Session 12 - Spinal Cord Injuries

Question 1

At which spinal levels do spinal injuries most commonly occur?

Answer 1

C6 or C7 (50%)
C2 (30%)

In children, C1-C2 more likely to be injured in view of having heavier heads with lax ligaments.

Question 2

What are the mechanisms of spinal cord injury?

Answer 2

Hyperflexion (forward movement)
Hyperextension (backward movement)
Lateral stress (sideways movement)
Rotation (twisting of the head)
Compression (force along the axis of the spine downward from the head or upward from the pelvis)
Distraction (pulling apart of the vertebrae)

Question 3

Give examples of flexion injuries.

Answer 3

Fractures - anterior wedge, flexion teardrop, Clay-shoveller’s

Dislocations - anterior subluxation, bilateral interfacet dislocation, antlanto-occipital dislocation, anterior Atlanta-axial dislocation)

Often leads to neurological injury

Question 4

Give examples of extension injuries.

Answer 4

Fractures - hangman’s, teardrop

Dislocation - anterior atlanto-axial dislocation

Question 5

What are the possible causes of complete cord transaction syndrome?

Answer 5

Trauma 
Infection
Transverse myelitis
Abscess
Tumour

Question 6

How will complete cord transaction syndrome present?

Answer 6

Loss of all sensory modalities bilaterally below the lesion
Complete paralysis below the lesion
Spinal shock and autonomic dysfunction occurs with higher lesions
Hypotension
Priapism

Question 7

What is Brown-Sequard syndrome?

Answer 7

Complete hemisection of the cord.

Leading to unilateral compression/injury.

Question 8

What are the possible causes of Brown-Sequard syndrome?

Answer 8

True complete hemisection is rare, but may be caused by:

• penetrating trauma
• fractured vertebrae
• tumour
• abscess
• multiple sclerosis

Question 9

What are the clinical features of brown-Sequard syndrome?

Answer 9

Ipsilateral to side of injury:

• loss of motor function (corticospinal tract)
• loss of proprioception, vibration, fine touch and two point discrimination (dorsal column)

Contralateral to side of injury:
- loss of pain, temperature and crude touch sensation (spinothalamic tract)

Question 10

What are the causes of anterior cord syndrome?

Answer 10

Often occur as a result of flexion injury
- leading to fractures or dislocations of vertebrae or herniated discs

Can also be due to injury to the anterior spinal artery

• vascular or atherosclerotic disease in the elderly
• iatrogenic secondary to cross-clamping of the aorta intraoperatively

Question 11

What are the clinical features of anterior cord syndrome?

Answer 11

Flaccid paralysis below level of lesion (corticospinal tract)
Loss of pain/temperature/crude touch below lesion (spinothalamic)
Autonomic dysfunction (bowel, bladder, sexual function)

Preservation of modalities carried by the dorsal column.

Question 12

What are the causes of central cord syndrome?

Answer 12

Trauma
- hyperextension injury of cervical spine in elderly 
- hyperflexion injury of cervical spine in younger patients 
Disruption of blood flow to spinal cord
Cervical spinal stenosis 
Degenerative spinal disease
Syringomyelia
Central canal ependymoma

Question 13

What is syringomyelia?

Answer 13

Development of syrinx (cyst) in the central canal.

Unknown aetiology

Question 14

What are the symptoms of syringomyelia?

Answer 14

Initial symptoms arise from the obliteration of spinothalamic fibres decussating in the white commissure. Loss of sensitivity to painful and thermal stimuli in a ‘cape-like’ distribution. Dorsal column pathways intact.

Question 15

What are the clinical features of central cord syndrome?

Answer 15

More extensive motor weakness found in the upper extremities than lower extremities.
More extensive motor weakness found distally compared to proximally in the limbs.
Motor dysfunction more extensive than sensory dysfunction.
Bladder dysfunction and urinary retention.

Question 16

What are the causes of posterior cord syndrome?

Answer 16

Very rare syndrome.

More likely to be caused by chronic pathological processes rather than trauma.
- spondylosis
- spinal stenosis
- infections
- vitamin b12 deficiency
Occlusion/infarction of the paired posterior spinal arteries.

Question 17

What are the clinical features of posterior cord syndrome?

Answer 17

Loss of: proprioception, vibration, two point discrimination, light touch

Motor function and spinothalamic modalities remain intact.

Question 18

How are spinal cord injuries managed?

Answer 18

Non-surgical:

• consider intubation (C5 or above)
• ICU admission
• early immobilisation of the c-spine
• c-spine restriction maintained for approximately six weeks
• Physiotherapy/ occupational therapy

Surgical:

• progressive neurological deficits
• unstable spinal fractures

Question 19

How are spinal cord injuries initially evaluated and treated?

Answer 19

ABCDE approach 
Assume spinal injury if:
- head injury present
- unconscious or confused
- spinal tenderness
- extremity weakness
- loss of sensation 

Consider intubation for injuries at C5 or above
Use log-roll, backboard and rigid C-collar

Question 20

How do you ‘clear’ the spine?

Answer 20

Patient is alert and oriented (to person, place, time and event)
No language barrier
Not intoxicated
No midline posterior tenderness
No focal neurological deficit
No painful distracting injuries