SPINAL CORD INJURIES

Anatomy & Pathophysiology

J C King

Definition
Insult to spinal cord resulting in a change,
in the normal motor, sensory or autonomic
function. This change is either temporary
or permanent.

Mechanisms:
i) Direct trauma
ii) Compression by bone fragments /
haematoma / disc material
iii) Ischemia from damage / impingement
on the spinal arteries

Statistics:
National Spinal Cord Injury Database
{ USA Stats }
MVA
44.5%
Falls
18.1%
Violence
16.6%
Sports
12.7%
55% cases occur in 16 30yrs of age
81.6% are male!

South African Statistics (GSH Acute Spinal Cord

Injury Unit 2007)
MVA
56%
Falls
16%
Gunshot Injuries
11%
Blunt Assault
6%
Diving Accidents
5%
Stab Wounds
4%
Sport Injuries
3%

Other causes:
Vascular disorders
Tumours
Infectious conditions
Spondylosis
Iatrogenic
Vertebral fractures secondary to osteoporosis
Development disorders

Anatomy :
Spinal cord:
Extends from medulla oblongata L1
Lower part tapered to form conus
medullaris

On the surface :
Deep anterior median fissure
Shallower posterior median sulcus
Spinal cord segment :
Section of the cord from which a pair of
spinal nerves are given off

Hence:

31 pairs of spinal nerves:

8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal

 Dorsal root sensory fibres

Ventral root motor fibres
Dorsal and ventral roots join at
intervertebral foramen to form the spinal
nerve

Physiology and function

Grey matter sensory and motor nerve cells
White matter ascending and descending
tracts
Divided into - dorsal
- lateral
- ventral

Tracts :

1) Posterior column:
Fine touch
Light pressure
Proprioception

2) Lateral corticospinal tract :

Skilled voluntary movement
3) Lateral spinothalamic tract :
Pain & temperature sensation

 Posterior column and lateral corticospinal

tract crosses over at medulla oblongata
Spinothalamic tract crosses in the spinal
cord and ascends on the opposite side

NB to understand this as it helps to

understand the clinical features of injury
patterns and the neurological deficit

Dermatomes
Area of skin innervated by sensory axons
within a particular segmental nerve root
Knowledge is essential in determining
level of injury
Useful in assessing improvement or
deterioration

Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
2007 Elsevier

Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
2007 Elsevier

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

Spinal Cord Injury Classification

Quadriplegia :
injury in cervical region
all 4 extremities affected
Paraplegia :
injury in thoracic, lumbar or sacral
segments
2 extremities affected

Injury either:
1) Complete

2) Incomplete

Complete:
i) Loss of voluntary movement of parts
innervated by segment, this is
irreversible
ii) Loss of sensation
iii) Spinal shock

Incomplete:
i)

Some function is present below site of

injury
ii) More favourable prognosis overall
iii) Are recognisable patterns of injury,
although they are rarely pure and
variations occur

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 Shock vs Neurogenic Shock

Spinal Shock :
Transient reflex depression of cord function below level
of injury
Initially hypertension due to release of catecholamines
Followed by hypotension
Flaccid paralysis
Bowel and bladder involved
Sometimes priaprism develops
Symptoms last several hours to days

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

 Loss of vasomotor tone pooling of blood

Loss of cardiac sympathetic tone bradycardia
Blood pressure will not be restored by fluid
infusion alone
Massive fluid administration may lead to
overload and pulmonary edema
Vasopressors may be indicated
Atropine used to treat bradycardia

Types of incomplete injuries

i)

Central Cord Syndrome

ii)

Anterior Cord Syndrome

iii) Posterior Cord Syndrome

iv) Brown Sequard Syndrome
v)

Cauda Equina Syndrome

i)

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

ii) Anterior cord Syndrome:

Due to flexion / rotation
Anterior dislocation / compression fracture
of a vertebral body encroaching the
ventral canal
Corticospinal and spinothalamic 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

ii) 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

iv) 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)
Loss of proprioception and fine
discrimination (dorsal columns)
Pain and temperature loss on the opposite
side below the lesion (spinothalamic)

v) Cauda Equina Syndrome:

Due to bony compression or disc protrusions

in lumbar or sacral region
Clinically
Non specific symptoms back pain
- bowel and bladder dysfunction
- leg numbness and weakness
- saddle parasthesia

In conclusion;
Spinal Cord Injuries:
Devastating event to both patient and
family.
Huge impact on society
After receiving First World care in
tertiary institutions, many of our patients
return to impoverished communities
Here they face huge challenges in terms of
survival

thank you

References:
1. Andrew T Raftery, et al. Applied Basic Science for
Basic Surgical Training. Second edition 2008;8:219223
2. ATLS, et al. Student Course Manual. 7th Edition
2004;7:177-204
3. Keith L Moore et al. Clinically Orientated Anatomy. 3rd
Edition1992;4:359-369
4. Segun T Dawodu et al. eMedicine Specialities. March
2009
5. K Frielingsdorf, R N Dunn et al. SAMJ. March
2007,Vol. 97,No. 3