Paraplegia

Spinal Cord
Elongated part of CNS
Begins at continuation of
medulla oblongata at
the level of upper border
of atlas vertebra
In adult from Foramen
Magnum till Lower
border of L1
In newborn, till L3
In fetus, till S3
Protected by:
- Vertebral column
- Meninges
- CSF

Spinal Cord External features

Conus medullaris:
- Cone-shaped, distal
end of spinal cord
Below conus
medullaris, the
vertebral canal
contains only cauda
equina (nerve roots,
appeared like tail of
the horse)

Two major
enlargements :
1. Cervical enlargement
-. Spinal nerves C5 T1
-. Due to increased
number of neurons
supplying upper limb
muscles
2. Lumbosacral
enlargement
-. Spinal nerves L1 S3
-. Due to increased

Blood supply
Anterior spinal artery formed from branches of the
vertebral arteries. They travel in the anterior median
fissure.
Posterior spinal arteries originate from the vertebral
artery / posteroinferior cerebellar artery.
Additional arterial supply is via theanteriorandposterior
segmental medullary arteriessmall vessels which enter
via the nerve roots. The largest anterior segmental
medullary artery is thearteryof Adamkiewicz. It arises
from the inferior intercoastal artery, and supplies the
inferior 2/3 of the spinal cord.
Venous drainage is largely carried out by the three
anterior and threeposterior spinal veins, with additional
return via the anterior and posterior medullary and
radicular veins.

Spinal Cord Internal Features

Central canal surrounded by gray and white

matter:
- Gray matter Rich in nerve cell bodies, form
H-shaped in central regions of the cord
- White matter Surrounds gray matter, rich in

Gray matter - Nerve Cell Groups

Posterior Grey Column Substantia gelatinosa, Nucleus

proprius,
Nucleus Dorsalis
Anterior Grey Column Medial / Central / Lateral
Lateral Grey Column Intermediolateral group :

NUCLEUS
Substantia
gelatinosa
Nucleus
proprius

Nucleus
dorsalis
Visceral
afferent
nucleus

FUNCTION
- Apex of posterior gray column
Receives afferent fibres of :
PAIN, TEMPERATURE, TOUCH
- Situated anterior to Substantia
gelatinosa
PROPRIOCEPTION
(position&movement)
Two-point DISCRIMINATION
VIBRATION
Proprioceptive endings
(muscle&tendon spindles)
Visceral afferent information

Spinal nerves
Posterior root of spinal nerve contains processes of
sensory neurons that carry information to CNS
Cell bodies of the neurons are clustered forming posterior
root ganglion
Anterior root contains motor nerve fibers; away from CNS
A spinal segment = area of the spinal cord that gives rise
to posterior and anterior rootlets that form a single pair
of spinal nerve
Each spinal nerve divides into 2 major branches : a small
dorsal ramus & a much larger ventral ramus
Posterior rami supplies nerve fibres to the synovial joints
of the vertebral column, deep muscles of the back, and
the overlying skin.
Anterior rami supplies nerve fibres to much of the
remaining area of the body, both motor and sensory.
31 pairs of spinal nerves

Spinal Tracts
Ascending tract sensory pathway
Descending tract motor pathway

ASCENDING TRACTS
FUNCTIONS
Spinothalamic pathway
Lateral spinothalamic
Pain and temperature
tract
Simple touch & pressure
Anterior spinothalamic
tract
Spinocerebellar pathway - Lower limbs and trunk
Posterior spinocerebellar Proprioceptive impulse
tract
Proprioceptive impulse
Anterior spinocerebellar
tract
Dorsal white column
Proprioceptive impulse,
Fasciculus gracilis
fine touch, vibration
Fasciculus cuneatus
sense, tactile localization,
*Tabes dorsalis = tertiary syphilis;
degeneration of
discrimination
nerve of dorsal column; loss of proprioception,
vibration, discriminative touch

DESCENDING TRACTS

FUNCTIONS

Corticospinal tract

Voluntary movements

Reticulospinal tract

Voluntary movements,
muscle tone

Rubrospinal tract
Tectospinal tract

Vestibulospinal tract

Facilitates control of flexor

tone
Reflex postural
movements in response to
visual stimuli
Maintenence of balance

Segmental Spinal Cord Level & Function

Level
C1-C6
C1-T1
C3-C5
C5-C6
C6-C7
C7-T1
T1-T11
T7-L1
L1-L4
L4-S1
L4-S2

Function
Neck flexors
Neck extensors
Diaphragm (mostly C4)
Shoulder movements, raise arms,
flex elbow, supinates arm
Extends elbows and wrists, pronates
wrists
Flexes wrist, supply small muscles of
the hand
Intercostals muscles
Abdominal muscles
Thigh, hip muscles
Hamstrings, dorsiflexion of foot
Plantar flexion of foot, toe

Effects of Spinal Injury Different levels

C1 C4 (most severe form)
Paralysis in arms, hands, trunk and legs
Patient may not be able to breathe on his or her own,
cough, or control bowel or bladder movements
Ability to speak is sometimes impaired or reduced
Requires complete assistance with activities of daily
living, such as eating, dressing, bathing, and getting
in or out of bed
C5 C8
may be able to breathe on their own and speak
normally

C5 injury
Patient can raise his or her arms and bend elbows
some or total paralysis of wrists, hands, trunk and legs
Can speak and use diaphragm, but breathing will be
weakened
C6 injury
Nerves affect wrist extension
Paralysis in hands, trunk and legs
Can speak and use diaphragm, but breathing will be
weakened
Little or no voluntary control of bowel or bladder
C7 injury
Nerves control elbow extension and some finger
extension
Most can straighten their arm and have normal

C8 injury
Nerves control some hand movement
Should be able to grasp and release objects
Little or no voluntary control of bowel or bladder
T1 T5
Corresponding nerves affect muscles, upper chest,
mid-back and abdominal muscles
Arm and hand function is usually normal
Paralysis of the trunk and lower limbs(paraplegia)
Loss of sensation below the nipples

T6 T12
Nerves affect muscles of the trunk (abdominal and
back muscles) depending on the level of injury
Normal upper-body movement, paraplegia
Fair to good ability to control and balance trunk
while in the seated position
Able to cough productively (if abdominal muscles
are intact)
Little or no voluntary control of bowel or bladder

L1 L5
Injuries generally result in some loss of function in
the hips and legs
Little or no voluntary control of bowel or bladder
May be able to walk with assistance
S1 S5
Injuries generally result in some loss of functioning
of the hips and legs
Little or no voluntary control of bowel or bladder
Most likely will be able to walk

PARAPLEGI
A
Def: Paralysis of lower limbs

Causes
Trauma
Vertebral body fracture/dislocation
Hyperextension injury
Direct puncture, stab, or missile

Chronic compression of Spinal Cord

Chronic Compression of Spinal Cord

Pressure on the spinal arteries ->
ischemia of spinal cord with degeneration
of nerve cells and their fibers
Pressure of on spinal veins -> edema of
spinal cord with interference in the
function of neurons
Direct pressure on white and gray matter
on spinal cord and spinal nerve roots ->
interferes nerve conduction

 Extradural
Herniation of intervertebral disc (Lumbar
disc herniation)
Posterior part of the annulus fibrosus of the
disc ruptures, and the central nucleus
pulposus is pushed posteriorly

Spinal epidural hematoma

Infectious disorders (e.g., abscess,
tuberculosis)
Primary and secondary tumors of
vertebrae

 Intradural
Extramedullary
Tumors such as meningiomas and nerve
fibromas

Intramedullary
Primary tumors of spinal cord such as
gliomas

Destructive Spinal Cord Syndrome

 Complete Cord Transection Syndrome

Results in complete loss of all sensibility
and voluntary movement below the level of
lesion.
Can be caused by fracture dislocation of
vertebral column, bullet or stab wound, or
expanding tumor.

 Associated features:
Bilateral lower motor neuron paralysis and
muscular atrophy in the segment of the
lesion anterior gray columns
Bilateral spastic paralysis below the level of
lesion descending tracts other than
corticospinal tract
Bilateral loss of all sensations below the level
of lesion posterior white columns, lateral
and anterior spinothalamic tracts
Loss of voluntary control on bladder and
bowel function

 Anterior Cord Syndrome

Can be caused by cord contusion during
vertebral fracture or dislocation, by injury
to the anterior spinal artery, or by a
herniated intervertebral disc.

 Associated features:
Bilateral lower motor neuron paralysis in the
segment of the lesion and muscular atrophy
anterior gray columns
Bilateral spastic paralysis below the level of the
lesion anterior corticospinal tract and tracts
other than corticospinal tract
Bilateral loss of pain, temperature, and light
touch sensations below the level of the lesion
anterior and lateral spinothalamic tracts
Tactile discrimination, vibratory and
proprioceptive sensations are preserved because
posterior white columns are undamaged

 Central Cord Syndrome

The cord is pressed on anteriorly by the
vertebral bodies and posteriorly by the
bulging of ligamentum flavum, causing
damage to the central region of spinal
cord.

 Associated features:
Bilateral lower motor neuron paralysis in the
segment of the lesion and muscular atrophy
anterior gray columns
Bilateral spastic paralysis below the level of lesion
with characteristic sacral sparing motor upper
limb fibers located medially and lower limbs fibers
located laterally
Bilateral loss of pain, temperature, light touch, and
pressure sensations below the level of the lesion
with characteristic sacral sparing sensory upper
limb fibers located medially and lower limbs fibers
located laterally
Tactile discrimination, vibratory and proprioceptive

 Brown-Sequard Syndrome
Will be discussed later

Brown-Sequard Syndrome

 hemisection of the spinal cord as a result of, for example,

bullet or stab wounds, syringomyelia, spinal cord tumor, or
hematomyelia.
Signs and symptoms:
1. ipsilateral LMN paralysis in the segment of the lesion
(resulting from damage to LMNs)
2. ipsilateral UMN paralysis below the level of the lesion
(resulting from damage to the lateral corticospinal tract)
3. ipsilateral zone of cutaneous anesthesia in the segment
of the lesion (resulting from damage to afferent fibers that
have entered the cord and have not yet crossed)
4. ipsilateral loss of proprioceptive, vibratory, and twopoint discrimination sense below the level of the lesion
(resulting from damage to the dorsal columns)
5. contralateral loss of pain and temperature sense below
the lesion (resulting from damage to the spinothalamic
tracts, which have already decussated below the lesion)

 Hyperesthesia may
be present in the
segment of the
lesion or below the
level of the lesion,
ipsilaterally, or on
both sides.
In practice, "pure"
Brown-Sequard
syndromes are rare
because most
lesions of the
spinal cord are
irregular.

Investigations

PHYSICAL EXAMINATION
Patient may appears well or dyspneic, conscious
and normal higher cortical functions.
Weakness in lower limbs, difficulty in walking and
gait disturbances, walking aids can be observed
when the patient make their way to the clinic
room.
Motor system
Upper extremity muscle tone & power is normal.
In both lower extremities - increase in muscle tone,
spasticity, weakness, increased tendon reflexes

Medical Research Council Scale for muscle power

0

No muscle contraction visible

Flicker of contraction but no movement

Joint movement when effect of gravity eliminated

Movement against gravity but not against examiners resistance

Movement against resistance but weaker than normal

Normal power

 Sensory system
Normal sensory
functions for upper
extremities
Lower extremities
loss of sensation
(decreased light touch
sensation, loss of
temperature sensation,
dull pain with pinprick test)

 Imaging X- ray, MRI ( Magnetic

Resonance Imaging),CT scan and
myelography
- fractures, herniated disc, dislocation,
collapse
-to assess level of spinal involvement,
X-ray
cord compression, morphology
and
Compression
fracture
extent of abscess

 MRI

Fracture of L1 vertebrae

Destruction of
vertebrae with
abscess

 Myelography for those who cannot

undergo MRI (pacemaker, metal)
Cord
compression

 Lumbar puncture for Cerebrospinal Fluid

analysis , increase in leukocytes may indicate
infection (TB).
Full blood count to check for infection or
inflammation (neutrophil count > 7.5 x 109/L)
U & E for culture(UTI from urethral catheter )
Pulmonary function test to assess lung function
Pulse oxymeter to measure amount of oxygen
in the blood

Management
Stabilize spine via surgery remove
fragments of bones, realignment of
herniated discs, fractured vertebrae

 Maintain ability to breathe

ventilator, tracheostomy tube,
oxygen mask

 Muscle spasm muscle relaxants (diazepam,

baclofen)
Loss of bladder function indwelling of bladder
catheter
Bowel management maintain adequate fiber
and fluid intake, stimulant laxatives (bisacodyl)
Rehabilitation physical therapy to maintain
and strengthen existing muscle function, gait
retaining, usage of walking aids, wheelchair.
Frequent change of patients position to guard
against bed sores.
Anticoagulants (warfarin) given as prophylaxis
against deep venous thrombosis (bed-ridden).