spinal cord injury

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Slide 1 :

Spinal Cord Injury Presented By Dr Vipan Kumar, Resident Surgery Moderator Col M S Gill, Sr Adv Surgery & Neurosurgery AHRR, Delhi Cantt – 10

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Epidemiology 27 – 47 cases/million C-spine injuries MVAs - 50% falls - 25% sports activities - 10% 60% of all spine injuries in children; upper cervical spine. C5-C6 is the most commonly injured level in adults.

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Dorsal root – sensory fibres Ventral root – motor fibres Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve

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Grey matter – sensory and motor nerve cells White matter – ascending and descending tracts

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Tracts : 1. Posterior column: Fine touch Light pressure Proprioception Lateral corticospinal tract : Skilled voluntary movement 3. Lateral spinothalamic tract : Pain & temperature sensation

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Posterior column and lateral corticospinal tract crosses over at medulla oblongata Spinothalamic tract crosses in the spinal cord and ascends on the opposite side ……..understand this as it helps to understand the clinical features of injury patterns and the neurological deficit

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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

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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 Lower Limbs : L2 - Hip flexors L3,4 - Knee extensors L4,5 – S1 - Knee flexion L5 - Ankle dorsiflexion S1 - Ankle plantar flexion

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Injury either: Complete / Incomplete Primary /Secondary Complete: Loss of voluntary movement of parts innervated by segment, this is irreversible Loss of sensation Spinal shock

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Incomplete: Some function is present below site of injury More favourable prognosis overall Are recognisable patterns of injury, although they are rarely pure and variations occur

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Muscle Strength Grading(MRC) 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

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Spinal Cord Injury defined by ASIA Impairment Scale ASIA – American Spinal Injury Association : (Frankel’s Grade) A – Complete: no sensory or motor function preserved. B – Incomplete: sensory, but no motor function. C – Incomplete: motor function preserved but not useful.. power graded < 3. D – Incomplete: motor function preserved and power graded 3 or more. E – Normal: sensory and motor function normal.

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Types of incomplete injuries Central Cord Syndrome Anterior Cord Syndrome Posterior Cord Syndrome Brown – Sequard Syndrome Cauda Equina Syndrome

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Central Cord Syndrome : Typically in older patients Hyperextension injury Compression of the cord anteriorly by osteophytes and posteriorly by ligamentum flavum

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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

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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)

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Clinically: Loss of power Decrease in pain and sensation below lesion Dorsal columns remain intact Prognosis is poor

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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

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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

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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) …………Prognosis is good

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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 ……imaging & surgery with in hrs..prognosis deteriorates rapidly over time

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Radiological Evaluation

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Plain Films AP, lateral, oblique open mouth Swimmer's view 85% SCI are detected In lateral views

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Upper limits of prevertebral soft tissue level of C1: 10 mm level of C4: 7 mm level of C6-7: 20 mm

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Inter-spinous process widening (on AP radiographs) More than 1.5 times the interspinous distance at the levels above and below is abnormal. anterior subluxation of 3 mm of one body on another (or >20% of the AP distance) indicates instability. angulation greater than 11° is suggestive of instability.

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Other Investigations flexion and extension views, CT and MRI MRI essential for suspected spinal cord injury all soft tissues (disk and ligamentous structures) are shown in much better detail.

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Injuries of the Upper Cervical Spine

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Odontoid Anatomy Steele's rule of thirds The dens, subarachnoid space, and spinal cord each occupy 1/3 of the area of the canal at the level of the atlas.

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Types of Cervical Spine injuries Atlanto - occipital dislocation. Condylar fractures. Atlanto-axial instability Atlas fractures. Odontoid fractures. Hangman's fractures SCIWORA

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Atlas fractures cervicomedullary junction remains unchanged because of capacity of spinal canal. Jefferson’s fracture Bursting # of C1 ring

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Clinical Features isolated C1 fractures rarely have associated cord injury. symptoms neck tenderness need neck support pharyngeal protuberance. dysphagia.

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Treatment Rigid collar in virtually all cases

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Odontoid Fractures Odontoid fractures are the M/C fractures of C2.

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Classification

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Clinical Features need high index of suspicion in all trauma patients many signs and symptoms are non-specific vertebral artery compression may cause brain stem ischemic symptoms. most patients unwilling to go from supine to sitting position without supporting their heads with their hands.

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