NEUROLOGICAL EXAMINATION OF SPINAL CORD INJURY Dr. Osama Neyaz Assistant Professor Department Of PMR ANATOMY OF SPINE 7 cervical vertebrae
12 thoracic vertebrae 5 lumbar vertebrae 5 fused sacral vertebrae 3-4 small bones comprising the coccyx Spinal cord ends as conus medullaris at level of first lumbar vertebra lumbar and sacral nerve roots exit below this and form the cauda equina
ANATOMY OF SPINE ANATOMY OF SPINE NEUROANATOMY 1&2 Posterior Columns: convey Ipsilateral information about two Point discrimination, proprioception And vibratory sense
5 Lateral Spinothalamic Tract: carries Pain and Temperature Information From contralateral extremity 4 Lateral Corticospinal Tract: Carries Motor Information from Contralateral Brain to Ipsilateral Extremity MECHANISMS OF INJURY
Epidural hematoma Displacement of posterior wall of the vertebral body JEFFERSON FRACTURE A comminuted fracture of the ring of C1. Compression of base of skull against C1 Results in cracking the ring of C1 Best seen on open mouth x-ray
ATLANTOAXIAL AND DENS FRACTURES The result of hyperflexion or hyperextension injuries 8% of Dens Fractures associated with C1 fractures C2 Fractures Dens Fracture : Hyperflexion Injury
Hangman Fracture : Hyperextension Injury Traumatic spondylolisthesis of the axis Bilateral fractures through the pars interarticularis of the axis FLEXION TEARDROP FRACTURE Hyperflexion of the subaxial cervical spine
Retropulsion of the larger portion of a vertebral body into the spinal canal, detached from an anterior fragment (teardrop) Often associated with an anterior cord syndrome. CLAY-SHOVELERS FRACTURE
Avulsion fracture of the spinous process of C6, C7, or T1. It is not typically associated with neurologic injury. THORACOLUMBAR TRAUMA Mechanism of injury Compression
Distraction Rotation CHANCE FRACTURE Failure of all three columns due to flexiondistraction Falls from a height Strikes part of the torso on an immovable object Injury pattern most likely to cause SCI
THE THREE-COLUMN CONCEPT OF SPINAL ANATOMY The anterior column: ALL + anterior portion of the vertebral body + anterior portion of the disk. The middle column: posterior portion of the vertebral body + the posterior portion of the disk + PLL The posterior column: the pedicles facet joints + laminae + supraspinous ligament, interspinous ligament + facet joint capsule + ligamentum flavum.
STABLE Vs UNSTABLE FRACTURE When the integrity of the middle and either the anterior or the posterior column is affected, the spine is likely to be unstable. The columns can be affected by: Fracture Ligamentous disruption Gunshot wounds
Because of the nature of the injury, can affect more than one column and the spine can still remain stable. SCI can occur without obvious radiographic findings. CLINICAL SYNDROMES AFTER INCOMPLETE SPINAL CORD INJURY Central Cord Syndrome
Brown-Sequard Syndrome Anterior Cord Syndrome Conus Medullaris Syndrome Cauda Equina Syndrome CENTRAL CORD SYNDROME Motor>Sensory Loss Upper>Lower Extremity Loss Distal >Proximal Muscle Weakness
Classically occurs with hyperextension injuries of the cervical spine BROWN-SEQUARD LESION A burst fracture with posterior displacement of bone fragments compresses one side of the spinal cord. Loss of Ipsilateral Proprioception, Light Touch and
Motor Function Loss of Contralateral Pain and Temperature Sensation Due to hemisection of the cord due to penetrating injury Incomplete lesions most common ANTERIOR CORD SYNDROME A large disk herniation compresses
the anterior aspect of the spinal cord, leaving the dorsal columns intact. Loss of Motor function, Pain and Temperature Sensation Preservation of Light touch, Vibratory Sensation and Proprioception CONUS MEDULLARIS SYNDROME
A burst fracture of with posterior displacement of bone fragments compresses the conus medullaris. Injury to sacral cord, lumbar nerve roots causing Areflexic bladder Loss of control of bowels Knee jerk relexes preserved, ankle jerk absent Signs similar to cauda equina syndrome except more likely to be bilateral
CAUDA EQUINA SYNDROME A central disk herniation at L4-L5 level compresses the cauda equina. Injury to nerve roots and not spinal cord itself Muscle weakness and decreased sensation in affected dermatomes Decreased bowel and bladder control
CLASSIFICATION OF SPINAL CORD INJURY Patients are classified according to the ASIA Impairment Scale (AIS) Combined efforts from ASIA: American Spinal Injury Association ISCOS: International Spinal Cord Society COMPONENTS OF THE TEST
Three Main Parts to the Exam: Strength Testing Light Touch Sensation Pinprick Sensation Lowest Level of motor control: Voluntary Anal Contraction Lowest Level of Sensation: Deep Anal Pressure
NEUROLOGIC EXAM: DERMATOMES C5- Deltoid C6 Thumb T12 Symphysis Pubis L4 Medial aspect of leg C7 Middle Finger C8 - Little Finger
L5 - Space between first and second toes S1 Lateral border of the foot S3 Ischial Tuberosity T4 Nipple T8 Xiphoid
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