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Anatomy of the Spinal Cord

The spinal cord, like the brain, is composed of gray matter

and white matter.

The white matter contains ascending and descending fiber

tracts, while the gray matter contains neurons of different
Anterior horns contain mostly motor neurons
Lateral horns mostly autonomic neurons, and
Posterior horns mostly somatosensory neurons
participating in a number of different afferent

In adults, the spinal cord is shorter than the vertebral

column: it extends from the craniocervical junction to
lower border of L1

The segments of the neural tube (primitive spinal cord)

correspond to those of the vertebral column only up to the
third month of gestation, after which the growth of the
spine progressively outstrips that of the spinal cord.

Nerve roots exit from the spinal canal at the numerically

corresponding levels, so that the lower thoracic and
lumbar roots must travel an increasingly long distance
through the SAS to reach the intervertebral foramina
through which they exit.

The spinal cord ends as the conus medullaris (or conus

terminalis) at the lower level of L1.

Below this level, the lumbar sac or thecal sac contains only
nerve root filaments, the so-called cauda equina (horses

Major Ascending and Descending Tracts of the Spinal Cord
Ascending Tracts
There are 3 main sensory systems entering the spinal cord:
1. Pain and Temperature lateral spinothalamic tract
2. Proprioception stereognosis medial lemniscus (fasciculus
gracilis and fasciculus cuneatus)
3. Light touch anterior spinothalamic tract

Descending Tracts 5 ; these systems are important in the postural
control of the limbs.
1. Vestibulospinal tract and reticulospinal tract - facilitate axial and
proximal limb movements.
2. Corticospinal tract and corticorubrospinal tract facilitate distal
limb movements.


Segmental nerve root innervating a muscle

Again important in determining level of injury

Upper limbs:

C5 - Deltoid

C 6 - Wrist extensors

C 7 - Elbow extensors

C 8 - Long finger flexors

T 1 - Small hand muscles

Lower Limbs :

L2 - Hip flexors

L3,4 - Knee extensors

L4,5 S1 - Knee flexion

L5 - Ankle dorsiflexion

S1 - Ankle plantar flexion


Reflects spinal cord's segmental functional organization

Specific area in which the spinal nerve travels or
Useful in assessment of specific level SCI

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters


C3, 4, 5

C5, 6


C8, T1



L1, 2





sensory: top of shoulder

motor: diaphragm
sensory: top of shoulder
sensory: thumb and index finger
sensory: middle finger
sensory: little finger
sensory: level of nipple
sensory: level of umbilicus
sensory: inguinal crease
sensory: medial thigh, calf
sensory: lateral calf
sensory: lateral foot
motor: anal sphincter tone
sensory: perianal


Diseases of the nervous system may be confined to the

spinal cord, where they produce a number of distinctive

Spinal cord contains, in small cross-sectional area, almost

entire motor output and sensory input of trunk and limbs -
spinal cord disorders are frequently devastating.

Clinical Effects of Spinal Cord Injury

When the spinal cord is suddenly and virtually or

completely severed, three disorders of function are at
once evident:

(1) all voluntary movement in parts of the body below the

lesion is immediately and permanently lost;

(2) all sensation from the lower (aboral) parts is abolished;


(3) reflex functions in all segments of the isolated spinal

cord are suspended.

Define the level of injury

hallmark of spinal cord damage!
below which sensory / motor / autonomic
function is disturbed
most caudal spinal segment with normal
sensation and muscle strength of 3/5 or better
absent deep tendon reflexes below the level of
the lesion

Completeness of cord injury

Complete lesion no preservation of any motor or sensory


Incomplete lesion any residual motor or sensory function

more than 3 segments below the level of injury

Signs of incomplete cord injury

Any sensation or voluntary movement of the lower


Sacral sparing preservation of sensation at the anus,

perineum, voluntary anal contraction

All spinal cord syndromes are incomplete lesions

Preservation of sacral reflexes (bulbocavernosus reflex,

anal wink) does not qualify lesion as incomplete


In all vertebrates, acute spinal cord concussion or

complete cord transection is followed by SPINAL SHOCK

Transient profound loss of all SPINAL REFLEXES below level

of injury (in addition to complete PARALYSIS and
ANESTHESIA below level)

1. Flaccid paralysis
2. Absence of reflexes (muscle stretch, plantar,abdominal &
3. Hypotonic paralysis of bowel & bladder (ileus,
gastroparesis, urinary and bowel retention) priapism.
4. Hypotension (not present if lesion is below lower thoracic
level) with anhydrosis and flushed warm peripheral skin
( poikilothermy). *
5. Hypotension without compensatory tachycardia (if high
cervical lesion), i.e.NEUROGENIC SHOCK (interrupted
sympathetic outflow vasodilation & bradycardia)

Neurogenic shock

Triad of

i) hypotension

ii) bradycardia

iii) hypothermia

More commonly in injuries above T6

Secondary to disruption of sympathetic outflow from T1


Where they come from

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters

Clinical Effects of Spinal Cord Injury

The last effect, called spinal shock, involves tendon as well

as autonomic reflexes. It is of variable duration (1 to 6
weeks as a rule but sometimes far longer)

Less complete lesions of the spinal cord result in little or

no spinal shock, and the same is true of any type of lesion
that develops slowly.

Injury defined by ASIA Impairment Scale
ASIA American Spinal Injury Association :
A Complete: no sensory or motor function preserved in sacral
segments S4 S5
B Incomplete: sensory, but no motor function in sacral segments
C Incomplete: motor function preserved below level and power
graded < 3
D Incomplete: motor function preserved below level and power
graded 3 or more
E Normal: sensory and motor function normal

Muscle Strength Grading:
5 Normal strength
4 Full range of motion, but less than normal strength against
3 Full range of motion against gravity
2 Movement with gravity eliminated
1 Flicker of movement
0 Total paralysis


Syndrome of Acute Paraplegia or Quadriplegia Due to Complete
Transverse Lesions of the Spinal Cord

Trauma ->most frequent cause

Types of Injury
Severe forward flexion injury ;
Hyperextension injury ;
Whiplash injury
High-velocity missile penetrates the vertebral
canal and damages the spinal cord directly;
Indirect consequence of a vascular mechanism.

Pathology of Spinal Cord Injury

As a result of squeezing or shearing of the spinal cord,

there is destruction of gray and white matter and a
variable amount of hemorrhage, chiefly in the more
vascular central parts -> traumatic necrosis (are maximal
at the level of injury and one or two segments above and
below it)

As a lesion heals, it leaves a gliotic focus or cavitation with

variable amounts of hemosiderin and iron pigment.

Progressive cavitation (traumatic syringomyelia) may

develop after an interval of months or years - > lead to a
delayed central or incomplete transverse cord syndrome.

In most traumatic lesions, the central part of the spinal

cord, with its vascular gray matter, tends to suffer greater
injury than the peripheral parts.

Transient Cord Injury (Spinal Cord Concussion)

Transient loss of motor and/or sensory function of the

spinal cord that recovers within minutes or hours but
sometimes persists for a day or several days.

Spinal cord concussion from direct impact is observed

most frequently in athletes engaged in contact sports
(football, rugby,and hockey).

Cervical cord injury

Cervicomedullary junction (above C3): extensive lesions

involve adjacent medullary centers vasomotor and
respiratory collapse neurogenic hypotension, apnea
unresponsiveness (difficult diagnosis) death (in absence
of ventilatory support).

C4-5 - quadriplegia with preserved respiratory function

(functional diaphragm)

C5-6 - sparing shoulder muscles (loss of biceps and

brachioradialis reflexes).

C7 - sparing biceps (loss of triceps reflex).

C8 - sparing triceps (paralyzed fingers and wrist flexion)

ipsilateral HORNER'S SYNDROME may occur at any cervical

level lesion.

Thoracic cord injury

Best localized by SENSORY LEVEL on trunk

nipples (T4), umbilicus (T10)

BEEVOR SIGN - observe abdominal wall musculature and

umbilicus by asking patient to interlock fingers behind
head in supine position and attempt to sit up:
lesions below T9 paralyze lower abdominal
muscles upward movement of umbilicus
(BEEVOR sign) + loss of lower superficial
abdominal reflexes.
unilateral lesions movement of umbilicus to
normal side; absent superficial abdominal
reflexes on involved side.
midline back pain is useful localizing sign.

Thoracic spinal cord transection

Causes paraplegia

Transection of the upper thoracic cord spares the upper

limbs but impairs breathing (involvement of intercostal
muscles) and may also cause paralytic ileus through
involvement of the splanchnic nerves.

Transection of the lower thoracic cord spares the

abdominal muscles and does not impair breathing.

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters


The main syndromes to be considered are:
(1) a complete or almost complete sensorimotor
myelopathy that involves most or all of the ascending and
descending tracts (transverse myelopathy)
(2) a painful radicular syndrome (segmental radiculopathy)

Transverse Myelopathy

When spinal cord transection syndrome arises gradually

rather than suddenly, e. g., because of a slowly growing
tumor, spinal shock does not arise.

The transection syndrome in such cases is usually partial,

rather than complete.

Progressively severe spastic paraparesis develops below

the level of the lesion, accompanied by a sensory deficit,
bowel, bladder, and sexual dysfunction, and autonomic
manifestations (abnormal vasomotor regulation and
sweating, tendency to decubitus ulcers).

Usually seen in degenerative changes with central canal


Segmental Radiculopathy

Radiculopathy / myelopathy due to compression by mass

of disc material:

herniation into lateral recess or neural foramen

(posterolateral herniation) spinal root

herniation into spinal canal (central herniation)

spinal cord compression (in cervical thoracic
region) or cauda equina compression (in
lumbosacral region).

Roots above C8 exit above corresponding vertebral body;
remaining roots exit below their respective vertebral bodies

Types of incomplete injuries

Central Cord Syndrome
Anterior Cord Syndrome
Posterior Cord Syndrome
Brown Sequard Syndrome
Cauda Equina Syndrome

1. Central Cord Syndrome :

Typically in older patients

Hyperextension injury

Compression of the cord

anteriorly by osteophytes and
posteriorly by ligamentum flavum

Also associated with fracture

dislocation and compression

More centrally situated cervical

tracts tend to be more involved hence

flaccid weakness of arms > legs

Perianal sensation & some lower extremity movement and

sensation may be preserved

Classic Central Cord

most common of INCOMPLETE SCI syndromes!

Etiology: neck hyperextension (esp. in patients with

spondylosis) cord compression between bony bars
anteriorly and thickened ligamentum flavum posteriorly
cord hypoperfusion in watershed distribution (mostly
central portion of cord central gray and most central
portions of pyramidal & spinothalamic tracts).

central cord syndrome is an ischemic lesion (frequently no

radiologically identifiable fractures!!!) - neurologic changes
tend to improve with time!


Fluid filled cavitation in the center of the cord

Cervical cord most common site

Loss of pain and temperature related to the
crossing fibers occurs early

cape like sensory loss

Weakness of muscles in arms with atrophy and
hyporeflexia (AHC)
Later - CST involvement with brisk reflexes in the
legs, spasticity, and weakness

May occur as a late sequelae to trauma

Can see in association with Arnold Chiari malformation

2. Anterior cord Syndrome:

Due to flexion / rotation

Anterior dislocation /
compression fracture of a
vertebral body encroaching the
ventral canal

Corticospinal and spinothalamic

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters

tracts are damaged either by direct trauma or

ischemia of blood supply (anterior spinal arteries)

Loss of power

Decrease in pain and sensation below lesion

Dorsal columns remain intact

3. Posterior Cord Syndrome:

Hyperextension injuries with

fractures of the posterior
elements of the vertebrae

Proprioception affected ataxia

and faltering gait

Usually good power and sensation

4. Brown Sequard Syndrome:

Hemi-section of the cord

Either due to penetrating


i) stab wounds

ii) gunshot wounds

Fractures of lateral mass of


Paralysis on affected side (corticospinal) IPSILATERAL

Loss of proprioception and fine discrimination (dorsal


Pain and temperature loss on the opposite side below the

lesion (spinothalamic) CONTRALATERAL

Conus syndrome

Due to a spinal cord lesion at or below S3, is also rare.

It can be caused by spinal tumors, ischemia, or a massive

lumbar disk herniation.

An isolated lesion of the conus medullaris produces the

following neurological deficits:

Detrusor areflexia with urinary retention and overflow

incontinence (continual dripping)

Fecal incontinence - Impotence

Saddle anesthesia (S3S5) - Loss of the anal reflex

Cauda equina syndrome

Involves the lumbar and sacral nerve roots, which descend

alongside and below the conus medullaris, and through
the lumbosacral subarachnoid space, to their exit
a tumor (e. g., ependymoma or lipoma) is the
usual cause.

Patients initially complain of radicular pain in a sciatic

distribution, and of severe bladder pain that worsens with
coughing or sneezing.

Later, severe radicular sensory deficits, affecting all

sensory modalities, arise at L4 or lower levels.
Lesions affecting the upper portion of the cauda equina
produce a sensory deficit in the legs and in the saddle
There may be flaccid paresis of the lower limbs with
areflexia; urinary and fecal incontinence also develop,
along with impaired sexual function.
With lesions of the lower portion of the cauda equina, the
sensory deficit is exclusively in the saddle area (S3S5), and
there is no lower limb weakness, but urination, defecation,
and sexual function are impaired.
Tumors affecting the cauda equina, unlike conus tumors,
produce slowly and irregularly progressive clinical
manifestations, as the individual nerve roots are affected
with variable rapidity, and some of them may be spared
until late in the course of the illness.

Examination and Management of the Spine-Injured Patient

The level of the spinal cord and vertebral lesions can be

determined from the clinical findings.

Diaphragmatic paralysis occurs with lesions of the upper

three cervical segments (an unrelated transient arrest of
breathing is common in severe head injury).

Complete paralysis of the arms and legs usually indicates a

fracture or dislocation at C4-C5.

If the legs are paralyzed and the arms can still be abducted
and flexed, the lesion is likely to be at C5-C6

Paralysis of the legs and only the hands indicates a lesion

at C6-C7

The level of sensory loss on the trunk, determined by

perception of pinprick, is an accurate guide to the level of
the lesion

In all cases of SCI our primary concern is that movement

(especially flexion) of the cervical spine be avoided.

The patient should be placed supine on a firm, flat surface

(with one person assigned, if possible, to keeping the head
and neck immobile)

Have the patient remain on the board until a lateral film or

a CT or MRI of the cervical spine has been obtained.

A neurologic examination with detailed recording of

motor, sensory, and sphincter function is necessary to
follow the clinical progress of SCI.

If a cervical spinal cord injury is associated with vertebral

dislocation, traction on the neck is necessary to secure
proper alignment and maintain immobilization.

This is best accomplished by use of a halo brace, which, of

all the appliances used for this purpose provides the most
rigid external fixation of the cervical spine.

This type of fixation is usually continued for 4 to 6 weeks,

after which a rigid collar may be substituted.

Halo Brace

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters

Spinal Cord Tumors

Complete or partial spinal cord transection syndrome

(including conus syndrome and cauda equina syndrome) is
often caused by a tumor.

Spinal cord tumors are classified into three types, based on

their localization
Extradural tumors (metastasis, lymphoma,
Intradural extramedullary tumors (meningioma,
Intradural intramedullary tumors (glioma,
Extradural neoplasms

tend to grow rapidly, often producing progressively severe

manifestations of spinal cord compression: spastic paresis
of the parts of the body supplied by the spinal cord below
the level of the lesion, and, later, bladder and bowel

Pain is a common feature.

Dorsally situated tumors mainly cause sensory

disturbances; lateral compression of the spinal cord can
produce BrownSquard syndrome

Intradural Extramedullary Tumors

Most commonly arise from the vicinity ofthe posterior


They initially produce radicular pain and paresthesiae.

Later, as they grow, they cause increasing compression of

the posterior roots and the spinal cord

The result is a progressively severe spastic paresis of the

limbs, and paresthesiae (particularly cold paresthesiae) in
both limbs

The sensory disturbance usually ascends from caudal to

cranial until it reaches the level of the lesion.

The spine is tender to percussion at the level of the

damaged nerve roots, and the pain is markedly
exacerbated by coughing or sneezing.

Hyperesthesia is not uncommon in the dermatomes

supplied by the affected nerve roots; this may be useful for
clinical localization of the level of the lesion.

As the spinal cord compression progresses, it eventually

leads to bladder and bowel dysfunction.

Ventrally situated tumors can involve the anterior nerve

roots on one or both sides, causing flaccid paresis, e. g., of
the hands (when the tumor is in the cervical region).

Intradural Intramedullary Tumors

Can be distinguished from extramedullary tumors by the

following clinical features:
They rarely cause radicular pain, instead causing
atypical (burning, dull) pain of diffuse
Dissociated sensory deficits can be an early
Bladder and bowel dysfunction appear early in
the course of tumor growth.
The sensory level (upper border of the sensory
deficit) may ascend, because of longitudinal
growth of the tumor, while the sensory level
associated with extramedullary tumors generally
remains constant, because of transverse growth.
Muscle atrophy due to involvement of the
anterior horns is more common than with
extramedullary tumors.

Spasticity is only rarely as severe as that

produced by extramedullary tumors.

High cervical tumors

can produce bulbar manifestations aswell as
fasciculations and fibrillations in the affected
Extramedullary tumors are much more common
overall than intramedullary tumors.
Tumors at the level of the foramen magnum
(meningioma, neurinoma)
often initially manifest themselves with pain,
paresthesia, and hypesthesia in the C2 region
(occipital and great auricular nerves). They can
also cause weakness of the sternocleidomastoid
and trapezius muscles (accessory nerve).

Dumbbell tumors (or hourglass tumors)

So called because of their unique anatomical configuration

These are mostly neurinomas that arise in the

intervertebral foramen and then grow in two directions:
into the spinal canal and outward into the paravertebral

They compress the spinal cord laterally, eventually

producing a partial or complete BrownSquard syndrome.


Extradural neoplasm
Extradural neoplasm
Intradural Extramedullary Tumor
Intradural Intramedullary Tumor



- Dr. Sengs powerpoint lecture

NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters