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Spinal Cord Injury: Causation & Pathophysiology

Spinal Cord Injury: Causation & Pathophysiology

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05/21/2015

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vol 12 no 9 february 2005
emergency nurse
 
29
clinical
This article has been subjectedto double blind peer review
T
he incidence of spinal cord injuryworldwide stands at about 20 newcases per million of population a year(Glass 1999), but is double this figure inthe US (DeVivo 2002).In the western world, the greatestcauses of spinal and spinal cord injuriesare related to risk taking incidents, such asdrink driving and non-adherence to safetyprocedures (DeVivo 2002, Grundy
et al 
2001, Healy
et al 
2004). As such, thesemay be preventable through educativestrategies and by enforcing road safetyand health and safety measures.Spinal cord trauma can lead to differentdegrees of motor and sensory loss. Thisarticle will examine the effects of injuryevents on the spinal cord by relating thebiomechanics of injury to the anatomy ofthe vertebral column.It will also consider the neurologicalsequellae of injury and describe some ofthe presentations classified under the Inter-national Standards for Neurological Class-ification of Spinal Cord Injury (AmericanSpinal Injury Association 2002).
THE VERTEBRAL COLUMN
There are three points along the vertebralcolumn that are particularly susceptibleto injury: the junctions of C7 and T1and that of T12 and L1, and vertebraT7. To understand why these areas aresusceptible, it is important to be familiarwith the anatomy of the vertebralcolumn.The vertebral column comprises 33 vert-ebrae that are held firmly together byligaments forming a ‘fortress’ around thespinal cord.Most of the vertebrae conform to thestandard model, with a large vertebralbody, spinous and transverse processes,laminae and pedicles.Those of the upper cervical spinehowever, namely the atlas and the axis,and those in the sacrococcygeal region,are unusual.The upper cervical spine is the only regionwhere significant rotation is needed. This isfacilitated by the odontoid, or peg, processthat protrudes upwards from the body ofthe axis and articulates with a facet on theposterior surface of the anterior ring of theatlas, acting as a pivot for the latter.The vertebrae in the sacrococcygealregion, meanwhile, are fused into a solidmass, but with intervertebral foraminapersisting between the sacral vertebrae.The spinal column is comprised of morethan bone. Each vertebra must articulatewith other vertebrae and bones, and thereneeds to be some flexibility and mobilityin the intervertebral joints. This is providedby the intervertebral discs between the junction of C1 and C2 and that of L5 andS1, which also help to absorb shock.There are eight types of spinal ligaments,which connect vertebrae throughout thecolumn, either to other vertebrae or toother bone such as the ribs, and help tokeep the column stable (Table 1).
SPINAL CORD INJURY: CAUSATIONAND PATHOPHYSIOLOGY
In the second of three articles on spinal cord injury,
FINTAN SHEERIN
describes some of the causesand effects of spinal cord trauma
Fintan Sheerin BNS, PgDipEd,RMHN, RGN, RNT is a lecturerpractitioner in spinal cord injury,National Spinal Injuries Unit,Mater Misericordiae UniversityHospital, Dublin, and schoolof nursing and midwifery,University College Dublin
Table 1. Types of spinal ligament
>
Ligamentum flavum: between laminae
>
Supraspinous ligament: between the tips of spinous processes
>
Interspinous ligament: between spinous processes
>
Anterior longitudinal ligament: on the anterior surface connecting the body ofone vertebra to that of another
>
Posterior longitudinal ligament: on the posterior surface connecting body to body
>
Intertransverse ligament: between transverse processes
>
Ligamentum nuchae: between cervical spinous processes
>
Radiate ligaments: connecting vertebrae to ribs.Schneck 2002
 
clinical
30
emergency nurse
vol 12 no 9 february 2005
Cervical region
Of the five regions, the cervical is most flex-ible and mobile. The vertebrae here are smallwith superior articular facets facing posterio-medially and upwards (Barker 2001).The nearly horizontal direction of thespinous processes in this region allowsfor greater extension, with the exceptionof C1 and C2, which articulate differentlyand which have only rudimentary spinousprocesses.Force applied to the cervical spine doesnot always result in localised vertebraldamage, however, because the flexibilityof the region, and the ability of the neck tomove in anteriorposteriolateral directions,can help transfer the force downwards tothe thoracic spine where there is little orno flexibility.
Thoracic region
The thoracic spine has larger vertebraeand thinner interverterbal discs than thecervical region, and has inferiorly directedspinous processes (Tortora and Grabowski1996). The superioposteriolateral orient-ation of superior articular facets and thearticulation with the ribs create a relativelyrigid and immobile structure (Chiles andCooper 1996).The junction between C7 and T1 representthe border between the flexible cervicalspine and the rigid thoracic spine, and isthe most susceptible to vertebral columndamage. This is because, when force isapplied to the cervical spine, it is directeddownwards because of the latter’s flexibility,and is focused on the cervical-thoracic junction. The region must be examined onX-ray therefore before it is given the all-clear(Prendergast and Sullivan 2000, Walker1998, Young and Shea 1998).A similarly important junction existsbetween T12 and L1, which is betweenthe rigid thoracic and more mobile lumbarregions. This is the second most common siteof spinal injury (Chiles and Cooper 1996).Another significant injury site is T7,the apex of the largest primary curve ofthe vertebral column. Primary curves areremnants of the spinal curve present atbirth (Sheerin 2004).This vertebra is at risk of injury because itprovides a ‘buckling’ point if compressiveforces are applied directly along the axialskeleton.The vertebral column can be describedtherefore as a stable structure that supportsthe upper appendicular skeleton and head,while protecting the delicate neurologicaltissues of the spinal cord.It can be divided into five principleregions: cervical, thoracic, lumbar, sacraland coccygeal. Each has specific structuralvariations and properties (Fig. 1).The cervical and thoracic regions are themost common sites of spinal injury.
Fig. 1. Vertebral column divisions and characteristics
Cervical
>
flexible
>
allows movement
>
seven verterbrae
>
small bones
Thoracic
>
inflexible and rigid
>
allows little movement
>
12 verterbrae
>
larger bones
Lumbar
>
slightly flexible
>
allows some movement
>
five verterbrae
Sacral
>
inflexible: fused
>
no movement
>
five verterbrae
   P   E   T   E   R   G   A   R   D   E   N   E   R
Coccygeal
 
clinical
vol 12 no 9 february 2005
emergency nurse
 
31
CAUSATION OF SPINAL CORD INJURY
The main causes of spinal cord injury fallinto the following categories:
> 
Traumatic:
motor vehicle accidents(MVAs), falls, sports injuries, objectsfalling onto the head, assault
> 
Non-traumatic:
degenerative, infectiveor oncogenic spinal lesions.Of the principal mechanisms of injury,however, MVAs (Guin 2001) and falls(DeVivo 2002) account for the vastmajority.
Motor vehicle accidents
Motor vehicle accidents account foraround 39 per cent of spinal cord injuriesin the UK (Harrison 2004).The mechanism of injury in MVAscan be simple or can involve a complexcombination of forces focused on thevertebral column. These forces are limitedby safety devices such as side impact bars,airbags and head rests.When a vehicle is travelling at, say,70mph, everything in the vehicle,including the driver, is travelling at thesame speed. The impact of the vehiclewith another vehicle or object leads to asudden deceleration to 0mph. Because it issecured to the vehicle by the seatbelt, thedriver’s body achieves this sudden velocitychange, but the head does not.Instead, the head continues to travelforward until the vertebral structureprevents it from any further displacement.It then travels downwards causing severedistraction – or pulling apart – of theposterior vertebral column, and damageto the ligamentous complex between,and covering, the spinous processes: ahyperflexion injury.At the same time, there is severecompression along the anterior vertebralcolumn with the potential for vertebralbody damage (Fig. 2). The force of theforward moving vehicle creates an equaland opposite force when it suddenly stops.This violently ‘whips’ the driver’s head andneck in the opposite direction.If the headrest is absent or ineffective, thedriver’s head moves back over the upper edgeof the seat and then downwards leadingto severe anterior distraction with anteriorlongitudinal ligamentous damage, andposterior compression with fractures of thespinous processes: a hyperextension injury.These two events allow the vertebraeto ‘ride over’ those below them, resultingin spinal cord contusion or transectioncaused by the loss of vertebral alignment.These injuries usually involve the lowcervical region, namely C5 to C7 (Hickey2003).It is important to remember that duringan MVA there may be other forces at playthat can cause different injuries. If thevehicle turns over for example, the driver’shead can rotate leading to displacementof facet joints.The forces involved in MVAs can causesuch severe damage to vertebrae C1 andC2 that the cord is affected, so that theperson involved cannot self-ventilate. Insuch circumstances, death is the mostcommon outcome (Schoen 2000).
Fig. 2. Mechanism of injury in motor vehicle accidents
   H   A   R   R   I   S   O   N

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