Orthopaedics

1. Spinal Cord Injuries
Natangwe Shimhanda
12/11/2019

2. Overview
• Relevant Anatomy
• Facts/Definitions
• Mechanism and Classification
• Incomplete Spinal Cord Syndromes
• ASIA chart
• Management
• Steroids
• References

7. Dermatomes

8. Myotomes
• Segmental nerve root innervating a muscle
• Upper limb:
– C5 - Deltoid
– C6 – Wrist extensors
– C7- Elbow extensors
– C8 – long finger flexors
– T1- Small hand muscles

9. • Lower Limbs:
– L2 – hip flexors
– L3,4 – Knee Extensors
– L4,5-S1 – Knee Flexion
– L5- Ankle Dorsiflexion
– S1- Ankle Plantar Flexion

10. Facts
• Men 85% > women 15%
• TRAUMA (US)= MVA (40%), Violence (22%), Falls
(22%), Sports (8%)
• Non-trauma = malignancy, infection (TB, epidural
abscess), vascular
• Cord Injuries: Cervical = 60%, Thoracic = 30%,
lumbar = 4%, and Sacral = 2%

11. Demographics
• Bimodal distribution
– young individuals with significant trauma
– older individuals that have minor trauma compounded by
degenerative spinal canal narrowing
• It is estimated that 3-25% of all spinal cord injuries occur after
initial traumatic episode due to improper immobilization and
transport.

12. Pathophysiology
• primary injury
– damage to neural tissue due to direct trauma
(usually irreversible)
• secondary injury
– injury to adjacent tissue due to decreased
perfusion
– lipid peroxidation
– free radical / cytokines
– cell apoptosis

13. Spinal Cord Injury
• Spinal shock - transient loss of function below
the level of injury (rarely lasts for more than
48 hours)
• Neurogenic Shock - functional
sympathomectomy, ↓BP & ↓HR (not
responsive to IVH)

14. Classification
• Complete: Absence of sensory & Motor function in lowest
sacral segments after resolution of spinal shock
• Incomplete (preservation of any sensory or motor function –
esp. sacral sparing = big toe flexion, perianal sensation and
bulbocavernosus reflex)

15. Types Of Incomplete Injuries
• Central Cord Syndrome -
hyperextension
• Anterior Cord Syndrome –
flexion/rotation
• Brown-Séquard Syndrome – knife in
the back
• Posterior Cord Syndrome – rare.
Hyperextension/knife
• Cord Concussion = full resolution
within 48hrs

16. Central cord Syndrome
• Hyperextension
• Common in elderly with
preexisting Spondylosis
and cervical stenosis
• Motor: Arm > Leg
weakness
• Sensory: Arms>Legs
• Reflexes: may vary
• Usually sacral sensory
sparing

18. Anterior Cord Syndrome
• Anterior spinal artery
compressed by bone
fragments
• Primarily affects motor
– paralysis
(corticospinal tracts)
• Rarely involves dorsal
columns
• Can occur with AAA

20. Hyperflexion
Injuries
Oedema posteriorly.
Ruptured ligamentum flavum
and interspinous ligament.

21. Brown-Séquard

22. All ROUTES Lead to the Thalamus

23. • Penetrating Injuries or rotational or
fracture/dislocation
• Ipsilateral motor loss (corticospinal) &
proprioception
• Contralateral sensory (pain/temp) loss
(spinothalamic)

24. Posterior Cord Syndrome
• Rare
• Loss of proprioception
and vibration
• Good prognosis
• Penetrating back
trauma or
hyperextension – with
# vertebral arch

25. Cauda Equina Syndrome
• Not a cord syndrome. Technically a LMN lesion.
• LMN lesion = loss of knee reflexes. Leg weakness
• Bladder/bowel dysfunction
• Loss of anal tone
• Sexual dysfunction

26. • SCIWORA
– (spinal cord injury without radiological
abnormality)
• Dx = no bony or ligamentous injury on x-ray or
CT
– With MRI real “SCIWORA” is rare.
– There is usually cord/ligament injury on MRI
– More common in children – spine more flexible
and less likely to #
– Typically in the cervical region

27. Examination
• Primary survey first
• Cord and vertebral injuries will be picked up on 2° survey
• Head – toe approach
• Look – head, neck, mouth (prevertebral haematoma), paradoxical breathing, lap
seatbelt sign, gross deformity, priapism usually reflects a complete cord injury,
bilateral horner’s syndrome (>T1 and sometimes >T4)
• Feel – feel along the midline of the neck – feeling for deformity and areas of
maximal tenderness. Log Roll
• Examine each modality separately. Head – neck – upper limbs – torso – lower
limbs
• Motor – grading /5
• Sensory – soft touch (dorsal columns) and pain (spinothalamic). ?just pain?
• Reflexes – especially anal tone
• Documentation….

29. ASIA

30. Diagnostics
• XRAY (appropriate views)
• Myelography
• CT Scan
• MRI

31. Xrays
40 years old man with hx of
falling into a +/- 40m well,
Presented with no motor
activity below Knees,
Sensation is Intact but
reduced below the knees
as well

33. 34 years male involved in an MVA, driver
unrestrained, presented with backpain.
O/E: no neurological fall out but there
was swelling and tendernerness around
L1

38. Initial Management
• Steroids (controversial)
• Neck Immobilization Collar
• Back Immobilization with back support
• Traction with weights and pulleys

39. Cochrane 2012
• Found that methylprednisolone within 8 hrs gave a
significant recovery of motor function
• Contraindications: heavily contaminated wounds,
bowel perforation , sepsis
• Considerations: Type 2 DM, peptic ulcer risk

40. Surgical Management
• Surgical Decompression
• Fixation/ stabilization with a steel rod
• External Immobilization with a brace/cast

41. Complications
• Immediate:
– Respiratory arrest
– Spinal shock
• Long term:
– Auttonomic dysreflexia
– Contractures

42. References
• Louis Solomon et al, 2010, Apley’s System of Orthopaedics
and fratures. 9th edition. Hodder Education
• Derek Moore, 2006. Spinal Cord Injuries. Updated:
8/9/2019.
https://www.orthobullets.com/spine/2006/spinal-cord-
injuries
• Members of the Orthopaedic Department at Oshakati State
Hospital, 2018. Intern Doctors Handbook by Orthopaedic
Department at IHO
• Bracken M, 2012. Steroids for Acute Spinal cord Injury.
Cochrane Review.
https://www.cochrane.org/CD001046/INJ_steroids-acute-
spinal-cord-injury