OVERVIEW OF SPINAL CORD INJURIES IN EMERGENCY
- 1. Anatomy of cord and spine By Ame Mehadi|Assistant professor| Haramaya University
- 2. Anatomy : Spinal cord: Extends from medulla oblongata L1 Lower part tapered to form conus medullaris
- 6. 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
- 8. Hence: 31 pairs of spinal nerves: 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal
- 9. Dorsal root sensory fibres Ventral root motor fibres Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve
- 11. Physiology and function Grey matter sensory and motor nerve cells White matter ascending and descending tracts Divided into - dorsal - lateral - ventral
- 13. Tracts : 1) Posterior column: Fine touch Light pressure Proprioception
- 14. 2) Lateral corticospinal tract : Skilled voluntary movement 3) Lateral spinothalamic tract : Pain & temperature sensation
- 15. 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
- 16. Thank you
- 17. 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
- 18. Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM) 息 2007 Elsevier
- 19. Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM) 息 2007 Elsevier
- 20. 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
- 21. Lower Limbs : L2 - Hip flexors L3,4 - Knee extensors L4,5 S1 - Knee flexion L5 - Ankle dorsiflexion S1 - Ankle plantar flexion
- 22. Spinal Cord Injury Classification Quadriplegia : injury in cervical region all 4 extremities affected Paraplegia : injury in thoracic, lumbar or sacral segments 2 extremities affected
- 23. Injury either: 1) Complete 2) Incomplete
- 24. Complete: i) Loss of voluntary movement of parts innervated by segment, this is irreversible ii) Loss of sensation iii) Spinal shock
- 25. 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
- 26. 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
- 27. 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
- 28. 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
- 29. 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
- 30. 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
- 31. 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
- 33. Types of incomplete injuries i) Central Cord Syndrome ii) Anterior Cord Syndrome iii) Posterior Cord Syndrome iv) Brown Sequard Syndrome v) Cauda Equina Syndrome
- 34. i) Central Cord Syndrome : Typically in older patients Hyperextension injury Compression of the cord anteriorly by osteophytes and posteriorly by ligamentum flavum
- 35. 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
- 38. 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)
- 39. Clinically: Loss of power Decrease in pain and sensation below lesion Dorsal columns remain intact
- 41. 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
- 43. 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
- 44. 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)
- 46. 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
- 47. 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
- 48. thank you
- 49. References: 1. Andrew T Raftery, et al. Applied Basic Science for Basic Surgical Training. Second edition 2008;8:219- 223 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