Traumatic Spinal Cord Injuries

Dr. Essam Elmorshidy

Anatomy

• The spinal cord occupies the

upper four-fifths of the
vertebral canal. It extends
from the foramen magnum
and ends distally at the level
of the L1–L2 disc space
where it tapers to form the
conus medullaris.
Anatomy

• Distal to the termination of the

spinal cord (conus), the lumbar,
sacral, and coccygeal roots
continue as a leash of nerves
termed the cauda equina.
• The filum terminale is a fibrous
band that extends from the distal
tip of the spinal cord and
attaches to the first coccygeal
segment.
 . How many spinal nerves exit from the
spinal cord?
• The spinal nerves exit from the spinal cord in pairs. There
are 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5
lumbar, 5 sacral, and 1 coccygeal
• In the cervical region, there are eight cervical nerve roots and only
seven cervical vertebra. The first seven cervical nerve roots exit the
spinal canal above their numbered vertebra. The C8 nerve root is
atypical because it does not have a corresponding vertebral element,
and exits below the C7 pedicle
• In the thoracic and lumbar spine, the relationship between the nerve
root and vertebra changes as the nerve roots exit the spinal canal by
passing below the pedicle of their named vertebra
What is the distribution of spinal injuries
according to spinal region?

It is estimated that 20% of spinal injuries occur in the cervical

region , 30% in the thoracic region, and 50% in the lumbar and sacral
region. More than 15% of patients with traumatic spines fracture have a
second, noncontiguous vertebral column fracture.
What are the most common causes of
spinal cord injury?
• Vehicular accidents (39.3%)
• Falls (31.8%)
• Acts of violence, including gunshot wounds and stabbings (13.5%)
• Sport-related injuries (8%)
• Medical/surgical causes (4.3%)
• Miscellaneous causes (3.1%)
 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)
 Complete spinal cord injury

Total absence of sensory and motor function below the anatomic

level of injury in the absence of spinal shock. Recovery from
spinal shock typically occurs within 48 hours following an acute
spine injury
Incomplete
spinal
cord injury

Residual spinal cord and/or

nerve root function exists
below the anatomic level of
injury, including partial
preservation of sensory and/or
motor function at S4–S5
(termed “sacral sparing”).
Patterns of
incomplete
neurologic injury

• Central cord syndrome:

occurs in the elderly with
forced hyperextension of
the neck, such as a rear-end
collision. There is paralysis
and burning pain in the
upper extremities, with
preservation of most
functions in the lower
extremities.
Hemisection
(Brown Sequard)
• is typically caused by a clean-
cut injury such as a knife
blade, and results in
ipsilateral paralysis and loss
of proprioception along with
contralateral loss of pain
perception below the level of
the injury.
• Anterior cord syndrome is typically
seen with burst fractures of the
vertebral bodies. There is loss of
motor function, pain and temperature
sensation bilaterally below the injury,
but vibratory and positional sense are
preserved.
 Conus medullaris syndrome
Damage to the sacral segments of the spinal cord located in the conus
medullaris, which typically results in an areflexic bowel and bladder,
lower extremity sensory loss, and incomplete paraplegia.
• Cauda equina syndrome:
damage to lumbosacral
nerve roots within the
neural canal results in
variable lower extremity
motor and sensory
function, bowel and
bladder dysfunction, and
saddle anesthesia.
ASIA
classification
How are the sensory and motor components assessed in the
determination of a neurologic level of spinal cord injury?
• Sensory component: Light touch and pinprick sensation are tested for
each dermatome and graded on a three-point scale:
0 Absent
1 Impaired (partial or altered appreciation,
including hyperesthesia)
2 Normal
The sensory level is the most caudal dermatome where both
light touch and pinprick are normal and where all rostral
dermatomes are also normal.
Sensory
dermatomes
Identify the key muscles that are tested in
determining the motor level.
Upper extremities:
• C5 Elbow flexors (biceps, brachialis)
• C6 Wrist extensors (extensor carpi radialis longus and brevis)
• C7 Elbow extensors (triceps)
• C8 Finger flexors (flexor digitorum profundus) to the middle finger
• T1 Small finger abductors (abductor digiti minimi)
Identify the key muscles that are tested
in determining the motor level.
Lower extremities:
• L2 Hip flexors (iliopsoas)
• L3 Knee extensors (quadriceps)
• L4 Ankle dorsiflexors (tibialis anterior)
• L5 Long toe extensors (extensor hallucis longus)
• S1 Ankle plantar flexors (gastrocnemius, soleus)
 Distinguish between skeletal and neurologic level of injury in
the assessment of a person with a traumatic spinal cord injury?

The skeletal level of injury is defined as the level in the spine where the
greatest vertebral damage is found on radiographic examination. The
neurologic level of injury is defined as the most caudal segment of the
spinal cord with normal sensory function and antigravity (grade 3 or
more) motor function bilaterally, provided that sensory and motor
function proximal to this segment is intact.
In a patient with a traumatic spinal cord injury,
what medical treatments have proven beneficial?
• Initial resuscitation to raise and maintain blood pressure to a mean
arterial blood pressure of 85 mm Hg is beneficial to the injured spinal
cord. In an acute spinal cord injured-patient, this usually requires the
addition of pressor agents.
• Hypoxemia must be avoided. Supplemental oxygen is routinely
administered, and ventilatory support is utilized as indicated.
• The use of neuroprotective agents such as methylprednisolone has
been controversial.
Initial evaluation and
management of a trauma patient
with a potential spine injury.

• All trauma patients are assumed to

have a spine injury until proven
otherwise
• The injured patient should be
immobilized at the accident scene with
a rigid cervical collar supplemented
with lateral bolsters and straps
secured to a long spine board to
immobilize the entire spine.
 ABCDE in trauma patients
A: Airway maintenance while taking care to protect the cervical spine
B: Breathing and ventilation
C: Circulation and control of hemorrhage
D: Disability assessment including a brief evaluation of neurologic
status and Glasgow Coma Scale (GCS)
E: Exposure and environmental control, which includes fully exposing
the patient and measures to prevent hypothermia.
What is spine clearance?
• Spine clearance is the process of accurately confirming the absence of
a spine injury. Following blunt trauma, patients are assumed to have a
spine injury and are immobilized until clearance is performed.
Identify six complications of spinal cord injury that
may manifest within the first 2 days after injury.
• Hypotension,
• bradycardia,
• hypothermia,
• hypoventilation,
• gastrointestinal bleeding,
• ileus
Key Points
1. Patients with high-energy injury mechanisms or altered mental status
should be assumed to have sustained a significant spinal injury and undergo
immediate spinal immobilization during extrication, transport, and initial
evaluation.
2. Patients with neurologic injury are assessed according to the Standards for
Neurologic Classification established by the American Spinal Injury
Association (ASIA).
3. Hypotension and hypoxemia require aggressive treatment in the spinal
cord-injured patient.
4. The clinical syndromes resulting from spinal cord injury depend on the
level of injury and the anatomic tracts involved by the injury.