The document provides an overview of incomplete spinal cord injuries. Some key points: - Spinal cord injuries can range from complete to incomplete, depending on the severity and location of the lesion in the spinal cord. Incomplete injuries result in partial preservation of motor or sensory function below the injury level. - The American Spinal Injury Association (ASIA) scoring system is used to clinically classify spinal cord injuries based on motor and sensory function. Injuries are classified on a scale from A (complete injury) to D (near normal function). - Recovery from incomplete injuries is possible, though most occurs within the first year as spontaneous recovery plateaus. Sensory preservation is a predictor of potential motor recovery.

1. Incomplete spinal cord
injury
Aditya Johan Romadhon

2. Introduction
• Traumatic spinal cord injury (SCI) is a life changing neurological condition with
substantial socioeconomic implications for patients and their care-givers
• The clinical outcomes of SCI depend on the severity and location of the lesion
and may include partial or complete loss of sensory and/or motor function
below the level of injury
• Etiologically, more than 90% of SCI cases are traumatic and caused by
incidences such as traffic accidents, violence, sports or falls
• SCI typically affects the cervical level of the spinal cord (50%) with the single
most common level affected being C5
• Other injuries include the thoracic level (35%) and lumbar region (11%)

3. “displaced bone
fragments, disc
materials, and/or
ligaments bruise or
tear into the spinal
cord tissue”
The initial
mechanical forces
delivered to the
spinal cord at the
time of injury is
known as primary
injury
SCI commonly
results from a
sudden, traumatic
impact on the
spine that fractures
or dislocates
vertebrae
The life expectancy
of SCI patients
highly depends on
the level of injury
and preserved
functions

4. Characteristic
Four main
characteristic
mechanisms of
primary injury have
been identifified
Impact plus persistent
compression
Impact alone with
transient compression
Distraction
Laceration/transection

5. The most common form of
primary injury is impact plus
persistent compression, which
typically occurs through burst
fractures with bone fragments
compressing the spinal cord
Impact alone with transient
compression is observed less
frequently but most
commonly in hyperextension
injuries
Distraction injuries occur
when two adjacent vertebrae
are pulled apart causing the
spinal column to stretch and
tear in the axial plane
Lastly, laceration and
transection injuries can occur
through missile injuries,
severe dislocations, or sharp
bone fragment dislocations

6. ionic imbalance and neurotransmitter accumulation
Ischemia
vasospasm,
systemic hypotension
causing spinal shock
Disrupt blood vessels and cell membranes
The form of primary injury, these forces directly damage ascending and descending pathways in the spinal cord

7. To date, the most
effffective clinical
treatment to limit tissue
damage following
primary injury is the
early surgical
decompression (<24 h
post-injury) of the
injured spinal cord

8. Generally, SCI can be
classifified as either
complete or
incomplete
Complete SCI,
neurological
assessments show
no spared motor or
sensory function
below the level of
injury
The first
classifification
system, “Frankel
Grade,” was
developed by Frankel
and colleagues in
1969
The American Spinal
Injury Association
(ASIA) scoring system
is currently the most
widely accepted and
employed clinical
scoring system for
SCI

9. American Spinal Injury Association (ASIA) Scoring System
In this system, sensory function
is scored rom 0 to 2
(0 = absent, 1 = altered, 2=
normal)
And motor function from 0
to 5

10. Scoring System
The first step in ASIA
system is to identify
the neurological
level of injury (NLI)
Upon identifying the
NLI, if the injury is
complete (AIS = A),
“zone of partial
preservation” (ZPP)
is determined
ZPP is defifined as
all the segments
below the NLI that
have some
preserved sensory
or motor function
Complete loss of
motor and
preservation of
some sensory
functions below the
neurological level of
the injury is
categorized as AIS B
If motor function is
also partially spared
below the level of
the injury, AIS score
can be C or D
The AIS is scored D
when the majority of
the muscle groups
below the level of
the injury exhibit
strength level of 3 or
higher

12. As time passes, SCI patients experience some spontaneous recovery of motor and sensory functions
Most of the functional recovery occurs during the first 3 months and in most cases reaches a plateau by
9 months after injury
However, additional recovery may occur up to 12–18 months post-injury
Patients with incomplete paraplegia generally have a good prognosis in regaining locomotor ability
(∼76% of patients) within a year
Complete paraplegic patients, however, experience limited recovery of lower limb function if their NLI is
above T9
An NLI below T9 is associated with 38% chance of regaining some lower extremity function
In patients with complete paraplegia, the chance of recovery to an incomplete status is only 4% with
only half of these patients regaining bladder and bowel control

13. One proposed reason for
this association is that
pinprick fibers in lateral
spinothalamic tract travel in
proximity of motor fifibers in
the lateral corticospinal
tract, and thus, preservation
of sensory fifibers can be an
indicator of the integrity of
motor fifiber
Maintenance of pinprick
sensation at the zone of
partial preservation or in
sacral segments has been
shown as a reliable
predictor of motor recovery
An association between
sensory and motor recovery
has been demonstrated in
SCI where spontaneous
sensory recovery usually
follows the pattern of motor
recovery

14. Hypovolemia and hemodynamic shock in SCI patients due to excessive bleeding and
neurogenic shock result in compromised spinal cord perfusion and ischemia
Increased tissue pressure in edematous injured spinal cord and hemorrhage-induced
vasospasm in intact vessels further disrupts blood flow to the spinal cord
Vascular insult, hemorrhage and ischemia ultimately lead to cell death and tissue destruction
through multiple mechanisms, including oxygen deprivation, loss of adenosine triphosphate
(ATP), excitotoxicity, ionic imbalance, free radical formation, and necrotic cell death
Cellular necrosis and release of cytoplasmic content increase the extracellular level of
glutamate causing glutamate excitotoxicity (the main excitatory neurotransmitter in the CNS)

16. Severe acute spinal cord lesion there are two
clinical stages:
Spinal shock : loss of all reflex activity
below the level of lesion, flaccid limbs,
atonic bladder with incontinence, atonic
bowel, loss of genital reflexes and
vasomotor control
Heightened reflex activity : after 1-2 weeks
associated with spasticity of the limbs,
brisk reflexes and extensor plantar
response, spastic bladder and hyperactive
autonomic function (sweating)

17. The clinical feature
Below L1 level, the cauda equina will be affected and the patient will have LMN syndrome affecting the leg and
bladder
when it occurs above the level L1 causes spastic paraparesis or tetraparesis at high cervical level
Lesion above C5 cause UMN signs in the arms and legs
Lesion between C5 and T1 cause LMN and sometime UMN signs in the arm and UMN signs in the legs
Lesion affecting the cord below T1 will not involve the arms

18. The spinal cord extends from the top of the C1 vertebra to the bottom of the body of the L1

19. Medulla Spinal Collumn

20. Projectory Tracts

21. Somatotopic

22. Sensory Pathways

24. Sensory Input

25. A dermatome is an area of skin that is
mainly supplied by a single spinal nerve

26. Motor Pathways

27. Myotome
The anatomical
term myotome refers to the
muscles served by a spinal
nerve root (a set of muscles
innervated by a specific, single
spinal nerve)

28. Autonomic Nerve System

30. The Clinical Syndrome of Spinal Cord Disease
Paresis is the correct term to describe incomplete paralysis, Plegia means complete paralysis and Palsy used when the paralysis affects cranial motor
nerve (bell’s palsy, pseudobulbar palsy) or a static weakness (cerebral palsy)
The words “plegia” “palsy” and “paresis” are sometimes used interchangeably to describe weakness
Paralysis is the complete loss of voluntary movement
Brown-Sequard syndrome (Unilateral lesion causing UMN involvement of one side)
Tetraparesis (UMN involvement of all four limbs)
Paraparesis (UMN involvement of legs only)
There are tree main motor syndromes associated with spinal cord disease

31. PARAPARESIS (SPASTIC PARAPARESIS OR PARAPLEGIA)
Paraparesis
indicates bilateral
UMN damage
involving the
axons that
innervate the legs
from both
corticospinal
tracts
The clinical signs
include :
Increased tone
with spasticity
Increased
reflexes with
clonus
Extensor plantar
response
(Babinski sign)
Sphincter
dysfunction

32. TETRAPARESIS (SPASTIC TETRAPARESIS, TETRAPLEGIA, QUADRIPARESIS,
QUADRIPLEGIA)
It is usually caused
by lesion in the
high cervical cord,
occasionally due to
brainstem
Spastic tetraparesis
produces the same
clinical picture as
paraparesis but
involves both arms
and legs

34. BROWN SEQUARD SYNDROME (UNILATERAL CORD LESION)
Brown Sequard syndrome
is rare in its pure form but
partial forms are more
common
Ipsilateral spastic leg and
sometimes arm if the
lesion above C5, with brisk
reflexes and an extensor
plantar response
Ipsilateral loss of joint
position sense and
vibration or touch (dorsal
column), contralateral loss
of pain and temperature
o Pain fibers ascend a few spinal segments before entering the dorsal horn
to synapse
o If the lesion damages the anterior horn cell as well as the white matter
tracts then the patient will have UMN signs below the level of the lesion
and LMN signs at and about the level of the lesion

36. A framework of Physiotherapy
Management
The overall purpose of
Physiotherapy for patients with
spinal cord injury is to improve
health related quality of life
By improving patient’s ability to
participate in activities of daily
life
The International Classification
of Functioning Disability and
Helath (ICF) can be used to
describe the process involved in
formulating a physiotherapy
programs

37. Step one : Assessing impairments, activity limitation and participation retrictions
Step two : Setting goal with respect to activity limitation and participation retrictions
Step three : Identifying key impairments
Step four : Indentifying and administering
treatments
Step five : Measuring
outcomes

38. Assessing impairements, functional limitations and
participation restrictions
Various sources need
to be used
Age, cause of injury,
time since injury,
neurological status,
orthopaedic status,
other injuries and
complications,
medical and surgical
management etc
Well accepted
assessment tool used
to measure functional
limitation and
parcitipation restriction
including :
Functional
Independence Measure
(FIM)
Spinal Cord
Independence
Measure
Quadriplegic Index of
Function
Specific assessment i.e
ability to walk 6
minutes walk test, TUG,
10m walk test

39. These goals should
be expressed in
term of
participation
restrictions (i.e
return to work or
school)
Sub domains of mobility,
self care and domestic
life
Goals should be
SMART (Specific,
Measurable,
Attainable,
Realistic and
Timebound)

40. Setting goals for patients with complete lesions

41. Once goals of treatment
are defined in term of
activity limitation and
participation restriction, it
is necessary to determine
which impairements
prevent the attainment of
each goal
Key impairement need to be linked to
specific activity limitation and
participation restriction
Anatomical and functional
limitation are different

42. C6 - tetraplegia sitting
Passive tension in the paralysed
hamstring muscle helps maintain
the trunk in upright position
Hamstring cannot prevent a
forward fall if they are highly
extensible

43. SEKIAN
&
TERIMAKASIH