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Spinal cord injury

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Spinal cord injury

Classification and external
resources

ICD-10 G95.9, T09.3

DiseasesDB 12327 29466

eMedicine emerg/553
neuro/711
pmr/182 pmr/183
orthoped/425

MeSH D013119

Spinal cord injury causes myelopathy or damage to white matter or myelinated fiber
tracts that carry sensation and motor signals to and from the brain. [1][2] It also damages
gray matter in the central part of the spine, causing segmental losses of interneurons and
motorneurons. Spinal cord injury can occur from many causes, including:

• Trauma such as automobile crashes, falls, gunshots, diving accidents, war

injuries, etc.
• Tumor such as meningiomas, ependymomas, astrocytomas, and metastatic
cancer.
• Ischemia resulting from occlusion of spinal blood vessels, including dissecting
aortic aneurysms, emboli, arteriosclerosis.
• Developmental disorders, such as spina bifida, meningomyolcoele, and other.
• Neurodegenerative diseases, such as Friedreich's ataxia, spinocerebellar ataxia,
etc.
• Demyelinative diseases, such as Multiple Sclerosis.
• Transverse myelitis, resulting from spinal cord stroke, inflammation, or other
causes.
 • Vascular malformations, such as arteriovenous malformation (AVM), dural
arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and
aneurysm.

Contents
[hide]

• 1 Classification
• 2 The Effects of Spinal Cord Injury
o 2.1 The Location of the Injury
 2.1.1 Cervical injuries
 2.1.2 Thoracic injuries
 2.1.3 Lumbar and Sacral injuries
 2.1.4 Central Cord and Other Syndromes
• 3 Treatment
• 4 See also

• 5 External links

[edit] Classification
The American Spinal Cord Injury Association or ASIA defined an international
classification based on neurological levels, touch and pinprick sensations tested in each
dermatome, and strength of ten key muscles on each side of the body, i.e. shoulder shrug
(C4), elbow flexion (C5), wrist extension (C6), elbow extension (C7), hip flexion (L2).
Traumatic spinal cord injury is classified into five types by the American Spinal Injury
Association and the International Spinal Cord Injury Classification System.

• A indicates a "complete" spinal cord injury where no motor or sensory function is

preserved in the sacral segments S4-S5. Since the S4-S5 segment is the lower
segmental, absence of motor and sensory function indicates "complete" spinal
cord injury.
• B indicates an "incomplete" spinal cord injury where sensory but not motor
function is preserved below the neurological level and includes the sacral
segments S4-S5. This is typically a transient phase and if the person recovers any
motor function below the neurological level, that person essentially becomes a
motor incomplete, i.e. ASIA C or D.
• C indicates an "incomplete" spinal cord injury where motor function is preserved
below the neurological level and more than half of key muscles below the
neurological level have a muscle grade of less than 3.
• D indicates an "incomplete" spinal cord injury where motor function is preserved
below the neurological level and at least half of the key muscles below the
neurological level have a muscle grade of 3 or more.
 • E indicates "normal" where motor and sensory scores are normal. Note that it is
possible to have spinal cord injury and neurological deficit with completely
normal motor and sensory scores.

In addition, there are several clinical syndromes associated with incomplete spinal cord
injuries.

• The Central cord syndrome is associated with greater loss of upper limb function
compared to lower limbs.
• The Brown-Séquard syndrome results from injury to one side with the spinal
cord, causing weakness and loss of proprioception on the side of the injury and
loss of pain and thermal sensation of the other side.
• The Anterior cord syndrome results from injury to the anterior part of the spinal
cord, causing weakness and loss of pain and thermal sensations below the injury
site but preservation of proprioception that is usually carried in the posterior part
of the spinal cord.
• Tabes Dorsalis results from injury to the posterior part of the spinal cord, usually
from infection diseases such as syphilis, causing loss of touch and proprioceptive
sensation.
• Conus medullaris syndrome results from injury to the tip of the spinal cord,
located at L1 vertebra.
• Cauda equina syndrome is, strictly speaking, not really spinal cord injury but
injury to the spinal roots below the L1 vertebra.

One can have spine injury without spinal cord injury. Many people suffer transient loss of
function ("stingers") in sports accidents or pain in "whiplash" of the neck without
neurological loss and relatively few of these suffer spinal cord injury sufficient to warrant
hospitalization. In the United States, the incidence of spinal cord injury has been
estimated to be about 35 cases per million per year, or approximately 10,500 per year (35
* 300). In China, the incidence of spinal cord injury was recently estimated to be as high
as 65 cases per million per year in urban areas. If so, assuming a population of 1.3 billion,
this would suggest an incidence of 84,500 per year (65 * 1300).

The prevalence of spinal cord injury is not well known in many large countries. In some
countries, such as Sweden and Iceland, registries are available. About 450,000 people in
the United States live with spinal cord injury (one in 670), and there are about 11,000
new spinal cord injuries every year (one in 30,000). The majority of them (78%) involve
males between the ages of 16-30 and result from motor vehicle accidents (42%), violence
(24%), or falls (27%). This is likely due to increased risk-taking behavior in men.

[edit] The Effects of Spinal Cord Injury

 Divisions of Spinal
Segments

Segmental Spinal Cord

The exact effects of a spinal cord injury vary according to Level and Function
the type and level injury, and can be organized into two
types: Level Function

• In a complete injury, there is no function below the Cl-C6 Neck flexors

"neurological" level, defined as the lowest level that
Cl-Tl Neck extensors
has intact neurological function. If a person has some
level below which there is no motor and sensory C3, Supply
function, the injury is said to be "complete". Recent C4, diaphragm
evidence suggest that less than 5% of people with C5 (mostly C4)
"complete" spinal cord injury recover locomotion.
• A person with an incomplete injury retains some Shoulder
sensation or movement below the level of the injury. movement, raise
The lowest spinal cord level is S4-5, representing the arm (deltoid);
anal sphincter and peri-anal sensation. So, if a person C5, flexion of elbow
is able to contract the anal sphincter voluntarily or is C6 (biceps); C6
able to feel peri-anal pinprick or touch, the injury is externally rotates
said to be "incomplete". Recent evidence suggest that the arm
over 95% of people with "incomplete" spinal cord (supinates)
injury recover some locomotory ability.
Extends elbow
In addition to a loss of sensation and motor function below and wrist (triceps
C6,
the point of injury, individuals with spinal cord injuries will and wrist
C7
often experience other complications of spinal cord injury: extensors);
pronates wrist
• Bowel and bladder function is regulated by the sacral C7,
region of the spine, so it is very common to Flexes wrist
T1
experience dysfunction of the bowel and bladder,
including infections of the bladder, and anal Supply small
incontinence. C7,
muscles of the
• Sexual function is also associated with the sacral T1
hand
region, and is often affected.
• Injuries of the C-1, C-2 will often result in a loss of Intercostals and
T1
breathing, necessitating mechanical ventilators or trunk above the
-T6
phrenic nerve pacing. waist
• Inability or reduced ability to regulate heart rate,
T7- Abdominal
blood pressure, sweating and hence body
L1 muscles
temperature.
• Spasticity (increased reflexes and stiffness of the L1,
limbs). L2,
• Neuropathic pain. Thigh flexion
L3,
• Autonomic dysreflexia or abnormal increases in L4
blood pressure, sweating, and other autonomic
responses to pain or sensory disturbances. L2,
• Atrophy of muscle. L3, Thigh adduction
• Superior Mesenteric Artery Syndrome L4
L4,
L5, Thigh abduction
S1
Extension of leg
L5,
 • Osteoporosis (loss of calcium) and bone degeneration.
• Gallbladder and renal stones.

[edit] The Location of the Injury

Knowing the exact level of the injury on the spinal cord is important when predicting
what parts of the body might be affected by paralysis and loss of function.

Below is a list of typical effects of spinal cord injury by location (refer to the spinal cord
map to the right). Please keep in mind that while the prognosis of complete injuries are
predictable, incomplete injuries are very variable and may differ from the descriptions
below.

[edit] Cervical injuries

Cervical (neck) injuries usually result in full or partial tetraplegia (Quadraplegia).

Depending on the exact location of the injury, one with a spinal cord injury at the cervical
level may retain some amount of function as detailed below, but are otherwise completely
paralyzed.

• C3 vertebrae and above : Typically lose diaphragm function and require a

ventilator to breathe.
• C4 : May have some use of biceps and shoulders, but weaker
• C5 : May retain the use of shoulders and biceps, but not of the wrists or hands.
• C6 : Generally retain some wrist control, but no hand function.
• C7 and T1 : Can usually straighten their arms but still may have dexterity
problems with the hand and fingers. C7 is generally the level for functional
independence.

[edit] Thoracic injuries

Injuries at the thoracic level and below result in paraplegia. The hands, arms, head, and
breathing are usually not affected.

• T1 to T8 : Most often have control of the hands, but lack control of the abdominal
muscles so control of the trunk is difficult or impossible. Effects are less severe
the lower the injury.
• T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance
is very good.

[edit] Lumbar and Sacral injuries

The effect of injuries to the lumbar or sacral region of the spinal canal are decreased
control of the legs and hips, urinary system, and anus.

[edit] Central Cord and Other Syndromes

Central cord syndrome (picture 1) is a form of incomplete spinal cord injury
characterized by impairment in the arms and hands and, to a lesser extent, in the legs.
This is also referred to as inverse paraplegia, because the hands and arms are paralyzed
while the legs and lower extremities work correctly.

Most often the damage is to the cervical or upper thoracic regions of the spinal cord, and
characterized by weakness in the arms with relative sparing of the legs with variable
sensory loss.

This condition is associated with ischemia, hemorrhage, or necrosis involving the central
portions of the spinal cord (the large nerve fibers that carry information directly from the
cerebral cortex). Corticospinal fibers destined for the legs are spared due to their more
external location in the spinal cord.

This clinical pattern may emerge during recovery from spinal shock due to prolonged
swelling around or near the vertebrae, causing pressures on the cord. The symptoms may
be transient or permanent.

Anterior cord syndrome (picture 2) is also an incomplete spinal cord injury. Below the
injury, motor function, pain sensation, and temperature sensation is lost; touch,
proprioception (sense of position in space), and vibration sense remain intact. Posterior
cord syndrome (not pictured) can also occur, but is very rare.

Brown-Séquard syndrome (picture 3) usually occurs when the spinal cord is

hemisectioned or injured on the lateral side. On the ipsilateral side of the injury (same
side), there is a loss of motor function, proprioception, vibration, and light touch.
Contralaterally (opposite side of injury), there is a loss of pain, temperature, and deep
touch sensations.

[edit] Treatment
Treatment for acute traumatic spinal cord injuries have consisted of giving a high dose
methylprednisolone if the injury occurred within 8 hours. The recommendation is
primarily based on the National Acute Spinal Cord Injury Studies (NASCIS) II and III.
Some of the claims of the studies have been challenged as being from faulty
interpretation of the data.

Scientists are investigating many promising avenues of treatment for spinal cord injury.
Thousands of articles in the medical literature describe work, mostly in animal models,
aimed at reducing the paralyzing effect of injury to the spinal cord and promoting
regrowth of functional nerve fibers. Despite the devastating effects of the condition,
commercial funding for spinal cord cure research is limited, owing primarily to the small
size of the population of potential beneficiaries. Despite this, a number of experimental
treatments have reached controlled human trials. In addition, nerve protection and
regeneration strategies are being studied in more common conditions like Alzheimer's
Disease, Parkinson's Disease, Amyotrophic Lateral Sclerosis and Multiple sclerosis.
There are many similarities between these neurodegenerative diseases and spinal cord
injury, and this research adds considerable new information relevant to spinal cord injury
treatment.

Advances in the science of spinal cord injury treatment are newsworthy, and considerable
media attention is drawn towards new developments. Aside from the use of
methylprednisolone, none of these developments have reached even limited use in the
clinical care of human spinal cord injury. Around the world, proprietary centers offering
stem cell transplants and treatment with neuroregenerative substances are fueled by
glowing testimonial reports of neurological improvement. Independent validation of the
results of these treatments is lacking.[3]

[edit] See also

• Kevin Everett#2007 neck injury

[edit] External links

• Miami Project to Cure Paralysis Noted for experimental cooling protocol used on
Kevin Everett
• United Spinal Association A membership organization dedicated to improving the
quality of life of individuals with spinal cord injuries and related disorders.
• Rehabilitation Research and Training Center (RRTC) on Spinal Cord Injury:
Promoting Health and Preventing Complications through Exercise
• CareCure Forums- Dr. Wise Young's SCI Forum
• SCI Images - Images of Spinal Cord Injury
• [1]- Spinal Cord Injury Levels and Classification
• Spinal Cord Injury Peer Support Patient, Carer and Spouse Support
• [2] The Spinal Cord Injury Project, W.M. Keck Center for Collaborative
Neuroscience at Rutgers University
• EMSCI Network European Multicenter Study about Spinal Cord Injury
• Brigham and Women's Hospital Translational Pain Research Clinical trials for
pain following SCI
• Pediatric and Adolescent Spinal Cord Injury
• Rehabilitation Engineering Research Center on Wheeled Mobility
• Spinal Cord Injury Forums SCI Support Forums
• International Institute for Research in Paraplegia Research funding foundation,
based in Zurich
• Spinal Cord Injuries Emergency Medicine for Spinal Cord Injuries
• Trefethen, Tre. User's Manual for the Paralyzed Penis: Love after spinal cord
injury American Sexuality Magazine. Accessed 3-22-07.
• About Spinal Cord Injury Spinal Cord Injury FAQ for those with SCI, and their
families, by Canadian Paraplegic Assocation - Ontario.
 [show]
v•d•e
Nervous system

[show]
v•d•e
Nerves: spinal nerves

[show]
v•d•e
Injuries, other than fractures, dislocations, sprains and strains (S00-T14,
850-929)

Retrieved from "http://en.wikipedia.org/wiki/Spinal_cord_injury"

Categories: Spinal cord | Medical emergencies | Neurotrauma
Hidden categories: Cleanup from September 2007 | All pages needing cleanup

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