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Anatomy of the Spine

and the Spinal Cord

Dept. of Neurosurgery Hasan Sadikin General


Hospital
Medical School of Padjadjaran University
Bandung

The Spine
Composed of 33
vertebrae
7 cervical
12 thoracic
5 lumbar
5 sacral + 4
coccyx (fused)
Act to support the trunk
and transfer muscular
load
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The Spine

Natural curvature in sagital plane


Cervical lordosis - average of 9o (concave bacwards)
Thoracic kyphosis -average of 39o (concave forwards)
Lumbar lordosis - average of 57o
Thoracic kyphosis of more than 15o over 3 adjacent vertebrae is
considered abnormal
Congenital development
Wedge fractures
Viewed in the coronal plane, should appear symmetrical
Slight scoliosis (curvature in lateral plane) is normal due to
of pure symetry in anatomy

The Spine - Vertebrae


Vertebrae
Irregular bone
Anterior elements - Vertebral body
Thin cortical shell (<1mm) surrounding trabecular
centrum
Posterior elements
- Cortical and lamellar bone
- Superior and inferior articular processes
- Spinosus process
- Transverse processes
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Typical Vertebrae

Regional Characteristics of Vertebrae

Cervical

Body
Small, wide side to side
Spinous process
Short, bifid, projects posteriorly
Vertebral foramina
Triangular
Transverse processes
Contain foramina
Superior & inferior articulating
processes
Superior facets directed
superoposteriorly
Inferior facets directed inferoanteriorly
Movement allowed
Flexion, extension, lateral flexion,
rotation
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Regional Characteristics of Vertebrae

Thoracic

Body
Larger than cervical,heart shaped,bears
two costal demifacets
Spinous process
Long, sharp, projects inferiorly
Vertebral foramen
Circular
Transverse processes
Bear facets for ribs (Except T11&T12)
Superior & inferior articulating
processes
Superior facets directed posteriorly
Inferior facets directed anteriorly
Movement allowed
Rotation, lateral flexion possible but limited
by ribs, flexion & extension prevented

Regional Characteristics of Vertebrae

Lumbar

Body
Massive, kidney shaped
Spinous process
Short, blunt, projects posteriorly
Vertebral foramen
Triangular
Transverse processes
Thin & tapered
Superior & inferior articulating
processes
Superior facets directed posteromedially
(or medially)
Inferior facets directed anterolaterally (or
laterally)
Movement allowed
Flexion & extension ; some lateral flexion,
rotation prevented
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Regional Characteristics of Vertebrae

Sacrum

Composed of five fused sacral vertebrae


Inferior half of the sacrum is not
weightbearing
Provide strength & stability to the pelvis and
transmits the weight of the body to the
pelvic girdle
Sacral canal contains nerve root of the
cauda equina
The sacrum is tilted so that articulates with
L5 vertebrae at the lumbosacral angle which
varies from 130-160o
Pelvic surface is smooth & concave
Dorsal surface is rough & convex
Sacral hiatus results from the absence of
the laminae & spinous process of S5
vertebrae
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Regional characteristics of Vertebrae

Coccyx
Formed by four
rudimentary vertebrae
Remnant of the sceleton
of the tail
Pelvic surface is concave
& smooth
Dorsal surface is convex
& rough

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Abnormal Fusion of Vertebrae


Approximately 5% of people, L5 vertebrae partly
or completely incorporated into the sacrum
(hemisacralization & sacralization of L5 vertebrae)
In other people, S1 vertebrae separated from the
sacrum & partly or completely fused with L5
vertebrae (lumbarization of S1 vertebrae)
When L5 is sacralized, the L5/S1 level is strong & the
L4//L5 level degenerates producing painful
symptoms
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Joints of the Spine

Atlanto-occipital joints
Atlantoaxial joints
Costovertebral joints
Joints of the vertebral bodies
(intervertebral [IV] discs)
Joints of the vertebral arches
(zygapophysial joints/facet joints)
Sacroiliac joints
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Intervertebral Disc
Notochord & mesenchym derivates
Intervertebral disc - comprised of three parts :
nucleus pulposus
annulus fibrosus
hyaline cartilage end plates
( Williams,1989 ; White III & Pamjabi, 1990 ; Holm,1990 ; Willis & Burton,1992)

Acts as a thick-walled cylinder to distribute load, support


stability & flexibility of the spine
A pair of vertebral bodies with the intervening disc is called
Motion segmen
Functional unit

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Intervertebral Discs

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Annulus Fibrosus

A ring consisting of 15-25


concentric lamellae of
fibrocartilage forming the
circumference of the IV discs.

The fibers forming each


lamella run obliquely from one
vertebra to another

The fibers in the lamellae are


orientated at an angle
( =30o) to the horizontal
plane

The fibre direction changes in


alternating layers by 120o 16

Annulus Fibrosus

The collagen fibres of the inner two-thirds of the AF sweep around into the
vertebral endplate, forming its cartilagineous component.
The peripheral fibres of the anulus are anchored into the bone of ring apophysis
The arrangement of AF allowing movement between adjacent vertebrae and provides
a strong bond between them
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Annulus Fibrosus

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Annulus Fibrosus

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Annulus Fibrosus
Collagen : 50 70 %
Proteoglycan : 10 20 % H2O <<
Outer side : Collagen type I >>

Tension
Force

(Pearson et al.,1969&1972 ; Eyre & Muir, 1975 ; Buckwalter et al.,1976;


Gosh et al.,1977)

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Nucleus Pulposus

More cartilagineous than fibrous and normally highly elastic


30-50% of IV Disc volume
Located more posteriorly than centrally because the lamellae of AF
are thinner and less numerous posteriorly than anteriorly or
laterally
Has a high content of water (70-90%) that is maximal at birth and
decreases wiith advancing age
Acts like a shock absorber for axial forces and like semifluid ball
bearing during flexion, extension, rotation and lateral flexion of the
spine
NP is avascular and receives nourishment by diffusion from blood
vessels at the periphery of AF and vertebral body
NP having no nerves, so it is insensitive
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Nucleus Pulposus
Collagen : 15%-25% (Collagen type 2 >>)
Proteoglycan : 50% H2O (90%)

Compression
Force

(Pearson et al.,1969&1972 ; Eyre & Muir, 1975 ; Buckwalter et al.,1976;


Gosh et al.,1977)

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Disc Problems

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Disc Problems
Disc degeneration
Disc herniation

Different Entity : - Disc Herniation


- Disc Degeneration

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Disc Degeneration
Initial degeneration in the human spinal column
occurs in the NP
Characterized by a gradual loss of chondroitin
sulfate and water content loss of turgor and
resilience
With increasing age AF gradually loses some of its
elasticity, particularly posteriorly where it is
relatively thin more easilly separated or even
torn NP protude or herniate - site of weakness in
the AF
Second site of weakness is the thin cartilage
end plate through which nuclear material may
protrude into the underlying cancellous bone of the
vertebral body and thereby form a Schmorls node
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balance
EXTERNAL LOAD

.
Type of work
. Weight of load
. Duration of load

INTERNAL STRENGTH

.
Mechanical insult
.
Mechanical injuries
. Nutritional disturbance
(Pope et al., 1991)

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Degenerative Process
Circumferential tear of A.F./Disc Degeneration

mechanical insult
mechanical injuries
nutrition

natural aging
anatomical variation
( genetic )

radial tear of A.F./ Disc Herniation

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( RADIAL TEAR )

( CIRCUMFERENTIAL TEAR)

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(COMBINED)

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Disc Herniation
Herniation of the NP and parts of disc into or through the AF is well recognized cause of low back pain
(LBP)
95% of lumbar disc herniation (LDH) occur at the L4/5 or L5/S1 levels
As people get older, their NP lose their turgor and become thinner because of dehydration and degeneration.
Flexion of the spine produces compression anteriorly and streching or tension posteriorly toward the thinnest
part or the AF.
If the degeneration of the posterior longitudinal ligament (PLL) and wearing of the AF has occurred, the NP may
herniate into the vertebral canal and compress the spinal cord or the nerve roots of the cauda equina.

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Disc Herniation
Usually occur posterolaterally, where the AF is relatively
thin and poorly suported by either the PLL.
Posterolateral disc herniation more likely to be symptomatic
because of the proximity of the spinal nerve roots.
Localized back pain of disc herniation disc results from
pressure on the PLL and periphery of the AF and from local
inflamation resulting from chemical iritation by substances
from the ruptured NP
Chronic pain resulting from the spinal nerves being
compressed by the herniated disc is reffered to the area
(dermatome) supplied by that nerve
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Disc Herniation

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Disc Herniation

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Disc Herniation

Protrusion I

radial tear A.F. part 1

Protrusion II

radial tear A.F. part 2

Protrusion III

radial tear A.F. part 3

(Darwono, A.B, 2000)

Subligament
Transligament

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Disk Degeneration
Grade 0

: no change

Grade 1

: Local disruption

Grade 2

: Partial disruption ( < 50 % )

Grade 3

: Total disruption

( < 10 % )

( > 50 % )

(Sachs, et al., 1987)


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Disc Herniation
Lumbago
An acute mid and low back pain radiating down

the posterolateral aspect of the thigh and leg


Often caused by a posterolateral herniation of a
lumbar IV disc at the L5/S1 level that affects the
S1 component of the sciatic nerve

Sciatica

A pain in the lower back and hip radiating


down the back of the thigh into the leg
according to the distribution of one or more
roots of the sciatic nerves
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Sciatic Nerves

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Dermatomes

Diagram beside
demonstrated the
dermatomal distribution in
different individuals
(percentage values are for
those in whom at least
exhibit the particular
pattern)
Black area

: 75 %

Shaded area : 50 %
Stippled area : 25 %

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Disc Degeneration &


Osteoarthritis

Loss of the NP results in


increased flexibility in the
disc as well as loss of disc
height
1 g reduction in NP causes
0.8 mm loss in disc
height and 0.2 mm increase
in annular bulge
Degeneration of the NP is
followed by change in the
facet capsules
Generally measured clinically
through reductions in disc
space (radiographs) or using
MRI to estimate hydration
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Disc Injury
Occurs most in cervical and lower lumbar spine
Disc compresses nerve roots or duramater (surrounding
spinal cord)
May be due to a combination of excessive loading and
preliminary disc degeneration
AF fibres rupture and fail through fissuring
With age, NP degrades and no longer transfers pressure
across the nucleus

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Structural elements of the Spine


Anterior column

Middle component

Posterior complex

Unstable = Middle column + at least one other column


(Denis, 1983)

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DENIS CLASSIFICATION
. System was developed by Denis based on analysis of both plain radiographs
and CT, & has achieved wide acceptance. This notion was developed after
analyzing his own trauma practice.
( Spine, 1983; Clin Orthop, 1984 )

. The concept of three columns is :


. simple to understand,
. useful in managing thoracolumbar injuries,
. useful in understanding the mechanism of injury,
. and assessing stability.
( Spine, 1983; Clin Orthop, 1984 )

. Three columns paradigm has been Biomechanically tested & found to be Valid
( Panjabi et al., Spine, 1995 )

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DENIS CLASSIFICATION
Combination of four basic mechanism of injury :
. Compression
. Distraction
. Rotation
. Shear

Displace spinal column


beyond its physiologic range :
. in translation x, y, z axis
. in angulation x, y, z axis
. in a combination of these
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DENIS CLASSIFICATION

Type of
Fracture

Column involvement
_______________________________________________________________
Anterior
Middle
Posterior
_________________________________________________________________________________
Compression

Compression

None

None or distraction
( in severe fractures )

Burst

Compression

Compression

None or distraction

Seat Belt
(Flexion-distraction)

None or Compression

Distraction

Distraction

Fracture-dislocation

Compression and / or
rotation, shear

Distraction and / or
rotation, shear

Distraction and / or
rotation, shear

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The loss of the ability of the spine under physiologic loads to maintain
relationships between vertebrae in such a way that there is neither
damage nor subsequent irritation to the spinal cord or its nerve roots,
and in addition there is no development of incapacitating deformity
or pain
( White & Panjabi, 1990 )

Mechanical Instability :

( Biomechanical study & Clinical Observations )

. Loss of 50 % vertebral body height ( Montesano, 1988 )


. Angulation of the Thoracolumbar junction > 20 degrees
( Nagel, J Bone Joint Surg, 1981 )

. Compression and Burst fractures should be considered acutely unstable


( Benson et al., J Spinal Disord, 1992 )

. Failure of at least two of denis three columns


( Haher et al., Spine, 1991 )
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Facet Joints

Act to limit shear and torsion


motions between vertebrae
Orientation of facet changes along
length of spine
Cervical : couple lateral
bending and torsional motion
Thoracic : coronal plane
orientation of joint surfaces
Lumbar : sagital plane
orientation of joint surfaces
Facets carry 10-20% of compressive
load in upright standing, >50% of
anterior shear load in forward fexion
Facet joint capsules are highly
innervated and have been shown to
be a source of LBP
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Facet Joints

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Sacroiliac Joint
Connects the sacrum to
the ilium
The stability depends on :
Joint configuration - L
shaped
Extensive ligamentous
support
* Sacroiliac ligaments
* Accessory sacroiliac
ligaments
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Ligaments of the Spine

Connected between adjacent


vertebrae along length of spine
Act to limit excessive motion
Anterior and posterior
longitudinal ligaments
Ligamentum flavum
Inter- and supraspinosus
ligaments
Intertransverse ligaments
Facet joint capsules

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Ligaments of the Spine


Anterior longitudinale ligaments
covers and connects the anterolateral aspects of
the vertebral bodies and IV discs
ultimate load of 340 N
strongly attached to the the vertebral bodies
but loosely attached to AF
maintains stability of the joints between the
vertebral bodies and help prevent hyperextension
of the spine

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Ligaments of the Spine


Posterior longitudinale ligaments
runs within the vertebra canal along the posterior
aspects of the vertebral bodies
ultimate load of 180 N
strongly attached to the AF and the posterior
edges of the vertebral bodies
helps prevent hyperflexion of the spine and
posterior protrusion of the discs
provided with nociceptive (pain) nerve endings
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Spine Musculature
Muscle of the spine are part of
the trunk musculature
Three groups of muscles in
the back : superficial,
intermediate, and deep
group
Deep / intrinsic back muscles
are grouped according to their
relationship to the surface :
superficial, intermediate,
and deep layer
Muscle injury generally occurs
during forcible lengthening
while the muscle is activated
(contracting)
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Sprains and Strains

Result from excessive physical demands on the back


Lifting something too heavy, sudden fall, car crash or sport injury
can cause soft tissues (ligaments, muscles and tendons) to stretch
too much
The ligaments, muscles and tendon work together to handle the
external forces the spine encounters during movement (bending,
forward and lifting)
Sprains and strains are similar disorders affecting different soft
tissues in the spine
Sprains are limited to the ligaments
Strains affects muscles, tendons and muscle-tendon
combinations

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The Spinal Cord


Elongated cylindrical mass of nerve
tissue occupies the upper 2/3 of the
vertebral canal
FOM 1st or 2nd Lumbar Spine
(42-45 cm)
Conus medullaris conical distal
Filum terminale 1st seg. coccyx
Ascensus medullorum
Intumescentia cervicalis
(C 3 Th. 2)
Intumescentia lumbalis
(Th. 10 L2)
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Segments of the Spinal Cord


Composed of 31
segments :
8 cervical
12 thoracal
5 lumbalis
5 sacralis
1 coccygeus

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Anatomy of the Spinal Cord

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The Spinal Nerves

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The Cervical Plexus

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The Brachial Plexus

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Brachial Plexus Injuries


Upper Plexus Type
(Erb-Duchenne)

Lower Plexus Type


(Klumpke)

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The Lumbar Plexus

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The Sacral Plexus

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Pathways in Spinal Cord

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Motor pathways in Spinal Cord

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The Pyramidal System

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Pain and Temperature Fibers

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Proprioceptive Fibers

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Touch and Pressure

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Neural Injuries
Spinal injuries damage the cord or the
nerve roots or both
Partial or complete
3 varieties :
1. Neuropraxia
2. Cord Transection
3. Root transection
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Anatomical Levels

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Anatomical Levels

N. C1 Occiput & C1
N. C2 C1 & C2
N. C5 C4 & C5
N. C8 C7 & T1
N. T1 T1 & T2
N. L4 L4 & L5

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Anatomical Levels
Cervical Spine
Level of cord level of bony damage
Level C5 vert. isolates lower cervical
cord, thoracic cord, lumbar & sacral cord
Below C5 vert. partial sparing of the
upper limb

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Anatomical Levels
Between T1 & T10 Vertebrae
1st Lumbar cord seg. ~ T10 Vert.
Transection at T10 Vert. Spares the
thoracic cord, isolates the entire lumbar &
sacral cord

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Anatomical Levels
Below T10 Vertebra
The cord bulge at the T10 & L1 Vert tapers to
an end at the interspace between the L1 & L2
vert.
L2 S4 nerve roots arise from the conus
medullaris cauda equina
Spinal injuries above the T10 vert. cord
transection
Spinal injuries between the T10 & L1 vert.
cord & nerve root lesions
Spinal injuries below the L1 vert. nerve root
lesions
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Resulting from incomplete traumatic lesions


(Schneider & Kahn, 1971; Bosch, Stauffer, & Nickel, 1971)

1. Incomplete SCI : Central C. S., Brown Sequard S., Anterior C.S.,


Posterior C.S., Monoparesis upper extremity (rare)
90 % : Brown S.S., Central C.S., and Anterior C.S.
2. Complete SCI : total motor & sensory distal loss;
If bulbocavernosus r. (+), sacral sen. & motor (-)
paralysis permanent & complete
Generalizations :
1. Greater sparing motor & sensory distal greater expected
recovery
2. More rapid recovery greater amount of recovery
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3. New recovery ceases, plateau reached no further recovery

CENTRAL CORD SYNDROME


Most common
Hyperextension inj. on spondylosis
Flexion inj. on younger patient
Anterior spinalis artery disturbance
Arm suffer more severe than leg :
- Arm flaccid weakness
- Leg spastic weakness
Sparing :
- Sensory variable
- Bladder & bowel function variable
- Sacral pin-prick sens. preserved

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BROWN SEQUARD SYNDROME


Caused by hemisection of the S.C as a
result of :
Unilateral laminar or pedicle fracture
penetrating injury
rotational injury resulting in subluxation

Injury side :

lmn paralysis in the segment of the lesion


umn paralysis below the level of the lesion
cutaneous anesthesia in the segment of the lesion
hyperesthesia below the anesthetic zone
loss of proprioceptive, vibratory, & 2 point
discrimination below the level of the lesion

Contra-lateral side :
power normal
pinprick & temp. sens. absent
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ANTERIOR CORD SYNDROME


Caused by :
Hyperflexion inj. in which
bone or disc fragmen compress
anterior spinal artery & cord
Complete motor loss, loss of pain
& temperature discrimination
Sparing : deep touch, position
sense, & vibratory sensation

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POSTERIOR CORD SYNDROME


Caused by :
Extension injury with fracture
of post. elements vertebra (rare)
Loss of :
Proprioception vibrating sense
ataxia, walking very difficult
Sparing :
Other sensory & motor function

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A MIXED SYNDROME
Unclassifiable combination of several syndromes
Small precentage of incomplete SCI do not fit one
of the previous syndromes
SYNDROME CONUS MEDULLARIS
Injury of Sacral cord (conus) & lumbar nerve roots
areflexed bladder, bowel, and lower extremities,
flaccid paralysis in perineum & loss of all bladder
and perianal muscle control
Irreversible : bulbocavernosus r. & perianal wink (-)
CAUDA EQUINA SYNDROME

Injury between conus & lumbosacral nerve roots


Loss of : areflexic bladder, bowel, & lower limb
Complete l. : Bowel, bladder, perianal area, lower extremity
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Loss of function, bulbocavernosus r, anal wink are absent

THANK YOU

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