SPINAL CORD INJURY o Artery of Adamkiewicz (Radularis

Magna) – arise from T9-L2 from the

Paraplegia – complete paralysis of all or part of
the trunk and (B) LE; lesions of the thoracic or
 Partial/complete disruption of the SC (L) side of 70% of the population lumbar cord or cauda equina
 Paralysis, sensory loss, altered autonomic  Veins of the SC – drain mainly into internal Complete – absence of sensory and motor in
activity BELOW the level of the injury venous plexus lowest sacral segments (S4 and S5)
Relevant Anatomy: Spinal Cord  Zone of Partial Preservation – dermatomes
 Extends from the foramen magnum – L1 in Spinal Cord Tracts and myotomes caudal to neurologic level
adults and up to L3 in newborns Ascending of injury c partial innervation
 Nearly cylindrical, 1 cm in diameter, with  Lateral Spinothalamic – conveys superficial Incomplete – Partial preservation of functions
cervical and lumbar enlargements sensations (pain, temperature, light below neurologic level including lowest sacral
(plexuses) touch); decussates at the SC, ascends 2-3 segments
Vertebral Level Spinal segments  Sacral Sparing – voluntary anal sphincter
(Radiographic) Segment/s  Dorsal Column Medial Lemniscus – contraction/sensory function in lowest
(Neurologic) conveys deep sensations (vibration, sacral segments; indicates possibility of SC
Cervical +1 proprioception, 2-point discrimination, recovery
Upper Thoracic +2 light touch); decussates at the brainstem Mechanisms of Injury
(T1-T6) Descending Flexion – common in MVA/head-on collisions
Lower Thoracic +3  Corticospinal – controls fine movement of  Vertebral body > 50% displaced on x-ray
(T7-T9) ipsilateral limbs; decussates at the  Both facets dislocate, unstable (both
T10 L1 - L2 medulla oblongata ligaments are torn)
T11 L3 – L4
 Corticobulbar – innervates several cranial  Common in C5-C6
T12 L5
nerves; terminates at the brainstem  85% suffer neurologic injuries, likely to be
L1 Sacral and
Etiology a complete injury
coccygeal
Attachments Traumatic – most frequent cause of injury Hyperextension – common in acceleration-
 Denticulate Ligaments – extensions of the  Vehicular Accidents – major cause; >45 deceleration injuries, rear-end collision
pia mater; stabilizes the SC y/o  Stable, only ALL is disrupted
 Filum Terminale – extension of the pia  Violence – commonly by gunshot wounds  Can be seen in hyperextension of the C-
mater; extends from the apex of the conus  Falls – occurs in >45 y/o spine, appearing as Central Cord
medullaris to the coccyx to anchor SC  Diving – m/c sports-related cause Syndrome (Walking SCI), which commonly
Non-traumatic – account for ~39% of SCIs spares the LE
 Spinal nerve roots
Blood Supply  Vascular diseases – spinal cord infarction,  Commonly occurs in older persons c
AVM degenerative changes in the neck
 Anterior Spinal Artery – arise from the
vertebral arteries; narrowest at T8, prone  Infections – syphilis, transverse myelitis,  UE more commonly involved than LE, with
to damage during HTN (watershed area) Pott’s disease bowel, bladder, and sexual dysfunction at
 Tumors/neoplastic diseases various degrees
 Posterior Spinal Artery – arise from either
the vertebral arteries directly or the PICA Classification  Common in C4-C5
Tetraplegia – complete paralysis of all four Compression
 Radicular Arteries – branches of local
arteries from the aorta (deep cervical, extremities and trunk, including respiratory  M/c in C5
intercostal, and lumbar), enter the muscles; lesions of the cervical cord  Wedge-shaped vertebra on x-ray, may
vertebral canal through the IV foramina involve injury to nerve roots/SC
  Stable, ligaments intact  Most caudal key muscle group c at least C Incomplete Motor function
Flexion-Rotation 3/5 with segments above graded 5/5 preserved below
 Unilateral facet jt dislocation  Possible score of 100 (25 pts per neurologic level, more
 Vertebral body displacement > 50% on x- extremity) than half of key muscles
Key Myotomes: below neurologic level
ray, narrowing of the spinal canal and
have < 3/5 MMT
neural foramen Myoto Index Muscle Action
D Incomplete At least half of key
 Unstable if PLL is disrupted me
muscles below
 Common in C5-C6 C5 Biceps, brachialis Elbow flexion neurologic level > 3/5
 May disrupt the IV disc, facet jt, and C6 Extensor carpi radialis Wrist extension MMT
interspinous ligament s vertebral fx C7 Triceps brachii Elbow extension E Normal Sensory and motor
C8 Flexor digitorum Finger flexion functions
 ~75% s neurologic symptoms, likely
profundus (of middle
incomplete injury
finger) Incomplete SCI Syndromes
Other Fx of the Spine
T1 Abductor digiti minimi Small finger
 Jefferson – burst fx of the C1 ring, usually Central Cord Syndrome (Schneider) – m/c
abduction
no neurologic findings if pt survives incomplete SCI syndrome
L2 Iliopsoas Hip flexion
 Hangman – burst fx of C2, body separated L3 Quadriceps Knee extension  An acute cervical SCI
from posterior element, no SCI L4 Tibialis anterior Ankle  Greater impairment of motor function of
 Odontoid – fx of C2 odontoid process at dorsiflexion the UE than LE, typically recover ability to
base L5 Extensor hallucis Big toe ambulate but with weakness of distal UE
 Chance – m/c seen in pts wearing lap seat longus extension and loss of fine motor skills
belts, transverse fx of lumbar spine S1 Gastrocnemius Ankle  Hyperextension injury on an individual c
through bodies and pedicles plantarflexion long-standing cervical spondylosis, from
Assessment pinching of post cord by ligamentum
 According to sensory, motor, and Neurologic flavum/ant compression by osteophytes
neurologic level of injury  Most caudal segment c intact motor and Brown-Sequard Syndrome – hemisection of the
Sensory sensory on both sides of the body SC, typically by GSW or stab wounds
 Most caudal segment of the SC c normal  Recommended to record each side  Ipsilateral: Motor and proprioception
(2/2) sensation of pinprick and light touch separately deficits
on (B) sides of the body Skeletal  Contralateral: Pain and temperature deficit
 28 key sensory dermatomes  Where greatest vertebral damage is several dermatome segments below level
recorded through radiographic evaluation of injury
 Face used as normal control point
ASIA Impairment Scale Anterior Cord Syndrome (Beck’s) – d/t
2 Normal
 American Spinal Cord Injury Association ischemia/infarct of the ant 2/3 of the SC; related
1 Impair Gra Impairment Description to flexion injuries of the cervical cord
ed de  Loss of motor function (corticospinal
0 Absent A Complete No motor/sensory tracts) and pain and temperature
Key Dermatomes: function in sacral sensation (lateral spinothalamic tracts)
segments Posterior Cord Syndrome (Posterior Spinal Artery)
Motor B Incomplete Sensory but no motor – least frequent syndrome; lesions of the
function below posterior 1/3, occlusion of the post spinal artery,
neurologic level
infection e.g. syphilis (Tabes Dorsalis), or
pernicious anemia (vitamin B12 deficiency)
 Proprioceptive loss with intact pain,
temperature, light touch, and motor
function spared in varying degrees
Conus Medullaris Syndrome – injury to conus
medullaris and lumbar nerve roots; L1 fx, tumar,
gliomas, vascular injury, spina bifida, tethered
cord
 Common in injuries at level of T12 - L2
 Good prognosis for walking
Cauda Equina Syndrome – injury to lumbosacral
nerve roots c/in neural canal; L2 fx or below,
sacral fx, pelvic ring fx, associated c spondylosis
 Areflexive bladder, bowel, and LE, saddle
anesthesia, paralysis of the sphincters
Treatment
Wheelchair Prescription
 C1 - C4 – chin control
 C5 – manual c projection
 C6 - C7 – friction hand rim
 C8 – normal manual
Orthotic Prescription
Neurologic Level Expected Outcomes
Mid-thoracic (T6-T9) (B) KAFO, crutches,
swing-to gait
High Lumbar (T12- (B) KAFO, crutches,
L3) reciprocating gait
orthosis c walker
Low Lumbar (L4-L5) Community
ambulation:
(B) AFO c crutch/cane
Complications and Associated Conditions o Seizures, cardiac arrest,  Rostral SCI results in loss of sympathetic
Spinal Shock subarachnoid hemorrhage, stroke, communication while parasympathetic
 Areflexia below level of injury immediately death remains intact
p injury  Symptoms:  Orthostatic hypotension can be
 Believed to result from very abrupt o HTN, bradycardia, headache, experienced during early transitions of
withdrawal of connections between higher profuse sweating, spasticity, posture, usually only significant in pts c
centers and the SC restlessness, vasoconstriction below SCI above T6
 Absence of DTR, impaired autonomic level of lesion, vasodilation above o Blurred vision, ringing in the ears,
regulation (hypotension, loss of control of level of lesion, piloerection, blurred light-headedness, fainting
sweating and piloerection), vision  Tx:
bulbocavernosus, cremasteric, and  Diagnosis: 20-30 mmHg rise in BP (250- o Gradual progression to the vertical
Babinski reflexes, and a delayed plantar 300/200-220 mmHg) position
response  Tx: o Pharmacologic agents – ephedrine,
 Initial period lasts ~24 hrs, longest time in o Place pt in an upright position. low-dose diuretics
1-6 mos o Eliminate triggers Impaired Temperature Control
Motor and Sensory Impairments o Pharmacologic:  D/t cut-off of hypothalamic control
Autonomic Dysreflexia  Nifedipines – calcium-channel  No control of cutaneous blood flow and
 Potentially life-threatening pathological blocker level of sweating, loss of ability to shiver
autonomic reflex  Nitrates – vasodilators below level of lesion
 Typically appears in pts c lesions above  Captopril – ACE inhibitor  Initially, hypothermia may occur, but
T6 (sympathetic splanchnic outflow in T1- Spastic Hypertonia hyperthermia is a more common
L1)  Velocity-dependent increase in resistance complication later
 Pt’s BP can reach a systolic of 220 to passive stretch Pulmonary Impairment
 Produces autonomic activity from noxious  Part of the UMN Syndrome (spasticity,  Leading cause of death in pts c high
stimuli (triggers): muscle spasms, abnormally high muscle tetraplegia (C1-C2)
o Distended/irritated bladder/bowel – tone, hyperactive stretch reflexes, clonus) Level
Respiratory
m/c  Emerges below level of lesion p spinal of Intervention
Muscles
 Distended bladder shock evolves; gradual increase in first 6 Injury
 Blocked catheter mos, plateau 1 yr p injury Artificial
 UTI  Occurs in most SCIs except cauda equina C1 – SCM, upper traps, ventilator,
 Kidney stones syndrome C2 cervical extensors phrenic nerve
o Noxious cutaneous stimuli below stimulation
 Tx:
level of lesion Partial diaphragm, Acute,
o Muscle relaxants – baclofen, C3 –
scalenes, levator mechanical
o Pressure sores botulinum neurotoxin C4
scapulae ventilation
o Kidney malfunction  Adverse effects: weakness, Diaphragm,
o ES below level of lesion drowsiness, dizziness Assistance
C5 – pectorals, SA,
o Labor o Myotomy, tenotomy, rhizotomy – with airway
C8 rhomboids,
clearance
o Fx cutting of the nerve roots latissimus dorsi
 HTN triggered by AD can cause: Cardiovascular Impairment T1 – Some intercostals,
T5 erector spinae
 T6 – Intercostals,
T10 abdominals
 Injuries below T10 are likely to have near-
normal respiratory function
 Paradoxical breathing pattern –
paralysis/paresis of scalenes and
intercostals
o Flattening of upper chest wall,
decreased chest wall expansion,
dominant epigastric rise during
inspiration
Bladder and Bowel Dysfunction
Bladder
 Alteration of micturition (S2-S4)
o Spastic/Hyperreflexive/UMN Bladder
– occurs in lesions above the conus
medullaris
 Empties in response to filling
pressure (detrusor muscle is
hyperreflexive)
 Failure to store urine
o Flaccid/Areflexive/LMN Bladder –
lesion of sacral segments/conus
medullaris
 No reflex action of the
detrusor muscle
 Failure to empty urine
 Tx: Catheterization
Bowel
 Spastic/Reflex/UMN Bowel – lesions above
S2
 Flaccid/Areflexive/LMN Bowel – S2-S4 or
cauda equina lesions
Sexual Dysfunction
Males
 Erection – greater capacity in UMNL and
incomplete lesions
o Reflexogenic – external physical
stimulation, mediated through S2-
S4
o Psychogenic – cognitive activity e.g.
sexual fantasy
 Ejaculation – greater capacity in LMNL and
incomplete lesions
o Orgasm – cognitive, psychogenic
o Ejaculation – physical occurrence
Female
 Menstrual cycle – interrupted for 4-5 mos
but returns
Secondary Medical Complications
Pressure Sores – unrelieved pressure, shearing
forces
 Especially common in the sacral area,
heels, and ischium
 Evaluated and predicted using Braden
scale
Deep Vein Thrombosis – from development of a
thrombus within a vein
 Leads to thrombophlebitis: local swelling,
erythema, heat
 More likely to occur in acute stages
 Tx:
o Early mobilization, pneumatic
compression sleeves
o IVC filter
o Prophylactic anticoagulant drug
therapy (heparin, warfarin) for 2-3
mos
Pain
 Nociceptive – musculoskeletal/visceral in
nature
 Neuropathic – central pain, damage to the
nervous system and can be below, at, or
above level of injury, treated with
Pregabalin (Lyrica)
Heterotopic Ossification – osteogenesis usually
near jts below level of the lesion
 Often occurs in the hip and knee