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SPINAL

CORD INJURY AND COMPRESSION



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
kinds:
Anterior horns contain mostly motor neurons
Lateral horns mostly autonomic neurons, and
Posterior horns mostly somatosensory neurons
participating in a number of different afferent
pathways

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
tail)



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.

Myotomes

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

Dermatomes

Reflects spinal cord's segmental functional organization

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








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

C3,4

C3, 4, 5

C5, 6

C7

C8, T1

T4

T10

L1, 2

L3,4

L5

S1

S2,3,4

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 SPINAL CORD

Diseases of the nervous system may be confined to the


spinal cord, where they produce a number of distinctive
syndromes.

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;


and

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


cord are suspended.
2

Define the level of injury


LEVEL
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


function

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


extremities

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

SPINAL SHOCK

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 &
cremasteric)
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


L2


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
resistance
3 Full range of motion against gravity
2 Movement with gravity eliminated
1 Flicker of movement
0 Total paralysis

SPINAL CORD INJURY



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

DISEASES OF THE SPINAL CORD


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


stenosis



Segmental Radiculopathy

Radiculopathy / myelopathy due to compression by mass


of disc material:

herniation into lateral recess or neural foramen


(posterolateral herniation) spinal root
compression.

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


i)
Central Cord Syndrome
ii)
Anterior Cord Syndrome
iii)
Posterior Cord Syndrome
iv)
Brown Sequard Syndrome
v)
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
fractures

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!

Syringomyelia

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)
Clinically:

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
Clinically:

Proprioception affected ataxia


and faltering gait

Usually good power and sensation



4. Brown Sequard Syndrome:

Hemi-section of the cord

Either due to penetrating


injuries:


i) stab wounds


ii) gunshot wounds

Fractures of lateral mass of


vertebrae
Clinically:

Paralysis on affected side (corticospinal) IPSILATERAL

Loss of proprioception and fine discrimination (dorsal


columns) IPSILATERAL

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
foramina;
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
area.
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,
plasmacytoma)
Intradural extramedullary tumors (meningioma,
neurinoma)
Intradural intramedullary tumors (glioma,
ependymoma)
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
dysfunction.

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


roots

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
localization.
Dissociated sensory deficits can be an early
finding.
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
limb.
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
space.

They compress the spinal cord laterally, eventually


producing a partial or complete BrownSquard syndrome.

A.
B.
C.
D.

Extradural neoplasm
Extradural neoplasm
Intradural Extramedullary Tumor
Intradural Intramedullary Tumor

--END--

Reference:

- Dr. Sengs powerpoint lecture

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