Mini Symposium - Spinal injuries Flashcards
The 7th rib articulates with which vertebral bodies?
T6 and T7
How many vertebral segments are in the cervical region, thoracic region, lumbar and sacral region?
7,12,5,5
Pressure on the spine causes UMN or LMN signs?
UMN
Pressure on the nerve after leaving the spinal column causes LMN or UMN signs?
LMN - probably pain as well
What might be the cause of myelopathy/pressure on the spinal cord?
Arthritic facet joint, tumout on spinal cord, infection
What nerve root is responsible for shoulder abduction?
C5
Which nerve root is responsible for squeezing of the fingers?
C8
Which nerve root is responsible for splaying fingers?
T1
What does walking on heels test?
L4 and L5
What does walking on tip toes test?
Tests S1 - gastrosoleus
How many beats of clonus is abnormal?
Anyhting more than 3 is abnormal
What is the most sensitive test for arthritis?
Internal rotation of the hip
If a patient has lower back pain, what test can be done to test for herniated disk?
Straight leg test - herniation is often at the L5 disk
How can the specificity of the straight leg test be increased?
Dorsiflexion of the foot
What is a positive straight leg test?
If the patient experiences sciatic pain when the straight leg is at an angle of between 30 and 70 degrees, then the test is positive and a herniated disk is a possible cause of the pain
What test is used for high lumbar disc prolapses?
Femoral stretch test - reproduces pain down the front of the leg
Which spinal segments are involved with supplying the sphincters?
S2,3,4 keeps the poo off the floor
What are the erector spinae muscles?
Iliocostalis
Longissimus
Spinalis
Where are the following dermatomes?
L1,3,4,5 S1, S2
L1 is speedo
L3 is the medial border of the knee
L4 is the front of the knee and the big toe
L5 is the first web space of the foot
S1 is the lateral border of the foot
S2 is the back of the thigh
Upper limb Myotomes
Upper limbs:
C5 - Shoulder abduction (deltoid)
C 6 - Elbow flexion/ Wrist extensors (biceps)
C 7 - Elbow extensors (triceps)
C 8 - Long finger flexors (FDS/FDP)
T 1 - Finger abduction (interossei)
What test can be used to screen for upper motor neurone lesion in the hands?
Hoffmans test - it is sometimes described as a similar reflex as the babinski sign although the mechanisms are completely different - hoffmans is a deep tendon reflex, can be used to establish pathology in the corticospinal tract
Lower limb myotomes
Lower Limbs
L2 - Hip flexion (iliopsoas)
L3,4 - Knee extension (quadriceps)
L4 - Ankle dorsiflexion (tib ant)
L5 - Big toe extension (EHL)
S1 - Ankle plantar flexion (gastroc)
What is the epidemiology of spinal cord injuries?
Male more common than feamles - peak incidence is 20 - 29 years
What are the most common causes of spinal cord injury?
Falls
Road traffic accident
Sport
Knocked over / collision / lifting
Trauma - unspecified
Sharp trauma / assult
Other causes:
Tumours
Spinal cord stroke (infarct)
Transverse myelitis (infections)
Thoracoabdominal aortic aneurysm
Here is the difference between complete or incomplete spinal injury
Complete
Ø no motor or sensory function distal to lesion
Ø no anal squeeze
Ø no sacral sensation
Ø ASIA Grade A
Ø no chance of recovery
Incomplete
Ø Some function is present below site of injury
Ø More favorable prognosis overall
NOT ABLE TO DETERMINE ACUTELY AS PATIENT MAY BE IN SPINAL SHOC
Here is the ASIA classification for spinal injuries
What is tetraplegia?
- AKA Quadriplegia
- Partial or total loss of use of all four limbs and the trunk
- Loss of motor/sensory function in cervical segments of the spinal cord
When can tetraplegia affect breathing?
Phgrenic nerve C3,4 and 5
What is paraplegia?
- Partial or total loss of use of the lower-limbs
- Impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord
- Arm function spared
Possible impairment of function in trunk
Where does a fracture occur for paraplegia?
Thoracic / lumbar fractures
Give examples of partial cord syndromes?
Central cord syndreom
Anterior cord syndrome
Brown - sequard syndrome
What is central cord syndrome?
Cervical spinal injury
Most commonly due to hyperextension injuries in people with cervical spondylosis
More common in people over the age of 50 because osteoarthritis in the neck region causes weakening of the vertebrae
Most common incomplete spinal cord injury problem
What is the presentation of central cord syndrome?
CCS is characterized by disproportionately greater motor impairment in upper compared to lower extremities, and variable degree of sensory loss below the level of injury in combination with bladder dysfunction and urinary retention
•Perianal sensation & lower extremity power persevered
If you look here the Lower limbs are more peripheral than the upper limbs in the lateral corticospinal tract
What is anterior cord syndrome?
Anterior spinal artery syndrome (also known as “anterior spinal cord syndrome”) is a medical condition where the anterior spinal artery, the primary blood supply to the anterior portion of the spinal cord, is interrupted, causing ischemia or infarction of the spinal cord in the anterior two-thirds of the spinal cord and medulla oblongata. It is characterized by loss of motor function below the level of injury, loss of sensations carried by the anterior columns of the spinal cord (pain and temperature), and preservation of sensations carried by the posterior columns (fine touch, vibration and proprioception). Anterior spinal artery syndrome is the most common form of spinal cord infarction
What type of injury causes anterior cord syndrome?
Anterior compression fracture
What type of injury is brown sequard syndrome?
Hemi section of the spinal cord - usually penetrating injuries
What is the distribution of brown sequard syndrome?
paralysis on the affected side (corticospinal tracts), loss of proprioception and fine discrimination (these are in the dorsal columns)
And on the opposite side there is loss of pain and temperature sensation - spinothalamic tracts
What are neuroprotective intervenstions after a primary injury to the spinal cord?
Management involves ABCD and ATLS
ATLS - advanced trauma life support
Airway = c spine control
Breathing = ventilation and oxygenation, concominant chest injuries
Circulation = IV fluids, consider neurogenic shock (low blood pressure and HR, loss of sympathetic tone, vasopressors)
What is spinal shock?
Transient depression of cord function below the level of injury
FLaccid paralysis
Areflexia
Last several hours to days after the injury
What is neurogenic shock?
This is an actual shock syndrome - attributed to the disruption of autonomic pathways in the spinal cord
Hypotension - loss of systemic vascular resistance
Bradycardia - unopposed vagal activity
Hypothermia
Injuries above T6
Secondary to disruption of sympathetic outflow
Disability for ABCD
- Asses Neurological Function
- Including PR and Perianal sensation
- Log Rolling
- Document
What are the relevant imaging techniques?
X - rays
Ct scanning - bony anatomy
MRI - if neurological deficit or children
What type of fracture is this?
Chance fracture - caused by excessive flexion of the spine, often unstable
(commonly caused by lap seatbelts)
How is surgical fixation performed?
Most are performed psteriorly
Pedicle screws are the preferred method
Surgical fixation is for unstable fractures
What is the long term management for spinal cord injury?
- Spinal Cord Injury Unit- intermediate term
- Physiotherapy
- Occupational therapy
- Psychological support
- Urological /Sexual counseling
Summary
- Although spinal fractures are common SCI is rare
- Complete injuries have no function below trauma
- Incomplete injuries have variable function
- Preventing secondary insult is key- ABCD
- Assessment involves testing myotomes and dermatomes
- Important to understand the difference between neurogenic and spinal shock
