Spinal cord

Starts from foramen magnum
Ends filum terminale

Spinal cord arrangement

Blood supply of spinal cord

Anterior spinal artery (from vertebral) Posterior spinal arteries (Derived intercostals) + Artery of adamkewicz (between T8 and T12)

Spinal cord injuries

1. Complete
   • Motor: flaccid to spastic paralysis below level of lesion (cf strokes) with positive Babinski (plantar) reflex
   • Sensory deficit
   • Autonomic - affect para/sympathetic output from cord
2. Partial
   

   	Mechanism	Deficit
   Central	Hypertextension of C-spine Compression of cord against disc	Motor weakness of mainly upper limbs Sensory loss less severe (cause peripheral)
   Anterior	Anterior aspect (infarction anterior spinal artery)	Loss of motor function (corticospinal tracts) Loss of pain/temperature (spinothalamic) Dorsal columns preserved
   Brown-sequard	Spinal hemisection	Loss motor below lesion Contralateral loss of pain/temp (crosses at level) Ipsilateral loss of dorsal column (crosses higher up)
   Cauda-Equina	Lumbar / sacral root injury due to prolapsed disc	Saddle anaesthesia Loss of bladder / bowel control

Spinal Shock

Temporary state state of flaccid paralysis that usually occurs after spinal injury
Takes 3-4 weeks to resolve
Due to loss of excitatory stimuli from supraspinal levels

Suspicion of spinal cord injury in unconscious patients

1. Hypotension due to vasodilation (loss of sympathetic outflow)
2. Bradycardia (unopposed vagal stimulation)
3. Paradoxical breathing - phrenic works, intercostals dont'
4. Hypothermia
5. Priapsim
6. Urinary retention with overflow incontinence
7. Lax anal sphincter tone

Examination of Immobilsed patient

1. ATLS principles
2. If awake: examine for head injury, neck pain, stiffness, focal neurology, parasthesia, altered sensation in hands
   • If suspicious: - AP/lateral/open mouth x-rays
   • If not: remove collar, examine for other
3. If not awake: CT
   • Perform when not possible to obtain adequate X-rays (although ATLS states you should perform in all cases of head injury)

Management of spinal injuries

1. Immediate:
   • C-spine immobilisation + inline immobilisation
   • ATLS survey for other injury
   • Respiratory management - O2, ventilation
   • Manage hypotension
   • Manage hypothermia
   • Prevent gastric dilation (NGT)
   • Bladder catheterisation
   • DVT / gastric ulcer prophylaxis
2. Intermediate:
   • If within 8 hours: IV steroids (methylprednisolone 30mg)
   • Surgical stabilisation - unstable injuries, retropulsed fragments
3. Long-term management
   • Prevention of decubitus ulcers
   • Nutritional support (high spinal injuries)
   • Bowel care: regular enemas, bulk-forming laxatives
   • Bladder care
   • Physiotherapy - help clear lung secretions
   • Psychological support