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Epidemiology

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mean age 33 yrs 75% males

Predisposing factors
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degenerative disease of spine spinal canal stenosis ankylosing spondylitis Down's syndrome Klippel-Feil syndrome Arnold-Chiari malformation metastatic CA osteomyelitis rheumatoid arthritis

Pathophysiology
25% of spinal cord injuries occur after primary injury Primary injury Results from focal injuries (eg avulsion, contusion, laceration and intraparenchymal haemorrhage) and diffuse lesions (eg concussive and diffuse axonal injury). Further mechanical disruption can result from external compression or angulation and ischaemic damage from occlusion of arterial supply Secondary injury Results from:
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Cellular hypoxia Oligaemia o Immediately after an acute spinal cord injury major reduction in blood flow occurs at the level of the lesion. Becomes progressively worse over the first few hours if left untreated. Pathophysiology underlying this ischaemia is unclear but involves both systemic and local effects. Putative local mechanisms include vasospasm, endothelial

Thereafter remains near normal during first 24 hours  Central grey matter perfusion remains low for at least first 24 hours Oedema due to an injury-induced neurochemical cascade Exacerbated by hypotension Site of injury Most likely to occur at sites of maximum mobility • • Adults C6 Children <8 yrs old C2 Clinical features • • • • "level" of cord lesion is conventionally the most caudal location with normal motor and sensory function spinal shock may mimic a complete cord lesion with total loss of motor and sensory function distal to injury. However if lesion is incomplete some function will return 99% of patients with a complete lesion over 24 h will not show functional recovery patients with partial lesion may regain substantial or even normal neurological function even though the initial neurological deficit may be severe .• swelling or damage. Central grey matter. along with adjacent white matter is more severely affected than peripheral white matter.  White matter perfusion typically decreases within 5 minutes of injury and begins to return to normal within 15 mins. o Systemic hypotension can cause further decreases in spinal cord blood flow but induced hypertension may not necesssarily reverse the ischaemia. haemorrhage causing obstruction of small blood vessels. loss of autoregulation and impaired venous drainage. It may instead cause marked hyperaemia in adjacent parts of the spinal cord o Pattern of decreased perfusion within the spinal cord differs.

• presence of bulbocavernous reflex (contraction of anal sphincter on pinching penile shaft) or anal-cutaneous reflex (contraction of anus in response to stroking of perianal skin) indicates sacral sparing and a more favourable prognosis .

Neurogenic shock Neurogenic shock is manifested by the triad of hypotension. In a study showing a high incidence of autonomic dysfunction. and sometimes sustained priapism develops.Injury to the spinal cord in the cervical region. Spinal shock Spinal shock is a state of transient physiologic (rather than anatomic) reflex depression of cord function below the level of injury. bradycardia. including of the bowel and bladder. These symptoms tend to last several hours to days until the reflex arcs below the level of the injury begin to function again (eg. including orthostatic hypotension and impaired cardiovascular control. The different clinical presentations of the above causes of tissue damage are explained further below.Definitions and Pathophysiology Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change. sensory. in the neurologic evaluation of patients with SCI. Shock tends to occur more commonly in injuries above T6. lumbar. it was recommended that an assessment of autonomic function be routinely used. Neurogenic shock needs to be differentiated from spinal and hypovolemic shock. secondary to the disruption of the sympathetic outflow from T1-L2 and to unopposed vagal tone. or autonomic function.1. or sacral segments. is observed. and hypothermia. Flaccid paralysis. with associated loss of all sensorimotor functions. following SCI. is noted. Hypovolemic shock tends to be associated with tachycardia. along with American Spinal Injury Association (ASIA) assessment. Autonomic dysreflexia See the article Autonomic Dysreflexia in Spinal Cord Injury.2 The following terminology has developed around the classification of SCI: • • Tetraplegia (replaces the term quadriplegia) . hematoma. including the cauda equina and conus medullaris SCI can be sustained through different mechanisms. with associated vascular dilatation. with the following 3 common abnormalities leading to tissue damage: • • • Destruction from direct trauma Compression by bone fragments.3 .Injury in the spinal cord in the thoracic. either temporary or permanent. leading to a decrease in vascular resistance. muscle stretch reflex [MSR]). followed by hypotension. An initial increase in blood pressure due to the release of catecholamines. with associated loss of muscle strength in all 4 extremities Paraplegia . or disk material Ischemia from damage or impingement on the spinal arteries Edema could ensue subsequent to any of these types of damage. The International Standards for Neurological and Functional Classification of Spinal Cord Injury is a widely accepted system describing the level and extent of injury based on a systematic motor and sensory examination of neurologic function. in its normal motor. bulbocavernosus reflex.

Incomplete: Sensory. causes a relatively greater ipsilateral proprioceptive and motor loss.4 • • Complete . the terms paraparesis and quadriparesis now have become obsolete. Brown-Séquard syndrome. using the following categories1. and most key muscles below the neurologic level have muscle grade greater than or equal to 3.Preservation of sensory or motor function below the level of injury. with contralateral loss of sensitivity to pain and temperature. while the sacral segments occasionally may show preserved reflexes (eg. C . bulbocavernosus and micturition reflexes). C8 ASIA A with zone of partial preservation of pinprick to T2). Other classifications of SCI include the following: • • Central cord syndrome often is associated with a cervical region injury and leads to greater weakness in the upper limbs than in the lower limbs.2. With the ASIA classification system. E . bowel. Definitions of complete and incomplete SCI are based on the above ASIA definition with sacralsparing. and lower limbs. The ASIA classification using the description of the neurologic level of injury is employed in defining the type of SCI (eg. and most key muscles below the neurologic level have muscle grade less than 3.Motor strengths and sensory testing The extent of injury is defined by the ASIA Impairment Scale (modified from the Frankel classification). • • . Conus medullaris syndrome is associated with injury to the sacral cord and lumbar nerve roots leading to areflexic bladder. Perform a rectal examination to check motor function or sensation at the anal mucocutaneous junction. function is preserved below the neurologic level and extends through sacral segments S4-S5. Anterior cord syndrome often is associated with a lesion causing variable loss of motor function and sensitivity to pain and temperature. which often is associated with a hemisection lesion of the cord. D .Complete: No sensory or motor function is preserved in sacral segments S4-S5. with sacral sensory sparing. proprioception is preserved.Incomplete: Motor function is preserved below the neurologic level.Absence of sensory and motor functions in the lowest sacral segments Incomplete .4 B . including the lowest sacral segments Sacral-sparing is evidence of the physiologic continuity of spinal cord long tract fibers (with the sacral fibers located more at the periphery of the cord).Incomplete: Motor function is preserved below the neurologic level. Indication of the presence of sacral fibers is of significance in defining the completeness of the injury and the potential for some motor recovery. The presence of either is considered sacral-sparing. but not motor.1.Normal: Sensory and motor functions are normal. This finding tends to be repeated and better defined after the period of spinal shock.2 : • • • • • A .

and the corresponding level of injury is indicated: • • • • • • • • • • C5 ..Medial side of antecubital fossa T2 .Supraclavicular fossa C4 . no matter how briefly that strength is maintained during the examination.Wrist extensors (extensor carpi radialis longus and brevis) C7 . The muscles are tested with the patient supine.Ankle plantar flexors (gastrocnemius.No movement Muscle strength always should be graded according to the maximum strength attained.Third intercostal space (IS) T4 . leading to areflexic bladder.Long toe extensors (extensors hallucis longus) S1 .Elbow flexors (biceps. The following key muscles are tested in patients with SCI.Ankle dorsiflexors (tibialis anterior) L5 .Knee extensors (quadriceps) L4 . brachialis) C6 .• Cauda equina syndrome is due to injury to the lumbosacral nerve roots in the spinal canal.Middle finger C8 .Submaximal movement against resistance 4 .Lateral side of antecubital fossa C6 .Movement with gravity eliminated 1 .Flicker of movement 0 .Top of the acromioclavicular joint C5 .Sixth IS at the level of the xiphisternum .Hip flexors (iliopsoas) L3 .Normal power 4+ .Apex of axilla T3 .Occipital protuberance C3 . bowel.Small finger abductors (abductor digiti minimi) L2 . Muscle strength is graded using the following Medical Research Council (MRC) scale of 0-5: • • • • • • • • 5 . soleus) Sensory testing is performed at the following levels: • • • • • • • • • • • • • C2 .Elbow extensors (triceps) C8 . and lower limbs.Little finger T1 .Slight movement against resistance 3 .Moderate movement against resistance 4.Thumb C7 .Movement against gravity but not against resistance 2 .Fourth IS at nipple line T5 .Finger flexors (flexor digitorum profundus) to the middle finger T1 .Fifth IS (midway between T4 and T6) T6 .

Absent 1 . Motor level . with motor level as defined above and sensory level defined by a sensory score of 2 Zone of partial preservation .Most caudal dermatome with a normal score of 2/2 for pinprick and light touch Sensory index scoring .Perianal area (taken as 1 level) Sensory scoring is for light touch and pinprick.Medial femoral condyle L4 .Ninth IS (midway between T8 and T10) T10 .Midanterior thigh L3 .Using the 0-5 scoring of each key muscle.Determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5) Motor index scoring .Seventh IS (midway between T6 and T8) T8 .Level of the greatest vertebral damage on radiograph Lower extremities motor score (LEMS) .Midpoint of inguinal ligament L1 . with total points being 25 per extremity and with the total possible score being 100 Sensory level .Dorsum of the foot at third metatarsophalangeal joint S1 .Impaired or hyperesthesia 2 . A LEMS of 20 or less indicates that the patient is likely to be a limited ambulator. as follows: • • • 0 .Popliteal fossa in the midline S3 .) Skeletal level of injury .Half the distance between T12 and L2 L2 .• • • • • • • • • • • • • • • T7 . with a total possible score of 50 (ie. L4. and S1] per extremity).Total score from adding each dermatomal score with possible total score (= 112 each for pinprick and light touch) Neurologic level of injury .Eighth IS (midway between T6 and T10) T9 .Intact A score of zero is given if the patient cannot differentiate between the point of a sharp pin and the dull edge.Ischial tuberosity S4-5 .Most caudal level at which motor and sensory levels are intact.11th IS (midway between T10 and T12) T12 .Lateral heel S2 .Uses the ASIA key muscles in both lower extremities. .Medial malleolus L5 . L5. A LEMS of 30 or more suggests that the individual is likely to be a community ambulator.10th IS or umbilicus T11 . L3. maximum score of 5 for each key muscle [L2.All segments below the neurologic level of injury with preservation of motor or sensory findings (This index is used only when the injury is complete.

which in turn is higher than among Hispanics. medical.5. 66.1%.6%.1%. • • Other causes of SCI include the following: • • • • • • • Vascular disorders Tumors9 Infectious conditions Spondylosis Iatrogenic injuries.Such injuries are responsible for many cases of SCI. SCI from a penetrating injury tended to be worse than that from a blunt injury. Older females with osteoporosis have a propensity for vertebral fractures from falls with associated spinal cord injury.8%.000 to 230.This is the most common cause of SCI in some urban settings in the United States.Epidemiology Spinal cord injury (SCI) due to trauma is not a common condition. as well as an important effect on the individual's psychosocial well-being. the incidence of SCI among whites is higher than among African Americans. and 1% in other populations. 8.1%) .000 cases per year in the United States. in Native Americans. Falls (18. in Asians. Spondylosis is also a common cause of SCI. Studies indicate that in the United States. the equivalent of 700-900 cases per million population. especially after spinal injections and epidural catheter placement Vertebral fractures secondary to osteoporosis Developmental disorders No statistical/epidemiologic data have been compiled for the occurrence of nontraumatic SCI.5%) .These are the major cause of traumatic SCI in the United States. or 10.4% of SCIs occur in whites.6. 1. but it has major functional.7 The most common causes of SCI include the following: • • Motor vehicle accidents (44. 1. The incidence of traumatic SCI in the United States is 30-60 new cases per million population. Violence (16. Traumatic SCI is more common in persons younger than 40 years. 21.7%) . in African Americans. and financial effects on the injured person. although a trend toward a slight decrease in violence-related SCI has been found.These are most common in persons at or above age 45 years. . Some sources cite 8 cases per 10.000 population per year.6%) . in Hispanics. One study showed that among patients who had suffered an assault. The sport that most commonly leads to SCI is diving. Race In the United States. while nontraumatic injury is more common in persons older than 40 years. but cancer alone may account for more SCI than does trauma.000 cases in the United States.8 Sports injuries (12. Figures on estimated prevalence vary from approximately 183.

In a study on pediatric SCI by Vitale and colleagues.36 per 100.99 cases per 100.14% Firearm injuries . with regard to the annual incidence rate of pediatric SCI. Marital status Single persons sustain SCIs more commonly than do married persons. while the mean age is 31.4 years. males constitute about 80% of persons with SCI. while nontraumatic SCI is more common in persons older than 40 years. The overall incidence of pediatric SCI is 1.0 case per 100.000 children. Also. Age More than 50% of all cases of SCI occur in persons aged 16-30 years. The marriage rate after SCI is annually about 59% below that of persons in the general population of comparable gender. and the mode age at injury is 19 years. The frequency in Asians was significantly lower than that in all other races (0.000 children).7% of those injured in a motor vehicle accident were not wearing a seatbelt.000 children).10 A significantly greater incidence of pediatric SCI was found in African Americans (1. Associated injuries Other injuries are often associated with traumatic SCI.8 years. it was found that. and traumatic brain injury affecting emotional/cognitive functioning (11. respectively).79 cases per 100.9% Sports injuries . Alcohol and drugs were found to have played a role in 30% of all pediatric SCI cases.53 cases per 100. 1455 children are admitted to US hospitals annually for SCI treatment.5%). one third will remain single 20 years postinjury.000 US children.8%).000 children vs 1. 67.000 children) than in Native Americans (1. ie. The median age is 26. loss of consciousness (17. and marital status. including bone fractures (29. As estimated from the above data. Research has indicated that among persons with SCI whose injury is approximately 15 years old.3%). with the following incidences reported10 : • • • • Motor vehicle accidents . Vitale and coauthors looked at the major causative factors of pediatric SCI as well. the likelihood that boys would suffer SCI was found to be more than twice that of girls (2.56% Accidental falls .7% Among children in the study. . age. using information from the Kids' Inpatient Database (KID) and the National Trauma Database (NTDB).15 cases per 100. Traumatic SCI is more common in persons younger than 40 years.87 case per 100. Greater mortality is reported in older patients with SCI. there were significant differences between patient populations (as stratified by race and sex).Sex The male-to-female ratio of individuals with SCI in the United States is 4:1.000 children) and Hispanics (0.

while the rate of marriages contracted after the injury is about 1. and was previously divorced.2. as follows: • • • • • • Less than a high school degree at 39. The most common day on which SCIs occur is Saturday. ambulatory.5% Complete paraplegia .7 times that of the general population. T12 is the most common level. Educational status The rate of injury differs according to educational status. paraplegic (not tetraplegic). African American.5. has less than a college education. previously divorced.1. Season SCIs occur most frequently in July and least commonly in February.18.21. and C6. Substance abuse The rate of alcohol intoxication among individuals who sustain SCI is 17-49%. living in a private residence.1% Other degree . which may be due to the increased frequency of motor vehicle accidents and of diving and other recreational sporting accidents during the day. nonambulatory.5 times that of the general population.9% Incomplete paraplegia .9% Associate degree . and previously divorced.8% High school degree . . has a thoracic level injury. without children. Injuries by ASIA classification • • • • Incomplete tetraplegia .6% Bachelors degree . Level and type of injury The most common levels of injury on admission are C4. and independent in the performance of activities of daily living (ADL). Marriage is more likely if the patient is a college graduate. while the level for paraplegia is the thoracolumbar junction (T12).5% The most common neurologic level of injury is C5.0.27. The divorce rate among persons with SCI who were married at the time of injury is higher if the patient is younger. In paraplegia.29. The most common type of injury on admission is ASIA level A.49. C5 (the most common). female.9% Masters or doctorate degree . The divorce rate among those who were married after the SCI is higher if the individual is male.The divorce rate annually among individuals with SCI within the first 3 years following injury is approximately 2.3% Complete tetraplegia . SCIs occur more frequently during daylight hours.7%.

greater functional capacity. the leading cause of death is suicide. especially after more elapsed time following injury. and less severe injury. while among persons with complete paraplegia. the leading causes of death are cancer and suicide (1:1 ratio). Persons employed tend to work full-time. there had been only a small. less severe injury. B.13 A 2006 study by Strauss and colleagues reported that among patients with SCI. male. statistically insignificant reduction in mortality in the post 2-year period for these patients. followed by heart disease. Leading cause of death The leading causes of death in patients following SCI are pneumonia and other respiratory conditions. and white and who have more formal education. nonviolent injury. Among patients with incomplete paraplegia. greater motivation to return to work. Studies have found that patients with SCI who suffer from pain have less life satisfaction than do patients in whom pain is well controlled.12. Life expectancy Approximately 10-20% of patients who have sustained an SCI do not survive to reach acute hospitalization. history of employment at the time of injury. and septicemia. the suicide rate is higher among individuals who are younger than 25 years.Employment Patients with SCI classified as ASIA D are more likely to be employed than individuals with ASIA A.11 The likelihood of employment after injury is greater in patients who are younger.18 In persons with SCI. .15. and 13 years (patients with paraplegia).16 Suicide and alcohol-related deaths are also major causes of death in patients with SCI.17. while about 3% of patients die during acute hospitalization. Individuals who return to work within a year of injury tend to return to the same job. 39 years (patients with low tetraplegia). 9 years (patients with low tetraplegia). this may also affect the patients' general outlook on life. The annual death rate for patients with acute SCI is 750-1000 deaths per year in the United States. Patients aged 20 years at the time they sustain an SCI have a life expectancy of approximately 33 years (patients with tetraplegia). followed by heart disease. and C. during the critical first 2 years following injury. Those individuals who return to work after a year of injury tend to work for a different employer at a different job requiring retraining. and ability to drive are more likely to return to work. a 40% decline in mortality occurred between 1973 and 2004.14 The study also found that during that same 31-year period. Individuals aged 60 years at the time of injury have a life expectancy of approximately 7 years (patients with tetraplegia). higher reported intelligence quotient (IQ). or 44 years (patients with paraplegia). Patients with greater functional capacity. subsequent trauma.