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Spinal Cord Injuries

Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries are complex injuries that involve damage to the neural tissue within the spinal canal. Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries are commonly the result of trauma. Clinical presentation varies depending on the site of injury and on whether the injury is complete or incomplete. Diagnosis is by clinical exam and imaging. Management is 2-fold, with immediate supportive care and stabilization of spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy followed by long-term rehabilitation with physiotherapy Physiotherapy Spinal Stenosis and treatment of complications. Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries are associated with multisystem complications.

Last updated: Jun 23, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

A spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injury is a complex injury that involves damage to the neural tissue within the spinal canal. This damage results in temporary or permanent damage and disrupts motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology, sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology, or autonomic functions.

Types

  • Complete injury: loss of motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function below the site of injury (through the S4 S4 Heart Sounds–S5 area of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy)
  • Incomplete injury: 
    • Preservation of some sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and/or motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology function (through the S4 S4 Heart Sounds–S5 area of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy
    • The different spinal lesions that cause incomplete injury are:
      • Central cord lesion 
      • Brown-Séquard syndrome Brown-Séquard syndrome Brown-Séquard syndrome (BSS) is a rare neurologic injury that causes hemisection of the spinal cord, resulting in weakness and paralysis of one side of the body and sensory loss on the opposite side. Brown-Séquard Syndrome 
      • Anterior cord lesion 
      • Posterior cord lesion 
      • Conus medullaris lesion  

Epidemiology

  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: 40 cases per million (based on a study from the 1990s)
  • 50% of injuries occur between the ages of 16–30 years. 
  • The average age of incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency is 40 years. 
  • Mortality Mortality All deaths reported in a given population. Measures of Health Status is higher in individuals > 60 years of age. 
  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency is higher in males.

Etiology

The major etiologic factors of spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries are: 

  • Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology vehicle accidents 
  • Falls, especially in older people 
  • Gunshot wounds Gunshot wounds Disruption of structural continuity of the body as a result of the discharge of firearms. Penetrating Chest Injury 
  • Stab injuries 
  • Sports injuries 
  • Tumors 
  • Spondylosis Spondylosis A degenerative spinal disease that can involve any part of the vertebra, the intervertebral disk, and the surrounding soft tissue. Central Cord Syndrome 
  • Vertebral fractures
  • Arterial occlusion 

Risk factors

Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries are mostly the result of accidents, and risk factors are usually hard to determine. But studies suggest that certain groups of individuals are more at risk than others: 

  • Men are more affected than women. Women account for only 20% of spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries. 
  • Alcohol abuse 
  • Individuals > 65 years old 
  • Individuals in the age group 16–30 years
  • Osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis 
  • Failure to use protective equipment, such as seat belts, helmets, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC)., while driving 
  • Engaging in risky sports, such as skydiving, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC)., without appropriate safety equipment

Pathophysiology

Clinically relevant anatomy

The spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy is formed by 31 segments protected by the bony vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy:

  • The vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy is longer than the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy.
  • Depending on the level, vertebral level and spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy level are not necessarily the same.

Cervical: 

  • 8 segments: C1–C8
  • Cervical cord segments give rise to nerve roots that exit above their corresponding vertebrae.
  • C8 nerve root emerges between C7 and T1.
  • C1–C8 segments lie within the C1–C7 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.
  • Cervical spinal segments innervate:
    • Diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy (C3–C5):
      • Phrenic nerve Phrenic nerve The motor nerve of the diaphragm. The phrenic nerve fibers originate in the cervical spinal column (mostly C4) and travel through the cervical plexus to the diaphragm. Diaphragm: Anatomy
      • Chief inspiratory muscles
    • Proximal upper limb sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology structures (C4–C7)
    • Distal upper limb sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology structures (C6–C8)
    • Hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology structures (C8–T1)

Thoracic:

  • 12 segments: T1–T12
  • Thoracic cord segments give rise to nerve roots that exit below their corresponding vertebrae.
  • T1–T12 segments lie within the T1–T8 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.
  • Thoracic nerve roots give rise to intercostal nerves:
    • Innervate the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen dermatomes Dermatomes Spinal Cord: Anatomy and muscles of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen, which participate in exhalation
  • Sympathetic innervation of the thoracic, abdominal, and pelvic viscera exits from the thoracic cord segments (as well as contributions from L1 and L2 segments).

Lumbar: 

  • 5 segments: L1–L5
  • Lumbar cord segments give rise to nerve roots that exit below their corresponding vertebrae.
  • L1–L5 segments lie within the T9–T11 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.
  • Lumbar (combined with sacral) spinal segments innervate:

Sacral:

  • 5 segments: S1 S1 Heart Sounds–S5
  • Sacral cord segments give rise to nerve roots that exit below their corresponding vertebrae.
  • S1 S1 Heart Sounds–S5 segments lie within the T12–L1 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.
  • Contribute to lower limb sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology and motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology function as above
  • Parasympathetic innervation of the abdominal and pelvic viscera exit from sacral segments S2 S2 Heart Sounds S4 S4 Heart Sounds.

Coccygeal: 

  • 1 segment
  • Arises from the conus medullaris
  • Lies within the L1 region of the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
Cross sectional view of the 31 spinal segments and their relationship to the bony vertebral column

Cross-sectional view of the 31 spinal segments and their relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship to the bony vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy

Image by Lecturio.

Individual spinal segments

  • Each segment consists of:
    • Pair of anterior/ motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology spinal nerve roots (left and right)
    • Pair of dorsal/ sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology spinal nerve roots (left and right)
  • The anterior and dorsal roots combine with each other on the lateral sides to form the spinal nerve.
  • The spinal nerve passes through the neural foramen as it exits the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
  • The extent of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy: base of the skull Base of the skull The inferior region of the skull consisting of an internal (cerebral), and an external (basilar) surface. Skull: Anatomy to lower margin of the L1 vertebral body Vertebral body Main portion of the vertebra which bears majority of the weight. Vertebral Column: Anatomy 
  • Cauda equina and the segmental spinal nerves Spinal nerves The 31 paired peripheral nerves formed by the union of the dorsal and ventral spinal roots from each spinal cord segment. The spinal nerve plexuses and the spinal roots are also included. Spinal Cord: Anatomy comprise the area below L1.
    • Cauda equina made up of contributions from:
      •  Lumbar nerve roots
      • Sacral nerve roots
      • Coccygeal nerve roots
  • Injuries below L1 are not classified as spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries.
Cross-sectional view of an individual spinal segment

Cross-sectional view of an individual spinal segment

Image by Lecturio.

Spinal tracts

The spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy consists of 4 major tracts: 

The tracts are organized on the basis of their function: motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology (descending) or sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology (ascending).

  • Corticospinal tracts Corticospinal Tracts Central Cord Syndrome: descending motor tracts Motor tracts Spinal Cord: Anatomy located anteriorly within the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy
  • Dorsal columns Dorsal Columns Posterior Cord Syndrome: ascending sensory tracts Sensory tracts Spinal Cord: Anatomy, responsible for transmitting the sensations of fine touch, proprioception Proprioception Sensory functions that transduce stimuli received by proprioceptive receptors in joints, tendons, muscles, and the inner ear into neural impulses to be transmitted to the central nervous system. Proprioception provides sense of stationary positions and movements of one’s body parts, and is important in maintaining kinesthesia and postural balance. Neurological Examination, and vibration Vibration A continuing periodic change in displacement with respect to a fixed reference. Neurological Examination
  • Lateral spinothalamic tracts Spinothalamic tracts A bundle of nerve fibers connecting each posterior horn of the spinal cord to the opposite side of the thalamus, carrying information about pain, temperature, and touch. It is one of two major routes by which afferent spinal nerve fibers carrying sensations of somaesthesia are transmitted to the thalamus. Central Cord Syndrome: ascending, responsible for the transmission of gross touch, pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, and temperature sensation
  • Anterior spinothalamic tracts Spinothalamic tracts A bundle of nerve fibers connecting each posterior horn of the spinal cord to the opposite side of the thalamus, carrying information about pain, temperature, and touch. It is one of two major routes by which afferent spinal nerve fibers carrying sensations of somaesthesia are transmitted to the thalamus. Central Cord Syndrome: ascending tracts Ascending tracts Spinal Cord: Anatomy that transmit gross touch and pressure
Major ascending and descending tracts of the spinal cord

Major ascending and descending tracts Descending tracts Spinal Cord: Anatomy of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy

Image by Lecturio.

Autonomic nerves

  • Originate in the hypothalamus Hypothalamus The hypothalamus is a collection of various nuclei within the diencephalon in the center of the brain. The hypothalamus plays a vital role in endocrine regulation as the primary regulator of the pituitary gland, and it is the major point of integration between the central nervous and endocrine systems. Hypothalamus and brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification stem
  • Descend in a poorly defined manner in the lateral aspects of the cord
  • Sympathetic fibers exit from T1–L2.
  • Parasympathetic fibers exit at the skull Skull The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy base via the vagus nerve Vagus nerve The 10th cranial nerve. The vagus is a mixed nerve which contains somatic afferents (from skin in back of the ear and the external auditory meatus), visceral afferents (from the pharynx, larynx, thorax, and abdomen), parasympathetic efferents (to the thorax and abdomen), and efferents to striated muscle (of the larynx and pharynx). Pharynx: Anatomy and from S2 S2 Heart Sounds S4 S4 Heart Sounds.

Vascular supply

  • Single anterior spinal artery Anterior Spinal Artery Anterior Cord Syndrome lies in the midline of the anterior cord and provides perfusion to the anterior ⅔ of the cord.
  • The 2 posterior spinal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology lie in the sulci of the dorsal columns Dorsal Columns Posterior Cord Syndrome and provide perfusion to the dorsal columns Dorsal Columns Posterior Cord Syndrome.
  • Anterior and posterior spinal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology originate from the vertebral arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology at the base of the skull Base of the skull The inferior region of the skull consisting of an internal (cerebral), and an external (basilar) surface. Skull: Anatomy.
  • Small radicular arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology from the thoracic and abdominal portions of the aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy may also contribute to arterial supply.
  • The area most vulnerable to ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage is in the midthoracic region distant from the vertebral arterial origin and proximal to the aortic contributions.

Mechanisms of injury

Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries occur in association with injury to the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy. The main abnormalities that cause tissue damage are: 

  • Injury from direct trauma Direct Trauma Toddler’s Fractures 
  • Compression Compression Blunt Chest Trauma injury resulting from:
    • Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types fragments
    • Spinal stenosis Spinal stenosis Spinal stenosis is the progressive narrowing of the central spinal canal, intervertebral foramen, and lateral recess, leading to compression of the nerve root. Spinal stenosis can occur in the cervical, thoracic, and lumbar spine and is commonly caused by degenerative bone disease (mostly affecting the elderly). Spinal Stenosis
    • Hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception
    • Spinal discs
    • Tumor Tumor Inflammation 
  • Ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage related to the spinal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology

Classification

Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries can be primary or secondary.

Primary injuries:

  • These injuries are usually the result of mechanical disruption, transection, or disruption of the neural elements. 
  • Primary injuries are usually coincidental with fractures and/or dislocation of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy
  • Nontraumatic causes of primary injury include:
    • Spinal tumors
    • Hematomas
    • Abscesses 

Secondary injuries (main causes):

  • Arterial disruption
  • Arterial thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus
  • Hypoperfusion secondary to shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock

Clinical Presentation

Clinical presentation of spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries depends on the site of the injury and the extent (i.e., complete versus incomplete injury). Impairment is determined by the American Spinal Injury Association (ASIA) impairment scale Scale Dermatologic Examination.

Table: American Spinal Injury Association (ASIA) impairment scale Scale Dermatologic Examination
Impairment scale Scale Dermatologic Examination Description
A: Complete No motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology or sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function preserved in the S4 S4 Heart Sounds–S5 segments
B: Incomplete
C: Incomplete
  • Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology function is preserved below the neurologic level.
  • More than half the key muscles below the neurologic level have a muscle grade < 3.
D: Incomplete
  • Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology function is preserved below the neurologic level.
  • At least half of the key muscles below the neurologic level have a muscle grade ≥ 3.
E: Normal Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology functions are normal.

General signs and symptoms observed:

  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, numbness, and loss of sensation in the area of injury and throughout the corresponding dermatome Dermatome Spinal Disk Herniation 
  • Paresthesia 
  • Reduced or absent response to painful stimuli 
  • Spastic, weak, or paralyzed muscles in the corresponding area of injury 
  • Loss of neural activity and reflexes below the level of injury
Table: Signs and symptoms specific to the area of injury
Area of injury Clinical presentation
Lumbosacral
  • Loss of control of lower limbs and hips
  • Loss of bowel and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess control
  • Sexual dysfunction Sexual dysfunction Physiological disturbances in normal sexual performance in either the male or the female. Sexual Physiology
Thoracic
  • Autonomic dysreflexia:
    • Hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
    • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder
    • Headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess
    • Nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics
    • Blurred vision Blurred Vision Retinal Detachment
    • Flushed skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
    • Nasal congestion
    • Ringing in the ears
  • Disruption in body-temperature regulation
  • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Bradycardia Bradycardia Bradyarrhythmia is a rhythm in which the heart rate is less than 60/min. Bradyarrhythmia can be physiologic, without symptoms or hemodynamic change. Pathologic bradyarrhythmia results in reduced cardiac output and hemodynamic instability causing syncope, dizziness, or dyspnea. Bradyarrhythmias
  • Pooling of blood in the limbs
Cervical
  • Quadriplegia Quadriplegia Severe or complete loss of motor function in all four limbs which may result from brain diseases; spinal cord diseases; peripheral nervous system diseases; neuromuscular diseases; or rarely muscular diseases. The locked-in syndrome is characterized by quadriplegia in combination with cranial muscle paralysis. Consciousness is spared and the only retained voluntary motor activity may be limited eye movements. This condition is usually caused by a lesion in the upper brain stem which injures the descending corticospinal and corticobulbar tracts. Locked-in Syndrome
  • Bradycardia Bradycardia Bradyarrhythmia is a rhythm in which the heart rate is less than 60/min. Bradyarrhythmia can be physiologic, without symptoms or hemodynamic change. Pathologic bradyarrhythmia results in reduced cardiac output and hemodynamic instability causing syncope, dizziness, or dyspnea. Bradyarrhythmias
  • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Disruption in body-temperature regulation
  • Breathing dysfunction

Diagnosis

Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries are a medical emergency and require immediate assessment and intervention. The different diagnostic methods are discussed.

History and physical examination

The important aspects to concentrate on in clinical presentation are:

  • Traumatic or nontraumatic history 
  • Site of injury based on neurologic examination:
    • Complete or incomplete injury 
    • Loss of motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology or sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function or both 
    • Grade of muscle strength Muscle strength The amount of force generated by muscle contraction. Muscle strength can be measured during isometric, isotonic, or isokinetic contraction, either manually or using a device such as a muscle strength dynamometer. Neurological Examination 
    • Type of paralysis: quadriplegia Quadriplegia Severe or complete loss of motor function in all four limbs which may result from brain diseases; spinal cord diseases; peripheral nervous system diseases; neuromuscular diseases; or rarely muscular diseases. The locked-in syndrome is characterized by quadriplegia in combination with cranial muscle paralysis. Consciousness is spared and the only retained voluntary motor activity may be limited eye movements. This condition is usually caused by a lesion in the upper brain stem which injures the descending corticospinal and corticobulbar tracts. Locked-in Syndrome/paraplegia/triplegia

X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests

  • Plain radiographs are taken to detect any fractures, dislocations, or soft tissue Soft Tissue Soft Tissue Abscess swelling Swelling Inflammation.
  • These radiographs are usually taken in the ED for a quick assessment.
  • Views of the suspected area of vertebral injury:
    • Anteroposterior
    • Lateral 
    • Oblique
    • Open-mouth odontoid views for cervical injuries

CT

  • Detects fractured bones, blood clots, and blood vessel damage
  • Preferred method for delineating bony abnormalities
  • Helical Helical Computed tomography where there is continuous x-ray exposure to the patient while being transported in a spiral or helical pattern through the beam of irradiation. This provides improved three-dimensional contrast and spatial resolution compared to conventional computed tomography, where data is obtained and computed from individual sequential exposures. Computed Tomography (CT) CT is more sensitive than a plain radiograph.
  • CT scan provides better visualization of extent and displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms of fractures than a plain radiograph.

MRI

  • Obtained to visualize the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy and soft tissues.
  • Superior to CT scans and plain radiographs for soft tissue Soft Tissue Soft Tissue Abscess visualization
  • MRI is used to assess nonosseous lesions, such as:
    • Extradural spinal hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception
    • Abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
    • Tumors
    • Disk rupture
    • Hemorrhage
    • Infarction
    • Contusion
    • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema 
  • MRI is conducted in an enclosed space; during this examination, it is difficult to monitor vital signs and maintain the airway Airway ABCDE Assessment.

Myelography

  • Myelography is used in combination with CT when MRI is contraindicated.
  • A soluble contrast medium is used to provide better visualization than a noncontrast CT.

Management

Immediate intervention

  • Stabilization and immobilization Immobilization Delirium of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy 
  • Maintenance of airway Airway ABCDE Assessment, breathing, and circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment
  • Hemodynamic support with vasopressors Vasopressors Sepsis in Children such as phenylephrine Phenylephrine An alpha-1 adrenergic agonist used as a mydriatic, nasal decongestant, and cardiotonic agent. Sympathomimetic Drugs, dopamine Dopamine One of the catecholamine neurotransmitters in the brain. It is derived from tyrosine and is the precursor to norepinephrine and epinephrine. Dopamine is a major transmitter in the extrapyramidal system of the brain, and important in regulating movement. Receptors and Neurotransmitters of the CNS, or norepinephrine Norepinephrine Precursor of epinephrine that is secreted by the adrenal medulla and is a widespread central and autonomic neurotransmitter. Norepinephrine is the principal transmitter of most postganglionic sympathetic fibers, and of the diffuse projection system in the brain that arises from the locus ceruleus. Receptors and Neurotransmitters of the CNS, if necessary
  • Administration of IV corticosteroids Corticosteroids Chorioretinitis to reduce inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, improve blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure, and preserve nerve function
  • Trauma surgery, neurosurgery Neurosurgery Neurosurgery is a specialized field focused on the surgical management of pathologies of the brain, spine, spinal cord, and peripheral nerves. General neurosurgery includes cases of trauma and emergencies. There are a number of specialized neurosurgical practices, including oncologic neurosurgery, spinal neurosurgery, and pediatric neurosurgery. Neurosurgery consultation

Surgical intervention

  • To remove bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types fragments and foreign objects 
  • To repair herniated discs 
  • Emergency decompression is done in selected cases: 
    • Acute spinal injury with progressive neurologic deterioration
    • Facet dislocation
    • Dislocated discs

Management of complications

  • Cardiovascular complications:
    • Neurogenic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock causes hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension and bradycardia Bradycardia Bradyarrhythmia is a rhythm in which the heart rate is less than 60/min. Bradyarrhythmia can be physiologic, without symptoms or hemodynamic change. Pathologic bradyarrhythmia results in reduced cardiac output and hemodynamic instability causing syncope, dizziness, or dyspnea. Bradyarrhythmias and is managed with vasopressors Vasopressors Sepsis in Children and IV fluids IV fluids Intravenous fluids are one of the most common interventions administered in medicine to approximate physiologic bodily fluids. Intravenous fluids are divided into 2 categories: crystalloid and colloid solutions. Intravenous fluids have a wide variety of indications, including intravascular volume expansion, electrolyte manipulation, and maintenance fluids. Intravenous Fluids.
    • External pacing and atropine Atropine An alkaloid, originally from atropa belladonna, but found in other plants, mainly solanaceae. Hyoscyamine is the 3(s)-endo isomer of atropine. Anticholinergic Drugs are considered in cases of extreme bradycardia Bradycardia Bradyarrhythmia is a rhythm in which the heart rate is less than 60/min. Bradyarrhythmia can be physiologic, without symptoms or hemodynamic change. Pathologic bradyarrhythmia results in reduced cardiac output and hemodynamic instability causing syncope, dizziness, or dyspnea. Bradyarrhythmias.
    • Autonomic dysreflexia → hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension may require fast-acting antihypertensive therapy
  • Respiratory complications: 
    • Airway management Airway management An airway, breathing, and circulation (ABC) assessment is the mainstay for evaluating and treating critically ill individuals. The airway assessment helps identify individuals with potential obstruction of the airway, which may benefit from airway management techniques to ensure adequate ventilation and oxygenation. Airway Management in cases of impending respiratory failure Respiratory failure Respiratory failure is a syndrome that develops when the respiratory system is unable to maintain oxygenation and/or ventilation. Respiratory failure may be acute or chronic and is classified as hypoxemic, hypercapnic, or a combination of the two. Respiratory Failure 
    • Tracheostomy Tracheostomy Surgical formation of an opening into the trachea through the neck, or the opening so created. Laryngomalacia and Tracheomalacia is considered in severe cases.
    • Secretions are frequently cleared to prevent aspiration.
    • Pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia is managed according to the type.
  • Deep venous thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus
    • Low-molecular-weight heparin 
    • Subcutaneous unfractionated heparin Unfractionated heparin A highly acidic mucopolysaccharide formed of equal parts of sulfated d-glucosamine and d-glucuronic acid with sulfaminic bridges. The molecular weight ranges from six to twenty thousand. Heparin occurs in and is obtained from liver, lung, mast cells, etc. , of vertebrates. Its function is unknown, but it is used to prevent blood clotting in vivo and vitro, in the form of many different salts. Anticoagulants 
    • Oral anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. Anticoagulants are not generally administered.
    • Intermittent pneumatic compression Intermittent pneumatic compression Instruments that generate intermittent forces, uniformed or graduated, to facilitate the emptying of veins. These devices are used to reduce limb edema and prevent venous thromboembolism, such as deep vein thrombosis in the legs. Thromboangiitis Obliterans (Buerger’s Disease)
  • Management of other complications:
    • Pressure sores are managed with backboards and with logrolling every couple of hours after spinal stabilization.
    • Urinary catheterization in individuals with no bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess control
    • Proton pump Pump ACES and RUSH: Resuscitation Ultrasound Protocols inhibitors for individuals with or at risk for gastric stress ulcers
    • A liquid diet is recommended in cases of paralytic ileus Ileus A condition caused by the lack of intestinal peristalsis or intestinal motility without any mechanical obstruction. This interference of the flow of intestinal contents often leads to intestinal obstruction. Ileus may be classified into postoperative, inflammatory, metabolic, neurogenic, and drug-induced. Small Bowel Obstruction.
    • Psychological counseling in individuals with depression
    • Skeletal muscle relaxants Skeletal muscle relaxants Spasmolytics are skeletal muscle relaxants medications which reduce forceful, involuntary muscle contraction. These medications have a variety of mechanisms, and can either act centrally to inhibit somatic motor neuron signals, or peripherally to prevent calcium release from the sarcoplasmic reticulum. Spasmolytics and/or botulinum toxin Botulinum toxin Toxic proteins produced from the species Clostridium botulinum. The toxins are synthesized as a single peptide chain which is processed into a mature protein consisting of a heavy chain and light chain joined via a disulfide bond. The botulinum toxin light chain is a zinc-dependent protease which is released from the heavy chain upon endocytosis into presynaptic nerve endings. Once inside the cell the botulinum toxin light chain cleaves specific snare proteins which are essential for secretion of acetylcholine by synaptic vesicles. This inhibition of acetylcholine release results in muscular paralysis. Botulism injections for muscle spasticity Spasticity Spinal Disk Herniation
    • Enteral or parenteral feeding in individuals deprived of essential nutrients owing to a liquid diet

Long-term management and rehabilitation

  • Short- and long-term physiotherapy Physiotherapy Spinal Stenosis may be necessary to enable the individual to perform daily activities independently.
  • Individuals will likely require evaluation for durable medical equipment:
    • Wheelchair
    • Cushions, padding, bedding
    • Braces, orthotics
    • Urinary catheters

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

Several factors contribute to the prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas of spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injuries, such as age, sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria, and site and type of injury.

  • Early death rate after admission: 4%–20%
  • Individuals with a cervical injury have a higher risk of death than individuals with thoracic or lumbar injury.
  • Individuals with incomplete injuries have a higher chance of making a full recovery than individuals with complete injury.
  • Life expectancy Life expectancy Based on known statistical data, the number of years which any person of a given age may reasonably expected to live. Population Pyramids is reduced owing to the increased risk of complications.

Differential Diagnosis

  • Aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection: tear in the inner layer of the aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy that presents as a sudden, severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in the chest or upper back. Paralysis may occur below the dissection owing to interruption in spinal arterial perfusion. Diagnosis is with radiography, CT scan, and MRI transesophageal echocardiography Transesophageal echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues using a transducer placed in the esophagus. Imaging of the Heart and Great Vessels. Management is with an endovascular stent-graft repair or a hybrid approach including open surgery and a stent repair.
  • Tertiary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis: late phase Late Phase Sepsis in Children of the syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis infection that usually occurs years after the initial exposure. Tertiary syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis presents with neurologic and cardiovascular complications. Neurologic complications may include tabes dorsalis Tabes dorsalis Parenchymatous neurosyphilis marked by slowly progressive degeneration of the posterior columns, posterior roots, and ganglia of the spinal cord. The condition tends to present 15 to 20 years after the initial infection and is characterized by lightning-like pains in the lower extremities, urinary incontinence; ataxia; severely impaired position and vibratory sense, abnormal gait, optic atrophy; Argyll-Robertson pupils, hypotonia, hyperreflexia, and trophic joint degeneration. Syphilis, which affects the posterior columns of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy. Diagnosis is based on history and laboratory investigations. Management includes the administration of antibiotics.   
  • Transverse myelitis Myelitis Inflammation of the spinal cord. Relatively common etiologies include infections; autoimmune diseases; spinal cord; and ischemia. Clinical features generally include weakness, sensory loss, localized pain, incontinence, and other signs of autonomic dysfunction. Relapsing Fever: disorder caused by inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy characterized by weakness in upper and lower limbs, paresthesia, and bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess and bowel disturbances. Transverse myelitis Myelitis Inflammation of the spinal cord. Relatively common etiologies include infections; autoimmune diseases; spinal cord; and ischemia. Clinical features generally include weakness, sensory loss, localized pain, incontinence, and other signs of autonomic dysfunction. Relapsing Fever is a common presentation of multiple sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor and other neuroinflammatory disorders. Diagnosis is with clinical presentation and imaging. Management is with IV steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors and plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products exchange. 
  • Stroke: brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification damage due to disrupted blood supply. Stroke presents with paralysis or numbness of the face, arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy, or leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy, headache Headache The symptom of pain in the cranial region. It may be an isolated benign occurrence or manifestation of a wide variety of headache disorders. Brain Abscess, and trouble walking and speaking. Diagnosis os by clinical presentation, imaging, and cerebral angiography Cerebral angiography Radiography of the vascular system of the brain after injection of a contrast medium. Carotid Artery Stenosis. Management includes anticoagulant therapy, supportive treatment, and in severe cases, stenting. 
  • Guillain-Barré syndrome Guillain-Barré syndrome Guillain-Barré syndrome (GBS), once thought to be a single disease process, is a family of immune-mediated polyneuropathies that occur after infections (e.g., with Campylobacter jejuni). Guillain-Barré Syndrome: disorder of the peripheral nervous system Peripheral nervous system The nervous system outside of the brain and spinal cord. The peripheral nervous system has autonomic and somatic divisions. The autonomic nervous system includes the enteric, parasympathetic, and sympathetic subdivisions. The somatic nervous system includes the cranial and spinal nerves and their ganglia and the peripheral sensory receptors. Nervous System: Anatomy, Structure, and Classification triggered by an acute bacterial or viral infection that presents with initial paresthesia in the feet and legs progressing to ascending paralysis. Other symptoms include walking abnormalities, fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium. Diagnosis is by CSF analysis CSF analysis Meningitis, electromyography Electromyography Recording of the changes in electric potential of muscle by means of surface or needle electrodes. Becker Muscular Dystrophy, nerve conduction studies. Management is with plasmapheresis Plasmapheresis Procedure whereby plasma is separated and extracted from anticoagulated whole blood and the red cells retransfused to the donor. Plasmapheresis is also employed for therapeutic use. Stevens-Johnson Syndrome and immunoglobulin therapy, analgesics, blood thinners, and physiotherapy Physiotherapy Spinal Stenosis.
  • Tick paralysis: occurs as a result of the injection of toxin by the bite of a tick. Symptoms occur within 2–7 days. Clinical presentation includes initial numbness and weakness in both legs that progresses to ascending paralysis and respiratory distress within hours. Deep tendon reflexes Deep Tendon Reflexes Neurological Examination are decreased or absent. Diagnosis is based on symptoms and finding an embedded tick, usually on the scalp. Managed by detecting/removing the tick, cleaning the bite location, and monitoring for respiratory distress.

References

  1. McDonald, J. W., Sadowsky, C. (2002). Spinal-cord injury. Lancet 359:417–425.
  2. Sekhon, L. H., Fehlings, M. G. (2001). Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine 26(24 Suppl):2–12. https://doi.org/10.1097/00007632-200112151-00002
  3. Simpson, L. A., Eng, J. J., Hsieh, J. T., Wolfe, D. L., Spinal Cord Injury Rehabilitation Evidence (SCIRE) Research Team. (2012). The health and life priorities of individuals with spinal cord injury: a systematic review. Journal of Neurotrauma 29:1548–1555. https://doi.org/10.1089/neu.2011.2226
  4. Bennett J., M Das, J., Emmady, P. D. (2021). Spinal cord injuries. StatPearls. Retrieved October 14, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK560721/
  5. Hansebout, R. R., Kachur, E. (2018). Acute traumatic spinal cord injuries. Retrieved October 14, 2021, from https://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury

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