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1. Trauma 2. Non trauma

1. Primary evaluation: manage the life threatening conditions ABCD splinting 2. Secondary evaluation : complete evaluation spine : mechanical & neurological stability

Spinal shock : loss of function of the spinal cord from level of injury to all of caudad Clinical : loss of motor, sensory & reflex The end of spinal shock : 1. return of at least 1 reflex : eg. Bulbocavernosus reflex or anal wink reflex 2. time > 48 hours

1. Incomplete cord injuries - anterior cord syndrome - Brown-Sequard syndrome - Central cord syndrome - Dorsal cord syndrome

2. Complete cord injury

Complete or incomplete cord injury triad of sacral sparing 1. perianal sensation(S2-4) 2.controlling of rectal sphincter(S2-4) 3. toe flexor(S1)

Points to consider in primary assessment 1.Life-treatening conditions must be identified and treated first 2.Hypotension and hypoxemia are deleterious injured spinal cord 3.Assessment & initial treatment must be performed with due care & protection of the spine because of potential spinal injury

Secondary assessment complete assessment Points to consider in secondary assessment 1. An alert, conscious patients is the best spinal cord monitor 2.Spinal cord motor deficit above C5 often will lead to respiratory insufficiency 3.Neurogenic shock : hypotension + bradycardia 4.Spinal shock = sacral areflexia 5.Prognosis is uncertain until spinal shock has abated.

6. Identifying any distal motor & sensory sparing is critical. 7.Unconscious patient should be assumed to have spinal injury. 8.Spinal cord injury can mask other ass. injury.

Clinical presentation

Spine pain : neck pain, back pain radiculopathy myelopathy

Pattern of neck pain

C2-3

C3-4

C4-5

C5-6

C6-7

Common level of compression

Spinal cord is shorter than spinal column.

Cervical radiculopathy
Pain radiating into arm + sensory/motor changes in a radicular distribution

Muhle, spine 2001

Flexion : widen foramen 18-31% Extension: narrowed foramen 16-20%

Symptoms
Depend on level of cervical nerve root

Cervical compression test

Spurling test

Positive= pain along nerve root

Cervical distraction test Positive =relieve symptom of nerve root pain

Shoulder abduction sign : move dorsal root ganglion more cephalolaterally

Cervical myelopathy
Spinal cord dysfunction :developed long tract sign Most common cause is cervical spondylotic myelopathy

Breig A, J Neurosurg 1966

Neck flexion: stretch spinal cord Neck extension: shorten & thicken spinal cord

Edwards W, Spine 1985

Concormittant CSM & L-stenosis = 15-30%

Cervical spondylotic myelopathy : dynamic factors

Symptoms of cervical myelopathy Weakness & muscle wasting Loss of hand dexterity Numbness & paresthesia Spasticity Loss of balance

The early symptom = spastic gait Bowel & bladder involvement : not usually complain

Physical examination
Spastic gait Lower limb spasticity Myelopathic hand signs : Hoffmans sign 10 seconds test finger escape sign inverted radial reflex Lhermitte sign *** Test the cranial nerves

Myelopathy UMNL of lower limbs LMNL of upper limbs

The reflex arc

Absent abdominal reflex in UMNL

Scapulohumeral reflex

Positive in spinal cord dysfunction above C3 level

spondylolisthesis

LBP Claudication

Gait: foot drop gait, spastic gait

Standing: posture, ROM, heel or toe gait,

step-off

Sitting: power, root tension sign

Lying supine: neuro exam., root tension sign

Lying prone: femoral stretch test

Stoop test

Reflex
L4 Knee jerk

Sensation
Medial foot

Strength
Knee extension Ankle inversion Dorsiflexion

L5

Hamstrings Tibialis posterior

1st web space

Hip abduction Dorsiflexion Great toe extension

S1

Achilles

Lateral border of foot

Plantar flexion Hip extension

Straight leg raising test Bowstring test Lasegues test Sitting root test Contralateral SLRT Femoral stretch test