Traumatic spinal cord injury, anatomy, clinical, etiology, classification, medical management and physical therapy rehabilitation.

1. Traumatic Spinal Cord Injury
(SCI)
Nishank Verma (PT)
MPT-Sports Medicine
1

2. 2

3. Gross Appearance of the Spinal Cord
• The spinal cord is roughly cylindrical in shape. It begins
superiorly at the foramen magnum in the skull, where
it is continuous with the medulla oblongata of the
brain, and it terminates inferiorly in the adult at the
level of the lower border of the first lumbar vertebra.
• In the young child, it is relatively longer and usually
ends at the upper border of the third lumbar vertebra.
Thus, it occupies the upper two-thirds of the vertebral
canal of the vertebral column and is surrounded by the
three meninges, the dura mater, the arachnoid mater,
and the pia mater.
3

4. • Further protection is provided by the cerebrospinal fluid, which
surrounds the spinal cord in the subarachnoid space.
• In the cervical region, where it gives origin to the brachial plexus,
and in the lower thoracic and lumbar regions, where it gives origin
to the lumbosacral plexus,the spinal cord is fusiformly enlarged; the
enlargements are referred to as the cervical and lumbar
enlargements.
• Inferiorly, the spinal cord tapers off into the conus medullaris, from
the apex of which a prolongation of the pia mater, the filum
terminale, descends to be attached to the posterior surface of the
coccyx.
• The cord possesses a deep longitudinal fissure called the anterior
median fissure in the midline anteriorly and a shallow furrow
called the posterior median sulcus on the posterior surface.
4

5. • Along the entire length of the spinal cord are
attached 31 pairs of spinal nerves by the anterior
or motor roots and the posterior or sensory
roots.
• Each root is attached to the cord by a series of
rootlets, which extend the whole length of the
corresponding segment of the cord.
• Each posterior nerve root possesses a posterior
root ganglion, the cells of which give rise to
peripheral and central nerve fibers.
5

6. 6

7. Structure Of The Spinal Cord
• The spinal cord is composed of an inner core of gray matter, which
is surrounded by an outer covering of white matter, there is no
indication that the cord is segmented.
Gray Matter
• On cross section, the gray matter is seen as an H-shaped pillar with
anterior and posterior gray columns, or horns, united by a thin
gray commissure containing the small central canal. A small lateral
gray column or horn is present in the thoracic and upper lumbar
segments of the cord.
• The amount of gray matter present at any given level of the spinal
cord is related to the amount of muscle innervated at that level.
Thus, its size is greatest within the cervical and lumbosacral
enlargements of the cord, which innervate the muscles of the upper
and lower limbs, respectively.
7

8. Structure
• As in other regions of the central nervous
system, the gray matter of the spinal cord
consists of a mixture of nerve cells and their
processes, neuroglia, and blood vessels.
• The nerve cells are multipolar, and the
neuroglia forms an intricate network around
the nerve cell bodies and their neurites.
8

9. Nerve Cell Groups in the Anterior Gray
Columns
• Most nerve cells are large and multipolar, and their
axons pass out in the anterior roots of the spinal
nerves as alpha efferents, which innervate skeletal
muscles.
• The smaller nerve cells are also multipolar, and the
axons of many of these pass out in the anterior roots of
the spinal nerves as gamma efferents, which innervate
the intrafusal muscle fibers of neuromuscular spindles.
• The nerve cells of the anterior gray column may be
divided into three basic groups or columns: medial,
central, and lateral.
9

10. Nerve Cell Groups in the Posterior Gray
Columns
• There are four nerve cell groups of the
posterior gray column:
• Two that extend throughout the length of the
cord and
• Two that are restricted to the thoracic and
lumbar segments.
10

11. • The substantia gelatinosa group is situated at the apex of
the posterior gray column throughout the length of the
spinal cord.
• The nucleus proprius is a group of large nerve cells
situated anterior to the substantia gelatinosa throughout
the spinal cord.
• The nucleus dorsalis (Clarke’s column) is a group of nerve
cells situated at the base of the posterior gray column and
extending from the eighth cervical segment caudally to the
third or fourth lumbar segment.
• The visceral afferent nucleus is a group of nerve cells of
medium size situated lateral to the nucleus dorsalis; it
extends from the first thoracic to the third lumbar segment
of the spinal cord.
11

12. Nerve Cell Groups in the Lateral Gray
Columns
• The intermediolateral group of cells form the
small lateral gray column, which extends from the
first thoracic to the second or third lumbar
segment of the spinal cord. The cells are
relatively small and give rise to preganglionic
sympathetic fibers.
• A similar group of cells found in the second, third,
and fourth sacral segments of the spinal cord give
rise to preganglionic parasympathetic fibers.
12

13. The Gray Commissure and Central
Canal
• In transverse sections of the spinal cord, the anterior
and posterior gray columns on each side are connected
by a transverse gray commissure; the gray matter
resembles the letter H. In the center of the gray
commissure is situated the central canal.
• The part of the gray commissure that is situated
posterior to the central canal is often referred to as the
posterior gray commissure; similarly the part that lies
anterior to the canal is called the anterior gray
commissure.
13

14. • The central canal is present throughout the spinal cord.
Superiorly, it is continuous with the central canal of the
caudal half of the medulla oblongata, and above this, it
opens into the cavity of the fourth ventricle.
• Inferiorly in the conus medullaris, it expands into the
fusiform terminal ventricle and terminates below
within the root of the filum terminale.
• It is filled with cerebrospinal fluid and is lined with
ciliated columnar epithelium, the ependyma.
• Thus, the central canal is closed inferiorly and opens
superiorly into the fourth ventricle.
14

15. White Matter
• The white matter, for purposes of description,
may be divided into anterior, lateral, and
posterior white columns or funiculi.
• The anterior column on each side lies between
the midline and the point of emergence of the
anterior nerve roots; the lateral column lies
between the emergence of the anterior nerve
roots and the entry of the posterior nerve roots;
the posterior column lies between the entry of
the posterior nerve roots and the midline.
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16. Tracts
• Ascending tracts
• Descending tracts
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17. 17
Tracts

18. Spinal cord injury (SCI)
• Spinal cord injury (SCI) is a relatively low-incidence, high-cost injury
that results in tremendous change in an individual’s life. Paralysis of
the muscles below the level of the injury can lead to limited and
altered mobility, self-care, and ability to participate in valued social
activities.
• In addition to the musculoskeletal system, many other body
systems are impaired after a SCI, including the cardiopulmonary,
integumentary, gastrointestinal, genitourinary, and sensory systems.
He psychosocial impact of SCI can be just as great as the physical
impact.
• Changes in body image and sexual function, incontinence, and
having to rely on others to complete everyday tasks that were
previously done without thought or effort can profoundly influence
a person’s identity. Rehabilitation is an important element toward
achieving a fulfilling and active life after SCI. Physical therapists play
a key role in the rehabilitation process.
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19. DEMOGRAPHICS AND ETIOLOGY
• It is estimated that approximately 11,000 new cases of SCI
occur in the United States annually. Between 225,000 and
288,000 individuals with SCI are currently living in the
United States.
• Spinal cord injury is generally thought to primarily affect
young adults. However, the age at injury has steadily
increased. During the 1970s the average age at the time of
injury was 28.7 years old. Between 2005 and 2008 this
increased to 37.1 years old.
• This may be due to the aging of the U.S. population and an
increase in falls as a cause of injury. he majority of persons
with SCI are male (78.3% male vs. 21.7% female).
19

20. Etiological categories of SCI
• Spinal cord injuries can be grossly divided into
two broad etiological categories: traumatic
injuries and nontraumatic damage. Trauma is the
most frequent cause of injury in adult
rehabilitation populations.
• Injury results from damage caused by traumatic
events such as motor vehicle accidents (40.4%),
falls (27.9%), violence (15.0%), and sports (8.0%).
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21. • Nontraumatic damage in adult populations generally
results from disease or pathological influence.
• Conditions that may damage the spinal cord are
vascular dysfunction (arteriovenous malformation
[AVM], thrombosis, embolus, or hemorrhage);
vertebral subluxations secondary to rheumatoid
arthritis or degenerative joint disease; spinal
neoplasms; syringomyelia; abscess of the spinal cord;
infections, such as syphilis or transverse myelitis; and
neurological diseases, such as multiple sclerosis and
amyotrophic lateral sclerosis.
• Nontraumatic etiologies account for approximately
39% of all SCIs.
21

22. • Fifty-six percent of patients experience cervical lesions
resulting in tetraplegia, whereas 43% of SCIs result in
paraplegia from thoracic, lumbar, or sacral lesions.
• The most common type of injury is incomplete
tetraplegia (39.5%), followed by complete paraplegia
(22.1%), incomplete paraplegia (21.7%), and complete
tetraplegia (16.3%).
• Individuals with an incomplete neurological SCI have a
longer life expectancy than those with a complete
injury, and individuals with more caudal injuries also
have a greater life expectancy.
• The financial impact of SCI is extremely high.
22

23. CLASSIFICATION OF SPINAL
CORD INJURIES
• Spinal cord injuries typically are divided into two broad
functional categories: tetraplegia and paraplegia.
• Tetraplegia refers to complete paralysis of all four
extremities and trunk, including the respiratory
muscles, and results from lesions of the cervical cord.
• Paraplegia refers to complete paralysis of all or part of
the trunk and both lower extremities (LEs), resulting
from lesions of the thoracic or lumbar spinal cord or
cauda equina.
23

24. Types of Paralysis
• Hemiplegia is a paralysis of one side of the
body and includes the upper limb, one side of
the trunk, and the lower limb.
• Monoplegia is a paralysis of one limb only.
• Diplegia is a paralysis of two corresponding
limbs (i.e.,arms or legs).
• Paraplegia is a paralysis of the two lower
limbs.
• Quadriplegia is a paralysis of all four limbs.
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25. 25
Neuroanatomical Organization
and Structure

26. 26

27. Designation of Lesion Level
• It is extremely important for clinicians and researchers
to be able to accurately determine the extent of
neurological impairment in terms of motor and sensory
loss when working with individuals with SCI.
• The extent of motor and sensory function after injury
has a large impact on the medical and rehabilitation
needs of the individual.
• The American Spinal Injury Association (ASIA) created
the International Standards for Neurological
Classification of Spinal Cord Injury (ISNCSCI) in an effort
to standardize the way in which severity of injury is
determined and documented.
27

28. • The neurological level is defined as the most caudal level of
the spinal cord with normal motor and sensory function on
both the left and right sides of the body. Motor level is
referred to as the most caudal segment of the spinal cord
with normal motor function bilaterally.
• Sensory level is defined in the same way except in terms of
sensory function. Sensory level is determined by testing the
patient’s sensitivity to light touch and pinprick on the left
and right side of the body at key dermatomes. Scoring of
sensation is based on a 3-point ordinal scale where 0 =
absent, 1 = impaired, and 2 = normal.
• Motor level is determined by testing the strength of a key
muscle on the right and left side of the body at myotomes
adjacent to the suspected level of impairment. Key muscle
strength is scored using the 6-point ordinal scale commonly
used for manual muscle testing.
28

29. • Assigning a single muscle to represent one myotome is a
generalization. Most muscles are innervated by more than one
segmental nerve root; usually two nerve roots innervate each
muscle. For example, the extensor carpi radialis longus receives
innervation from the C6 and C7 spinal nerve roots.
• For the purpose of determining motor and neurological level, the
key muscle is defined as having intact innervation if it has a manual
muscle test score of at least 3/5 (fair) and the next most rostral key
muscle exhibits 5/5 (normal) strength on the manual muscle test.
• If the rostral key muscle does not demonstrate 5/5 strength, but the
therapist feels that the muscle would test normally except for
factors that would impede normal testing (e.g., pain with testing or
difficulty with positioning), then this information should be carefully
documented. For myotomes that are not clinically testable (i.e., C1–
C4, T2–L1, and S2–S5) the motor level is defined as the same as the
sensory level. 29

30. • In determining neurological level there may be
differences in terms of level of sensory and motor
function and between the left and right sides of
the body.
• For example, a patient’s sensory level may be at
C5 on the left and C8 on the right, and the motor
level may be C5 on the left and T1 on the right.
• In these cases, it is not appropriate to assign a
single neurological level, because this can be
misleading. Each of the sensory and motor levels
on the right and left sides of the body should be
documented separately.
30

31. Complete Injuries, Incomplete
Injuries, and Zone of Partial
Preservation
• A complete anatomical transection of the spinal cord is rare.
However, even if the injury is not anatomically complete, it may
present as clinically complete. The ISNCSCI defines a complete
injury as having no sensory or motor function in the lowest sacral
segments (S4 and S5). Sensory and motor function at S4 and S5 are
determined by anal sensation and voluntary external anal sphincter
contraction.
• An incomplete injury is classified as having motor and/or sensory
function below the neurological level including sensory
and/ormotor function at S4 and S5.
• If an individual has motor and/or sensory function below the
neurological level but does not have function at S4 and S5, then the
areas of intact motor and/or sensory function below the
neurological level are termed zones of partial preservation.
31

32. ASIA Impairment Scale
• Individuals with incomplete injuries may have variable
clinical presentations in terms of motor and/or sensory
function below the neurological level.
• For example, one patient may have close to normal
sensory and motor function below the level of the
lesion whereas another with the same lesion level may
have impaired sensation and no motor function below
the neurological level.
• The ASIA impairment scale was created so that
clinicians and researchers could better communicate
the degree of motor and sensory impairment of
individuals with SCIs.
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34. 34

35. Clinical Syndromes
• Despite the disparity associated with
incomplete lesions, several syndromes have
emerged with consistent clinical features.
• Approximately one-fifth of all SCIs result in an
injury pattern similar to clinical SCI
syndromes.
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36. 36

37. Brown-Sequard Syndrome
• Brown-Sequard syndrome occurs from hemisection of
the spinal cord (damage to one side) and is typically
caused by penetration wounds, that is, gunshot or
stab. Partial lesions (termed Brown-Sequard plus
syndrome) occur more frequently; true hemisections
are rare.
• The clinical features of this syndrome are
asymmetrical. On the ipsilateral (same) side as the
lesion, there is paralysis and sensory loss.
• The ipsilateral loss of proprioception, light touch, and
vibratory sense is due to damage to the dorsal column;
paralysis results from damage to the lateral
corticospinal tract.
37

38. • On the side contralateral (opposite) to the lesion,
damage to the spinothalamic tracts results in loss
of sense of pain and temperature.
• This loss begins several dermatome segments
below the level of injury. This discrepancy in
levels occurs because the lateral spinothalamic
tracts ascend two to four segments on the same
side before crossing.
• Individuals with Brown-Sequard syndrome
typically achieve good functional gains during
inpatient rehabilitation.
38

39. Anterior Cord Syndrome
• Anterior cord syndrome is frequently related to flexion
injuries of the cervical region with resultant damage to the
anterior portion of the cord and/or its vascular supply from
the anterior spinal artery. his syndrome is characterized by
loss of motor function (corticospinal tract damage) and loss
of the sense of pain and temperature (spinothalamic tract
damage) below the level of the lesion.
• Proprioception, light touch, and vibratory sense are
generally preserved, because they are mediated by the
dorsal columns with a separate vascular supply from the
posterior spinal arteries.
• Individuals with anterior cord syndrome often require a
longer length of stay during inpatient rehabilitation
compared to people with other types of SCI clinical
syndromes. 39

40. Central Cord Syndrome
• Central cord syndrome is the most common SCI
syndrome. It generally occurs from hyperextension
injuries to the cervical region. It also has been
associated with congenital or degenerative narrowing
of the spinal canal.
• The resultant compressive forces give rise to
hemorrhage and edema, producing damage to the
most central aspects of the cord.
• There is characteristically more severe neurological
involvement of the upper extremities (UEs) (cervical
tracts are more centrally located) than of the LEs
(lumbar and sacral tracts are located more
peripherally)
40

41. • Varying degrees of sensory impairment occur
but tend to be less severe than motor deficits.
With complete preservation of sacral tracts,
normal sexual, bowel, and bladder function
may be retained.
• Patients with central cord syndrome typically
recover the ability to ambulate. Some distal
UE weakness and loss of fine motor control
remain, which can result in moderate to
severe limitations in the ability to perform
functional tasks.
41

42. Cauda Equina Injuries
• Cauda equina lesions are frequently anatomically incomplete owing to the
great number of nerve roots involved and the comparatively large surface
area they encompass (i.e., it would be unlikely that an injury to this region
would involve the entire surface area and all the nerve roots).
•
• Individuals with cauda equina injuries exhibit areflexic bowel and bladder
and saddle anesthesia. Lower extremity paralysis and paresis is variable
depending on the extent of the injury to the cauda equina. Cauda equina
lesions are peripheral nerve (lower motor neuron [LMN]) injuries.
• As such, they have the same potential to regenerate as peripheral nerves
elsewhere in the body. However, full return of innervation is not common
because (1) there is a large distance between the lesion and the point of
innervation; (2) axonal regeneration may not occur along the original
distribution of the nerve; (3) axonal regeneration may be blocked by glial-
collagen scarring; (4) the end organ may no longer be functioning once
reinnervation occurs; and (5) the rate of regeneration slows and finally
stops after about 1 year. 42

43. NEUROLOGICAL COMPLICATIONS AND
ASSOCIATED CONDITIONS
• Spinal cord injury results in a disruption of
communication from higher centers in the
central nervous system to the periphery. his
disruption results in loss of motor and sensory
function, as well as impaired autonomic
function.
43

44. Spinal Shock
• Immediately following SCI there is a period of areflexia that is
part of spinal shock. It is believed to result from the very
abrupt withdrawal of connections between higher centers
and the spinal cord.
• In addition to the loss of deep tendon reflexes, there is a loss
of the bulbocavernosus reflex, the cremasteric reflex, a
Babinski response, and a delayed plantar response.
• The initial period of total areflexia lasts approximately 24
hours. This is followed by a gradual return of reflexes 1 to 3
days after injury, a period of increasing hyperreflexia lasting 1
to 4 weeks, and final hyperreflexia 1 to 6 months after injury.44

45. • Motor and Sensory Impairments
• Motor and sensory impairments depends on the specific features of
the lesion.
• Autonomic Dysreflexia:-
• Autonomic dysreflexia (AD, also referred to autonomic
hyperreflexia) is a pathological autonomic reflex that can be life
threatening. Typically AD occurs in lesions above T6 (above
sympathetic splanchnic outflow).
• This clinical syndrome produces an acute onset of autonomic
activity from noxious stimuli below the level of the lesion. Afferent
input from these stimuli reach the lower spinal cord (lower thoracic
and sacral areas) and initiate a mass reflex response resulting in
elevation of blood pressure.
• This is a critical, emergency situation. Owing to the lack of inhibition
from higher centers, hypertension will persist if not treated
promptly. Hypertension triggered by AD can result in seizures,
cardiac arrest, subarachnoid hemorrhage, stroke, or even death.
45

46. 46

47. • Intervention:-
• The onset of symptoms should be treated as a
medical emergency. If lying flat, the patient
should be brought to an upright position,
inasmuch as blood pressure will be lowered in
this position, and loosen any tight clothing or
restrictive devices. Blood pressure and pulse
should be monitored. The individual should be
questioned as to possible triggers, starting
with urinary system.
• Spastic Hypertonia:-
47

48. Cardiovascular Impairment
• Sympathetic input comes from spinal segments T1 to L2
through the sympathetic trunk, which runs parallel to the
spinal cord. Sympathetic input increases heart rate and
contractility and peripheral vasoconstriction.
• A rostral SCI will result in a loss of sympatheti
communication between the brainstem and the heart,
while parasympathetic input remains intact. his causes
bradycardia and dilation of the peripheral vasculature
below the level of the lesion.
• Because of the disrupted balance between sympathetic and
parasympathetic input, as well as a lack of or decrease in
active muscle contraction and prolonged time in bed,
orthostatic hypotension is often experienced during early
transitions to a more upright posture.
48

49. • Impaired Temperature Control
• After damage to the spinal cord the
hypothalamus can no longer control
cutaneous blood flow or level of sweating.
This autonomic (sympathetic) dysfunction
results in loss of internal thermoregulatory
responses. he ability to shiver below the level
of the injury is also lost.
• Pulmonary Impairment
• Ventilatory and respiratory function varies
considerably, depending on the level of lesion.
49

50. 50

51. Bladder and Bowel Dysfunction
• Spinal control for micturition originates from the sacral
segments of S2, S3, and S4.5 he level of the SCI dictates the
type of bladder dysfunction. Patients with lesions that
occur above the conus medullaris and sacral segments
develop a spastic or hyperreflexic bladder. This is also
termed a UMN bladder.
• Following a lesion of the sacral segments or conus
medullaris, a flaccid or areflexic bladder develops.5 his is
also termed a LMN bladder.
• There are generally two types of bladder dysfunction:
failure to store urine and failure to empty urine.
51

52. Bladder Management
• The primary goal of bladder management is to prevent or minimize
urinary tract complications. These include UTIs, hydronephrosis
(swelling of kidney due to backup of urine), renal calculi, bladder
calculi, and vesicoureteral reflux (backward flow of urine up the
ureter).
• The most frequently used method of bladder management is
intermittent catheterization.
• Suprapubic tapping involves tapping directly over the bladder with
fingertips, causing a reflexive emptying of the bladder.
• Individuals with an areflexive bladder can use the Valsalva
maneuver
52

53. Bowel Dysfunction
• In spinal cord lesions above S2 there is a spastic or
reflex bowel (UMN lesion). Because the
parasympathetic and internal sphincter connections
from S2–S4 are intact, reflex defecation can occur
when the rectum fills with stool. In S2–S4 or cauda
equina (peripheral nerves) lesions a flaccid or
areflexive bowel (LMN lesion) develops. With an
areflexive bowel the parasympathetic connections
from S2–S4 are not intact so the bowel will not
reflexively empty. his can cause feces to become
impacted and, because the external sphincter is flaccid,
incontinence can occur.
53

54. Bowel Management
• Safety and an appropriate, well-timed bowel care routine
are common goals for bowel management. Safety includes
continence in order to maintain intact and healthy skin,
prevent damage to colorectal structures, and prevent AD
due to bowel dysfunction. A typical bowel program involves
establishing a daily (or every other day) pattern of eliciting
a bowel movement.
• Nonreflex bowel management relies on manual evacuation
techniques and gentle Valsalva. Other factors that can play
a role in maintaining a consistent, safe bowel program
include eating a diet with appropriate amount of fiber, fluid
intake, physical activity, stool softeners, laxatives, and
bulking agents.
• Sexual Dysfunctions: 1. Male Response, 2. Female Response
54

55. Secondary Medical Complications
55

56. Prognosis
• The potential for recovery from SCI is directly
related to the neurological level of lesion and
completeness of the injury. An incomplete lesion
(ASIA B, C, or D) is a good prognostic indicator of
greater likelihood of recovery of motor function.
• Preservation of pinprick sensation at 4 months
after injury in the LEs or sacral region is
associated with a good prognosis for motor
recovery at 1 year after injury.
• Recovery of motor function generally plateaus
around 12 to 18 months after injury.
56

57. EARLY MEDICAL AND
REHABILITATION MANAGEMENT
IN THE ACUTE STAGE
• Emergency Care
• Fracture Stabilization
• Immobilization
57

58. PHYSICAL THERAPY MANAGEMENT IN
THE ACUTE STAGE OF RECOVERY
• Physical therapy Examination
• Motor and Sensory Function
• Respiratory
• Integument
58

59. • Passive Range of Motion
• Early Mobility Skills
• Physical therapy Interventions
• Respiratory Management
• Deep-Breathing Exercises
• Glossopharyngeal Breathing
• Air Shift Maneuver
• Respiratory Muscle Strengthening
• Coughing
• Abdominal Binder
• Manual Stretching
• Skin Care
59

60. • Early Strengthening and Range of Motion
• Early Mobility Interventions
• Education
• ACTIVE REHABILITATION
60