Spinal cord injury (SCI)

Introduction
 Spinal cord injury (SCI) is an insult to
the spinal cord resulting in a change,
either temporary or permanent, in its
normal motor, sensory, or autonomic
function.
 “the vibrant active and well-educated
people in our country”
Brief History
 Edwin Smith Papyrus
earliest of the person with spinal cord
injury (1700 BC )
During the 1940s, specialized centers
were developed for the person with
SCI.
Guttmann in England and Munro in
United States were the pioneers in
their respective countries. These units
Etiology
 Spinal cord injuries occur when blunt
physical force damages the vertebrae,
ligaments, or disks of the spinal
column, causing bruising, crushing, or
tearing of spinal cord tissue, and when
the spinal cord is penetrated (eg, by a
gunshot or a knife wound).
Definition of Terms
 * Tetraplegia (replaces the term
quadriplegia) - Injury to the spinal cord
in the cervical region, with associated
loss of muscle strength in all 4
extremities
 * Paraplegia - Injury in the spinal
cord in the thoracic, lumbar, or sacral
segments, including the cauda equina
and conus medullaris
 EPIDEMIOLOGY
Causes
motor vehicle accident 45.4%
Bradom
48%
Delisa

acts of violence 14.6% 15%

Sports 16.3% 14%
Falls 16.8% 21%
Age Goups 25-44 year old (26 y/o) 16-30 years of age
Males vs Female 2.4:1 to 4:1 80% are male
White vs. non-white 8:1 (urban ratio 3:1)

Prevalence 525 per 1 million, or 500- 900 per million. Thus,

128941 persons, to
1124 cases per million,
or 276,057 persons.
The most recent survey
estimated 721 per 1
million or 176,965
Incidence 29.4 persons
cases perin 11998. Less
million to 55 per million person per
than 5000 are
50 cases per million
estimated to be
institutionalized.
the national incidence
varies between 7,000
to 10,000 , the
prevalence of 150,000-
200,000.
year with 35 per million
per year surviving long
enough to be
hospitalized.
EPIDEMIOLOGY
 Quadriplegia -55%
 paraplegia -45%
 Other causes of SCI include the following:
 * Vascular disorders
 * Tumors
 * Infectious conditions
 * Spondylosis
 * Vertebral fractures secondary to
osteoporosis
 * Developmental disorders
Other Factors
 Race
 Sex
 Age
 Associated injuries
 Marital status
 Level and type of injury
 Substance abuse
 Season
 Educational status
 Employment
Life expectancy
 10-20% of patients who have sustained an
SCI do not survive to reach acute
hospitalization, while about 3% of patients
die during acute hospitalization
 People 20 years have a life expectancy of
approximately 33 years (patients with
tetraplegia), 39 years (patients with low
tetraplegia), or 44 years (patients with
paraplegia).
 Individuals aged 60 years at the time of
injury have a life expectancy of
approximately 7 years (patients with
tetraplegia), 9 years (patients with low
Leading cause of death
 pneumonia and other respiratory
conditions, followed by heart disease,
subsequent trauma, and septicemia.
Suicide and alcohol-related deaths are
also major causes of death in patients with
SCI. In persons with SCI, the Among
patients with incomplete paraplegia, the
leading causes of death are cancer and
suicide (1:1 ratio), while among persons with
complete suicide rate is higher among
individuals who are younger than 25
years.
Spinal Cord Injury:
Pathophysiology

 Mechanisms of Injury
 Clinical Syndromes
 Dermatomes and Myotomes
 Effects of Spinal Cord Injury
Definition of Terms
 Avulsion fx- tearing of a piece of bone away from
the main bone by the force of mm. contraction.
 Burst fx- a comminuted vertebral fx associated with
p° along the long axis of the vertebral column.
 Teardrop fx- a bursting type fracture of the cervical
region that produces a characteristic anterior-
inferior bone chip.
 Dysesthesias- bizarre, painful sensations
experienced below the level of the lesion following
SCI; described as burning, numbness, pins and
needles, or tingling sensations.
Mechanisms of Injury

 Flexion injury
 Hyperextension injury
 Compression injury
 Flexion-Rotation injury
Flexion Injury
 Head-on collision in which head strikes
steering wheel or windshield.
 Blow to back of head or trunk.
 Most common mechanism of SCI
Flexion Injury
 Associated  Potential
Fractures Associated Injuries
2. Wedge fx of anterior 2. Tearing of posterior
vertebral body ligaments.
3. High percentage of 3. Fractures of posterior
injuries occur from elements
C4-C7 and from T12- 4. Disruption of disk
L2 5. Anterior dislocation of
vertebral body.
Hyperextension Injury
 Strong Posterior force such as rear-
end collision.
 Falls with chin hitting a stationary
object
Hyperextension Injury
 Associated  Potential
Fractures Associated Injury
2. Fractures of posterior 2. Rupture of ALL.
elements. 3. Rupture of disk.
3. Avulsion fx of anterior
aspect of vertebrae.
Compression Injury
 Vertical or axial blow to head
(e.g diving, surfing, or falling objects)
 Closely associated with flexion
injuries.
Compression Injury
 Associated  Potential
Fractures Associated Injury
2. Concave fx of 2. Bone fragments may
endplate lodge in cord.
3. Explosion or burst fx 3. Rupture of disk.
(comminuted).
4. Teardrop fx.
Flexion-Rotation Injury
 Posterior to anterior force directed at
rotated vertebral column. (e.g rear-end
collision with passenger rotated toward
driver.)
Flexion-Rotation Injury
 Associated  Potential
Fractures Associated Injury
2. Fracture of posterior 2. Rupture of posterior
pedicles, articular and interspinous
facets, and laminae. ligaments.
3. Subluxation or
dislocation of facet
joints.
4. In thoracic and lumbar
regions, facets may
“lock”
Clinical Syndromes

 Brown- Sequard Syndrome

 Anterior Cord Syndrome
 Central Cord Syndrome
 Posterior Cord Syndrome
 Conus Medullary Syndrome
 Cauda Equina Syndrome
Brown- Sequard Syndrome
 Hemisection of the cord caused by
penetration wounds.
 Ipsilateral: loss of sensation in the
dermatome segment corresponding to
the level of lesion, paresis, impared
joint position sense and touch
localization.
Brown- Sequard Syndrome
 Contralateral: loss of pain and
temperature sensation below the level
of the lesion, dysesthesia.
Anterior Cord Syndrome
 Trauma on the anterior part of the cord
or damage of anterior spinal artery
 Loss of motor function
 Loss of sense of pain and
temperature.
Central Cord Syndrome
 Occurs from hyperextension of
cervical spine
 More severe neurological involvement
of the UE than the LE.
 Cord is pressed anteriorly by vertebral
body and posteriorly by bulging of the
ligamentum flavum.
Posterior Cord Syndrome
 Rare
 Motor function, sense of pain and light
touch preserved
 Loss of proprioception and epicritic
sensation below the level of the lesion.
 Wide based step gait.
Conus Medullaris Syndrome
 Compression of inferior end of conus
medullaris
 Causes: trauma, herniation, neoplasm,
and iatrogenic infections
 Effects: Lumbar stenosis, spina bifida,
areflexia of the bladder, bowel and
lower limbs.
Cauda Equina Syndrome
 Radiculopathies
 Causes: Same as Conus Medullaris
Syndrome
 Effects: Paraplegia, urinary dysfxn,
dec. rectal tone, sexual dysfxn, saddle
anesthesia, pain and absence of ankle
reflex.
Dermatomes and Myotomes

 Dermatome map
 Segmental spinal cord and
functions
Dermatomes
 Are strip-like areas of the skin
innervated by a single nerve root.
Dermatomes
 C1: -
 C2: occiput
 C3: supraclavicular fossa
 C4: acromion process
 C5: lateral arm
 C6: thumb
 C7: middle finger
 C8: little finger
 T1: medial arm
 T2: axilla
 T4: nipple area
 T6: xiphoid process
 T10: umbilicus
 L1: inguinal area
 L2: anterior thigh
 L3: medial aspect of the
knee
 L4: medial malleolus
 L5: dorsum of foot
 S1: lateral malleolus
 S2: popliteal fossa
 S3: groin, medial thigh to
knee
 S4-5: around the anus
 Myotomes

 Each muscle in the

body is supplied by
a particular level or
segment of the
spinal cord and by
its corresponding
spinal nerve
Myotomes
 C3, 4 and 5 supply the diaphragm (the large
muscle between the chest and the belly that
we use to breath).
 C5 also supplies the shoulder muscles and
the muscle that we use to bend our elbow.
 C6 is for bending the wrist back.
 C7 is for straightening the elbow.
 C8 bends the fingers.
 T1 spreads the fingers.
Myotomes
 T1 –T12 supplies the chest wall &
abdominal muscles.
 L2 bends the hip.
 L3 straightens the knee.
 L4 pulls the foot up.
 L5 wiggles the toes.
 S1 pulls the foot down.
 S3, 4 and 5 supply the bladder, bowel and
sex organs and the anal and other pelvic
muscles.
Segmental Spinal Cord and Function

Level Function

C1-C6 Neck Flexors

C1-T1 Neck Extensors

C3-C5 Diaphragm
C5, C6 Shoulder movement, raise arm (deltoid);
flexion of elbow (biceps); C6 externally
rotates the arm (supinates).
Segmental Spinal Cord and Function

C6, C7 Extends elbow and wrist (triceps and wrist

extensors); pronates wrist
C7, T1 Flexes wrist and supply small muscles of
the hand
T1-T6 Intercostals and trunk above the waist

T7-L1 Abdominal Flexion

L1-L4 Thigh Flexion

Segmental Spinal Cord and Function
L2-L4 Thigh adduction
L4-S1 Thigh abduction
L5-S2 Extension of leg at the hip (Gluteus
Maximus)
L2-L4 Extension of the leg at the knee
(quadriceps femoris)
L4-S2 Flexion of the leg at the knee (hamstrings)
L4-S1 Dorsiflexion of the foot (tibialis anterior),
Extension of toes
L5-S2 Plantar flexion of the foot and flexion of
toes
The Effects of Spinal Cord Injury

 Types of Injury
 Level of Injury
Types of Injury
 Complete Injury- means that there is
no function below the level of the
injury; no sensation and no voluntary
movement.
 Incomplete Injury- means that there is
some functioning below the primary
level of the injury.
Cervical Injury
 C3 vertebrae and above : Typically lose diaphragm
function and require a ventilator to breathe.
 C4 : May have some use of biceps and shoulders, but
weaker
 C5 : May retain the use of shoulders and biceps, but
not of the wrists or hands.
 C6 : Generally retain some wrist control, but no hand
function.
 C7 and T1 : Can usually straighten their arms but still
may have dexterity problems with the hand and
fingers. C7 is generally the level for functional
independence.
Thoracic Injury
 T1 to T8 : Most often have control of the hands,
but lack control of the abdominal muscles so
control of the trunk is difficult or impossible.
Effects are less severe the lower the injury.
 T9 to T12 : Allows good trunk and abdominal
muscle control, and sitting balance is very
good.
Lumbar and Sacral Injury
 The effect of injuries to the lumbar or
sacral region of the spinal canal are
decreased control of the legs and hips,
urinary system, and anus.
Functional Loss from SCI

 Based on Compete Lesions

 C1-4
Motor function Sensory function Respiratory fxn.
Tetraplegia: loss Loss of all sensory Loss of involuntary
of all motor function in the neck and voluntary
function from the and below (C4 respiratory
neck down supplies the function;
clavicle) ventilatory support
and a
tracheostomy
needed
 C5
Motor function Sensory function Respiratory fxn.
Tetraplegia: Loss Loss of all sensation Phrenic nerve
of all function below the clavicle intact but not the
beow the upper and most portions of intercostal muscles
shoulders the arms, hands,
Intact: SCM, chest, abdomen,
cervical and LE
paraspinal mm., Intact: head,
trapezius; can shoulders, deltoid,
control head. clavicle, portions of
the forearms.
 C6
Motor function Sensory function Respiratory fxn.
Tetraplegia: Loss Loss of everything Phrenic nerve
of al function listed for a C5 intact, but not the
below the lesion, but greater intercostal muscles
shoulders and arm and thumb
upper arms; lacks sensation
elbow, forearm, Intact: head,
and hand control. shoulders, arms,
Intact: deltoid, palms of the hands,
biceps, ER mm. of and thumbs
shoulders.
 C7
Motor function Sensory function Respiratory fxn.
Tetraplegia: loss of Loss of sensation Phrenic nerve
motor control to below the clavicle intact, but not the
portions of the arm and portions of the intercostal muscles
and hands. arms and hands.
Intact: voluntary Intact: head,
strength in shoulders, most of
shoulder the arms and
depressors, hands.
abductors, IR mm.
and radial wrist
extensors
 C8
Motor function Sensory function Respiratory fxn.
Tetraplegia: loss Loss of sensation Phrenic nerve
of motor control to below the chest and intact, but not the
portions of the in portions of the intercostal muscles
arms and hands. hands.
Intact: some Intact: sensation to
voluntary control face, shoulders,
of elbow arms, hands, and a
extensors, wrist, part of the chest.
finger extensors
and finger flexors.
 T1-6
Motor function Sensory function Respiratory fxn.
Paraplegia: loss loss of sensation Phrenic nerve
of everything below the midchest functions
below the area independently
midchest region, Intact: everything
including the trunk to the midchest Some impairments
mm. region including the of the intercostals
Intact: control of arms and hands.
fxn. to shoulders,
upper chest, arms
and hands.
 T6-12
Motor function Sensory function Respiratory fxn.
Paraplegia: loss of Loss of everything No interference
motor control below the waist with respiratory
below the waist Intact: shoulders, function
Intact: shoulders, chest, arms, and
arms, hands, and hands.
long trunk
muscles.
 L1-3
Motor function Sensory function Respiratory fxn.
Paraplegia: loss of Loss of sensation to No interference
control to most of the lower abdomen with respiratory
the legs and and legs. function.
pelvis. Intact: all
Intact: shoulders, sensations above
arms, hands, the lower abdomen
torso, hip rotation plus some sensation
and flexion, and to the inner and
some leg flexion. anterior thigh.
 L3-4
Motor function Sensory function Respiratory fxn.
Paraplegia: loss Loss of sensation to No interference
of control of portions of the with respiratory
portions of lower lower legs, feet, function.
legs, ankles, and and ankles
feet. Intact: al of the
Intact: all of the above, plus
above, plus sensations to the
increased knee upper legs.
extension.
 L4-S5
Motor function
Paraplegia: degree varies
Segmental motor control:
L4-S1: abduction and IR of
hip, ankle dorsiflexion, and
foot inversion.
L5-S1: foot eversion.
L4-S2: knee flexion.
S1-2: plantar flexion, ankle
jerk
S2-5: bowel/bladder control
Sensory function
Lumbar sensory nerves
innervate the upper legs and
portions of the lower legs.
L5: medial aspect of the foot
S1: lateral aspect of the foot
S2: posterior aspect of calf or
thigh
-sacral sensory nerves innervate
the lower legs, feet, and
perineum.
Voluntary bowel and bladder function

 C1-4 to L3-4: no bowel or bladder

control
 L4-S5: bowel and bladder control
possibly impaired.
*S2-4 segments control urinary
continence
*S3-5 segments control bowel
continence (perianal muscles)
 SPINAL CORD INJURY
DIFFERENTIAL DIAGNOSIS

Prepared by: Manalang, Al

Victoria R.
BSPT III-1
Non-traumatic
Motor Neuron Disease
 Amyotrophic Lateral Sclerosis

 Spinal Muscular Atrophy

Spondylotic Myelopathies
 Spondylosis

 Spondylolisthesis

 Spinal Stenosis

Infectious & Inflammatory Diseases

 Multiple Sclerosis
Neoplastic Diseases
1. Intradural Intramedullary
 Ependynoma

2. Intradural Extramedullary
 Meningioma

3. Extradural
 Neuroblastoma

Congenital/Developmental Disorder
 Spina Bifida
 Disease Signs & Symptoms
SPINAL CORD INJURY •Areflexia,
Motor & Sensory
Impairments, Spasticity, Bladder &
Bowel Dysfunction, Sexual
Dysfunction
AMYOTROPHIC •Painless weakness in hand, foot, arm
& leg
LATERAL SCLEROSIS •Speech, swallowing, walking
difficulty
•Atrophy & Fasciculations

•Depressed mm stretch reflexes

•Muscle cramping

SPINAL MUSCULAR •Muscle weakness, poor mm tone,

weak cry, limpness or tendency to
ATROPHY flop, difficulty sucking/swallowing
 SPONDYLOSIS •Back pain
•Sphincter & Bowel Dysfunction

SPONDYLO •Tingling & Numbness

•Slipping sensation when moving
LISTHESIS into an upright position
(SPINA BIFIDA OCCULTA)
•Dimple, depression, birthmark,
SPINA BIFIDA hairy patch over the affected part
(SPINA BIFIDA MANIFESTA)
•Swelling over the affected spine/
exposed spinal nerves @ the back
SPINAL STENOSIS •Numbness & Weakness
•Cramping or pain in legs, feet or
buttocks
MULTIPLE SCLEROSIS •Weakness, paresthesia, gait
difficulty, optic neuritis, diplopia,
ataxia, disturbed nutrition, vertigo
•Frequent headaches
•Seizures
EPENDYNOMA •Frequent nausea & vomitting
•Loss of balance/trouble walking

•Seizures

•Headaches that worsen with time

MENINGIOMA •Memory loss

•Changes in vision, such as seeing

double or blurriness
•Hearing loss

•Weakness in your arms/legs

 •Lump in the abdomen, neck or
chest
•Bulging eyes

•Dark circles around the eyes

(“black eyes”)
NEUROBLASTOMA •Bone pain

•Swollen stomach & trouble

breathing in infants
•Painless, bluish lumps under the
skin in infants
•Weakness or paralysis (loss of
ability to move a body part)
 DISEASE CAUSE AFFECTATION

SPINAL CORD Sudden severe blow to

the spine. (Car accident, Spinal Cord
INJURY fall, gunshot, or sporting
accident. Sometimes the
SC is damaged by
infection/spinal stenosis

AMYOROPHIC Mutation of a specific Both upper and lower

gene, the SOD1 gene. motor neuron that causes
LATERAL degeneration of
SCLEROSIS throughout the brain &
SC.

SPINAL Loss of the SMN1 gene Only a portion of one

from chromosome 5 limb such as forearm &
MUSCULAR hand, shoulder or thigh
ATROPHY
SPONDYLOSIS Stress fracture of the (Spondylolisthesis)
bone. I. Dysplastic- inf. L5
& SPONDYLO (Spondylosis) facet
LISTHESIS degenerative changes in II. Isthmic- L5- S1
the IV disks & vertebral III. Degenerative- L4-5
bodies followed by L3-4
(Spondyloisthesis)
IV. Traumatic- facet
Defect in the pars joints, lamina, pedicles
articularis- “sliding off V. Pathogenic
of vertebra”)

SPINAL due to the natural Legs

process of spinal
STENOSIS degeneration that occurs
with aging, caused by
spinal disc herniation,
osteoporosis or a tumor.
 Immune system attacks Nerve cells in the brain
MULTIPLE
the central nervous and in the spinal cord
SCLEROSIS system leading to
demyelination
Malignant cells form in 4th ventricle and
the tissues of the brain septum pellucidum in
EPENDYNOMA and spinal cord the spinal cord

meningiomas are Arachnoidal cells

inactivation mutations in
MENINGIOMA the neurofibromatosis 2
gene ; radiation

Malignant cells form in Abdomen, chest, spinal

NEURO
the nerve tissue of the cord, neck, head,
BLASTOMA adrenal gland, neck, Hip and legs
chest or spinal cord
 Occurs when the Neural tube
tissue surrounding the
SPINA BIFIDA developing spinal cord
of a fetus doesn’t close
properly
 COMPLICATIONS OF
SPINAL CORD INJURY
RESPIRATORY:
 Represents a particularly serious and
life threatening feature of SCI.

 Greater loss of respiratory function

with higher lesion level.
Diaphragm and External
Intercostals:
 Diaphragm-Innervated by Phrenic
Nerve (C3-C5).
C1-C3 lesion –respiratory are impaired or
lost.
 External Intercostals – Intercostal
nerve
- Paralysis results to decreased chest
expansion and lowered inspiratory
volume.
Accessory muscle for
inspiration
 SCM
 Trapezius
 Scalene
 Pectoralis Minor
 Serratus anterior

-muscles that assist in elevation of the

ribs.
-can sustain acutely injured patient.
 Muscle of Expiration
 Assist in maintaining the position of
the diaphragm
 Decreased ERV
 Decrease cough effectiveness
External Oblique
 Normal Function:
- Depresses the ribs and compresses
the chest wall.
- Decrease the ability to cough and
expel secretion.
CARDIOVASCULAR:
 DVT
- Risk factor: Loss of pumping
mechanism provided by active
contraction of LE musculature
Autonomic Dysreflexia
 Massive sympathetic discharge that is
triggered by noxious stimuli.
 Most commonly seen in person with
injuries above T6.
Metabolic:
 Hypercalcemia
- d/t immobilization in bone resorption.

- Exceeds the ability of the kidney to

excrete calcium.
Bladder dysfunction
 Micturition – voiding of urine:urination
 Conus Medullaris-spinal integration
center for micturition
 UMNL lesion – generally involving
T11-T12
 LMNL lesion – no reflex action of
detrussor muscle.
Skin

Pressure ulcer
-ulceration of soft tissue caused by
unrelieved pressure and shearing
forces
-Most common
Risk factor: impaired sensory function
and inability to change position.
Spasticity
 After acute SCI and phase of spinal
shock, development of reflex or tone
begins to increase
 Incidence is higher in cervical and
upper thoracic
 may contribute to improve function.
Pain
 Types of pain:
 Traumatic pain
- Arise from fracture ligamentous or soft
tissue damage; acute pain
 Nerve root pain
-arise from nerve root or near the cord
damage.
-sharp, stabbing, burning or shooting
pain.
-follows a dermatomal pattern.
-most common in cauda equina injury.
Spinal cord dysesthesias
 Painful sensation below the level of
lesion.
 Do not follow a dermatomal
distribution
 Burning or numbness, pins and
needles or tingling feeling.
Musculoskeletal pain
 Above the lesion of level
 Frequently involve shoulder joint
 Related to: faulty positioning
-inadequate ROM
-tightening of joint capsule and
surrounding tissue.