10.2.2 Spinal Cord Injury

Question 1

Define shock

Answer 1

State in body of inadequate perfusion for tissue oxygenation of essential organs
- important parts of body does not get enough blood

Question 2

Causes of shock

Answer 2

Where is the blood?
Hypovolemic shock
- bleed out / blood in pelvis
- blood is not in intravascular space
- tachy + hypotensive

Cardiogenic shock
- “pump stopped working”
- tachy + hypotensive

Septic shock
- “distributive shock” - blood distributed poorly to body
- vasodilatation
- capillary leak
- blood pool in periphery (legs)
- tachycardia + hypotensive

Anaphylactic shock
- “distributive shock”
- hypersensitivity reaction
- vasodilatation
- blood in periphery
- tachy + hypotensive

Neurogenic shock
- “distributive shock”
- bradycardia + hypotension
- blood pools in periphery
- blood cannot responds

Question 3

Define neurogenic shock

Answer 3

HEMODYNAMIC SEQUELAE OF SPINAL SHOCK
- Hypotension resulting from loss of peripheral vascular resistance
- Resulting from sympathetic outflow disruption (T1-L2) – Unopposed Vagal parasympathetic tone
- Hypotension, bradycardia and venous pooling, warm skin

Question 4

What happens when there is a disruption of the reflex pathway with a spinal cord injury?

Answer 4

Below level of injury
- no motor
- no sensation
- reflexes present

Question 5

What happens to the reflex pathway with spinal shock?

Answer 5

Every cell below injury stops working
- No motor
- no sensation
- no reflexes

Question 6

What is spinal cord dysfunction based on?

Answer 6

Based on physiological rather than structural disruption

Question 7

What reflex is used to assess spinal shock?

Answer 7

Bulbocavernosus reflex
- Contraction of the anal sphincter in response to- stimulation on Trigone of bladder (gentle catheter tug), -squeeze on the glans penis or gentle direct stimulation to the clitoris
- Absence indicates spinal shock,CAUDA EQUINA or CONUS MEDULLARIS INJURY
- Return of BC reflex indicates end of spinal shock– unlikely further improvement in neurology

ASIA score

Question 8

Grading of neurological injury

Answer 8

Can only be done after pt is out of spinal shock and reflexes have returned

Complete spinal cord injury:
- No sensation or voluntary motor function caudal to the level of injury
- Presence of intact BC reflex (no spinal shock)
- Reflexes return below level of injury
- Named by last level of partial neurological function
- Expect one to two levels of additional root return
- Prognosis for further recovery – extremely poor

Incomplete spinal cord injury:
- Some neurological function caudal to level of injury after return of BC reflex
- The greater the function, and the faster the recovery, the better prognosis expected
- Sacral sparing – perianal sensation, voluntary rectal motor function, great toe flexor activity – indicates @ least partial long tract continuity
- Potential for recovery following resolution of spinal shock

Question 9

Patterns of incomplete SCI: BROWN SEQUARD

Answer 9

Hemicord injury (half of spinal cord gets injured)
- Ipsilateral muscle paralysis
- Ipsilateral loss of proprioception / light touch
- Contralateral loss of pain and temperature
cut off one side; opposite side will be affected

Good prognosis
- >90% patients regaining bowel and bladder function, and ambulatory capacity

Question 10

Patterns of incomplete SCI: CENTRAL CORD SYNDROME

Answer 10

• Most common
• Frequently ass. with extension injury in cervical spondylosis
• Flaccid paralysis in UL; spastic paralysis in LL (arms»>legs)
• watershed areas

3 “mores”
- Motor > Sensory
- Upper > lower extremity
- Distal (hands) > proximal

Fair prognosis:
- 50-60% of patients regaining motor and sensory function to lower extremities
- Permanent central grey matter destruction results in poor hand function

Question 11

Patterns of incomplete SCI: CONUS MEDULLARIS SYNDROME

Answer 11

• T12-L1 injuries (tip of spinal cord)
• Loss of voluntary bowel and bladder control
• Mixed UMN & LMN lesion
• Preserved lumbar root function
• Complete or incomplete
• BC reflex may be permanently lost

Question 12

Cauda equina syndrome

Answer 12

• Caused by lumbosacral root compression within lumbar spinal canal
• Only LMN lesion
• Clinical findings:
  ➡️Saddle anaesthesia
  ➡️Bilateral radicular pain
  ➡️Numbness
  ➡️Weakness
  ➡️Hypo-/areflexia
  ➡️Loss of voluntary bladder or bowel control

Question 13

Which level does the spinal cord typically terminate in an adult?

Answer 13

L1/2

Question 14

Does spinal shock lead to hypotension and bradycardia?

Answer 14

No