Background

Epidemiology

 

National Spinal Cord Injury Statistical Center (2021) Facts and figures at a glance

- road traffic accident 40%

- falls 30%

- sports 10%

 

Chen et al Arch Phys Med Rehab 2016

- 80% male

- cervical (60%), thoracic (30%), lumbar (10%)

 

van der Berg et al Neuroepidemiology 2010

- bimodal age distribution

- 15 - 29 - motor vehicle accidents and sports

- > 50 - falls

 

Natural History

 

Khorasanizadeh et al J Neurosurg Spine 2019

- systematic review of 114 studies

- improvement of one ASIA grade

- grade A: 19%

- grade B: 74%

- grade C: 87%

- grade D: 47%

 

Mechanism of injury

 

Primary

- mechanical

- contusion / compression / stretch / laceration

 

Secondary

- ischemia

- pro-inflammatory state

- additional neuronal death

- microcystic cavitations

 

Definition

 

Neurological level

- lowest level at which motor and sensory function is normal

 

Complete lesion / no sacral sparing

- absence of sensory and motor function in the lowest sacral segment

- no sacral sparing

 

Incomplete lesion / sacral sparing

- presence of sacral and motor function in the lowest sacral segment

- indicates preserved function below the defined neurological level

 

Spinal shock

 

Refers to initial flaccid paralysis of all motor, sensory and reflexes absent below level of injury

 

An accurate assessment of spinal cord function can only be made when spinal shock has resolved (48 hrs in 99%)

 

Resolution of spinal shock

- return of cord mediated reflexes below the anatomic level of the injury

- bulbocavernosus reflex is the lowest and thus the first to return

 

Bulbocavernosus Reflex

- squeeze glans / clitoris or pull on urinary catheter

- causes anal contracture

- if present indicates S2-S4 region firing

- spinal shock resolved

- can prognosticate about level of neurological injury

 

Spinal Cord Injury Grading

 

Medical Research Council (MRC) Power Grading

 

0 - no visible movement

1 - palpable or visible contraction

2 - active movement with gravity eliminated

3 - active movement against gravity

4 - active movement against some resistance

5 - active movement against full resistance

 

ASIA Myotomes/Dermatomes (American Spinal Injury Association)

 

Upper Limb Motor Sensation Lower Limb Motor Sensation
C5 Elbow flexor Lateral arm L1   Inguinal ligament
C6 Wrist extension Dorsal thumb L2 Hip flexion Middle medial thigh
C7 Elbow extension Dorsum middle finger L3 Knee extension Anterior knee
C8 Finger flexion Dorsum little finger L4 Ankle dorsiflexion Medial malleous
T1 Interossei Medial arm sensation L5 Toe extension First webspace
T2   Armpit sensation S1 Ankle plantarflexion Heel
      S2   Back of knee

Sensory Levels

 

T4 - nipple

T7 - xiphisternum

T10 - umbilicus

T12 - groin

 

American Spinal Injury Association Impairment Scale (AIS)

 

A (complete): no motor or sensory

B (incomplete):  no motor, some sensory intact

C (incomplete):  > 50% muscle groups strength < grade 3

D (incomplete):  > 50% muscle groups strength > grade 3

E (normal) motor and sensory

 

Reflexes

 

Cremasteric Reflex T12-L1

- stroke thigh & scrotal contraction

 

Anal Wink S2-4

- stroke cleft for anal contract

 

Babinski

- upgoing = upper motor neuron injury

 

Oppenheim

- stroke tibial crest & toes go up