SPINAL CORD INJURY

By Lumauag, Hannah Marielle A.

PATIENT PROFILE

RMB
44 y.o.
Male
farmer
From Bago City
Catholic
 PAST MEDICAL HISTORY

Non-hypertensive
Non-diabetic
Non-asthmatic
No previous hospitalizations
No previous surgical operations
No known food or drug allergy
 PERSONAL-SOCIAL HISTORY

nonsmoker
occasional alcoholic beverage drinker
Diet: Fish, vegetables, rice, pork
 CHIEF COMPLAINT

Inability to move all extremities

 HISTORY OF PRESENT ILLNESS
Nature of Injury: Motor vehicular accident (driver)
Time of injury: 6:30 pm
Place of injury: Ma-ao
Date of injury: September 11, 2016

A day prior to admission, patient was riding his motorcycle when

he accidentally flew off his motorcycle because he was not able to
hit the brakes on a blind curve. Patient reportedly fell on the mud
with his head hyperextended. Patient was then brought to a
district hospital where he was then referred to our institution for
further evaluation and management.
 PHYSICAL EXAM
GENERAL SURVEY:
Awake, bed-bound, with cervical collar, conscious,
coherent, in respiratory distress, with NGT inserted
through left nostril
V/S: BP 110/80mmHg
CR 88 bpm
RR 22 cpm
Temp 36.4 C
 PHYSICAL EXAM
HEENT:
Skull is normocephalic without lesions. Face symmetric
without deformities or involuntary movements.
Anicteric sclera, pinkish conjunctiva. Pupils round,
briskly reactive to light. Ears symmetric without
discharges, skins lesions, or deformities. Nose
symmetric, nasal septum midline. No masses,
deformities nor lesions noted. Lips moist. Oral mucosa
and gums are pinkish.
 RESPIRATORY AND
CARDIOVASCULAR

Respiratory
Thorax symmetric with good chest expansion; sternum midline;
no deformities and lumps noted; Use of accessory muscles of
respiration noted; no tenderness upon palpation. Clear breath
sounds. No crackles, wheezes, or stridor. No clubbing noted.

Cardiovascular
Adynamic precordium; no bruits, heaves, or thrills noted. No
clicks and murmurs heard upon auscultation.
 ABDOMEN

Abdomen is flat with normoactive bowel sounds heard at 6 clicks

per minute. Abdomen is soft, nontender.

Genitalia, Rectum and Anus

Skin of penis and scrotum brown in color without discoloration,
redness, and swelling. No ulcers, scars lumps or areas of
tenderness noted. No ulceration, swelling, and redness upon
inspection of anus. Rectum is smooth with no lumps nor masses
felt. Good rectal sphincter tone noted. Fecal material on glove
noted upon examination. Prostate not enlarged, smooth, soft and
without lumps upon digital rectal examination.
 PERIPHERAL VASCULAR SYSTEM
AND MUSCULOSKELETAL SYSTEM

Peripheral Vascular System

Arms symmetric. Nailbeds pink with capillary refill of <2sec. Brachial
and radial pulse graded 2+. Femoral, popliteal, dorsalis pedis and posterior tibial
pulses graded 2+. Legs are symmetrical and bilaterally warm to touch. No edema
noted.

Musculoskeletal
TMJ in full range of motion, without tenderness. Shoulders symmetric,
with abrasion on the right shoulder; No deformity, no tenderness and with limited
range of motion. Unable to move elbow, wrist, hands, fingers and thumb. No
deformities, no swelling, no tenderness noted. Legs symmetric. Knees symmetric,
no swelling, no tenderness, no effusion. Ankles and feet symmetric, no
deformities, no tenderness.
 NEURO EXAM

MSE: The patient is alert, awake and cooperative. No

involuntary movements observed. Facial expressions are
appropriate to current mood. The patient is responsive to
questions. Speech is fluent with moderate loudness of
voice. Spoken words are clear and distinct. Thought
processes coherent. No hallucinations, delusions, flight of
ideas or confabulation noted; Patient is oriented to
person, place, and time. Attention span is good. Intact
insight, judgement, remote and recent memory.
Cranial Nerves:
CN I- sense of smell intact; able to identify smell of oranges
CN II- both pupils equally round and briskly reactive to light; pupils constrict from 4mm to 3mm
on both eyes; Visual acuity is 20/100 on right eye, 20/70 on left eye; red-orange reflex seen on
both eyes
CN III, IV and VI- unable to move gaze on temporal/lateral side, left eye; no ptosis or nystagmus
CN V- motor: temporal and masseter muscle strength 5/5, sensory: intact corneal reflexes, able to
feel pain, light touch, sharpness, and dullness on forehead, cheeks, and jaw.
CN VII- intact muscles of facial expression, able to raise eyebrows, smile, frown, close eyes, puff
out cheeks
CN VIII- hearing is intact on both ears; able to hear whispered voice
CN IX and X- intact gag reflex, able to swallow without difficulty, no hoarseness of voice
CN XI- sternocleidomastoid and trapezius muscles strengths 4/5; able to shrug and move neck
with minimal difficulty
CN XII- tongue is midline, symmetric, without atrophy, deviation, or fasciculations; words are
articulate
Motor: No tremors, tics, fasciculations, muscle atrophy noted. Normal muscle
tone (no spasticity or rigidity). Muscle strength 0/5 on both upper extremities
(flexion of arms, extension of arms, wrist extension, wrist flexion, grip, finger
abduction and adduction), 3/5 on trunk movements, hip flexion and
extension, hip adduction and abduction, knee flexion and extension,
dorsiflexion and plantar flexion).

Cerebellar: Gait not tested. Rapid alternating movements not tested.

Sensory: No pain, position and vibration, light touch, discriminative

sensations on dermatomal levels from L2-S3, right leg. Intact on other areas.
Deep Tendon Reflexes:
Biceps Triceps Brachioradialis Knee Ankle
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+

Other Reflexes:
Intact Bulbocavernosus reflex
Intact Deep Anal Pressure
Intact Voluntary Anal Sphincter Control
Intact Peri-anal Wink
 ADMITTING DIAGNOSIS

SPINAL CORD INJURY

QUADRIPLEGIA LEVEL OF
C3 SECONDARY TO
HYPERFLEXION INJURY
CASE DISCUSSION
 INCIDENCE

-approximately 40 new cases/million population (12,000/year)

-highest for persons 16 to 30 years of age
-current average age at onset is reported to be 40.2 years
-80% occurs in males
-most common causes of SCI in descending order of incidence are vehicular
crashes (42.1%), falls (26.7%), violence (15.1%), and sports (7.6%)
-more injuries occur on weekends and during the summertime
-tetraplegia more common than paraplegia (50.5% vs. 44.1%)
-subdivided into the following neurologic categories: incomplete tetraplegia
(30.1%), complete tetraplegia (20.4%), complete paraplegia (25.6%), and
incomplete paraplegia (18.5%)
 PRIMARY CAUSES OF DEATH

%
Diseases of the respiratory system (70% pneumonia) 22
Other heart disease 12
Infective and parasitic disease (94% septicemia usually 10
assoc with pressure ulcers or urinary tract or
respiratory tract infections)
Hypertensive & ischemic heart disease 8
Neoplasms 7
Diseases of pulmonary circulation (96% pulmonary 5
emboli)
Diseases of the genitourinary system 4
Suicides 4
Other causes 28
ANATOMY
 SPINAL CORD

-terminates at the level of the L1–L2

intervertebral disk, but can be as high as
the T12 or as low as the L3 vertebral
body
Conus medullaris - tapered end of the
spinal cord, which contains the sacral
cord segments
Cauda equina - the collection of long
lumbar and sacral roots found in the
canal, distal to the conus medullaris;
resembles a horse’s tail
Meninges:
>Pia matter- a vascular membrane covering the
spinal cord
>Arachnoid membrane
>Dura mater

Subarachnoid space (intrathecal space)- contains

CSF

S2 vertebrae - caudal margin of the dura mater

and arachnoid, the inferior extent of the
intrathecal space

Epidural space - located between the dura mater

and the periosteum of the vertebral bodies, and
contains an internal vertebral venous plexus, fat,
and loose areolar tissue
A cross-sectional view of the spinal cord
reveals a central butterfly-shaped region
of gray matter consisting of neuronal cell
bodies, their processes, supporting glial
cells, and small blood vessels surrounded
by white matter consisting of neuronal
fiber tracts and supporting glial cells.
Gray matter – 2 horns on each side: anterior (ventral) and posterior (dorsal) horns.

• posterior horn - cell bodies of sensory neurons

• anterior horn - cell bodies of interneurons and motor neurons

White matter - 3 columns on each side called the anterior, lateral, and posterior columns, further subdivided
into tracts
• gracilis tract - located in the medial posterior column, contains fibers from the T7–S5 dermatomes that
relay touch, vibration, and position sense; ascend ipsilaterally to medulla
• cuneatus tract - located in the lateral posterior column rostral to T6, contains fibers from dermatomes
above T7 that relay touch, vibration, and position sense; ascend ipsilaterally to medulla
• lateral spinothalamic tract - located peripherally in the lateral column, contains fibers that relay pain and
temperature sensations; this tract ascends contralaterally to the thalamus.
• lateral corticospinal tract - located centrally and posteriorly in the lateral column; contains fibers, most of
which emanate from the motor cortex, that are responsible for voluntary and reflex movement; 90% of
the fibers cross midline in the caudal medulla, forming the pyramidal decussations, and descend
contralaterally in the lateral corticospinal tract to terminate on interneurons and α- and γ-motor neurons
in the spinal cord.
• The remaining corticospinal fibers, located in the medial anterior column, do not cross midline in the
medulla but descend ipsilaterally in the anterior corticospinal tract. These fibers ultimately cross midline
segmentally near their terminations on interneurons and alpha and gamma motor neurons in the spinal
cord.
• About 55% of the corticospinal fibers terminate in the cervical cord, 20% in the thoracic cord, and 25%
in the lumbosacral cord.
• corticospinal neuron - known as an upper motor neuron (UMN)
• lower motor neuron (LMN) - motor neuron to which UMN synapses in the spinal cord,
which exits the spinal cord to innervate muscle

• If damage to the UMNs and LMNs within the spinal cord is localized to a few
segmental levels anywhere rostral to the conus medullaris  UMN syndrome: loss of
voluntary movement, spasticity, hyperreflexia, clonus, and development of Babinski’s
sign.

• If there is damage to a significant number of LMNs below the level of injury: loss of
voluntary movement occurs without the subsequent development of the other
components of the UMN syndrome.

Examples: SCI caused by an extensive vascular insult to the spinal cord, an injury occurring
at the conus medullaris, or an injury occurring at the cauda equina.

• Conus medullaris syndrome - injury of the sacral spinal cord and the lumbar nerve
roots within the spinal canal resulting in an areflexic bladder, bowel, and lower limbs.
Conus medullaris lesions localized to the proximal sacral cord can occasionally show a
preserved sacral reflex, such as the bulbocavernosus reflex.
• Cauda equina syndrome - injury to the lumbosacral roots within the spinal canal,
resulting in an areflexic bladder, bowel, and lower limbs.
After an acute UMN-predominant SCI, initial development of the UMN syndrome
is delayed by a process called SPINAL SHOCK, whereby there is a transient
suppression and gradual return of reflex activity below the level of injury.

Ditunno et al. have proposed a four-phase model of spinal shock:

• phase 1 - 0 to 24 hours postinjury; motor neuron hyperpolarization, manifesting

as hyporeflexia
• phase 2 - days 1 to 3 postinjury; denervation supersensitivity and receptor
upregulation, manifesting with reflex return
• phase 3 - 1 to 4 weeks postinjury; interneuron synapse growth, manifesting as
early hyperreflexia
• phase 4 - 1 to 12 months postinjury; long axon synapse growth, manifesting as
late hyperreflexia.
• two posterior spinal arteries, a
single anterior spinal artery, and
several segmental radicular
arteries
• posterior spinal arteries - supply
the posterior one third of the
spinal cord
• anterior spinal arteries - supply
the anterior two thirds of the
spinal cord
• segmental radicular arteries
travel through the intervertebral
foramina from the aorta and
divide into anterior and
posterior branches that
eventually anastomose with
their respective spinal arteries
 CLASSIFICATION OF SCI

• The diagnosis of SCI can be made promptly by performing a neurologic

examination.

• The sensory portion of the neurologic examination includes the testing of

a key point for absent, impaired, or normal sensation in each of the 28
derma- tomes on each side of the body for both light touch and pinprick.

• The testing of every key muscle should begin in the grade 3 testing
position. If the muscle is shown to have greater than antigravity strength
(grade 3), then the muscle should be tested in the grades 4 and 5 testing
positions. Conversely, if the muscle is shown to have less than anti- gravity
strength when tested in the grade 3 testing position, the muscle should be
tested in the grade 2 testing position. If the muscle is shown to not even
have grade 2 strength, then the grade 1 testing position is used.
 CLASSIFICATION OF SCI

ASIA Impairment Scale (AIS), which classifes an SCI into five categories of severity, labeled A
through E, based on the degree of motor and sensory loss.

• A - absence of any sensory or motor function in the sacral segments S4–S5; designated as
complete.

• B - SCI where sensation is preserved in the sacral segments S4–S5, but there is no motor
function caudal to three segments below the NLI

• C - SCI where sensation is preserved in the sacral segments S4–S5, but more than half the key
muscles below the NLI have a muscle grade less than 3/5

• D - sensation is preserved in the sacral segments S4–S5, but at least half the key muscles
below the NLI have a muscle grade greater than or equal to 3/5

• E- sensory and motor function is normal

**AIS categories B through E designate incomplete injuries.**

 NONTRAUMATIC SPINAL CORD
INJURY

Nontraumatic SCI can be caused by a variety of diseases:

• neoplastic
• infectious
• inflammatory
• vascular
• degenerative (spondylotic)
• congenital
• toxic-metabolic disorders
 OUTCOMES OF TRAUMATIC SPINAL
CORD INJURY

• COMPLETE TETRAPLEGIA - poor prognosis for recovering the ability to walk.

Only 2% to 3% of persons initially classified as having an AIS of A convert to AIS
D by 1 year

• INCOMPLETE TETRAPLEGIA - 90% of persons with central cord syndrome,

but only a few of those with anterior cord lesions, were able to ambulate after SCI.
Maynard et al.293 subsequently reported that 87% of persons with motor
incomplete tetraplegia initially were walking by 1 year, whereas 47% of persons
with sensory incomplete, but motor complete, tetraplegia were walking by 1 year.

• AMBULATION IN PARAPLEGIA - recovery of lower limb function in persons

with paraplegia is dependent on the completeness of injury and the level of injury.
Among persons with complete paraplegia, about 75% retain the same NLI at 1 year
that they had at 1 month postinjury, 20% gain a single level, and 7% gain two
neurologic levels; Persons with incomplete paraplegia have the best prog- nosis for
ambulation among all the groups of persons with traumatic SCI. Eighty percent of
individuals with incom- plete paraplegia regain functional hip exion and knee
extension within 1 year of injury, making both indoor and community-based
ambulation possible.
 ACUTE PHASE OF INJURY

first 24 hours after trauma – deadliest; primary and secondary injuries to the central
nervous system are the leading cause of death.
• ensuring an adequate airway, breathing, and circulation
• monitor closely for the need for ventilatory support  intubation is done when
necessary
• spine immobilization
• maintenance of adequate blood pressure target mean arterial blood pressure of 85
mm Hg for a minimum of 7 days  favorable outcomes
• Monitor core temperature
• Once stabilized medically, a thorough evaluation of neurologic status and spinal stability
is performed. The neurologic status is determined using the ISNCSCI.
• Computed tomography (CT) imaging of the entire spine is recommended because of
the lack of sensitivity of plain film protocols, particularly in the craniocervical region
and at the cervicothoracic junction.
• MRI evaluation is essential for evaluating nonbony tissues including the spinal cord,
nerve roots, ligaments, and intervertebral disks, and should be performed to evaluate
the area of a known or suspected SCI. MRI evaluation is particularly important for
identification of spinal pathology in persons with a neurologic deficit not identified by
CT and for those persons who are unconscious or obtunded.
• Surgery when indicated
 REHABILITATION PHASE OF
INJURY

Rehabilitation goals:
maximizing physical independence
becoming independent in direction of care
preventing secondary complications

 interdisciplinary team approach (led by physician, person with SCI, family members, physical
therapists, occupational therapists, nurses, aides, dieticians, psychologists, recreation therapists,
vocational therapists, and social workers or case managers)

• Physical skills training

• Wheelchair skills
• Spinal Cord Injury Education
• Home and environmental modifications
• Driver training
• Vocational training
• Reconstructive surgery of upper limbs
• Functional Electrical Stimulation for Therapeutic Exercise