Prof. Dr. dr.Tjokorda Gde Bagus Mahadewa, M.Kes., Sp.BS.

,
Subsp.TB.
1 Department of Neurosurgery, Faculty of Medicine Udayana University,
Prof. dr. I.G.N.G. Ngoerah Hospital, Denpasar, Indonesia
01 Definition Epidemiology 04 Spine Injury Classification

02 Clinical Examination 05 Spinal Cord Injury

Classification
03 Imaging 06 General Care
Spinal Cord
Injury

DEFINITION
Spinal cord injury (SCI) resulting from
“disturbance” of the spinal cord elements

SCI can be caused  direct injury to the

spinal cord itself OR from damage to the
tissue and bones (vertebrae) that surround
the spinal cord.
Epidemiology
“Acute traumatic SCI has an annual incidence of 15 to 40 cases
per 1 million ”
motor vehicle accidents (50%) and
unintentional falls (30%) are the leading mechanisms

Older adults are more susceptible to spinal injuries

Over one-half of SCIs occur in the cervical

region
Badhiwala JH, Wilson JR, Witiw CD, et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled
analysis of individual patient data. Lancet Neurol. 2020.
Epidemiology
Spinal cord injury (SCI) costs society excess of $7 billion
in annually
the greater cost of human suffering related to impaired
ambulation, respiratory complications, and bladder
dysfunction

As Clinician and Researcher 

Understandingof Current SCI Management & Rehab
Play IMPORTANT KEY ROLE
Morbidity & Mortality of SCI
Badhiwala JH, Wilson JR, Witiw CD, et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual pa tient data. Lancet Neurol. 2020.
BASIC SCIENCE : PHASES OF SPINAL
CORD INJURY
PRIMARY
INJURY

V
S
SECONDARY
INJURY
Clinical
Examination
Primary Survey

Secondary Survey

Sensory Level of Injury

Motoric Level of Injury

Neurologic Level of
Injury
 Primary Survey
02 Clinical Examination

Conduct the primary survey

focusing on
• Airway + C Spine control
E • Breathing
• Circulation
• Disability
• Exposure.

Maintain cervical and thoracolumbar motion restriction throughout this phase,

Until the spine is further evaluated during the secondary survey
 Primary Survey
02 Clinical Examination

Spinal motion restriction (SMR) can be achieved with

• a backboard “Assume anyone with high energy
• scoop stretcher accident have cervical injury until it is
• vacuum splint
• ambulance cot, or other similar devices.
proven otherwise ”
 Type of Cervical
Stabilization Pre –
Intra Hospital
Decision-making tool used to determine whenCervical should
radiography
utilized in patients following be
trauma

NEXUS Canadian C Spine

Criteria Rules
 Sensory Level of Injury
02 Clinical Examination
The secondary survey aims to obtain a full and detailed history and physical
examination after completion of the primary survey
Documentation
Serial documentation of abnormal physical findings for early identification
of
secondary injuries which may affect in management.
Mechanism of Injury
Any high-energy mechanism may result in spinal trauma. Low energy mechanisms,
such as ground level falls, place older adults at a high risk.
History
Ask about the presence of new onset neck or back pain, any associated
neurological deficit in the upper and/or lower extremities
 Sensory Level of Injury
02 Clinical Examination
The sensory level refers to the most caudal segment of the spinal cord with
normal sensory function.
This level is evaluated by examining the corresponding dermatomes.

Perform a systematic assessment of sensory level with light touch and a pinprick of each
dermatome using the face as control. Gradeeach sensory level as:

0 = Absent
1 = Altered (either decreased/impaired sensation or hypersensitivity)
2 = Normal
NT = Not testable
Recall ! Human Dermatome
 Sensory Level of Injury
02 Clinical
Spinal
Examination Area of Innervation
Nerve
C2 At least 1 cm lateral to the occipital protuberance (alternatively 3 cm behind the ear)
C3 Supraclavicular fossa (posterior to the clavicle) and at the midclavicular line
C4 Over the acromioclavicular joint
C5 Lateral (radial) side of the antecubital fossa (just proximal to elbow crease)
C6 Thumb, dorsal surface, proximal phalanx
C7 Middle finger, dorsal surface, proximal phalanx
C8 Little finger, dorsal surface, proximal phalanx
T1 Medial (ulnar) side of the antecubital fossa, just proximal to the medial epicondyle of the humerus
T2 Apex of the axilla
T3 Midclavicular line and the third intercostal space (IS) found by palpating the anterior chest to locate
the third rib and corresponding IS below it
T4 Fourth IS (nipple line) at the midclavicular line
 Sensory Level of Injury
02 Clinical
Spinal
Examination Area of Innervation
Nerve
T5 Midclavicular line and the fifth IS (midway between T4 and T6)
T6 Midclavicular line and the sixth IS (level of xiphisternum)
T7 Midclavicular line and the seventh IS (midway between T6 and T8)
T8 Midclavicular line and the eighth IS (midway between T6 and T10)
T9 Midclavicular line and the ninth IS (midway between T8 and T10)
T10 Midclavicular line and the tenth IS (umbilicus)
T11 Midclavicular line and the eleventh IS (midway between T10 and T12)
T12 Midclavicular line and the mid-point of the inguinal ligament
L1 Midway distance between the key sensory points for T12 and L2
L2 On the anterior-medial thigh at the midpoint drawn connecting the midpoint of inguinal ligament
(T12) and the medial femoral condyle
L3 Medial femoral condyle above the knee
 Sensory Level of Injury
02 Clinical Examination

Spinal Area of Innervation

Nerve
L4 Medial malleolus
L5 Dorsum of the foot at the third metatarsal phalangeal joint
S1 Lateral heel (calcaneus)
S2 Mid-point of the popliteal fossa
S3 Ischial tuberosity or infragluteal fold
S4-5 Perianal area less than one cm. lateral to the mucocutaneous junction (taken as one level)
 Motor Level of Injury
02 Clinical Examination
The strength of five key muscle groups in the upper extremities and five in the lower extremities is tested bilaterally
to determine the motor level of injury
Muscle strength graded using a 6-point score (0 to 5):

0/5 = Total paralysis

1/5 = Palpable or visible contraction
2/5 = Active movement, full range of motion (ROM) with gravity
eliminated 3/5 = Active movement, full ROM against gravity
4/5 = Active movement, full ROM against gravity and moderate resistance
in a muscle specific position
5/5 = Active movement, full ROM against gravity and full resistance in a functional muscle position, normal
for an otherwise unimpaired person
NT = Not testable (e.g., immobilization, severe pain prevents grading, limb amputation, or contracture of
greater
than 50 percent of the normal ROM)
 Motor Level of Injury
02 Clinical Examination
Key muscle groups for the upper and lower extremities with corresponding neurologic level and muscle movement(s)
Extremity Root Muscle Group Muscle Movement(s)
Level
C5 Elbow flexors Shoulder: Flexion, extension, abduction,
adduction, internal and external rotation
Elbow: Supination
C6 Wrist extensors Elbow: Pronation
Wrist: Flexion
C7 Elbow extensors Finger: Flexion at proximal joint, extension Thumb:
Upper Flexion, extension and abduction in plane of thumb

C8 Long finger Finger: Flexion at metacarpophalangeal (MCP)

flexors joint
Thumb: Opposition, adduction and abduction
perpendicular to palm
T1 Small finger Finger: Abduction of the index finger
abductor
 Motor Level of Injury
02 Clinical Examination
Key muscle groups for the upper and lower extremities with corresponding neurologic level and muscle
movement(s)
Extremity Root Muscle Group Muscle Movement(s)
Level
L2 Hip flexors Hip: Adduction
L3 Knee extensors Hip: External rotation
L4 Ankle dorsiflexors Hip: Extension, abduction, internal rotation
Knee: Flexion
Ankle: Inversion and eversion
Lower Toe: Metatarsophalangeal (MP) and
interphalangeal (IP) joint extension
L5 Long toe extensors Hallux and Toe: Distal and proximal
interphalangeal joints (DIP and PIP) flexion and
abduction
S1 Ankle plantar Hallux: Adduction
flexors
02 Clinical Examination

Neurologic Level of Injury

The neurologic level of injury is defined as the levels where
motor
functionThe
and most
sensation are or
distal bothcaudal
intact bilaterally:
level at which the motor (minimum
1 strength of 3 bilaterally with all levels proximally being 5) plus
The most distal level where sensation is intact on light touch and
2 pinprick with all proximal levels being intact.
02 Clinical Examination
03 Imaging
Plain radiographs of the cervical and thoracolumbar spine are most
X-Ray common use in the initial screening of spinal trauma but have a low
sensitivity.

Non-contrast, multidetector computerized tomography (MDCT) is

CT the initial imaging modality of choice to evaluate the cervical and
thoracolumbar spine. (Sensitivity 100% and Specificity 100%)

MRI is the only modality for evaluating the internal structure of the
MRI
spinal cord.
 Cervical X-Ray
03 Imaging

Can you determined the abnormality ?

 Thoracolumbal X-ray

03 Imaging

Can you determined the abnormality ?

03 Imaging

CT Cervical MRI Cervical

03 Imaging

CT Lumbosacral
WHAT CASE
NEED BE
OPERATE ?
TO
04 Spine Injury Classification
Spine trauma classification systems include specific injury characteristics, as well as the
patient’s medical or neurologic status.
Patient scores for the classification system are used to guide decision making regarding
surgery or nonsurgical management.

1 Cervical Subaxial Injury Classification System

2 Thoracolumbar Injury Classification System

3 AO Spine Injury Classification System

 Subaxial Cervical Spine Injury Classification
04 Spine Injury Classification (SLIC Score)

Score:
1-3= nonoperatively
4=surgeonpreference
≥ 5 = operative
04 Spine Injury Classification
Thoracolumbar injury classification and
severity score (TLICS)

Score:
1-3 = nonoperatively
4 = surgeon preference
≥ 5 = operative
04 Spine Injury The AO Spine Injury Classification
Classification

1 Upper Cervical Spine

2 Subaxial Cervical Spine

3 Thoracolumbar Spine

4 Sacral Injuries
 The AO Spine Injury Classification
04 Spine Injury Classification

Occipital Condyle and Craniocervical Junction

1 Upper Cervical Spine C1 Ring and C1-2 Joint

C2 and C2-3 Joint
04 Spine Injury Classification

The AO Spine Injury Classification

1 Upper Cervical Spine

AO Spine Classification Systems. AO Foundation. https://aospine.

aofoundation.org/clinical-library-and-tools/aospine-classification-systems
04 Spine Injury The AO Spine Injury Classification
Classification

Compression Injuries (Type A)

2 Subaxial Cervical Spine
Tension Band Injuries (Type B)
3 Thoracolumbar Spine Translation Injuries (Type C)
Facet Injuries (Type F)
04 Spine Injury Classification

The AO Spine Injury Classification

2 Subaxial Cervical Spine

AO Spine Classification Systems. AO Foundation. https://aospine.

aofoundation.org/clinical-library-and-tools/aospine-classification-systems
04 Spine Injury
Classification
The AO Spine Injury Classification

3 Thoracolumbar Spine

AO Spine Classification Systems. AO Foundation. https://aospine.

aofoundation.org/clinical-library-and-tools/aospine-classification-systems
04 Spine Injury
The AO Spine Injury Classification
Classification

Lower Sacrococcygeal Injuries (Type A)

4 Sacral Injuries Posterior Pelvic Injuries (Type B)

Spino-Pelvic Injuries (Type C)

04 Spine Injury
Classification
The AO Spine Injury Classification

4 Sacral Injuries

AO Spine Classification Systems. AO Foundation. https://aospine. aofoundation.org/clinical-library-

and-tools/aospine-classification-systems
05 Spinal Cord Injury Classification
Remember the Basic Topical Diagnostic !
Injury to the cervical spinal cord results in tetraplegia, with impaired function in
the upper and lower extremities.
Injury to the thoracic or distal spinal cord results in paraplegia, in
which function of the upper extremities is preserved

Patients with an incomplete SCI have some residual function distal to the
level of the injury, while those with complete SCI have complete lack of
function distal to the level of the injury.

Kirshblum S, Snider B, Rupp R, Read MS. Updates of the International Standards for Neurologic Classification of Spinal Cord Injury: 2015 and 2019. Physical Medicine and
Rehabilitation Clinics of North America. 2020; 31: 319–330. doi: 10.1016/j.pmr.2020.03.005
05 Spinal Cord Incomplete Spinal Cord Syndrome
Injury
Classification
1 Central cord syndrome 4 Brown-Sequard syndrome

2 Anterior cord syndrome 5 Conus medullaris syndrome

3 Posterior cord syndrome 6 Cauda equina syndrome

ANTERIOR CORD
SYNDROME
 Bilateral injury to the
spinothalamic tracts leads to
bilateral loss of pain and
temperature sensation below
the level of injury.
 Bilateral injury to
corticospinal tracts leads to
weakness or
paralysis below the level of
injury.
 As dorsal columns are
unaffected, tactile sensation,
proprioception, and vibratory
POSTERIOR CORD
SYNDROME

 Damage to dorsal
columns causes loss
of tactile sensation,
proprioception, and
vibratory sensation.
 As spinothalamic and
corticospinal tracts are
unaffected, there is the
preservation of pain
sensation, temperature
sensation, and motor
function.
COMPLETE SPINAL TRANSECTION

 These injuries typically

demonstrate complete

bilateral loss of motor

function, pain sensation,

temperature sensation,

proprioception, vibratory

sensation, and tactile

sensation

below the level of injury.

CENTRAL CORD
SYNDROME
 Injury is caused by
hyperextension of the
spine causing damage
primarily to the center of
the cord.
 This pattern of injury leads
to weakness affecting the
upper extremities more
so than the lower
extremities.
 There may also be an
associated loss of pain and
temperature sensation
below the level of injury.
BROWN-SEQUARD
SYNDROME
 Injury results from right or
left- sided hemisection of
the spinal cord.
 Transection of the
corticospinal and dorsal
column nerve tracts leads
to ipsilateral loss of
motor function,tactile
sensation,
proprioception, and
vibratory sensation
below the level of injury.
 Transection of the
spinothalamic tract leads to
contralateral loss of
pain and temperature
CAUDA EQUINA VS CONUS MEDULLARIS
SYNDROME
 WHEN TO
OPERATE ?

A meta-analysis of 4 prospective, multicenter SCI databases that were rated as high quality resulted in these
findings:
• Surgical decompression within 24 hrs of SCI was associated with
improvement at 1 year in: mean motor scores, light touch & pinprick sensory
scores, and ASIA Impairment Scale grades
• Post-op changes in total motor scores decreased as time to
decompression from injury increased during the first 24-36 hours, and
plateaued after 24-36 hours following SCI
• in cervical SCI, the motor score improvement associated with early
decompression is greater in the UEs extending cranially starting at or just
inferior to the injury level, than it is in the LEs

Badhiw ala JH, Wilson JR, Witiw CD, et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient
data. Lancet Neurol. 2021; 20:117–126
 Pharmacologic Management
06 General Care
The use of methylprednisolone within 8 hours following SCI cannot be definitely
recommended. (ATLS)
No other potential therapeutic agents have yet demonstrated efficacy for motor
recovery and neuroprotection.

Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013; 72 Suppl 2:93–105
 Venous Thromboembolism Prophylaxis
06 General Care
Initiate chemoprophylaxis as early as medically possible,
typically within 72 hours of injury, to reduce the risk of venous
thromboembolism (VTE).
Compression stocking is safe and necessary in spinal cord injury
patients to prevent VTE.
 Spinal Shock
06 General Care
Spinal shock is a total or near-total areflexia with the complete loss or
suppression of motor function and sensation distal to the anatomical lesion

Spinal shock can persist from days to weeks, and it can

be
prolonged due to toxic or septic syndromes.
The end of spinal shock for most patients is seen with :
• The early return of the deep plantar reflex with the
and
bulbocavernosus
• Cremasteric
• Ankle jerk
• Babinski sign
• knee jerk recovering in a progressive order.
 Ventilator Management
06 General Care

Early tracheostomy is recommended to aid in

mechanical ventilation during the acute and more
chronic phases of care for patients with SCI.

Consider stimulation of the diaphragm in high-SCI

patients in order to plan long-term ventilator
strategies and determine a patient’s potential to
wean from the ventilator.
 Tracheostomy Following Cervical Stabilization
06 General Care

Tracheostomy can be performed early after

anterior cervical spinal stabilization.
Open and percutaneous tracheostomy are
both safe techniques.
 Analgesia in Spinal Cord Injury
06 General Care
Pain management is a priority in the care of the acutely injured SCI patient to relieve
suffering and to prevent dysautonomia symptoms triggered by pain.

The multimodal approach to pain management is recommended in the acute pain

management of SCI patients. It consists of opiates, acetaminophen, or non-steroidal
anti-inflammatory agents.

For neuropathic pain, anticonvulsants (gabapentinoids, such as gabapentin and

pregabalin) and antidepressants (tricyclic antidepressants, such as amitriptyline or
novel antidepressants) are recommended over other modalities.
 Avoidance of Associated Symptoms of SCI
06 General Care

managed with physical therapy, and in some

Spasticity
cases, anti-spasticity medications.

Use clinical judgment and a validated

assessment tool to assess skin breakdown risks, and
Decubitus Ulcer prevent decubitus ulcers by avoiding known
modifiable risk factors such as pressure, shear
force, and moisture to the skin.
 Neurogenic Bowel and Bladder Acute Care Management
06 General Care

Initiate a bowel management program for all patients with

acute spinal cord injury.

The goal of effective bladder management is

preserve
to upper urinary tract structures and minimize
urinary tract infections.
 Mobilization and Rehabilitation for Acute Traumatic SCI
06 General Care
Injury Activities of Daily Mobility Interventions
Level Living
C1 – C4 Feeding and Power chair with tongue, chin, Recommendations for adaptive
communication possible head, or breath control. equipment such as call bells. Family
with adaptive and Requires mechanical engagement in interventions
augmentative equipment assistance for pressure relief

C5 Feeding and hygiene Power chair with hand control, Strengthen partially intact muscles.
with set-up assistance may propel over short Momentum strategy for bed mobility
and adaptive equipment distances on level surfaces and transfers.

C6 Feeding and dressing Propel manual wheelchair on Active pressure relief. Static sitting
with set-up assistance level surfaces balance. Wheelchair positioning
(high back). Tenodesis development.
 Mobilization and Rehabilitation for Acute Traumatic SCI
06 General Care
Injury Activities of Daily Mobility Interventions
Level Living
C7 – C8 Independent with Propel manual wheelchair on Dynamic sitting. Slideboard
feeding, dressing, most or all surfaces, including transfers. Fine motor training.
bathing, toileting. May outdoors.
require adaptive
equipment.

T1 – L1 Independent in all self- Stand with bracing/frame for Wheelchair propulsion, level ground.
care areas. exercises. Lower extremity self management.
L2 Independent in all self- Potential household Pop-over transfers. Low back
care areas. ambulation with bracing and wheelchair training.
assistive devices.
 Mobilization and Rehabilitation for Acute Traumatic SCI
06 General Care

Injury Activities of Daily Mobility Interventions

Level Living
L3 Independent in all self- Potential for community Assisted standing weight physiologic
care areas. ambulation with bracing and weight-bearing.
assistive devices.

L4 – S1 Independent in all self- Potential for community Standing balance training. Assisted
care areas. ambulation without assistive transfers and gait training.
devices.
 THANK YOU
TERIMA
KASIH
REFERENCE
s