic!tract!function

! Relatively!rare

Brown-Sequard Syndrome

! Hemi"section!of!cord!syndrome" Ipsilateral!motor!weakness,!ipsilateral!dorsal!column!and!contra!lateral!spinothalamic!loss!of!function

" Ipsilateral!loss!of!spinothalamic!function!at!level

Conus Medularis Syndrome

! Combination!of!LMNL!with!initial!flaccid!paralysis!of!!legs!and!anal!sphincter!followed!by!muscle!atrophy!!and!some!spasticity!and!hyperreflexia.

! Variable!sensory!picture!can!demonstrate!sacral!sparing!

Cauda Equina Injury ! LMNL!affecting!motor!function,!sensation!with!involvement!of!bowel!and!bladder.!

! Could!present!with!partial!or!complete!sparing!of!lumbar!roots!and!S1!roots.!

Spinal Shock

! The!neurogenic!shock! Loss!of!somatic!motor,!sensory,!and!sympathetic!autonomic!function!due!to!spinal!cord!injury.

! Degree!is!directly!related!to!the!severity!of!the!injury,!the!level!of!the!injury.!Thus!most!severe!in!complete!upper!cervical!spine!injuries.

! The!reflex!and!autonomic!components!of!neurogenic!shock!may!last!for!days!and!even!months.

! The!motor!and!sensory!deficits!detected!after!1!hour!of!the!injury!is!as!a!result!of!physical!cord!injury!and!not!because!of!spinal!shock.

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Spinal Shock! Somatic!motor!component!of!spinal!shock!consists!of!

paralysis,!flaccidity,!and!areflexia!with!respect!to!deep!tendon!reflexes!and!cutaneous!reflexes.

! Sensory!component!is!anesthesia!to!all!sensory!modalities.! Autonomic!component!is!systemic!hypotension,!skin!

hyperemia!and!bradycardia!due!to!sudden!loss!of!sympathetic!function!and!unopposed!parasympathetic!input.

Transient Spinal Syndromes! "Burning!Hands"!Syndrome! Spinal!Cord!Concussion

"Burning Hands" Syndrome

! Usually!seen!in!athletes,!characterized!by!transient!paresthesias!and!dysesthesias!in!the!upper!limbs!usually!the!hands.!May!have!long!tract!signs.

! These!symptoms!are!usually!bilateral!but!if!unilateral!think!root!or!plexus!neuropraxia.

! Could!be!associated!with!congenitally!narrow!canal,!ligamentous!instability,!disc!disease!and!intramedullary!pathology.

! Sometimes!also!described!as!"stingers"!or!"burners".

Spinal Cord Concussion

! Transient!loss!of!motor!and!or!sensory!function!of!the!spinal!cord!that!usually!recovers!within!minutes!but!always!within!hours.

! Clinically!patients!present!with!rapidly!improving!neurological!history!and!findings!on!exam!are!often!normal.

! Pathophysiology!is!not!exactly!known!but!appears!to!be!biochemical!in!nature!with!massive!outflow!of!potassium!from!intracellular!to!extracellular.!Then!ATP!pump!mechanism!is!overwhelmed!and!takes!time!to!catch!up

No Radiological abnormality! Objective!and!or!subjective!neurological!evidence" Sciwora" Sciworet

SCIWORA

! Spinal!Cord!Injury!without!Radiological!Abnormality! Term!used!in!children!and!includes!non!trauma!causes! SCIWORET! Spinal!Cord!Injury!without!Radiological!Evidence!of!Trauma

! Term!used!in!adults! Occurs!in:!Cervical!spondylosis!with!spinal!stenosis!

SCIWORET

! Spinal!Cord!Injury!without!Radiological!Evidence!of!Trauma

! Term!used!in!adults! Occurs!in:!Cervical!spondylosis!with!spinal!stenosis!