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Spinal pathology and

SCI classification

Alejandra Garrido Florez

PGY 2 LCH-PSC

References:

  • Cuccurullo, S. J., MD (2020). Physical medicine and rehabilitation board review (4th ed., pp. 549-562). Sringer Publishing Company, LLC.
  • Moore, D. W., MD (n.d.). Incomplete Spinal Cord Injuries. Orthobullets. https://www.orthobullets.com/spine/2008/incomplete-spinal-cord-injuries
  • Moore, D. W., MD (n.d.). Odontoid Fracture. Orthobullets. https://www.orthobullets.com/spine/2016/odontoid-fracture
  • Moore, D. W., MD (n.d.). Spine Biomechanics. Orthobullets. https://www.orthobullets.com/spine/2003/spine-biomechanics
  • PMR recap - SCI, spasticity and MS video.

Stability?

Spinal

pathology

Instability defined by:

- Injury to middle column as evidenced by:

  • widening of interpedicular distance on AP radiograph
  • loss of height of posterior cortex of vertebral body

- Disruption of posterior ligament complex combined with anterior and middle column involvement

Cervical spine

flexion and

hyperextension

injuries

Fractures &

SCI

Cervical

Jefferson fracture

Hangman’s fracture

Odontoid Fracture

Type 1

Type 2

Type 3

Chance fracture:

– Transverse fx of TL spine from posterior to anterior through the spinous process, pedicles, and vertebral body.

– Usually affects T12, L1, and L2 levels

– Typically due to falls/crush injury with acute hyperflexion of the thorax.

– Stable fx

- Rarely associated with neuro compromise

Vertebral body compression fracture (Anterior wedging)

- Axial compresion w/wo flexion

- Stable Fx

Thoracic

Non traumatic

SCI

- MCC of myelopathy: Cervical spinal stenosis due to spondylosis.

- In extension, the sagittal diameter of the cervical canal decreases.

- With cervical flexion the cord may be tethered over spondylotic anterior elements.

- MC presentation: gait disturbance and decreased balance

- Corticospinal tract involvement first with resultant leg weakness. This is followed by posterior column involvement with presentation of an ataxic-wide based gait.

- MRI is the gold standard for evaluation of cervical myelopathy and helps to identify the pathological causes.

- Treatment:

Asymptomatic to mild cases: Conservative treatment (therapy to improve gait pattern)

Moderate to severe myelopathy: Surgery may be indicated.

Spinal stenosis

with

Myelopathy

Transverse

myelitis

- TM is an inflammation of the spinal cord

- Most commonly affects the thoracic spinal cord.

- Symptoms evolve over several hours to several weeks

- Begins w/Leg paresthesias -> Pain is usually present at the involved cord segments -> Weakness + acute loss of reflexes -> later: hyperreflexia.

- F:M ratio 4:1, peaking in the 2nd and 4th decades.

- Etiology: Causes include idiopathic, MS, infections, and autoimmune or postinfectious inflammation

- Diagnostic testing includes MRI and lumbar puncture (CSF analysis).

- Prognosis: 1/3rd

– Rapid progression, back pain, and spinal shock predict poor prognosis.

Neuromyelitis

optica

- AKA Devic’s disease

- A fairly uncommon disease of the CNS -> causing a combination of optic neuritis and transverse myelitis.

- F predominance

- It's an immune mediated disease.

- Myelopathy severity is NMO>MS, and on MRI the lesions tend to be more longitudinal (more than three spinal segments).

- The optic neuritis can cause blindness in one or both eyes.

- Most of these lesions cause permanent deficits, although some flare-ups can be reversible.

- Tx:

  • IV glucocorticoids -> plasmapheresis if not response.
  • Long-term immunosuppression.

- Most commonly seen in DM and immunocompromised (IV drug use, Bact endocarditis, genitourinary infxn)

- M predominance

- Initial sympt -> Local pain

- Radicular pain and leg weakness, usually bilateral, occur in about 50%.

- Sympt preset for >2 w before Dx in >2/3rd of cases.

- AVOID LP!

- Dx: MRI

- Tx: Qx drainage and excision + Broad spectrum IV Abx

Epidural

abcess

Lichtheim's

Disease

- Degeneration of the posterior and lateral columns of the spinal cord

- Most severely affected are the posterior columns at the cervical and thoracic levels

- Usually begins in thoracic region and becomes ascending or descending

- Causes: Vit B12 deficiency (MC), Vit E and cooper deficiencies.

- Delayed complication of radiation -> spine or adjacent tissus

- Develops months or years after treatment

- Overall rare: <1% of pts will develp RM

- Incidence: total radiation dose, dose fraction and length of radiation.

- Weakness, loss of sensation, and sometimes a Brown-Séquard-like syndrome

- White matter primarily affected

- Symptoms appear after 6 months and most commonly begin after 9 to 15 months.

Dx: r/o other etiologies, gradual development of S and M loss below lvl of radiation, radiation dose and latency.

Radiation

Myelopathy

- Spinal neoplasms represent 15% of CNS tumors and are classified as either extradural (within spinal canal)or intradural (within spinal cord).

- ID and ED tumors approximately equal in prevalence.

- MC ID -> 1ry tumors

- MC ED w/2ndary compromise of SC -> metastatic (25% more prevalent than 1ry)

- MC symptom: local or radicular pain. W/wo weakness, depending on location.

Spinal cord

tumors

SCI Classification

SCI

Tetraplegia

VS

Paraplegia

Paraplegia

Tetraplegia

- Used to be Quadraplegia

- Impariement or loss of M &/or S function in cervial segment of spinal cord 2/2 damage of neural elements w/in spinal canal.

- Result: Impairment of all 4 extremities + trunk and pelvic organs.

- Does not refere to peripheral nerve or B.P injuries (ONLY UMN injury)

- Impairment or loss of M +/or S function in Thoracic, Lumbar or Sacral segment of spinal cord.

- Trunk, legs and pelvic organs may be involved -> arm function spared

- Includes Cauda Equina and Conus medullaris injuries, BUT NOT LMN injuries OUTSIDE neural canal (lumbosacral plexus or peripheral N. injury)

Complete

Vs

Incomplete

Complete

Incomplete

- SOME degree of motor +/or sensory function below the level of lesion.

- NO motor or sensory function below the level of lesion.

Dermatomes

Vs

Myotomes

Dermatomes

- Area of skin innvervated by sensory axons within EACH segmental nerve (root).

Myotomes

- Collection of msk fibers innervated by the motor axons w/in each segmental nerve (root)

UMN

VS

LMN

UMN vs LMN

Neurological

classification

of SCI

Int Standards for Neurological classification of SCI

Sensory

- 28 key sensory dermatomes.

- Face= normal control point.

- Test for light touch (LT, cotton swab) & pinprick (PP, safety pin).

- Important: Test S4-S5 dermatomes.

- Sensory lvl of injury: Most caudal segment of SC with normal (2/2 score) S function on BOTH sides of body for LT & PP.

Motor

strength

- There are 10 key myotomes (referred to as the key muscle groups) tested on the left and right sides of the body in the supine position.

- Motor level of injury: Most caudal key muscle group that is graded ≥3/5 with all the segments abovegraded 5/5 in strength. Motor level can be determined for each side of the body.

- Motor index scoring: A possible total score of 100 can be obtained when adding the muscle scores of the key muscle groups (25 points per extremity). It is recommended that the motor score should be separated into two scores, one composed of the 10 upper limb muscle functions, and one of the 10 lower limb muscle functions, with a maximum score of 50 each.

Anal exam

1. Deep Anal Pressure (DAP)

- Insertion of lubricated gloved finger into the anus with pressure applied to the anorectal wall using the thumb to gently squeeze the anus against an inserted index finger.

– The patient is asked if he or she can appreciate this digital pressure.

** If a patient has intact sensation to LT or PP at S4/S5, DAP is not required for classification in the current ISNCSCI exam (though the motor portion is still required).

2. Voluntary Anal Contraction (VAC)

- Insterting lubricated gloved finger into anus, and asking the patient to "squeeze my finger as if holding backa bowel movement."

* Differentiate volitional contraction from anal spasm when finger is inserted or anal contraction is triggered by valsalva.

– Botho DAP and VAC are recorded as either present (YES) or absent (NO) on the worksheet.

Neuro lvl

of injury

- Most caudal segment of the spinal cord with both normal sensory and motor function ≥3/5 with cephalad segments graded 5/5 on both sides of the body.

- The motor and sensory levels are the same in <50% of complete injuries.

- In cases where there is no key muscle level available (i.e., cervical levels at and above C4, T2– L1, and sacral levels below S2), the NLI is that which corresponds to the sensory level, if testable motor function above that level is also normal.

ASIA

grading

AIS:

1. NOON?

  • Yes: ASIA A, then list ZPPs
  • No: nex step

2. VAC?

  • Yes: ASIA C or D
  • No: check for M function >3 lvls below M lvl on either side.
  • If there is -> C or D
  • If no VAC or M function, no NOON -> ASIA B

3. MSK below NLI, are >50% of them >3/5 or better?

  • If no -> ASIA C
  • If yes -> ASIA D

4. Everything normal?

  • Yes -> ASIA E

Spinal Shock

- Temporary loss of ALL spinal reflex activity below the lvl of lesion.

- Loss f M and S accompanied by ATONIC paralysis of the bladder and bowel.

- Msk below lvl of injury become flaccid and hyporeflexic

- Autonomic function below lvl of lesion IMPAIRED.

Spinal Shock

- Phase 1: Areflexia of all reflexes below SCI level, which typically lasts for 24 hours. Reflexes begin to return within 24 hours.

- Phase 2: Initial reflex activity is noted, usually with the return of the delayed plantar response followed by the BCR and the anal wink. A positive Babinski sign may be noted at a later time.

- Phase 3: Early hyperreflexia—on average, muscle stretch reflexes return after 2 to 3 weeks. Some reflexes (e.g., bladder) may not return for up to 3 months (or later) after injury.

- Phase 4: Spasticity/Hyperreflexia—muscle stretch reflexes become hyperactive with the presence of pathologic reflexes below the lesion, resulting in spasticity.

Phases

1. Delayed plantar response

- Usually the 1st to return aft r SS.

- Toes flex and relax slowly

2. Bulbocavernous reflec (BCR):

- Returns soon after plantar response.

- Indicates there is an UMN injury, and reflex od S2-S4 (B&B) is pressent.

- if not present by 24hrs, LMN injury may be suspected.

3. Perianal sphincter reflex (anal wink)

- Indicates similar finding as BCR.

Reflexes

Anatomy overview

Incomplete

SCI

- MC of the incomplete SCI syndromes

- UE>LE Motor weakness, with variable loss of S, B&B function.

- Any age, but MC in older patients with cervical spondylosis who sustain a cervical hyperextension injury, usually from a fall.

- Recovery:

  • LEs recover first and to a greater extent. This is followed by improvement in bladder function, then proximal UE, and finally intrinsic hand function.
  • Age below 50 is a key positive prognostic indicator of functional recovery.

Central

cord synd

- Relative cord hemisection.

- Rare injury - 2% to 4% of all traumatic SCI (mostly penetrating trauma)

– At the level of lesion:

  • Ipsilateral flaccid paralysis (anterior horn cells)
  • Ipsilateral loss of all sensory modalities

– Below the level of lesion:

  • Ipsilateral paralysis (corticospinal tract)
  • Ipsilateral loss of light touch and proprioception (dorsal columns)
  • Contralateral loss of pain and temperature (spinothalamic tract)

- Overall, patients clinically present most often with a relative ipsilateral motor and proprioceptive loss, and contralateral loss of pain and temperature

Brown-Sequard Syndrome

- Affects the anterior 2/3rds of the SC while preserving the posterior columns

- Causes: flexion injuries, direct injury to the anterior spinal cord from bone fragments or disc herniation, or anterior spinal artery lesions.

- Results in:

  • Variable loss of motor function (corticospinal tract)
  • Variable loss of pain, temperature, and pinprick sensation (spinothalamic tract)
  • Preservation of proprioception, light touch, and deep pressure sensation (dorsal columns)

- Motor recovery is poor compared to other incomplete syndromes.

Anterior cord

Syndome

- Least common syndrome (<1% incidence) and has been omitted from recent versions of the International Standards

- Injury to the posterior columns results in proprioceptive loss (dorsal columns) with muscle strength, pain, and temperature modalities spared

- Prognosis for ambulation is poor secondary to the proprioceptive deficits

Posterior cord

Syndome

Consu Medullaris

vs

Cauda Equina

Functional

outcomes

after SCI

F.O

Tetraplegia

F.O

Paraplegia

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