Spinal cord injury (SCI



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


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

motor vehicle accident acts of violence Sports Falls Age Goups

Causes 45.4% 14.6% 16.3% 16.8%

Bradom 48% 15% 14% 21%


25-44 year old (26 y/o) 2.4:1 to 4:1 8:1 (urban ratio 3:1)

16-30 years of age 80% are male

Males vs Female White vs. non-white Prevalence


525 per 1 million, or 500- 900 per million. Thus, 128941 persons, to the national incidence 1124 cases per million, varies between 7,000 or 276,057 persons. to 10,000 , the The most recent survey prevalence of 150,000estimated 721 per 1 200,000. million or 176,965 29.4 persons in 1 million to cases per 1998. Less 55 per million person per than 5000 are 50 cases per million year with 35 per million estimated to be per year surviving long institutionalized. enough to be hospitalized.

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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
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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
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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 anteriorinferior 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

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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 Fractures
Wedge fx of anterior vertebral body High percentage of injuries occur from C4-C7 and from T12L2

Potential Associated Injuries
Tearing of posterior ligaments. Fractures of posterior elements Disruption of disk Anterior dislocation of vertebral body.





4. 5.

Hyperextension Injury

Strong Posterior force such as rearend collision. Falls with chin hitting a stationary object

Hyperextension Injury

Associated Fractures
Fractures of posterior elements. Avulsion fx of anterior aspect of vertebrae.

Potential Associated Injury
Rupture of ALL. Rupture of disk.


2. 3.


Compression Injury
Vertical or axial blow to head (e.g diving, surfing, or falling objects)  Closely associated with flexion injuries.

Compression Injury

Associated Fractures
Concave fx of endplate Explosion or burst fx (comminuted). Teardrop fx.

Potential Associated Injury
Bone fragments may lodge in cord. Rupture of disk.






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 Fractures
Fracture of posterior pedicles, articular facets, and laminae.

Potential Associated Injury
Rupture of posterior and interspinous ligaments. Subluxation or dislocation of facet joints. 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

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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
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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
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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


Are strip-like areas of the skin innervated by a single nerve root.

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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

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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


Each muscle in the body is supplied by a particular level or segment of the spinal cord and by its corresponding spinal nerve


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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.

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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 C1-C6 C1-T1 C3-C5 C5, C6 Function Neck Flexors Neck Extensors Diaphragm Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates).

Segmental Spinal Cord and Function
C6, C7 C7, T1 T1-T6 T7-L1 L1-L4 Extends elbow and wrist (triceps and wrist extensors); pronates wrist Flexes wrist and supply small muscles of the hand Intercostals and trunk above the waist Abdominal Flexion Thigh Flexion

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

Motor function
Tetraplegia: loss of all motor function from the neck down

Sensory function Respiratory fxn.
Loss of all sensory function in the neck and below (C4 supplies the clavicle) Loss of involuntary and voluntary respiratory function; ventilatory support and a tracheostomy needed

Motor function
Tetraplegia: Loss of all function beow the upper shoulders Intact: SCM, cervical paraspinal mm., trapezius; can control head.

Sensory function Respiratory fxn.
Loss of all sensation Phrenic nerve below the clavicle intact but not the and most portions of intercostal muscles the arms, hands, chest, abdomen, and LE Intact: head, shoulders, deltoid, clavicle, portions of the forearms.

Motor function
Tetraplegia: Loss of al function below the shoulders and upper arms; lacks elbow, forearm, and hand control. Intact: deltoid, biceps, ER mm. of shoulders.

Sensory function Respiratory fxn.
Loss of everything listed for a C5 lesion, but greater arm and thumb sensation Intact: head, shoulders, arms, palms of the hands, and thumbs Phrenic nerve intact, but not the intercostal muscles

Motor function
Tetraplegia: loss of motor control to portions of the arm and hands. Intact: voluntary strength in shoulder depressors, abductors, IR mm. and radial wrist extensors

Sensory function Respiratory fxn.
Loss of sensation below the clavicle and portions of the arms and hands. Intact: head, shoulders, most of the arms and hands. Phrenic nerve intact, but not the intercostal muscles

Motor function
Tetraplegia: loss of motor control to portions of the arms and hands. Intact: some voluntary control of elbow extensors, wrist, finger extensors and finger flexors.

Sensory function Respiratory fxn.
Loss of sensation Phrenic nerve below the chest and intact, but not the in portions of the intercostal muscles hands. Intact: sensation to face, shoulders, arms, hands, and a part of the chest.

Motor function
Paraplegia: loss of everything below the midchest region, including the trunk mm. Intact: control of fxn. to shoulders, upper chest, arms and hands.

Sensory function Respiratory fxn.
loss of sensation below the midchest area Intact: everything to the midchest region including the arms and hands. Phrenic nerve functions independently Some impairments of the intercostals

Motor function
Paraplegia: loss of motor control below the waist Intact: shoulders, arms, hands, and long trunk muscles.

Sensory function Respiratory fxn.
Loss of everything below the waist Intact: shoulders, chest, arms, and hands. No interference with respiratory function

Motor function
Paraplegia: loss of control to most of the legs and pelvis. Intact: shoulders, arms, hands, torso, hip rotation and flexion, and some leg flexion.

Sensory function Respiratory fxn.
Loss of sensation to No interference the lower abdomen with respiratory and legs. function. Intact: all sensations above the lower abdomen plus some sensation to the inner and anterior thigh.

Motor function Sensory function Respiratory fxn.
Paraplegia: loss of control of portions of lower legs, ankles, and feet. Intact: all of the above, plus increased knee extension. Loss of sensation to No interference portions of the with respiratory lower legs, feet, function. and ankles Intact: al of the above, plus sensations to the upper legs.

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
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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)



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


Signs & Symptoms

Motor & Sensory Impairments, Spasticity, Bladder & Bowel Dysfunction, Sexual Dysfunction


weakness in hand, foot, arm

& leg •Speech, swallowing, walking difficulty •Atrophy & Fasciculations •Depressed mm stretch reflexes •Muscle cramping


weakness, poor mm tone, weak cry, limpness or tendency to flop, difficulty sucking/swallowing



pain •Sphincter & Bowel Dysfunction

& Numbness •Slipping sensation when moving into an upright position (SPINA BIFIDA OCCULTA) •Dimple, depression, birthmark, hairy patch over the affected part (SPINA BIFIDA MANIFESTA) •Swelling over the affected spine/ exposed spinal nerves @ the back


& Weakness •Cramping or pain in legs, feet or buttocks



paresthesia, gait difficulty, optic neuritis, diplopia, ataxia, disturbed nutrition, vertigo



•Seizures •Frequent

nausea & vomitting •Loss of balance/trouble walking
•Seizures •Headaches


that worsen with time •Memory loss •Changes in vision, such as seeing double or blurriness •Hearing loss •Weakness in your arms/legs


in the abdomen, neck or


chest •Bulging eyes •Dark circles around the eyes (“black eyes”) •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)




severe blow to the spine. (Car accident, fall, gunshot, or sporting accident. Sometimes the SC is damaged by infection/spinal stenosis



of a specific gene, the SOD1 gene.


upper and lower motor neuron that causes degeneration of throughout the brain & SC.


of the SMN1 gene Only a portion of one from chromosome 5 limb such as forearm & hand, shoulder or thigh



(Spondylolisthesis) bone. I. Dysplastic- inf. L5 (Spondylosis) facet 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”)

fracture of the


to the natural process of spinal degeneration that occurs with aging, caused by spinal disc herniation, osteoporosis or a tumor.




system attacks Nerve cells in the brain the central nervous and in the spinal cord system leading to demyelination


cells form in 4th ventricle and the tissues of the brain septum pellucidum in and spinal cord the spinal cord


are inactivation mutations in the neurofibromatosis 2 gene ; radiation



cells form in Abdomen, chest, spinal the nerve tissue of the cord, neck, head, adrenal gland, neck, Hip and legs chest or spinal cord



when the tissue surrounding the developing spinal cord of a fetus doesn’t close properly





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

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Assist in maintaining the position of the diaphragm Decreased ERV Decrease cough effectiveness

External Oblique
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Normal Function: Depresses the ribs and compresses the chest wall. Decrease the ability to cough and expel secretion.

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.

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Hypercalcemia d/t immobilization in bone resorption. Exceeds the ability of the kidney to excrete calcium.


Bladder dysfunction
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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.

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.


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.

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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
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Above the lesion of level Frequently involve shoulder joint Related to: faulty positioning -inadequate ROM -tightening of joint capsule and surrounding tissue.

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