Spinal Cord

• Foramen Magnum  L1-L2 Adult

L2 -L3 Children

• Conus medullaris - pointed conical tip SC

(spinal integration center for micturation/ urination)

• Filum terminale
• Cauda equina
DIMENTIONS
• Length: 42- 45cm (17 inches)
• Diameter: 10-15 mm
*Spinal canal (17 mm)
PROTECTIVE STRUCTURES
• Spinal column
• Meninges
 Dura
 Arachnoid (subarachnoid space *CSF)
 Pia
* Denticulate ligament

Enlargements
*Cervical – brachial plexus
*Lumbar – lumbar plexus
INTERNAL ANATOMY
• Gray matter – central portion of SC
 Ventral (AHN) *pure motor
 Dorsal (PHN) *sensory DRG
 Middlle – interneurons
• Bell Magendie Law
• White matter
REXED LAMINAE
• Lamina I – Marginal zone
• Lamina II – SG nuclei *Gate control theory
• Lamina III – IV – Nucleus Proprius
 • Lamina VII – Dorsal Nucleus of Clarke
• Lamina IX - AHC
• Lamina X – Central Gray Commissure

PRIMARY ASCENDING TRACTS (SENSORY TRACTS)

• Spinothalamic tract (STT)
Anterior
Lateral
• Dorsal Column/ Medial Leminiscus
• Spinocerebellar
• Spinotectal
• Spinoreticular
• Spinothalamic Tract 2 levels above *Lissauer’s Tract
Anterior STT
Lateral STT
• Dorsal Column -Medial Leminiscus medulla oblongata
nucleus cuneatus -upper limb(T6 & above)
nucleus gracilis – lower limb (T6& below)
SPINOCEREBELLAR TRACT

Spinovisual reflex – mvt of the eye and head towards stimulus

*tectospinal tract
SPINORETICULAR TRACT
• Reticular activating system – wakefulness and drowsiness

PRIMARY DESCENDING TRACTS

(MOTOR TRACTS)
• Corticospinal tracts
• Corticobulbar
• Vestibulospinal
• Rubrospinal
• Reticulospinal
• Tectospinal tract
PYRAMIDAL TRACTS
CORTICOSPINAL TRACT (CST)
• Spinal nerves
• Lateral (CST)
• Anterior ( CST)
CORTICOBULBAR TRACT (CBT)
 Cranial nerves
EXTRAPYRAMIDAL TRACTS
VESTIBULOSPINAL TRACT
 RETICULOSPINAL TRACT
• Medial – facilitates voluntary mvts and increases mm tone
• Lateral – Inhibits voluntary mvts and decreases mm tone
RUBROSPINAL TRACT
• fine control of hand mvts
TECTOSPINAL TRACT
BLOOD SUPPLY OF THE SPINAL CORD
Anterior Spinal Artery (ASA) 1
Posterior Spinal Artery (PSA) 2
Radicular Arteries – supplies nerve roots
ADAMKIEWICZ –(T8-L4)
• Arteria Radicularis Magna
• Watershed zone (midthoracic) – (T4 -T6)

SPINAL CORD INJURY

I. Epidemiology
*young adults ( male >female)
Causes: Traumatic ( MVA>falls>violence>sports)
non traumatic ( Dse and pathological influence)
Functional categories:
• Tetraplegia/ Quadriplegia
• Paraplegia
II. Etiology

• Hyperflexion injury - *MC results to Anterior cord syndrome

• Hyperextension injury – MC in elderly due to fall results to central cord syndrome
• Flexion rotational
• Shearing – horizontal force directed to adjacent vertebral column segment
• Compression – excessive axial loading force
• Distraction - least common ; due to traction force (whiplash injury)
• Penetrating Injuries – gunshots or stab wounds
results to brown sequard syndrome
III. CLASSIFICATION
Complete – (-) sensory and motor below the level of lesion
Incomplete – preservation of sensory and motor fxn below the lesion
*graded using ASIA Scale
 Preservation of anal sensation (PAS)
 Voluntary anal contraction (VAC)
 Cutaneous sensation on the saddle area
 Active contraction of the toe flexion
INCOMPLETE SYNDROMES
• Anterior Cord Syndrome

• Posterior Cord Syndrome

• Central Cord Syndrome

• Brown Sequard Syndrome

• Cauda Equina

DESIGNATION OF LESION LEVEL

NEUROLOGICAL LEVEL
MOTOR LEVEL
SENSORY LEVEL
* light touch and pin prick
*Zone of partial preservation
ASIA IMPAIRMENT SCALE
A = COMPLETE
B = INCOMPLETE
C = INCOMPLETE
D = INCOMPLETE
E = NORMAL
TOTAL SENSORY INDEX SCORE(TSIS) = 112
TOTAL MOTOR INDEX SCORE (TMIS) = 50
COMPLICATIONS
SPINAL SHOCK
Gradual return of reflexes = 1-3days
Increasing hyperreflexia = 1-4 wks
Final hyperreflexia = 6 mo
(+) Bulbocavernosus reflex (S2-4) – 1st to return reflex
*Good Prognosis
(+) clitocavernosus reflex

MOTOR AND SENSORY IMPAIRMENT

MOTOR (+) Paresis/ Paralysis
SENSORY loss of pain and temp, light touch and proprioception
Note: seen below the lesion; motor and sensory impairment depends on the neurological level and the
completeness of the lesion.

AUTONOMIC DYSREFLEX
occurs usually lesions above T6
chronic stage > acute
complete > incomplete
Cause: noxious stimuli below the lesion resulting to sudden increase of BP
MC: Bladder and bowel distention/irritation
in SBP of 20-30 mmHg is diagnostic of an episosde of AD
INTERVENTION of AD
- look for the source of noxious stimuli ( check the catheter )
Medical / Nursing Assistance
Pharmacological Intervention
Nifedipine, nitrates and captopril

AUTONOMIC DYSREFLEXIA vs POSTURAL HYPOTENSION

SPASTIC HYPERTONIA
UMN Syndrome
 Spasticity
 Mm spasm
 Hypertonia
 Hyperreflexia
 Clonus

Pharmacological Mx:
Baclofen & Botulinum neurotoxin
Surgical Mx:
Tenotomy or Myotomy
 Icing
ES
CARDIOVASCULAR IMPAIRMENT
Impaired sympathetic function
 bradycardia
 vasodilation
 stroke volume
 cardiac output
IMPAIRED TEMPERATURE CONTROL
sympathetic dysfunction – leads to impaired thermoregulation
Hypothermia
Hyperthermia
PULMONARY IMPAIRMENT
- results from higher cervical level injury (>T10 level)
- MC CAUSE OF DEATH OF SCI
- Paralysis/ paresis of respiratory muscles
- inhalation (diaphragm and External Intercostals) * paradoxical breathing pattern
- exhalation
• Atelectasis and Pneumonia
Management:
mechanical ventilator , phrenic nerve stimulation
*assisted coughing ( Upward and inward during expiration)
BLADDER DYSFUNCTION
Above conus medullaris SPASTIC/HYPERREFLEXIC
Hyperreflexic detrusor mm
Mgt: 1. suprapubic tap
2. lower abdominal stroking
3. hair pulling
Below conus medullaris FLACCID/AREFLEXIC
Incompetent detrusor mm
Mgt: 1. Valsalva maneuver
2. Crede maneuver
SPASTIC/ REFLEXIVE BOWEL (UMN)
(+) reflex defecation
Mgt: 1. digital stimulation
2. suppositories
3. valsalva and abdominal massage
FLACCID/ AREFLEXIVE BOWEL (LMN)
 Cauda equina lesion
(-) reflex defecation
Mgt: 1 manual evacuation
2. gentle valsalva
 SEXUAL DYSFUNCTION
MALE RESPONSE
1. ERECTION  Psychogenic vs reflexogenic
• UMN> LMN
• incomplete>complete
Mgt: Topical agents, mechanical stimualtors
Medications (Viagra, Levitra, & Ciales)
2. EJACULATION
• LMN>UMN
• incomplete> complete
Mgt: vibratory stimulation and electroejaculation
SEXUAL DYSFUNCTION
FEMALE RESPONSE
1. AROUSAL  Psychogenic vs reflexogenic
UMN – Reflexogenic stimulation
-clitorial erection and vaginal lubrication
LMN – Psychogenic
2. Fertility – not severely affected than men
*interruption of menstrual cycle 4-5 mo after injury
SECONDARY COMPLICATIONS
1. Pressure ulcer

2. DVT

3. Pain

4. Contractures

5. Heterotrophic Ossification

6. Fx/ Osteoporosis

7. Syringomyelia
PROGNOSIS
FACTORS
 Neurologic level
 ASIA Scale (complete/incomplete)
 Preservation of pinprick in LEs and sacral region 4 mo after injury
- good motor recovery below lesion

Early Medical and Rehabilitation in Acute Stage

• Immobilization
 Cervical orthosis
*MC HALO – limits cervical mvts AP
Halo > Minerva > SOMI
TLSO
*MC TLSO body jacket – stable (provides extension support for immobilization)
- Jewett orthosis
• Early mobilization (ROM Exercises)
• Respiratory Mgt
- Breathing techniques (deep & glossopharengeal)
• Coughing
Self assisted coughing
Abdominal Binder
* decrease postural hypotension
Skin Care
Positioning e.g (sh abd and elbow extended)
Turning at least 2 hrs
Bed and matresses (air fluidized bed)
W/c - sits with pelvis in neutral or tilted anteriorly
push up maneuver (every 15 min for 2min)
leaning to the side/ forward
TILT IN SPACE AND RECLINING W/C

Early strengthening and ROM

1. Rom exercises
PARAPLEGIA – avoid SLR > 60 & hip flex > 90
TETRAPLEGIA – avoid head and neck mvt
ankle boots for heel cords – 90
2. Selective stretching
TETRAPLEGIA
tightness of the lower lumbar  trunk stability
longer finger flexors  tenodesis grasp (perform ADLs, manipulate objects and transfers)
Hamstrings – SLR of 100 deg – useful for fxnal activities
such as long sitting and LE dressing
Functional Outcomes For SCI Patients
C4
C5
C6
C7
C8
T1-T12
L1-L3
L4-l5
ORTHOSIS
Upper extremity orthosis
• C5 – uses balance forearm orthosis (BFO)
• C6 – uses tenodesis splint
Lower extremity orthosis
• T1-T8 KAFO + // bars or walker
• T9-T12 KAFO + walker
• L1-L3KAFO + Loftstrand Crutches
• L4 – L5 AFO + Loftstrand
• L5 – S1 rockerbar, rocker bottom, metatarsal bar
• TRANSFERS

C3 – Obese hydraulic lift

C5 – Dependent sliding transfer
C6 – Independent sliding board transfer
C7 – independent transfer w/o sliding board on all level surfaces
T1 – floor to w/c
T4 - sitting pivot
L3 standing pivot

BED MOBILITY

C6 – independent bed mobility w/ equipment

(overhead trapeze/triangle, siderails)
C7 -independent bed mobility w/o equipment in eating, toileting, & dress UE/LE

AMBULATION

T2 – Above – (SO) stand only

T3 – T11 - (TA) therapeutic ambulation
T12 – L2 - (HA) household ambulation
L3 – Below - (CA) community ambulation
Scott Craig Orthosis – T9-L12 – Swing to
L1-L3 – 4pt
L4-L5 – 2pt