SPINAL CORD INJURY
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Spinal cord injury occurs due to damage of the vertebral column from a trauma, car crush, gun-shot wound or either due to disease or degeneration for eg:-Cancer
Spinal cord injury more frequently occurs as a result of injury to vertebral column either fracture or dislocation.
The common site of spinal cord injury are:-
-Lower cervical region
-Thoracolumbar region
-Upper lumbar region
It also occurs due to forcible flexion and due to forcible extension too.
Male female ratio- 2:1
51% cases are seen in 16-30 yrs
ETIOLOGY
- TRAUMATIC :- Fall, assault, gun-shot injury, road traffic accident, sports injury
- NON - TRAUMATIC :- Atriovenous malformation 30% cases, thrombus, embolus, tumor, vertebral subluxation.
CLASSIFICATION OF SPINAL CORD INJURY
FUNCTIONAL
1- TETRAPLEGIA- Limbs, trunk including respiratory muscles, complete paralysis.
2- PARAPLEGIA - Paralysis of lower limb and lower part of the trunk.
ON THE BASIS OF INJURY
1- COMPLETE INJURY- Loss of all motor and sensory function below the level of lesion.
2- INCOMPLETE INJURY- Some function either motor or sensory remain intact below the level of lesion.
MECHANISM OF INJURY
-FLEXION INJURY- Injury occurs to C4 - C7 cord, head on collision on front side , flexion of neck.
-COMPRESSION INJURY - Vertical or axial blow to the head ( diving or falling from a height)
Commuted fracture or burst fracture will occur.
- HYPEREXTENSION INJURY- Strong post surface such as rare and collision fall with chin hitting on stationary object. In this injury, there is a fracture of post element such as spinous process lamina and facet.
-FLEXION WITH ROTATION - By posterior to anterior force directed at rotated vertebral column ( tear and collision with passenger rotated towards front). In this fracture of posterior structure such as lamina articular facet, pedicle will occur.
CLINICAL SYNDROME
1- BROWN SEQUARD SYNDROME
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It is a complete one side damage of the spinal cord ( stabbed / gun-shot)
-IPSILATERAL SIDE - Loss of reflexes clonus ( uncontrolled shivering ), loss of proprioception.
-CONTRALATERAL SIDE - Loss of pain and temperature.
2- ANTERIOR CORD SYNDROME
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Loss of motor function ( corticospinal tract)
Loss of pain and temperature ( spinothalamic tract)
Proprioception kinesthesia and vibratory sense are intact.
3- CENTRAL CORD SYNDROME
Only central cord is affected, due to axial blow.
There is characteristically more neurological involvement in upper extremity because the cervical tract are centrally placed.
Weakness in upper extremity is more prominent. Sensory impairment may occur.
4- POSTERIOR CORD SYNDROME
Posterior cord is affected.
Loss of proprioception, epicritic sensation ( involves loss of two point discrimination, graphesthesia, barognosis, stereognosis)
SACRAL SPARING
These are incomplete lesion in which most centrally located sacral tract are spare. In this perianal sensation and external anal sphincter contraction is present.
CAUDA EQUINA INJURY
- IN UPPER PART- Weakness of dorsiflexors, detrusor muscles, sensory deficit in inner calf muscles, impotence faecal incontinence will occur.
- IN LOWER PART- Weakness in plantarflexors or evertor muscles, ankle jerk is absent, sensory deficit in saddle area.
CLINICAL FEATURES
1- SPINAL SHOCK - Immediately following spinal cord injury, it is believed that there is withdrawl of the connection between highest centre and spinal cord.
It is characterized by absence of all reflex activities, flaccidity, loss of sensation, motor function below the level of lesion.
It is present several days to weeks.
First indicator of spinal shock resolving is the presence of bulbocavernosus reflex.
If positive, a reflex contraction of anal sphincter is present.
2- SENSORY IMPAIRMENT- It is present below the level of lesion ( depending upon the extent of injury)
3- MOTOR IMPAIRMENT - It is present below the level of lesion.
4- AUTONOMIC DISREFLEXIA- It is a pathological autonomic reflex that typically occurs in lesion above T6
SYMPTOMS
- Hypertension
- Bradycardia
- Pounding headache
- Restlessness
- Piloerection
- Drug therapy
- Orthostatic hypotension otherwise called as postural hypotension decreases in blood pressure when assuming an erect or vertical position.
- Reduced cerebral blood flow and decreased venous return.
- Dizziness
- Light headedness
- Faintness or blackout
- Impaired temperature control
- Respiratory impairment
- Spasticity
- Bowel impaction
- Bladder and bowel dysfunction
- Sexual dysfunction
COMPLICATIONS
- Pressure sores
- Ulceration of soft tissue caused by unrelieved pressure and shearing force.
- Impaired sensory function and inability to make appropriate positional changes
- Loss of vascular control
- Spasticity with resulting shearing force between the surface.
- Nutritional deficiency
PREVENTIVE MEASURES
- Inhibit the formation of CaPO4
- Maintain ROM and prevent deformity
- ROM exercises, proper positioning
- Use appropriate splint
- Stretching
- Anti - coagulant drug therapy
- Elastic support stocking
- Positioning of lower extremity to facilitate venous return
- Traumatic pain that arise from fracture, ligament or soft tissue damage, muscle spasm can be managed by immobilization, analgesics and TENS
- Dietary management, early and continuous weight bearing activities if possible.
In acute medical management phase
-When a spinal cord injury is inspected, effort should be made to avoid both active or passive movement of spine.
-Movement of spine can be avoided by straping the patient to a spinal backward or full body.
-Adjustable board use supporting cervical column or assistance from the multiple personal in moving the patient to the safety.
-These measures will assist in maintaining the spine in neutral, anatomical position and will prevent further neurological damage.
-Administration of high dose within 2- 8 hours of injury for 24 - 48 hours can modestly improve motor and functional recovery.
-On arrival at the emergency room, initial attention is focused on stabilizing the patient medically.
-A complete neurological examination is performed.
-Radiography and imaging study assist in determining the extent of damage and plan for management.
-Attention is directed towards preventing progression of neurological impairment by restoration of vertebral alignment and early immobilization of fracture site.
-Cardiac, haemodynamic and respiratory status are closely monitored.
-A urinary catheter typically is inserted.
-Unstable spinal fracture require early reduction and fixation.
SURGICAL MANAGEMENT
INDICATION- To restore bony anatomical alignment.
To prevent further damage to spinal cord, stabilizing fracture site.
Spinal injury for cervical fracture include decompression ( anterior/ posterior) fusion is achieved by bone grafting and may be combined with posterior wiring of spinous process.
SURGERY FOR THORACIC AND LUMBAR FRACTURE - Requires use of internal fixation divice which is used in combination with bone graft.
The three most common devices for achieving spinal alignment stability and internal fixation are:-
- Harrington distraction rods
- Harrington compression rods
- WE ISS compression sprain
Drugs for muscle relaxation are diazepam, dentroline sodium, declophen.
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