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1. Trauma2. Non trauma

1. Primary evaluation: manage the life threatening conditionsABCDsplinting

2. Secondary evaluation :

complete evaluationspine : mechanical & neurological stability

Spinal shock : loss of function of the spinalcord 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 reflex2. 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 injurytriad of sacral sparing1. perianal sensation(S2-4)2.controlling of rectal sphincter(S2-4)3. toe flexor(S1)

Points to consider in primary assessment1.Life-treatening conditions must be

identified and treated first2.Hypotension and hypoxemia are

deleterious injured spinal cord3.Assessment & initial treatment must be

performed with due care & protection of the spine because of potential spinal injury

Secondary assessmentcomplete assessment

Points to consider in secondary assessment1. An alert, conscious patients is the best

spinal cord monitor2.Spinal cord motor deficit above C5 often

will lead to respiratory insufficiency3.Neurogenic shock : hypotension + bradycardia4.Spinal shock = sacral areflexia5.Prognosis is uncertain until spinal shock

has abated.

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

•Spine pain : neck pain, back pain• radiculopathy• myelopathy

Clinical presentation

Pattern of neck pain

C2-3 C3-4C4-5

C5-6 C6-7

Common level of compression

Spinal cord is shorter than spinal column.

Cervical radiculopathyPain radiating into arm + sensory/motor changes in

a radicular distribution

Muhle, spine 2001Flexion : 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 signMost common cause is cervical spondylotic myelopathy

Breig A, J Neurosurg 1966Neck flexion: stretch spinal cordNeck 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 wastingLoss of hand dexterityNumbness & paresthesiaSpasticityLoss of balance

The early symptom = spastic gaitBowel & bladder involvement : not usually complaint

Physical examination

Spastic gaitLower limb spasticityMyelopathic hand signs :

Hoffman’s sign10 seconds testfinger escape signinverted radial reflex

Lhermitte sign*** Test the cranial nerves

Myelopathy UMNL of lower limbsLMNL of upper limbs

The reflex arc

Absent abdominal reflex in UMNL

Scapulohumeral reflex

Positive in spinal cord dysfunction above C3 level

LBPClaudication

spondylolisthesis

GaitGait: foot drop gait, spastic gait: foot drop gait, spastic gait

Standing: Standing: posture, ROM, heel or toe posture, ROM, heel or toe

gait, step-offgait, step-off

Sitting:Sitting: power, root tension sign power, root tension sign

Lying supine: Lying supine: neuro exam., root tension neuro exam., root tension

signsign

Lying proneLying prone: femoral stretch test: femoral stretch test

Stoop testStoop test

Reflex Sensation Strength

L4 Knee jerk Medial foot Knee extensionAnkle inversionDorsiflexion

L5 HamstringsTibialis posterior

1st web space Hip abductionDorsiflexionGreat toe extension

S1 Achilles Lateral border of foot

Plantar flexionHip extension

Straight leg raising testBowstring testLasegue’s testSitting root testContralateral SLRTFemoral stretch test