REVIEW OF ANATOMY, PATHOPHYSIOLOGY, MECHANISM ,VARIOUS SYNDROMES OF SPINAL CORD INJURY

2.  Partial or complete disruption of spinal cord
resulting in paralysis, sensory loss, altered
autonomic and reflex activities.

4.  CNS: Brain & spinal cord
 Base of the skull ( foramen
magnum) to lower margin of
the L1 vertebral body as conus
medullaris.
 Cauda equina:
 Below L1
 Lumbar, Sacral & Coccygeal spinal
nerves
 Filum terminale

5. Two enlargements:
 Cervical:
C3 to T1 segments
innervates arm
via brachial plexuses
 Lumbar:
L1 to S3 segments
innervates leg
via lumbosacral plexuses

6.  3 layers:
› Pia
› Arachnoid
› Dura matter

7. Segments: (31)
Cervical - C1- C8
Thoracic - T1- T12
Lumbar - L1- L5
Sacral - S1- S5
Coccygeal - 1
pair of spinal nerves
(mixed)
 ventral (motor)
 dorsal (sensory)

9.  1 anterior and 2 posterior
spinal arteries which arise
from the vertebral arteries.
 Various radicular arteries
branch off the thoracic and
abdominal aorta to provide
collateral flow.
 Venous drainage is usually by
3 anterior and 3 posterior
spinal veins.
 Spinal veins join the veins
draining the vertebral bodies
to form the internal vertebral
venous plexus.

11.  Spinal cord injury is a mortal condition and has been recognised as such since antiquity.
 Spinal cord injuries cause previously normal people to become handicapped. Furthermore,
most common affected age group being 20-29 signifying higher incidence in young, active
and productive population of the society.
 In India, fall from height is the leading cause for spinal cord insult. Road traffic accident is
the commonest cause in the younger age group i.e. 18-<25 years.
 Traumatic lesions are common in men and non-traumatic lesions are common in women.
 Majority of the cases are illiterate, poor villagers who are involved in high risk jobs.
 Lumbar level (T 10 and below) is the commonest level of lesion in individuals with
paraplegia.

13.  Tetraplegia refers to complete paralysis of all
four extremities and trunk, including the
respiratory muscles and resulting from
lesions of the cervical cord.
 Paraplegia refers to complete paralysis of all
or part of the trunk and both lower
extremities, resulting from lesions of the
thoracic or lumbar spinal cord or cauda
equina.

15.  COMPLETE INJURY- Having no sensory/
motor function in lowest sacral segments(S4-
S5).
Sensory function- anal sensations
Motor function- voluntary anal sphincter
contraction
 INCOMPLETE INJURY- Having motor/
sensory function below the neurological level
of lesion including sensory and/or motor
function at S4-S5.

17. ASIA Impairment Scale
Type of Injury Description
A=Complete
No motor or sensory function is preserved in the sacral
segments S4-S5.
B=Incomplete
Sensory but not motor function is preserved below the
neurological level and includes the sacral segment S4-S5.
C=Incomplete
Motor function is preserved below the neurological level, and
more than half of key muscles below the neurological level
have a muscle grade less than 3. Sensory function is
present below the neurological level and includes sacral
segments S4-S5.
D=Incomplete
Motor function is preserved below the neurological level, and
at least half of key muscles below the neurological level
have a muscle grade of 3 or more. Sensory function is
present below the neurological level and includes sacral
segments S4-S5.
E=Normal Motor and sensory function is normal

19.  Spinal cord transection and spinal shock:
 Immediately following SCI, there is a period of
areflexia- SPINAL SHOCK
 Transient reflex depression- not clearly
understood
 Withdrawal of connections between higher centers
and spinal cord
 Clinical features- Areflexia, flaccidity, loss of
sensory and motor function below the level of
lesion
 Lasts for days to weeks
 First reflex to suggest withdrawal from spinal
shock- Bulbocavernous reflex

20. Complete Cord Transection Syndrome:
 Complete cord transection syndrome results in
complete loss of all sensibility and voluntary movement
below the level of the lesion.
 Clinical features:
1. Bilateral lower motor neuron paralysis and muscular
atrophy in the segment of the lesion.
2. Bilateral spastic paralysis below the level of the lesion.
 A bilateral Babinski sign is present, and
 depending on the level of the segment of the spinal
cord damaged, bilateral loss of the superficial
abdominal and cremaster reflexes occurs.

21. 4. Bilateral loss of all sensations below the level of the
lesion. The loss of tactile discrimination and vibratory
and proprioceptive sensations is due to bilateral
destruction of the ascending tracts in the posterior white
columns. The loss of pain, temperature, and light touch
sensations is caused by section of the lateral and
anterior spinothalamic tracts on both sides.
5. Bladder and bowel functions are no longer under
voluntary control, since all the descending autonomic
fibers have been destroyed.

22. Anterior cord syndrome
 Clinical features:
1. Bilateral lower motor neuron paralysis in the segment
of the lesion and muscular atrophy.
2. Bilateral spastic paralysis below the level of the
lesion. The bilateral paralysis is caused by the
interruption of the anterior corticospinal tracts on both
sides of the cord.
3. Bilateral loss of pain, temperature, and light touch
sensations below the level of the lesion. These signs
are caused by interruption of the anterior and lateral
spinothalamic tracts on both sides.
4. Tactile discrimination and vibratory and
proprioceptive sensations are preserved because the
posterior white columns on both sides are
undamaged.

24. POSTERIOR CORD SYNDROME
 It is an extremely rare syndrome resulting in deficits of function
served by the posterior cord. This was seen in tebes dorsalis, a
condition found in late stage of siphylis.
 Clinical features:
 Preservation of motor function, sense of pain and light touch
 Loss of proprioception and epicretic sensation (two point
discrimination, graphesthesia, stereognosis) below the level of
lesion
 A wide base step gait

26. Central Cord Syndrome
 It is most often caused by hyperextension of the cervical region of
the spine.
 Clinical features:
 Bilateral lower motor neuron paralysis in the segment of the
lesion and muscular atrophy.
 Bilateral spastic paralysis below the level of the lesion with
characteristic sacral “sparing.”
 The lower limb fibers are affected less than the upper limb
fibers because the descending fibers in the lateral corticospinal
tracts are laminated, with the upper limb fibers located medially
and the lower limb fibers located laterally.

28.  Bilateral loss of pain, temperature, light touch, and
pressure sensations below the level of the lesion
with characteristic sacral “sparing.”
 The sparing of the lower part of the body may be
evidenced by (1) the presence of perianal
sensation, (2) good anal sphincter tone, and (3)
the ability to move the toes slightly.

29. Brown-Sequard Syndrome or Hemisection of the Cord:
 Incomplete hemisection is common; complete
hemisection is rare.
 Clinical features:
 Ipsilateral lower motor neuron paralysis in the segment of
the lesion and muscular atrophy. These signs are caused
by damage to the neurons on the anterior gray column
and possibly by damage to the nerve roots of the same
segment.

31.  Ipsilateral spastic paralysis below the level of the lesion. An
ipsilateral Babinski sign is present, and depending on the
segment of the cord damaged, an ipsilateral loss of the
superficial abdominal reflexes and cremasteric reflex occurs.
All these signs are due to loss of the corticospinal tracts on
the side of the lesion.
 Ipsilateral loss of tactile discrimination and of vibratory and
proprioceptive sensations below the level of the lesion. These
signs are caused by destruction of the ascending tracts in the
posterior white column on the same side of the lesion.

32.  Contralateral loss of pain and temperature
sensations below the level of the lesion. This is
due to destruction of the crossed lateral
spinothalamic tracts on the same side of the
lesion. Because the tracts cross obliquely, the
sensory loss occurs two or three segments
below the lesion distally.

34.  M:F = 3:1
 Age: > 50% of SCI occur in – age between16-30
years
Traumatic SCI is more common in <40 years,
Non-traumatic SCI is more common in > 40
years
 Only about 5% of spinal cord injuries occur in
children, but usually complete injury.
 Incidence: 30-60 cases / million population / year.

35.  Common causes of SCI :
Motor vehicle accidents (44.5%)
Falls (18.1%) especially in persons aged 45
years or older
Violence (16.6%)
Sports injuries (12.7%)
 Other causes :
Vascular disorders
Tumors
Infectious conditions
Spondylosis
Iatrogenic injuries, especially after spinal
injections and epidural catheter placement
Vertebral fractures secondary to osteoporosis
Developmental disorders

36.  Level and type of injury:
The most common levels are C4, C5 and C6
then thoracolumbar junction T12
 July, Saturday

37.  Injuries by ASIA classification
Incomplete tetraplegia - 29.5%
Complete paraplegia - 27.9%
Incomplete paraplegia - 21.3%
Complete tetraplegia - 18.5%
 Leading cause of death in patients following SCI :
- pneumonia and other respiratory conditions,
- bed sore
- by heart disease, subsequent trauma, and
septicemia

39.  Common mechanism of injury are;
 Flexion
 Compression
 Hyperextension
 Flexion-rotation