SPINE AND SPINAL CORD INJURY

Azharuddin, Dr. dr. Sp.OT,.K-Spine

Faculty of Medicine Syiah Kuala University/ Zainoel

Abidin Hospital Banda Aceh
February 26, 2017
Spinal cord injury

After incident, spinal cord edema occurs; (*FLACCID

PARALYSIS AND LOSS OF REFLEX ACTIVITY
BELOW THE LEVEL OF THE LESION)
• Spinal shock: Attributed to cord edema
from time of injury.
 Complete loss of skeletal muscle function
 Loss of bowel and bladder tone
 Loss of sexual function
 Loss of venous return;
HYPOTENSION/Bradycardia (loss of sympathetic input)
 Loss of ability to regulate body temp by
hypothalamus (client assumes environment temp)
Acute vs. chronic injuries;
complete vs. incomplete injuries
• “Acute”=sudden onset of symptoms
• “Complete” ?
What is a complete spinal cord injury?

• “Complete” = absence of sensory and motor

function in the perianal area (S4-S5)
Terminology

• Plegia = complete lesion

• Paresis = some muscle strength is preserved
• Tetraplegia (or quadriplegia)
• Injury of the cervical spinal cord
• Patient can usually still move his arms using the segments
above the injury (e.g., in a C7 injury, the patient can still flex
his forearms, using the C5 segment)
• Paraplegia
• Injury of the thoracic or lumbo-sacral cord, or cauda equina
• Hemiplegia
• Paralysis of one half of the body
• Usually in brain injuries (e.g., stroke)
Motor: how do you test each segment?
Sensory: how do you determine the level?
What is and how do you determine the level
of injury?
• Motor level = the last level with at least 3/5
(against gravity) function
• NB: this is the most important for clinical purposes
• Sensory level = the last level with preserved
sensation
• Radiographic level = the level of fracture on
plain XRays / CT scan / MRI
• NB: spine level does not correspond to spinal cord
level below the cervical region
What is the difference between spinal shock
and neurogenic shock?
• Spinal shock is mainly a loss of reflexes (flaccid
paralysis)
• Neurogenic shock is mainly hypotension and
bradycardia due to loss of sympathetic tone
Neurogenic shock

• Seen in cervical injuries

• Due to interruption of the sympathetic input
from hypothalamus to the cardiovascular
centers
• Hallmark: hypotension (due to vasodilation, due
to loss of sympathetic tonic input) is associated
with bradycardia (not tachycardia, the usual
response), due to inability to convey the
information to the vasomotor centers in the
spinal cord
Low cervical injuries (C6-T1)

• Usually able to breathe, although occasionally

cord swelling can lead to temporary C3-C5
involvement (need mechanical ventilation)
• The level can be determined by physical exam
So what do you expect with a cervical
lesion?
• Quadriplegia or quadriparesis
• Bowel/bladder retention (spastic)
• Various degrees of breathing difficulties
• Neurogenic and/or spinal shock
Cauda equina injuries (L2 or below)

• Paraparesis or paraplegia
• LMN (lower motor neuron) signs
• Thigh flexion is almost always preserved to
some degree
What is an incomplete lesion?
Initial Management

• Immobilization
• Rigid collar
• Sandbags and straps
• Spine board
• Log-roll to turn
• Prevent hypotension
• Pressors: Dopamine, not Neosynephrine
• Fluids to replace losses; do not overhydrate
• Maintain oxygenation
• O2 per nasal canula
• If intubation is needed, do NOT move the neck
Management in the hospital

• NGT to suction
• Prevents aspiration
• Decompresses the abdomen (paralytic ileus is common in the
first days)
• Foley
• Urinary retention is common
• Methylprednisolone (Solu-Medrol)
• Only if started within 8 hours of injury
• Exclusion criteria
• Cauda equina syndrome
• GSW
• Pregnancy
• Age <13 years
• Patient on maintenance steroids
CT scan

• Good in acute situations

• Shows bone very well
• Sagittal reconstruction is mandatory
• Soft tissues (discs, spinal cord) are poorly
visualized
• Do NOT give contrast in trauma patients
(contrast is bright, mimicking blood)
MRI

• Almost never an emergency

• Exception: cauda equina syndrome
• Shows tumors and soft tissues (e.g., herniated
discs) much better than CT scan
• May be used to clear c-spine in comatose
patients
 Surgical Decompression and/or Fusion

• Indications
• Decompression of the neural elements (spinal cord/nerves)
• Stabilization of the bony elements (spine)
• Timing
• Emergent
• Incomplete lesions with progressive neurologic deficit
• Elective
• Complete lesions (3-7 days post injury)
• Central cord syndrome (2-3 weeks post injury)
Soft and hard collars
Minerva vest and halo-vest
Male,22 yo, Burst fracture Cervical 6, frankel A
MALE, 23 YO, DISLOCATION C1-2, FRANKEL C
MALE, 23 YO, BILATERAL FACET DISLOCATION C 4-5 AIS A
IS THERE LIFE THREATENING??
MALE, 50 YO, BURTS L 1-2, AIS C
MALE 52 YO,
EARTHQUAKE
SURVIVOR
Male, 53 yo, pijay earthquake
Female, 52 yo, earthquake survivor
Male, 38 yo, earthquake survivor
Spinal cord crushing and pedicle, lamina fracture
Long term care

• Rehab for maximizing motor function

• Bladder/bowel training
• Psychological and social support
THANK YOU!