Types of Spinal Cord Injuries

General information about spinal tracts

• Ascending: Dorsal column-medial leminiscus (DCML), Anterolateral system

  • DCML: Proprioception, vibration, graphesthesia, barognosis, sternogenesis, 2-pt. discrimination, kinesthesia, fine touch

  • ALS: Spinothalamic tracts (STT)

    • Anterior: Crude touch

    • Lateral: Pain and temperature

• Descending: Corticospinal tracts

  • Corticospinal tracts: movement

Ascending tracts- receptive primary sensory input

• Fasciculus cuneatus: sensory tract for trunk, neck, and UE proprioception, vibration, 2-point discrimination, and graphesthesia

• Fasciculus gracilis: sensory tract for trunk and LE proprioception, vibration, two-point discrimination, and graphesthesia

• Spinocerebellar tract (dorsal): sensory tract that ascends to the cerebellum for IPSILATERAL subconscious proprioception, tension in muscles, joint sense, posture of the trunk and LE

• Spinocerebellar tract (ventral): sensory tract that ascends to the cerebellum with some fibers crossing, and subsequently recrossing at the level of the pons. IPSILATERAL subconscious proprioception, tension in muscles; joint sense and posture of trunk, UE, and LE

• Spinothalamic tract (anterior): sensory tract for crude touch and pressure

• Spinothalamic tract (lateral): sensory tract for pain and temperature sensation

Descending tracts- voluntary motor tract

• Corticospinal tract (anterior): pyramidal motor tract responsible for IPSILATERAL voluntary, discrete, and skilled mvmts

• Corticospinal tract (ipsilateral): pyramidal motor tract responsible for CONTRALATERAL voluntary fine mvmt

Anterior Cord syndrome

• Hyperflexion injury

  • Bilateral loss of pain and temperature sensation

  • Bilateral loss of motor function

Central cord syndrome

• Hyperextension

  • Loss of motor and sensory function

    • affects UE > LE

    • affects motor > sensory

  • Tracts affected

    • spinothalamic

    • corticospinal

    • dorsal column

• In small lesions to central cord only pain and temperature sensation lost

• In large lesions to central cord see “typical” presentation

  • called walking SCI

Brown- Sequard syndrome

• stab wound/ gunshot

  • C/L loss of pain and temperature sensation

  • I/L loss of vibration, position sense, and motor function (paralysis)

Cauda Equina syndrome

• Injury below L1

  • peripheral nerve injury

  • Flaccidity

  • Areflexia

  • Bowel and bladder dysfunction

Conus Medullaris

• Location: bilateral and symmetrical in perineum

• Sensory: saddle distribution, bilateral, symmetric

• Motor: symmetric

• Type: UMN + LMN signs

Posterior cord syndrome (sensory)

• compression of posterior spinal artery/ latrogenic

  • Loss of vibration, proprioception, 2-point discrimination, sternogenisis

  • Motor function is perserved

C1-C2

• Respiratory m.

  • Cervical spondylotic myelopathy

  • upper trap

  • Cervical extensors

• Tx

  • Ventilator or phrenic nerve stimulator

• Transfer: Mechanical lift

• W/C use

  • Power wheelchair

C3-C4

• Respiratory m.

  • Partial diaphragm

  • Scalenes

  • Levator scapulae

• Tx

  • Ventilator in acute phase can be weaned off

• Transfer: Mechanical lift

• W/C

  • Power wheelchair

C5

• Other muscles

  • Biceps, Brachioradialis, Brachialis

  • Infraspinatus, rhomboids, deltoids, supinators

• Tx

  • Ventilator in acute phase can be weaned off

• W/C

  • Manual w/c with plastic coated handrims and extensions

  • Dependent slide board transfers

  • Power w/c for long distances

  • Drive with adaptive equipment

C6

• Muscles

  • Pec major, ECR, Teres Minor, SA, LD, Infraspinatus, pronator

  • Tenodesis

• Tx

  • Assisted coughing

• W/C

  • Manual w/c with plastic-coated handrims and extensions

  • power w/c for long distances, independent slide board transfer

  • Drive with adaptive equipment

C7

• Muscles

  • FCR, EPB, EPL, Extrinsic finger ext, triceps

• Tx

  • Assisted coughing

• W/C

  • independent in home and community w/c w/ plastic coated handrims on level surfaces, need assistance with ramps, curbs, etc

  • independent, no slide board transfer

  • Drive with adaptive equipment , w/c in/ out

C8

• Muscles

  • FCU, FPL, extrinsic & intrinsic finger muscles

• Tx

  • Assisted coughing

• W/C

  • Can transfer from floor to chair

  • Manual, standard handrims for home, friction for community

  • Independent u/down curbs

T1-T5

• Muscles

  • intercostals, spinalis, and semispinalis

• Tx

  • Functional cough

• W/C

  • Floor to w/c transfer

  • manual w/c

  • independent ramps, curbs, uneven surfaces, standing parapodium, HKAFO

• T4: Sitting pivot independent

T6-12

• Muscles

  • intercostals, spinalis, and semispinalis, abdominals T7 and below

• Tx

  • Functional cough

• W/C

  • manual w/c

  • independent ramps, curbs, uneven surfaces, standing parapodium, HKAFO

L1, L2, L3

• Muscles

  • Gracilis, iliopsoas, QL, RF, sartorius

• w/c

  • used for energy conservation

• L1- HKAFO → hip flex

• L2- KAFO → hip flexion/ adduction

• L3- AFO and can walk short distances at home → knee extension

  • Can stand pivot transfer

L4, L5, S1, S2

• Muscles

  • L4- Tibialis anterior

  • L5- Extensor digitorum

  • S1- Plantar flexors

  • S2- Hamstrings

• L4- AFO

• L5- AFO

• S1- AFO

Spastic bladder (neurogenic)

• injury above S2 sacral segment

• Bladder contracts and reflexively empties in response to certain level of filling

  • Reflex action is present

• Frequent urination, sudden and intense urges (urge incontinence), and unpredictable leaking

Flaccid bladder (autonomous)

• Seen in injury at or below S2 sacral segment

• No reflex action is present

• Inability to feel when the bladder is full, overflow incontinence (where the bladder gets overly full, stretches, and dribbles/leaks), and an inability to empty completely

ASIA Impairment Scale

• A → complete

  • Motor → absent

  • Sensory → Absent (DAP, LT, or pinprick)

• B → incomplete

  • Motor → absent

  • Sensory → incomplete (present, any sensory function at S4/5 or DAP)

• C→ motor incomplete

  • Motor→ present <50% of key muscles >/= 3/5 below NLI

  • Sensory → OR absent w/ motor sparing >3 levels below the ipsilateral motor level on either side (non-key mm. too) with VAC/ DAP

• D→ motor incomplete

  • Motor → present, at least half of the key mm. below NLI are >/= 3/5

  • Sensory → OR absent with motor sparing >3 levels below the ipsilateral motor level >/= 50% mm. have >/= 3/5)

Assigning motor and sensory level easy steps

• Motor level

  • Lowest level at which strength is at least 3/5

  • All levels above are 5/5

• Sensory level

  • Lowest level where you have 2/2

  • All above levels are 2/2

s/s Autonomic dysreflexia

• Increase BP (systolic rise by 20-30 mmHg)

• Decrease HR

• Severe headache, anxiety

• constricted pupils, blurred vision

• Flushing, piloerection above level of lesion

• Dry, pale skin below lesion

• increased spasticity

Autonomic dysreflexia intervention

• Sit up and lower legs

• remove painful stimuli

  • loosen clothing, abdominal binder

  • check bladder distension: unclamp catheter, drain it

• Monitor vitals throughout: if still no change, medical/ nursing assistance > meds to lower BP (Nifedipine, nitrates and captopril)

Key muscles associated w/ different levels of the spinal cord

• C5: Elbow flexors

• C6: wrist extensors

• C7: Elbow extensors

• C8: Finger flexors

• T1: fifth finger abductors

• L2: hip flexors

• L3: Knee extensors

• L4: Ankle dorsiflexors

• L5: Great toe extensors

• S1: Ankle plantarflexor