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Spinal Spinal

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Spinal - PPT Presentation

Cord Injury Too big a topic for 30 minutes Goals Demographics Mechanisms of Injury amp Pathophysiology Presentation amp Diagnosis including common spinal cord syndromes ID: 494837

cord spinal injury amp spinal cord amp injury tracts dorsal syndrome anterior motor anal sensation lesion asia tract ventral pain reflex bladder

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Slide1

Spinal Cord InjurySlide2

Too big a topic for 30 minutes……………..Goals:Demographics

Mechanisms of Injury & PathophysiologyPresentation & Diagnosis including common spinal cord syndromes

Special Added Attraction:

Neuroanatomy Review!

ManagementLittle FunWon’t CoverBony spinal injuriesImagingSCIWORASlide3

Who gets spinal cord injuries and how?What is the cost and frequency?Slide4

Risk Factors Young male most likely victimMales 77-80%Alcohol involved in at least 25%

Underlying spinal diseasesCervical

spondylosis

Atlantoaxial

instabilityOsteoporosisSpinal arthropathies- ankylosis spondylitis or rheumatoid arthritisSlide5

Spinal Cord Injury Facts Direct medical expenses accrued over the lifetime of one patient- $500K- $2 millionTraumatic Spinal Cord Injury (TSCI)

Incidence 2010- 40 per million per year or approx. 12,400 annually2005- approx. 250,000 living survivors of TSCI in USA

Causes TSCI in US:

MVA 48%

Falls 16%Violence (GSW, SW, etc) 12%Sports accidents 10%Other 14%Slide6

Patients with spinal cord injuries are sick!Slide7

What are the mechanisms of injury?Primary vs Secondary Injury?Slide8

PathophysiologyMost produced in association with injury to vertebral columnFracture of one or more bony elementsDislocation at one or more joints

Tearing of ligamentsDisruption and/or herniation of the intervertebral discSlide9

Pathophysiology: Primary vs Secondary Injury Primary Injury- immediate effect of traumaForces of compression, contusion, shear injury to cord

Secondary Injury: Begins within minutes & evolves over hours

Complex & incompletely understood

Mechanisms

IschemiaHypoxiaInflammationEdemaExcitotoxicityApoptosisClinically manifest by neurologic deterioration over first 8-12

hrs

in patient who initially present with incomplete cord syndrome

Spinal cord edema develops within hours of injury

Maximal day 3-6

Begins to recede after day 9

Gradually by replaced hemorrhagic necrosis Slide10

Clinical PresentationHow do you assess the severity of spinal cord injury?Slide11

Clinical PresentationTypically pain at site of spinal fx

Patients with TSCI often have associated brain & systemic injuries that may limit patient’s ability to report localized painApprox

50% TSCI’s involve cervical cord and present with

quadriparesis

or quadriplegiaSeverity of spinal cord syndromes classified using American Spinal Injury Association (ASIA) ScaleThis is the “Stroke Scale” for Spinal Injury Slide12

TermsSacral SparingSensory sacral sparing includes sensation preservation (intact or impaired) at the anal

mucocutaneous junction (S4-S5 dermatome) on one or both sides for light touch or pin prick or deep anal pressure (DAP)

Motor sacral sparing includes presence of voluntary contraction of external anal sphincter on digital rectal exam

Bulbocavernosus

ReflexPull on foley or gently pinch penis or clitoris and monitor anal contractionIf reflex is intact, the anal sphincter will contractPresence of the reflex indicates an incomplete lesionAnal Wink (anocutaneous

reflex)

Contraction of anal sphincter in response to pinprick stimulus of perineum

Deep Anal Pressure

Examiner’s finger inserted and gentle pressure applies to

anorecal

wall

Alternatively, pressure can be applied by using thumb to gently squeeze the anus against the inserted index finger.

Consistently perceived pressure should be graded as being present or absent (YES or NO) Slide13

American Spinal Injury Association (ASIA)Slide14

Complete Cord Injury (ASIA Grade A)Rostral zone of spared sensory levels (C5 and higher dermatomes spared with C5-6 fx-dislocation), reduced sensation in the next cauda

l level, &

no

sensation in levels below, including

NONE in sacral segments S4-S5Reduced muscle power in level immediately below injury followed by complete paralysis more caudallyAcute stage- reflexes absent, no response to plantar stimulation, muscle tone flaccidMale w/ complete lesion may have priapismBulbocavernosus reflex usually absentUrinary retention and bladder distention occurSlide15

Incomplete Cord Injury (ASIA grades B-D)Various degrees of motor function in muscles controlled by levels of spinal cord caudal to injurySensation partially preserved in dermatomes below area of injury’Sensation often preserved to a greater extent than motor function because sensory tracts are located in more peripheral, less vulnerable areas of the cord

Bulbocavernosus

reflex and anal sensation often present

Incidence of incomplete vs complete has increased over last 50

yrsSlide16

Neuroanatomy of the Spinal CordSlide17

Spinal Cord anatomyCross-sectional anatomy — The spinal cord contains the gray matter, the butterfly-shaped central region, and the surrounding white matter tracts. The

spinal cord gray matter, which contains the neuronal cell bodies, is made up of the dorsal and ventral horns, each divided into several laminae

Slide18

Spinal Cord AnatomyVentral Horn:

Contains motor nuclei of the spinal cord

Also

contains interneurons mediating information from other descending tracts of the pyramidal and extrapyramidal motor systems.

Dorsal Horn:Entry point of sensory information into the CNS. Processes sensory informationModulates pain transmission through spinal and supraspinal

regulatory circuits. Slide19

Efferent Motor TractsPyramidal:

Originate in cerebral cortexCarry motor fibers to spinal cord & brainstem

Corticospinal Tract (CST)

: voluntary control of muscles of body

To ipsilateral musculatureAnterior Corticospinal Tract (15-20%): ends in cervical & upper thoracic cordLateral Corticospinal Tract (80-85%):Crosses in medulla & terminates in ventral horn.From ventral horn goes to spinal nerve and musclesCorticobulbar Tract: voluntary control of muscles of faceExtrapyramidalOriginate in brainstem & carry fibers to spinal cord

Responsible for involuntary & automatic control of muscular function such as muscle to ne, balance, posture, & locomotion

Tectospinal

tract: mediates

reflex postural movements of the head in response to visual and/or acoustic input

Vestibulospinal

: balance, posture, antigravity muscles

Reticulospinal

:

Medial

Reticulospinal

: increases tone & facilitates voluntary movements

Lateral

Reticulospinal

: decrease tone & inhibits voluntary movements

Rubrospinal

: via red nucleus ?fine motor handSlide20

Afferent Sensory TractsDorsal Column Medial Lemniscal

(DCML)Pathway:

Ipsilateral fine touch (tactile sensation), vibration, & proprioception

In brainstem it is transmitted thru the medial lemniscusEnter cord into dorsal horn and then go to ipsilateral Dorsal ColumnsDorsal Columns = Posterior ColumnsFasciculus cuneatus: cervical/thoracic- lateral localization/orientationFasciculus

gracilis

: lumbar/sacral- medially localization/orientation

Spinothalamic:

Enter cord and cross midline (anterior(aka ventral) commissure)

then go to

contralateral

Anterior STT or

Lateral STT

Anterior Spinothalamic: contralateral crude touch & pressure

Sensations not accurately localized (itch & tickle)

Lateral Spinothalamic: contralateral pain & temperature

Cervical medial localization/orientation

Sacral lateral localization/orientation

Spinocerebellar Tracts: The

dorsal and ventral spinocerebellar tracts carry inputs mediating unconscious proprioception directly to the cerebellum

Spinoreticular

tract carries deep pain input to the reticular formation of the brainstemSlide21

Spinal Cord Blood supplyA single anterior and two posterior spinal arteries supply the spinal cord

Anterior spinal artery supplies anterior 2/3 of the cordPosterior spinal arteries primarily supply the dorsal columns

Anterior & Posterior spinal arteries arise from vertebral arteries in neck

Various radicular arteries branch off the thoracic and abdominal aorta to provide addition blood supply to the spinal arteries

Artery of Adamkiewcz (aka Great Ventral Radicular Artery)Largest & most consistent of radicular branchesSupplies the Anterior Spinal ArteryEnters spinal cord anywhere btn T5 &L1 (usually T9-T12)

Anterior Spinal Artery uninterrupted

along the entire length of the spinal

cord in most

In

others, it is discontinuous, usually in

midthoracic

segment

These

individuals more susceptible to vascular

injury

The

primary watershed area of the spinal cord in most people is in the

midthoracic

regionSlide22
Slide23

Location of lesion in central cord syndromeSlide24

Central Cord SyndromeCharacterized by

loss of pain and temp sensation in the distribution of one or several adjacent dermatomes at the site of the spinal cord lesion

As

a central lesion enlarges,

encroachs on medial aspect of the corticospinal tracts or on the anterior horn gray matter, producing weakness in the analgesic areas. There are usually no bladder symptoms.Due to disruption of crossing spinothalamic

fibers in the ventral commissure.

Dermatomes above & below the lesion have normal pain & temp sensation, creating the so-called “suspended sensory level”

Vibration & proprioception ( Dorsal Columns) are often spared.

Most

frequently result of

hyperextension injury

in patients with long-standing cervical spondylosis.

Get disproportionately

greater motor impairment in upper compared with lower extremities, bladder dysfunction, and a variable degree of sensory loss below the level of injury Slide25

Location of lesion in Brown-Sequard syndromeSlide26

Brown-Sequard Syndrome

A lateral hemisection

syndrome

involves the dorsal column, corticospinal tract, and spinothalamic tract unilaterally.Produces ipsilateral weakness, loss of vibration, & proprioception & contralateral loss of pain and temperature

. The unilateral involvement of descending autonomic fibers does not produce bladder symptoms.

CAUSES

: knife or bullet injuries & demyelination are most common causes. Rarer causes include spinal cord tumors, disc herniation, infarction & infections.Slide27

Location of lesion in Anterior (Ventral) Cord SyndromeSlide28

Anterior (ventral) cord syndromeRelatively rare historically related to decreased blood supplyusually

includes tracts in the anterior two-thirds of the spinal cord,

Corticospinal

tracts, S

pinothalamic tracts, and descending autonomic tracts to the sacral centers for bladder control Corticospinal tracts injury produce weakness and reflex changes. Spinothalamic tract deficit produces bilateral loss of pain & temp sensation. Tactile, position, & vibratory sensation as normal since controlled by DORSAL COLUMNS

Urinary incontinence is usually present

Causes: spinal

cord infarction, intervertebral disc herniation, and radiation myelopathy.Slide29

Location of lesion in posterior (dorsal) cord syndrome Slide30

Dorsal (posterior) cord syndromeBilateral involvement of dorsal columns, corticospinal tracts, &

descending autonomic tracts to bladder control centers in sacral cordDorsal column symptoms include gait ataxia and

paresthesias

Corticospinal

tract dysfunctions produces weaknessAcute: muscle flaccidity & hyporeflexiaChronic: muscle hypertonia and hyperreflexiaExtensor plantar responses and urinary incontinence may also be presentCAUSES

:

MS,tabes

dorsalis

,

Friedreich

ataxia,

subacute

combined degeneration, vascular malformations, epidural and

intradural

extramedullary

tumors, cervical

spondylotic

myelopathy, and

atlantoaxial

subluxation.Slide31

Cauda Equina Syndrome

Involves lumbosacral nerve roots of cauda

equine & may spare the cord itself

Injury to the nerve roots will classically produce

flaccid paralysis of muscles of lower limbs (muscles affected depend on level of injury) and areflexic bowel & bladder.Often asymmetricAll sensory modalities are similarly impaired & may be partial or complete loss of sensationSacral reflexes, bulbocavernosus & anal wink, will be absent

Causes:

intervertebral

disc herniation, epidural abscess, epidural tumor,

intradural

extramedullary

tumor, lumbar spine

spondylosis

, and a number of inflammatory conditions including spinal

arachnoiditis

, chronic inflammatory demyelinating polyneuropathy, and sarcoidosis Slide32

Conus medullaris syndrome

S

imilar to

Cauda

Equina but injury is more rostral in cord (L1 & L2 area)Most commonly due to thoraco-lumbar bony injuryDepending on level of lesion, may manifest with mixed picture of upper motor neuron (due to conus injury) and lower motor neuron symptoms (due to nerve root injury).Some cases difficult to clinically distinguish from cauda

equina

injury

Sacral segments may occasionally show preserved reflexes (

ie

bulbocavernosus

& anal wink) with higher lesions of

conus

medullaris

There

is early and prominent sphincter dysfunction with flaccid paralysis of the bladder and rectum, impotence, and saddle (S3-S5) anesthesia.

Leg

muscle weakness may be mild if the lesion is very restricted and spares both the lumbar cord and the adjacent sacral and lumbar nerve roots.

Causes:

disc herniation, spinal fracture, and tumors Slide33
Slide34

Transient Paralysis & Spinal ShockImmediately after SCI, may be a physiological loss of all spinal cord function caudal to level of injury with flaccid paralysis, anesthesia, absent bowel & bladder control, loss of reflex activityIn males, especially those with cervical cord injury, priapism may develop.

May also be bradycardia & hypotension not due to causes other than the spinal cord injury. May be secondary to loss of K from injured cells & accumulation in the extracellular space causing decreased axonal transmissionSlide35

Initial Evaluation & ManagementABCDECapnography

High cervical injuries may require intubationHypoxia in face of cord injury can adversely affect outcome

Hypotension-

hypoperfusion

can adversely affect outcomeDetailed neuro exam ASAP (ASIA format useful)Slide36

Glucocorticoids for Rx of TSCI? Still controversial?Not recommended at HFH“Steroids

and Spinal Cord Injures: Steroids

are NOT indicated for spinal cord

injury”

HFH Trauma Practice Guidelines p.35 Slide37

Prognosis for TSCI- Initial ASIA Grade A (Complete TSCI)10-15% improve

3% improve to ASIA Grade D<10% will be ambulatory at 1 year

Initial ASIA Grade B:

54% recover to C or D

40% regain some ambulatory abilityInitial ASIA Grade C:62% able to ambulate independentlyInitial ASIA Grade D:97% able to ambulate independentlyMost recovery for patients with incomplete TSCI takes place in first 6 monthsSlide38

The Beer ?Who is this? Slide39

Frank Netter MD“The Michelangelo of Medicine”1906-1991