spinal cord injury with medical and surgical management

1. SPINAL CORD INJURY
SAYALI GUJJEWAR
MPT II

2. SPINAL CORD
• The spinal cord is a long cylindrical lower part of the central nervous system.
• Occupies upper two-third of the vertebral canal and is enclosed in meninges.
• Gives rise to 31 pairs of spinal nerves.
• 45 cm in adult male and 42 cm in adult female.
• Extends from upper border of atlas vertebra to lower border of first lumbar vertebra in adult and in children
upto third lumbar vertebra.
• Superiorly, it is continuous with medulla oblongata, inferiorly it terminates as conus medullaris.
• The spinal cord are protected by three membranous coverings called the meninges (dura mater, arachnoid
mater and pia mater).
• Below the level of conus medullaris only pia matter continues as a thin fibrous cord, the filum terminale (20 cm
long).

4. BLOOD SUPPLY OF SPINAL CORD
Anterior spinal artery
• Formed by the union of 2 arteries
• From vertebral artery
• Supply anterior ⅔ of spinal cord
Posterior spinal arteries
• Arise from vertebral artery or posterior
inferior cerebellar arteries (PICA)
• Descend close to the posterior roots
• Supply posterior ⅓ of spinal cord
Segmental spinal arteries

5. INTRODUCTION
•Spinal cord injury (SCI) is damage to the spinal cord that results in a loss of function.
•Men > women
•TRAUMATIC: MVA , Violence , Falls , Sports –diving, horseriding
•NON-TRAUMATIC: malignancy, infection (TB, epidural abscess), vascular (x-clamping aorta)
•Cord Injuries: Cervical = 60%, Thoracic = 30%, lumbar = 4%, and Sacral = 2%
•Most common at C5,6,7 due to greatest mobility at these levels.
•Most common vertebrae involved are C5, C6, C7, T12, and L1 because they have the greatest ROM.
•Caused by:
•Cutting, compression, or stretching of the spinal cord: Causing loss of distal function, sensation, or motion
•Unstable or sharp bony fragments pushing on the cord
•Pressure from bone fragments or swelling that interrupts the blood supply to the cord causing ischemia.

6. CAUSES
•Bullet or stab wound
•Traumatic injury
•Electric shock
•Extreme twisting of the middle of the body
•Landing on the head during a sports injury
•Fall from a great height

7. RISK FACTORS
•Alcohol intoxication
•Drug abuse
•Participation in high-risk activities:
•Diving
•Contact sports
•Osteoporosis
•Degenerative Disease Of Spine
•Spinal Canal Stenosis
•Ankylosing Spondylitis
•Down's Syndrome
•Klippel-feilSyndrome
•Arnold-chiariMalformation
•Metastatic CA
•Osteomyelitis
•Rheumatoid Arthritis

8. MECHANISMS
Distraction – in hyperextension (eg.
Hanging), significant impact on the
head or face.
Compression of the bony spine –
directly compromise the spinal canal
and spinal cord.
Torsion – falls, high energy vehicle
collisions – can tear the spinal cord
tissue.
Penetration – in gun shot or stab injury

9. HYPEREXTENSION INJURY

10. HYPERFLEXION INJURIES

11. SCIWORA (SPINAL CORD INJURY WITHOUT
RADIOGRAPHIC ABNORMALITY)
•More common in children and is presumably the result of temporary
hyperdistraction or torsion of the neck insufficient to disrupt the bony skeleton.
•Incidence 3-5% (x-ray/CT)
•Higher incidence above 60 yo - Posterior vertebral spurs due to spondylosis.
Ligamentum flavum bulging due to loss of disc height. Risk of central cord
syndrome after hyperextension injury.

12. PRIMARY INJURY
•25% of spinal cord injuries occur after primary injury.
•Primary injury results from focal injuries (eg: avulsion, contusion, laceration and
intra-parenchymal hemorrhage) and diffuse lesions (e.g. concussive and diffuse
axonal injury).
•Further mechanical disruption can result from external compression or
angulation and ischemic damage from occlusion of arterial supply.

13. SECONDARY INJURY
•Immediately after an acute spinal cord injury major reduction in blood flow occurs at the
level of the lesion.
•Becomes progressively worse over the first few hours if left untreated.
•Pathophysiology underlying this ischaemia is unclear but involves both systemic and local
effects.
•Putative local mechanisms include vasospasm, endothelial swelling or damage,
haemorrhage causing obstruction of small blood vessels, loss of autoregulation and
impaired venous drainage.
•Results from:
•Cellular hypoxia
•Oligaemia

14. PATHOPHYSIOLOGY

15. TYPES OF SPINAL CORD INJURY
COMPLETE SPINAL CORD INJURIES
•Total motor & sensory loss distal to the injury after Spinal shock
(usually lasts for 24-48hrs) is over.
•When the bulbocavernosus reflex is positive & no sacral sensation or
motor function has returned, paralysis will be permanent & complete
in most patients.
INCOMPLETE SPINAL CORD INJURIES
•Some motor or sensory functions is spared distal to the cord injury.
•Voluntary sphincter contraction, toe flexor contraction–present.
•Prognosis-Good

16. PATTERNS OF MULTIPLE SPINAL INJURY :
Pattern: A. Primary lesion occur between C5 & C7 with secondary injuries at T12 or the lumber
spine.
Pattern: B. Primary injury at T2-T4 with secondary injury in cervical spine.
Pattern: C. Primary injury occur between T12 & L2 with secondary injuries from L4-L5.

17. SPINAL CORD INJURY SYNDROMES
•ANTERIOR CORD SYNDROME
•CENTRAL CORD SYNDROME
•POSTERIOR CORD SYNDROME
•BROWN-SEQUARD SYNDROME
•CAUDA EQUINA SYNDROME

18. ANTERIOR CORD SYNDROME
•Due to ischemia (eg. aortic injury) – blood
supply from anterior spinal artery is
distrupted (anterior spinal artery
compressed by bone fragments).
•Damage to cortico-spinal and spinothalamic
tracts – paralysis, abnormal touch, pain and
temperature sensation.
•Posterior columns unaffected – vibration
and joint position senses preserved.
•Flexion/rotation injury

19. CENTRAL CORD SYNDROME
•Central gray matter is damaged.
•Bladder dysfunction – present as
urinary retention.
•Hyperextension injury
•Motor: Arm > Leg weakness
•Sensory: Arms>Legs
•Usually sacral sensory sparing

20. POSTERIOR CORD SYNDROME
•Rare
•Loss of proprioception and vibration
•Good prognosis
•Penetrating back trauma or
hyperextension injury.

21. BROWN-SEQUARD SYNDROME
•Hemisection of the cord
•Usually in penetrating trauma, Knife in
back or rotational or
fracture/dislocation.
•Ipsilateral paralysis and loss of
vibration and joint position sense, with
contralateral loss of pain and
temperature sensation.
•Rare

22. CAUDA EQUINA SYNDROME
•Presents with loss of bowel and baldder function with LMN signs on lower limbs.
•Sensory signs – unpredictable.
•Not a cord syndrome. Technically a LMN lesion.
•Saddle anaesthesia
•Loss of anal tone
•Sexual dysfunction

23. Cruciate Paralysis of Bell
•Odontoid rams into the cord
•Paralysis of one arm and the opposite leg
Conus Medullaris Syndrome
•May have some UMN signs (increased tone and hyperreflexia)

24. SIGNS AND SYMPTOMS
AIRWAY:
•Airway reflexes are lost and gastric stasis – can have aspiration.
BREATHING:
•Above C4 – diaphragm is paralysed – apnea.
•T2-T12 – innervates intercostal muscles – fractures above – diaphragmatic
breathing – limited expansion, decreased TV and FRC, impaired cough, inc RV.
•Decreased muscle power – pneumonia is common.
•ARDS and pulmonary emboli also occur

25. CIRCULATION:
•Damage above T2 – sympathetic innervation of heart lost – loss of reflex, tachycardia,
impaired LV function and risk of severe bradycardia and asystole following unopposed vagal
stimulation.
NEUROLOGICAL:
•Spinal shock – flaccidity and areflexia – duration is variable.
•Following a/c phase of spinal shock – majority of patients with lesion above T7 – autonomic
dysreflexia (mass spinal reflex when area below the lesion is stimulated)
•Develops severe bradycardia, hypertension, flushing and sweating above the lesion –
triggered by distended bladder or bowel, pressure sores etc

26. TEMPERATURE:
•Hypothermia due to peripheral vasodialatation.
BIOCHEMICAL AND ENDOCRINE:
•Increased ADH – water retention
•Glucose intolerance
•NG tube – hypokalemic metabolic alkalosis
•Hypoventilation – respiratory acidosis
•Osteoporosis and hypercalcemia

27. SKIN – pressure sores
THROMBOELASTOGRAM – DVT and embolism.
MUSCULOSKELETAL – muscle spasms and contractures.
PSYCHOLOGICAL – reactive depression

28. DIAGNOSTIC TESTS
•Complete blood count (e.g. Hb, RBC, WBC)
•Arterial blood gas level
PaO2:85-95 mm of Hg
PaCO2:35-45 mm of Hg
•X- RAYS
•COMPUTERIZED TOMOGRAPHY (CT) SCANS
•MAGNETIC RESONANCE IMAGING (MRI)
•MYELOGRAPHY

29. COMPLICATIONS
•Blood pressure changes - can be extreme (autonomic
hyperreflexia)
•Chronic kidney disease
•Complications of immobility: Deep vein thrombosis,
Pulmonary infections, Skin breakdown, Contractures
•Increased risk of urinary tract infections
•Loss of bladder control
•Osteoporosis and Fractures
•Heterotopic Ossification
•Cardiovascular disease
•Shock
•Syringomyelia-
•Neuropathic/Spinal Cord Pain
•Pokilothermia in patients with lesion above T1
•Hyponatraemia common in first week.
•Loss of bowel control
•Loss of sensation
•Loss of sexual functioning (male impotence)
•Muscle spasticity
•Paralysis of breathing muscles
•Paralysis (paraplegia, quadriplegia)
•Pressure sores

30. MANAGEMENT:
Primary(Pre-hospital) management-
Initial treatment of patients with cord injury focuses on
two aspects -preventing further damage and
resuscitation.
Immobilization with a hard cervical collar (in case of
cervical spine injuries) and care in transportation of
patient is of paramount importance if the spine is
unstable.
Resuscitation is aimed at airway maintenance, adequate
oxygen saturation of peripheral blood, restoring blood
pressure to acceptable limits, preventing bradycardia,
done simultaneously to prevent any ischemic damage to
the already compromised cord.
Secondary (Hospital) Management:
Medical Management
Conservative (General)-
Conservative (Medical)-
Surgical Management
Surgical Decompression
Surgical Stabilization
Fixation of Vertebra
Fixation of Spine
Artificial disc implantation Spinal

31. Conservative(General)-
Immediate Management-
Goals
•Resuscitation according to ATLS guidelines
•Determination of neurological injury
•Prevention of neurological deterioration
•Ongoing ID & Tx of associated injuries
•Prevention of complications
•Initiation of definitive management for vertebral
column injury or SCI
Conservative(Medical)
•Epidural Steroid Injection
•Intradiscal thermoplasty(IDET)
•Nucleoplasty
•Facet Injections, and/or Medial Branch Blockade
•Radio Frequency Rhizotomy or Denervation

32. Surgical
•Surgical Decompression
•Surgical Stabilization
•Spinal fusion
•Fixation of Vertebra
•Fixation of Spine
•Discectomy, foramenotomy and laminectomy (Some times needed).
•Artificial disc implantation.