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NEUROSCIENCE
III
Spinal
Cord
Injury
and
Compression
[by:
mee-shell
]
#teammasters
1
Define
the
level
of
injury
LEVEL
hallmark
of
spinal
cord
damage!
below
which
sensory
/
motor
/
autonomic
function
is
disturbed
most
caudal
spinal
segment
with
normal
sensation
and
muscle
strength
of
3/5
or
better
absent
deep
tendon
reflexes
below
the
level
of
the
lesion
Completeness
of
cord
injury
Complete
lesion
no
preservation
of
any
motor
or
sensory
function
Incomplete
lesion
any
residual
motor
or
sensory
function
more
than
3
segments
below
the
level
of
injury
Signs
of
incomplete
cord
injury
Any
sensation
or
voluntary
movement
of
the
lower
extremities
Sacral
sparing
preservation
of
sensation
at
the
anus,
C3,4
perineum,
voluntary
anal
contraction
sensory:
top
of
shoulder
All
spinal
cord
syndromes
are
incomplete
lesions
C3,
4,
5
Preservation
of
sacral
reflexes
(bulbocavernosus
reflex,
motor:
diaphragm
anal
wink)
does
not
qualify
lesion
as
incomplete
sensory:
top
of
shoulder
C5,
6
SPINAL
SHOCK
sensory:
thumb
and
index
finger
In
all
vertebrates,
acute
spinal
cord
concussion
or
C7
complete
cord
transection
is
followed
by
SPINAL
SHOCK
sensory:
middle
finger
Transient
profound
loss
of
all
SPINAL
REFLEXES
below
level
C8,
T1
of
injury
(in
addition
to
complete
PARALYSIS
and
sensory:
little
finger
ANESTHESIA
below
level)
T4
sensory:
level
of
nipple
1. Flaccid
paralysis
T10
2. Absence
of
reflexes
(muscle
stretch,
plantar,abdominal
&
sensory:
level
of
umbilicus
cremasteric)
L1,
2
3. Hypotonic
paralysis
of
bowel
&
bladder
(ileus,
sensory:
inguinal
crease
gastroparesis,
urinary
and
bowel
retention)
priapism.
L3,4
4. Hypotension
(not
present
if
lesion
is
below
lower
thoracic
sensory:
medial
thigh,
calf
level)
with
anhydrosis
and
flushed
warm
peripheral
skin
L5
(
poikilothermy).
*
sensory:
lateral
calf
5. Hypotension
without
compensatory
tachycardia
(if
high
S1
cervical
lesion),
i.e.NEUROGENIC
SHOCK
(interrupted
sensory:
lateral
foot
sympathetic
outflow
vasodilation
&
bradycardia)
S2,3,4
motor:
anal
sphincter
tone
Neurogenic
shock
sensory:
perianal
Triad
of
i)
hypotension
DISEASES
OF
THE
SPINAL
CORD
ii)
bradycardia
Diseases
of
the
nervous
system
may
be
confined
to
the
iii)
hypothermia
spinal
cord,
where
they
produce
a
number
of
distinctive
More
commonly
in
injuries
above
T6
syndromes.
Secondary
to
disruption
of
sympathetic
outflow
from
T1
Spinal
cord
contains,
in
small
cross-sectional
area,
almost
L2
entire
motor
output
and
sensory
input
of
trunk
and
limbs
-
spinal
cord
disorders
are
frequently
devastating.
Where
they
come
from
Clinical
Effects
of
Spinal
Cord
Injury
When
the
spinal
cord
is
suddenly
and
virtually
or
completely
severed,
three
disorders
of
function
are
at
once
evident:
(1)
all
voluntary
movement
in
parts
of
the
body
below
the
lesion
is
immediately
and
permanently
lost;
(2)
all
sensation
from
the
lower
(aboral)
parts
is
abolished;
and
(3)
reflex
functions
in
all
segments
of
the
isolated
spinal
cord
are
suspended.
2
NEUROSCIENCE
III
Spinal
Cord
Injury
and
Compression
[by:
mee-shell
]
#teammasters
Clinical
Effects
of
Spinal
Cord
Injury
Pathology
of
Spinal
Cord
Injury
The
last
effect,
called
spinal
shock,
involves
tendon
as
well
As
a
result
of
squeezing
or
shearing
of
the
spinal
cord,
as
autonomic
reflexes.
It
is
of
variable
duration
(1
to
6
there
is
destruction
of
gray
and
white
matter
and
a
weeks
as
a
rule
but
sometimes
far
longer)
variable
amount
of
hemorrhage,
chiefly
in
the
more
Less
complete
lesions
of
the
spinal
cord
result
in
little
or
vascular
central
parts
->
traumatic
necrosis
(are
maximal
no
spinal
shock,
and
the
same
is
true
of
any
type
of
lesion
at
the
level
of
injury
and
one
or
two
segments
above
and
that
develops
slowly.
below
it)
As
a
lesion
heals,
it
leaves
a
gliotic
focus
or
cavitation
with
Injury
defined
by
ASIA
Impairment
Scale
variable
amounts
of
hemosiderin
and
iron
pigment.
ASIA
American
Spinal
Injury
Association
:
Progressive
cavitation
(traumatic
syringomyelia)
may
A
Complete:
no
sensory
or
motor
function
preserved
in
sacral
develop
after
an
interval
of
months
or
years
-
>
lead
to
a
segments
S4
S5
delayed
central
or
incomplete
transverse
cord
syndrome.
B
Incomplete:
sensory,
but
no
motor
function
in
sacral
segments
In
most
traumatic
lesions,
the
central
part
of
the
spinal
C
Incomplete:
motor
function
preserved
below
level
and
power
cord,
with
its
vascular
gray
matter,
tends
to
suffer
greater
graded
<
3
injury
than
the
peripheral
parts.
D
Incomplete:
motor
function
preserved
below
level
and
power
graded
3
or
more
Transient
Cord
Injury
(Spinal
Cord
Concussion)
E
Normal:
sensory
and
motor
function
normal
Transient
loss
of
motor
and/or
sensory
function
of
the
spinal
cord
that
recovers
within
minutes
or
hours
but
Muscle
Strength
Grading:
sometimes
persists
for
a
day
or
several
days.
5
Normal
strength
Spinal
cord
concussion
from
direct
impact
is
observed
4
Full
range
of
motion,
but
less
than
normal
strength
against
most
frequently
in
athletes
engaged
in
contact
sports
resistance
(football,
rugby,and
hockey).
3
Full
range
of
motion
against
gravity
2
Movement
with
gravity
eliminated
Cervical
cord
injury
1
Flicker
of
movement
Cervicomedullary
junction
(above
C3):
extensive
lesions
0
Total
paralysis
involve
adjacent
medullary
centers
vasomotor
and
respiratory
collapse
neurogenic
hypotension,
apnea
SPINAL
CORD
INJURY
unresponsiveness
(difficult
diagnosis)
death
(in
absence
of
ventilatory
support).
C4-5
-
quadriplegia
with
preserved
respiratory
function
(functional
diaphragm)
C5-6
-
sparing
shoulder
muscles
(loss
of
biceps
and
brachioradialis
reflexes).
C7
-
sparing
biceps
(loss
of
triceps
reflex).
C8
-
sparing
triceps
(paralyzed
fingers
and
wrist
flexion)
ipsilateral
HORNER'S
SYNDROME
may
occur
at
any
cervical
level
lesion.
Thoracic
cord
injury
Best
localized
by
SENSORY
LEVEL
on
trunk
nipples
(T4),
umbilicus
(T10)
Syndrome
of
Acute
Paraplegia
or
Quadriplegia
Due
to
Complete
BEEVOR
SIGN
-
observe
abdominal
wall
musculature
and
Transverse
Lesions
of
the
Spinal
Cord
umbilicus
by
asking
patient
to
interlock
fingers
behind
Trauma
->most
frequent
cause
head
in
supine
position
and
attempt
to
sit
up:
Types
of
Injury
lesions
below
T9
paralyze
lower
abdominal
Severe
forward
flexion
injury
;
muscles
upward
movement
of
umbilicus
Hyperextension
injury
;
(BEEVOR
sign)
+
loss
of
lower
superficial
Whiplash
injury
abdominal
reflexes.
High-velocity
missile
penetrates
the
vertebral
unilateral
lesions
movement
of
umbilicus
to
canal
and
damages
the
spinal
cord
directly;
normal
side;
absent
superficial
abdominal
Indirect
consequence
of
a
vascular
mechanism.
reflexes
on
involved
side.
midline
back
pain
is
useful
localizing
sign.
Thoracic
spinal
cord
transection
Causes
paraplegia
Transection
of
the
upper
thoracic
cord
spares
the
upper
limbs
but
impairs
breathing
(involvement
of
intercostal
muscles)
and
may
also
cause
paralytic
ileus
through
involvement
of
the
splanchnic
nerves.
Transection
of
the
lower
thoracic
cord
spares
the
abdominal
muscles
and
does
not
impair
breathing.
NEUROSCIENCE
III
Spinal
Cord
Injury
and
Compression
[by:
mee-shell
]
#teammasters
3
DISEASES
OF
THE
SPINAL
CORD
Types
of
incomplete
injuries
The
main
syndromes
to
be
considered
are:
i) Central
Cord
Syndrome
(1)
a
complete
or
almost
complete
sensorimotor
ii) Anterior
Cord
Syndrome
myelopathy
that
involves
most
or
all
of
the
ascending
and
iii) Posterior
Cord
Syndrome
descending
tracts
(transverse
myelopathy)
iv) Brown
Sequard
Syndrome
(2)
a
painful
radicular
syndrome
(segmental
radiculopathy)
v) Cauda
Equina
Syndrome
Transverse
Myelopathy
1.
Central
Cord
Syndrome
:
When
spinal
cord
transection
syndrome
arises
gradually
Typically
in
older
patients
rather
than
suddenly,
e.
g.,
because
of
a
slowly
growing
Hyperextension
injury
tumor,
spinal
shock
does
not
arise.
Compression
of
the
cord
The
transection
syndrome
in
such
cases
is
usually
partial,
anteriorly
by
osteophytes
and
rather
than
complete.
posteriorly
by
ligamentum
flavum
Progressively
severe
spastic
paraparesis
develops
below
Also
associated
with
fracture
the
level
of
the
lesion,
accompanied
by
a
sensory
deficit,
dislocation
and
compression
bowel,
bladder,
and
sexual
dysfunction,
and
autonomic
fractures
manifestations
(abnormal
vasomotor
regulation
and
More
centrally
situated
cervical
sweating,
tendency
to
decubitus
ulcers).
tracts
tend
to
be
more
involved
hence
Usually
seen
in
degenerative
changes
with
central
canal
flaccid
weakness
of
arms
>
legs
stenosis
Perianal
sensation
&
some
lower
extremity
movement
and
sensation
may
be
preserved
Classic
Central
Cord
most
common
of
INCOMPLETE
SCI
syndromes!
Etiology:
neck
hyperextension
(esp.
in
patients
with
spondylosis)
cord
compression
between
bony
bars
anteriorly
and
thickened
ligamentum
flavum
posteriorly
cord
hypoperfusion
in
watershed
distribution
(mostly
central
portion
of
cord
central
gray
and
most
central
portions
of
pyramidal
&
spinothalamic
tracts).
Segmental
Radiculopathy
central
cord
syndrome
is
an
ischemic
lesion
(frequently
no
Radiculopathy
/
myelopathy
due
to
compression
by
mass
radiologically
identifiable
fractures!!!)
-
neurologic
changes
of
disc
material:
tend
to
improve
with
time!
herniation
into
lateral
recess
or
neural
foramen
(posterolateral
herniation)
spinal
root
Syringomyelia
compression.
Fluid
filled
cavitation
in
the
center
of
the
cord
herniation
into
spinal
canal
(central
herniation)
Cervical
cord
most
common
site
spinal
cord
compression
(in
cervical
thoracic
Loss
of
pain
and
temperature
related
to
the
region)
or
cauda
equina
compression
(in
crossing
fibers
occurs
early
lumbosacral
region).
cape
like
sensory
loss
Weakness
of
muscles
in
arms
with
atrophy
and
hyporeflexia
(AHC)
Later
-
CST
involvement
with
brisk
reflexes
in
the
legs,
spasticity,
and
weakness
May
occur
as
a
late
sequelae
to
trauma
Can
see
in
association
with
Arnold
Chiari
malformation
Roots
above
C8
exit
above
corresponding
vertebral
body;
remaining
roots
exit
below
their
respective
vertebral
bodies
2.
Anterior
cord
Syndrome:
Due
to
flexion
/
rotation
Anterior
dislocation
/
compression
fracture
of
a
vertebral
body
encroaching
the
ventral
canal
Corticospinal
and
spinothalamic
4
NEUROSCIENCE
III
Spinal
Cord
Injury
and
Compression
[by:
mee-shell
]
#teammasters
tracts
are
damaged
either
by
direct
trauma
or
Later,
severe
radicular
sensory
deficits,
affecting
all
ischemia
of
blood
supply
(anterior
spinal
arteries)
sensory
modalities,
arise
at
L4
or
lower
levels.
Clinically:
Lesions
affecting
the
upper
portion
of
the
cauda
equina
Loss
of
power
produce
a
sensory
deficit
in
the
legs
and
in
the
saddle
Decrease
in
pain
and
sensation
below
lesion
area.
Dorsal
columns
remain
intact
There
may
be
flaccid
paresis
of
the
lower
limbs
with
areflexia;
urinary
and
fecal
incontinence
also
develop,
3.
Posterior
Cord
Syndrome:
along
with
impaired
sexual
function.
Hyperextension
injuries
with
With
lesions
of
the
lower
portion
of
the
cauda
equina,
the
fractures
of
the
posterior
sensory
deficit
is
exclusively
in
the
saddle
area
(S3S5),
and
elements
of
the
vertebrae
there
is
no
lower
limb
weakness,
but
urination,
defecation,
Clinically:
and
sexual
function
are
impaired.
Proprioception
affected
ataxia
Tumors
affecting
the
cauda
equina,
unlike
conus
tumors,
and
faltering
gait
produce
slowly
and
irregularly
progressive
clinical
Usually
good
power
and
sensation
manifestations,
as
the
individual
nerve
roots
are
affected
with
variable
rapidity,
and
some
of
them
may
be
spared
4.
Brown
Sequard
Syndrome:
until
late
in
the
course
of
the
illness.
Hemi-section
of
the
cord
Either
due
to
penetrating
Examination
and
Management
of
the
Spine-Injured
Patient
injuries:
The
level
of
the
spinal
cord
and
vertebral
lesions
can
be
i)
stab
wounds
determined
from
the
clinical
findings.
ii)
gunshot
wounds
Diaphragmatic
paralysis
occurs
with
lesions
of
the
upper
Fractures
of
lateral
mass
of
three
cervical
segments
(an
unrelated
transient
arrest
of
vertebrae
breathing
is
common
in
severe
head
injury).
Clinically:
Complete
paralysis
of
the
arms
and
legs
usually
indicates
a
Paralysis
on
affected
side
(corticospinal)
IPSILATERAL
fracture
or
dislocation
at
C4-C5.
Loss
of
proprioception
and
fine
discrimination
(dorsal
If
the
legs
are
paralyzed
and
the
arms
can
still
be
abducted
columns)
IPSILATERAL
and
flexed,
the
lesion
is
likely
to
be
at
C5-C6
Pain
and
temperature
loss
on
the
opposite
side
below
the
Paralysis
of
the
legs
and
only
the
hands
indicates
a
lesion
lesion
(spinothalamic)
CONTRALATERAL
at
C6-C7
The
level
of
sensory
loss
on
the
trunk,
determined
by
perception
of
pinprick,
is
an
accurate
guide
to
the
level
of
the
lesion
In
all
cases
of
SCI
our
primary
concern
is
that
movement
(especially
flexion)
of
the
cervical
spine
be
avoided.
The
patient
should
be
placed
supine
on
a
firm,
flat
surface
(with
one
person
assigned,
if
possible,
to
keeping
the
head
and
neck
immobile)
Have
the
patient
remain
on
the
board
until
a
lateral
film
or
a
CT
or
MRI
of
the
cervical
spine
has
been
obtained.
A
neurologic
examination
with
detailed
recording
of
motor,
sensory,
and
sphincter
function
is
necessary
to
follow
the
clinical
progress
of
SCI.
If
a
cervical
spinal
cord
injury
is
associated
with
vertebral
Conus
syndrome
dislocation,
traction
on
the
neck
is
necessary
to
secure
Due
to
a
spinal
cord
lesion
at
or
below
S3,
is
also
rare.
proper
alignment
and
maintain
immobilization.
It
can
be
caused
by
spinal
tumors,
ischemia,
or
a
massive
This
is
best
accomplished
by
use
of
a
halo
brace,
which,
of
lumbar
disk
herniation.
all
the
appliances
used
for
this
purpose
provides
the
most
An
isolated
lesion
of
the
conus
medullaris
produces
the
rigid
external
fixation
of
the
cervical
spine.
following
neurological
deficits:
This
type
of
fixation
is
usually
continued
for
4
to
6
weeks,
Detrusor
areflexia
with
urinary
retention
and
overflow
after
which
a
rigid
collar
may
be
substituted.
incontinence
(continual
dripping)
Fecal
incontinence
-
Impotence
Halo
Brace
Saddle
anesthesia
(S3S5)
-
Loss
of
the
anal
reflex
Cauda
equina
syndrome
Involves
the
lumbar
and
sacral
nerve
roots,
which
descend
alongside
and
below
the
conus
medullaris,
and
through
the
lumbosacral
subarachnoid
space,
to
their
exit
foramina;
a
tumor
(e.
g.,
ependymoma
or
lipoma)
is
the
usual
cause.
Patients
initially
complain
of
radicular
pain
in
a
sciatic
distribution,
and
of
severe
bladder
pain
that
worsens
with
coughing
or
sneezing.
NEUROSCIENCE
III
Spinal
Cord
Injury
and
Compression
[by:
mee-shell
]
#teammasters
5
Spinal
Cord
Tumors
Spasticity
is
only
rarely
as
severe
as
that
Complete
or
partial
spinal
cord
transection
syndrome
produced
by
extramedullary
tumors.
(including
conus
syndrome
and
cauda
equina
syndrome)
is
often
caused
by
a
tumor.
High
cervical
tumors
Spinal
cord
tumors
are
classified
into
three
types,
based
on
can
produce
bulbar
manifestations
aswell
as
their
localization
fasciculations
and
fibrillations
in
the
affected
Extradural
tumors
(metastasis,
lymphoma,
limb.
plasmacytoma)
Extramedullary
tumors
are
much
more
common
Intradural
extramedullary
tumors
(meningioma,
overall
than
intramedullary
tumors.
neurinoma)
Tumors
at
the
level
of
the
foramen
magnum
Intradural
intramedullary
tumors
(glioma,
(meningioma,
neurinoma)
ependymoma)
often
initially
manifest
themselves
with
pain,
Extradural
neoplasms
paresthesia,
and
hypesthesia
in
the
C2
region
tend
to
grow
rapidly,
often
producing
progressively
severe
(occipital
and
great
auricular
nerves).
They
can
manifestations
of
spinal
cord
compression:
spastic
paresis
also
cause
weakness
of
the
sternocleidomastoid
of
the
parts
of
the
body
supplied
by
the
spinal
cord
below
and
trapezius
muscles
(accessory
nerve).
the
level
of
the
lesion,
and,
later,
bladder
and
bowel
dysfunction.
Dumbbell
tumors
(or
hourglass
tumors)
Pain
is
a
common
feature.
So
called
because
of
their
unique
anatomical
configuration
Dorsally
situated
tumors
mainly
cause
sensory
These
are
mostly
neurinomas
that
arise
in
the
disturbances;
lateral
compression
of
the
spinal
cord
can
intervertebral
foramen
and
then
grow
in
two
directions:
produce
BrownSquard
syndrome
into
the
spinal
canal
and
outward
into
the
paravertebral
space.
Intradural
Extramedullary
Tumors
They
compress
the
spinal
cord
laterally,
eventually
Most
commonly
arise
from
the
vicinity
ofthe
posterior
producing
a
partial
or
complete
BrownSquard
syndrome.
roots
They
initially
produce
radicular
pain
and
paresthesiae.
Later,
as
they
grow,
they
cause
increasing
compression
of
the
posterior
roots
and
the
spinal
cord
The
result
is
a
progressively
severe
spastic
paresis
of
the
limbs,
and
paresthesiae
(particularly
cold
paresthesiae)
in
both
limbs
The
sensory
disturbance
usually
ascends
from
caudal
to
cranial
until
it
reaches
the
level
of
the
lesion.
The
spine
is
tender
to
percussion
at
the
level
of
the
damaged
nerve
roots,
and
the
pain
is
markedly
exacerbated
by
coughing
or
sneezing.
Hyperesthesia
is
not
uncommon
in
the
dermatomes
supplied
by
the
affected
nerve
roots;
this
may
be
useful
for
A. Extradural
neoplasm
clinical
localization
of
the
level
of
the
lesion.
B. Extradural
neoplasm
As
the
spinal
cord
compression
progresses,
it
eventually
C. Intradural
Extramedullary
Tumor
leads
to
bladder
and
bowel
dysfunction.
D. Intradural
Intramedullary
Tumor
Ventrally
situated
tumors
can
involve
the
anterior
nerve
roots
on
one
or
both
sides,
causing
flaccid
paresis,
e.
g.,
of
--END--
the
hands
(when
the
tumor
is
in
the
cervical
region).
Reference:
Intradural
Intramedullary
Tumors
-
Dr.
Sengs
powerpoint
lecture
Can
be
distinguished
from
extramedullary
tumors
by
the
following
clinical
features:
They
rarely
cause
radicular
pain,
instead
causing
atypical
(burning,
dull)
pain
of
diffuse
localization.
Dissociated
sensory
deficits
can
be
an
early
finding.
Bladder
and
bowel
dysfunction
appear
early
in
the
course
of
tumor
growth.
The
sensory
level
(upper
border
of
the
sensory
deficit)
may
ascend,
because
of
longitudinal
growth
of
the
tumor,
while
the
sensory
level
associated
with
extramedullary
tumors
generally
remains
constant,
because
of
transverse
growth.
Muscle
atrophy
due
to
involvement
of
the
anterior
horns
is
more
common
than
with
extramedullary
tumors.
6 NEUROSCIENCE III Spinal Cord Injury and Compression [by: mee-shell ] #teammasters