18. Pathophysiology and Management of Spinal Cord Injuries

Question 1

What are the forces involved in injury of the spine?

Answer 1

Hyperflexion - forwards movement of the head, hyperextension - backward movement, lateral stress - sideways movement, rotation - twisting of head, compression - force along the axis of spine downward from head of up from pelvis, distraction - pulling apart of vertebrae.

Question 2

What are the fractures associated with flexion injury?

Answer 2

Anterior wedge, flexion teardrop, Clay-shoveller’s.

Question 3

What are the dislocations associated with flexion injury?

Answer 3

Anterior subluxation, bilateral interfacet dislocation, atlanto-occipital dislocation, anterior atlanto-axial dislocation.

Question 4

What are the fractures associated with extension injury?

Answer 4

Hangman’s, teardrop.

Question 5

What is the dislocation associated with extension injury?

Answer 5

Anterior atlanto-axial.

Question 6

What are the causes of complete cord transection syndrome?

Answer 6

Trauma, infarction, transverse myelitis, abscess, tumour.

Question 7

What are the clinical features of complete cord transection syndrome?

Answer 7

Spinal shock and autonomic dysfunction and higher lesions, priapism (prolonged sustained erection), complete loss of sensation below lesion, complete paralysis below lesion.

Question 8

What is Brown-Sequard syndrome?

Answer 8

Hemisection of the cord.

Question 9

What are the causes of Brown-Sequard syndrome?

Answer 9

Penetrating trauma, fractured vertebrae, tumour, abscess, multiple sclerosis.

Question 10

What are the clinical features of Brown-Sequard syndrome on the side of injury?

Answer 10

Loss of motor function (corticospinal tract); loss of conscious proprioception, vibration and touch sensation (dorsal column).

Question 11

What are the clinical features of Brown-Sequard syndrome on the contralateral side of injury?

Answer 11

Loss of pain and temperature sensation (spinothalamic tract).

Question 12

What can cause anterior cord syndrome?

Answer 12

Flexion injury, or anterior spinal artery injury in atherosclerotic disease or cross clamping of the aorta.

Question 13

What are the clinical features of anterior cord syndrome?

Answer 13

Flaccid paralysis below lesion, loss of pain/temperature, autonomic dysfunction, preservation of dorsal column modalities.

Question 14

What are the causes of central cord syndrome?

Answer 14

Hyperextension of C spine in elderly, hyperflexion of C spine in younger patients, disrupted blood flow to SC, C spinal stenosis, degenerative spinal disease, syringomyelia, central canal ependymoma.

Question 15

What is syringomyelia?

Answer 15

Development of a syrinx/cyst in or within the central canal, central cord syndrome.

Question 16

What are the symptoms of syringomyelia?

Answer 16

Initially obliteration of spinothalamic fibres as they decussate in the white commissure so loss of sensitivity to pain and thermal stimuli in a cape-like distribution.

Question 17

What are the clinical features of central cord syndrome?

Answer 17

Motor > sensory, upper extremity > lower extremity, bladder dysfunction and urinary retention.

Question 18

What are the causes of posterior cord syndrome?

Answer 18

Spondylosis, spinal stenosis, infections, vitamin B12 deficiency, occlusion/infarction of paired posterior spinal arteries.

Question 19

What are the clinical features of posterior cord syndrome?

Answer 19

Loss of dorsal column modalities, motor function and sensation of pain/temperature/firm touch remain intact.

Question 20

What are the non-surgical management of cord injuries?

Answer 20

Intubation if C5 or above, ICU admission, C-spine immobilisation ASAP, C-spine restriction for 6 weeks, physiotherapy, occupational therapy.

Question 21

When are the surgical management of cord injuries used?

Answer 21

Progressive neurological deficits or unstable spinal fractures.

Question 22

What is the initial management of SC injuries?

Answer 22

ABCDE approach; assume spine injury if head injury present, unconscious or confused, spinal tenderness, extremity weakness, loss of sensation; intubation if C5 or above; log-roll, backboard, rigid C collar.

Question 23

How is the spine ‘cleared’?

Answer 23

Alert and oriented, no language barrier, not intoxicated, no midline posterior tenderness, no focal neurological deficit, no painful distracting injuries.