Spinal Cord Injury/ Radiculopathy

Question 1

(1) Injury to the spinal cord results in characteristic neurologic symptoms.
(2) Related to the pattern of tracts that are present in spinal cord anatomy.

Answer 1

Spinal cord injury:
Presentation

Question 2

(1) 40 million persons per year affected
(2) MVA (47%), Falls (23%), Violence (14%), Sports (9%)
(3) Largely affects young male

Answer 2

Spinal cord injury:
Epidemiology

Question 3

Most traumatic spinal cord injuries occur with injury to

Answer 3

vertebral column

Question 4

(1) Depends on spinal cord level affected

(2) Immediately after injury there may be complete physiologic loss of all spinal cord
function below level of injury
(a) Flaccid paralysis
(b) Anesthesia
(c) Absent bowel or bladder control
(d) Loss of reflex activity

(3) Physiologic loss can be transient and there may be recovery

(4)*** Delayed symptom onset can occur due to spinal cord swelling

Answer 4

Presentation of spinal cord injury

Question 5

(1) Should always focus on ABCs first
(2) Take care to immobilize the C-spine with cervical collar ASAP
(3) Patient with high cervical injury may have poor respiratory function and may require
intubation if necessary
(4) Maintain oxygenation and blood pressure
(5) Insert a Foley catheter if bladder paralysis is suspected
(6) Sedate patient if necessary
(7) Steroid use is controversial, consult with Medical Officer prior to administration. Theoretically decreases swelling and inflammation after cord injury.
(8) MEDEVAC ASAP!
(a) C-spine CT and Neurosurgical Consultation
(9) NEXUS Criteria for C-Spine XR

Answer 5

Treatment and management of spinal cord injury

Question 6

Methylprednisolone (Solumedrol) 125mg IM/IV q 4-6 hours prn

1) MOA: Anti-inflammatory; inhibits multiple inflammatory cytokines
2) Adverse Reactions: Adrenal insufficiency, steroid psychosis, infection,
increased blood sugars, arrhythmias, HTN, GI bleeding, GERD
3) Contraindications: Hypersensitivity to milk protein, severe infection,
hypertensive urgency/emergency

Answer 6

Steroid use spinal cord injury

Question 7

(a) Lumbar disk herniation is usually due to bending or heavy loading (e.g., lifting) with the back in flexion, causing herniation or extrusion of disk contents (nucleus pulposus) into the spinal cord area.
(b) However, there may not be an inciting incident.
(c) Disk herniations often occur from degenerative disk disease (desiccation of the annulus fibrosis) in patients between 30 and 50 years old.
(d)*** The L5-S1 disk is affected in 90% of cases.
(e) Compression of neural structures, such as the sciatic nerve, causes radicular pain.
(f) Severe compression of the spinal cord can cause the cauda equina syndrome, a surgical emergency.

Answer 7

Radiculopathy.

Question 8

(a) Pain with back flexion or prolonged sitting
(b) Radicular pain into the leg due to compression of neural structures
(c) Lower extremity numbness and weakness
(d) Discogenic pain typically is localized in the low back at the level of the affected disk and is worse with activity.
(e) Sciatica” causes electric shock- like pain radiating down the posterior aspect of the leg often to below the knee.
(f) A significant disk herniation can cause numbness and weakness, including weakness with plantar flexion of the foot (L5/S1) or dorsiflexion of the toes
(L4/L5).
(g) The cauda equina syndrome should be ruled out if the patient complains of perianal numbness or bowel or bladder incontinence.
(h) Clinical presentation depends on level of herniation

Answer 8

Radiculopathy clinical presentation

Question 9

1) L1- pain, paresthesia and sensory loss in the inguinal region
2) L2, L3, L4 – acute back pain that radiates around anterior aspect of thigh to knee and may have weakness of hip flexion, knee extension and hip adduction
3) L5 – most common radiculopathy; back pain radiating down lteral aspect of the leg into the foot and decreased strength in foot dorsiflexion, toe extension, foot inversion, foot eversion
4) S1 – pain radiating down posterior aspect of leg into the foot. Weakness in plantar flexion due to gastrocnemius

Answer 9

***Clinical presentation depends on level of herniation

Question 10

Straight leg testing
1) Lay patient supine and raise patients extended leg on the symptomatic side with foot dorsiflexed
2) Lasegue’s sign – presence or worsening of radicular pain with straight leg maneuver

Answer 10

Radiculopathy:
Physical examination

Question 11

MRI is the best method to assess the level and morphology of the herniation and is recommended if surgery is planned but

Answer 11

Plain radiographs are helpful to assess spinal alignment (scoliosis, lordosis), disk space narrowing, and OA changes

Question 12

(a) First-line treatments include modified activities; NSAIDs and other analgesics

(b) Muscle relaxants can help with acute symptomatic relief
1) Cyclobenzaprine (Flexeril) 5mg PO Q8Hr and can increase dose to 7.5 –10mg

(c) Reevaluation of the patient 4-6 weeks should occur

(d) If pain is persistent at reevaluation then further adjunctive treatments should be considered (physical therapy)

(e) If physical therapy is unsuccessful then consult to pain management or surgery should be considered depending on severity of symptoms

(f) Following nonsurgical treatment for a lumbar disk for over 1 year, the incidence of low back pain recurrence is at least 40% and is predicted by longer time to initial resolution of pain

Answer 12

Treatment chronic px