2: Clinical Presentations Flashcards
What are the three considerations for motor and sensory function?
- Level of injury
- Complete or incomplete
- Clinical syndrome
Is spastic hypertonia related to UMN or LMN damage?
UMN
When will you see spastic hypertonia?
After spinal shock resolves
Where will you see spastic hypertonia?
Below the level of the injury
What symptoms are related to spastic hypertonia?
- Spasticity
- Hyperreflexia
- Clonus
- Hypertonia
- Muscle spasm
How is spasticity managed?
Stretch, exercise, electrotherapy, heat, massage, vibration therapy, medication
What are the six characteristics of autonomic dysfunction?
- Spinal shock
- Neurogenic shock
- Bradyarrhythmia
- Hypotension
- Orthostatic hypotension
- Impaired cardiovascular reflexes
What is the definition of spinal shock?
Body’s reaction to abrupt withdrawal of connection between higher centers and spinal cord
What are the symptoms of spinal shock?
- Absent reflexes
- Flaccid tone
- Absent sensation below injury
- No sweating or piloerrection
- Hypothermia
What is the duration of spinal shock?
Typically 24 hours – can last weeks
When will reflexes return following spinal shock?
Gradual return in 1-3 days
If there is a positive bulbocavernosus reflex, what is the prognosis?
Good
Injuries above what level are at risk of neurogenic shock?
T6
Why does neurogenic shock occur?
Sympathetic output to the heart is lacking, which results in parasympathetic input being unopposed
What is BP with neurogenic shock?
Systolic < 90 mmHg
What is HR with neurogenic shock?
< 50 bpm
What is the result of neurogenic shock?
Bradyarrhythmia, AV conduction block, hypotension
What is orthostatic hypotension?
Decrease in BP when assuming upright posture from supine
What change in systolic and diastolic BP are indicative of orthostatic hypotension?
Systolic drop > 20 mmHg
Diastolic drop > 10 mmHg
What are the two causes of orthostatic hypotension?
- Disrupted balance between sympathetic and parasympathetic input
- Lack of or decrease in active muscle contraction and prolonged time in bed
What % of people with SCI experience orthostatic hypotension?
75% in the acute stages
What are the symptoms of orthostatic hypotension?
Blurred vision, dizziness, ringing in ears, light headedness, nausea, dyspnea, fainting
What are treatment considerations for orthostatic hypotension?
Adapt gradually to vertical, compressive stockings, ACE wraps, abdominal binder, medication
What is autonomic dysreflexia?
Acute onset of autonomic activity due to noxious stimuli below the level of injury
What LOI can experience autonomic dysreflexia?
Above T6, more likely if it is a complete injury
What is the response of HR and BP with autonomic dysreflexia?
Rise in systolic BP by 20-30 mmHg and decreased HR
What are symptoms of autonomic dysreflexia?
Pounding headache, flushing, sweating above LOI, vasoconstriction below LOI, anxiety, restlessness, blurred vision, spots in visual field, muscle spasm
What is the cause of autonomic dysreflexia?
Noxious stimuli
What is the treatment for autonomic dysreflexia?
Elevate head, identify and remove the noxious stimuli, prophylactic medication
What are symptoms of autonomic dysreflexia in children?
Sleepy, irritable, crying, different BP ranges
What are three other likely cardiovascular impairments with SCI?
- Reduced exercise tolerance
- Lower stroke volume
- Reduced cardiac output
With cervical SCI, what is the average systolic BP when in supine?
110 mmHg
With cervical SCI, what is the average systolic BP when seated?
100 mmHg
What cardiovascular impairments should you be mindful of with cervical SCI?
- Lower BP values
- Lower peak HR
- Post exercise hypotension
What symptoms will you see with DVT?
- Vasodilation
- Absent or reduced LE muscle function
- Immobility
What are risk factors for DVT in the SCI population?
- Male
- Flaccid paralysis
- Complete lesions
- Paraplegia
What are symptoms of PE in the SCI population?
Chest pain, SOB, tachycardia, sweating, apprehension, fever, cough
What is the most common cause of of death in people who live 30+ years with a SCI?
Cardiovascular disease
Why are SCI patients more likely to develop cardiovascular complications?
Sedentary lifestyle, higher percentage of body fat, lipid abnormalities, altered glucose metabolism, insulin resistance, diabetes
What are the two pediatric cardiovascular considerations?
- Higher BP compared to adults
- High risk for developing obesity
What are the four risk factors for respiratory complications?
- Higher LOI
- Increased age
- Thoracic trauma
- Prior history of respiratory disease, aspiration, smoking
What pulmonary impairments are most common in cervical LOI?
- Pneumonia
- Ventilatory failture
- Atelectasis
What pulmonary impairments are most common in thoracic LOI?
- Pleural effusion
- Atelectasis
- Pneumothorax/hemothorax
What LOI will require mechanical ventilation?
C1-C2
What are three pulmonary effects of higher lesion?
- Elevated resting bronchomotor tone
- Loss of expiratory reserves
- No cough effectiveness
What happens to rib motion with higher LOI?
Paradoxical rib motion - decrease as time passes
What sleep disorder is common in higher level cervical SCI?
Sleep apnea
What are the pulmonary impairments with lower thoracic/lumbar SCI?
Most muscles of inhalation are intact, but can have impaired function of muscles of forces exhalation
What lower LOIs will will have decreased cough effectiveness and decreased rib stability?
T1-T5
Why does SCI result in thermoregulation complications?
Interruption in communication between the spinal cord and the hypothalamus
What systems control temperature?
Sympathetic and somatic nervous systems
What thermoregulation impairment will happen initially with SCI?
Hypothermia and peripheral vasodilation
How will thermoregulation impairments change over time with SCI?
Will have hyperthermia below the LOW due to lack of sympathetic control of sweat glands - exercise induced
What is osteoporosis?
Reduction in bone mass due to loss of calcium and collagen
When do SCI patients see the greatest reduction in bone mass?
The first few months following the injury
Where will osteoporosis develop in a patient with SCI?
Extremities below the LOI, more severe in LE
What does osteoporosis increase the likelihood of in SCI patients?
Fracture and kidney/bladder stones
What population is at higher risk of fractures related to osteoporosis after SCI?
Motor complete, paraplegia, white, greater time since injury, advanced age, female, lower BMI
What is heterotopic ossification?
Formation of new bone within the soft tissue
What are the four causes of heterotopic ossification?
- Tissue hypoxia
- Abnormal Ca metabolism
- Microtrauma, vigorous stretching
- Local pressure
Where will heterotopic ossification develop?
Always below the LOI, most likely large proximal joints
What are symptoms of heterotopic ossification?
Pain, erythema, swelling, decreased ROM, local warmth
What are causes of DJD?
Mechanical stress, muscle imbalance, spasticity or flaccidity, improper ADL, incorrect exercise, pre-existing conditions
What are complications associated with DJD?
Bursitis, tendonitis, arthritis, impingement
What are the two types of nociceptive pain?
Musculoskeletal and visceral
What is neuropathic pain?
Damage or impingement of nerve roots of SC at or near the LOI
What is syringomyelia?
Formation of cyst or cavity within the spinal cord
What happens to syringomyelia over time?
Expands due to pressure in the epidural veins and compresses the spinal cord
What symptoms are associated with syringomyelia?
Pain, sensory loss, weakness
What are causes of genitourinary complications with SCI?
Abnormal bladder function requiring prolonged use of indwelling catheter, intermittent catheterization, improper management
What are common urinary tract complications associated with SCI?
Urinary retention, bladder infection, reflux or urine into ureters
What can urinary tract infection result in?
Kidney/bladder stones, hydronephrosis, pyelonephritis, kidney failure, septicemia, death
What are the most common GI complications?
GI bleed and stress ulcers in the stomach and duodenum
When are GI bleeds and stress ulcers likely to develop?
Within the acute phase following SCI
What are causes of GI complications in SCI?
Shock, emotional stress, circulating catecholamines, steroids, mechanical ventilation, unopposed parasympathetic input to stomach
What GI complications are associated with spinal shock?
Paralytic ileus, gastric dilation
What are other GI complications that are associated with SCI?
Fecal impaction, bowel obstruction, superior mesenteric artery syndrome, pancreatitis, esophagitis, gallstone disease, chronic constipation, hemorrhoids
When will a patient with SCI have a neurogenic bowel and bladder?
Lesions above the conus medullaris and sacral segments
Describe neurogenic bladder
Contracts and reflexively empties in response to certain level of filling pressure
What muscle is hyperactive with neurogenic bladder?
Detrusor - increased tone of sphincter
What happens to the detrusor muscle with neurogenic bladder?
Contraction with small urine volumes, lack of coordination between detrusor and sphincters
Describe a neurogenic bowel
Reflex defecation when rectum fills with stool
When will a patient with SCI have a flaccid bladder and bowel?
Lesion of sacral segments or conus medullaris
What is a flaccid bladder?
No reflex action of detrusor muscle with inability to store urine
What is an areflexive bladder?
Excessive expansion
What is a flaccid bowel?
Bowel does not reflexively empty, feces impacted, incontinence due to external sphincter flaccidity
How will SCI affect male fertility?
Likely infertile
What is the state of the UMN sexual response in males with SCI?
- Intact reflexogenic response
- Impaired psychogenic response
What is the state of the LMN sexual response in males with SCI?
- Impaired reflexogenic response
- Preserved psychogenic response
How will SCI affect female fertility?
Unchanged
What is the state of the UMN sexual response in females with SCI?
- Intact reflexogenic response
- Impaired psychogenic response
What is the state of the LMN sexual response in females with SCI?
- Impaired reflexogenic response
- Preserved psychogenic response
How is menstruation effected by SCI?
Interrupted 4-5 months
What is the most common congenital anomaly associated with myelomeningocele?
Arnold Chiari
What are four NMR considerations for myeloningocele?
- Arnold Chiari
- Hydrocephalus
- Hydromyelia
- Tethered cord
What are the effects of MSK impairments associated with myelomeningocele?
Positioning, body image, weightbearing, ADLs, energy expenditure, mobility, joint contractures, pathologic fractures
What are common spinal deformities and postural problems associated with myelomeningocele?
Forward head, rounded shoulders, kyphosis, scoliosis, excessive lordosis, anterior pelvic tilt
What are hip deformities associated with myelomeningocele?
In-toeing, out-toeing, windswept, hip flexion, contractures, hip dysplasia
What are knee deformities associated with myelomeningocele?
Tibial torsion, flexion contractures
What are foot and ankle deformities associated with myelomeningocele?
Equinus, club foot, calcaneal deformity, cavo-varus deformity, plano-calgus deformity
What are four MSK pediatric considerations?
- Hip subluxation/dislocation
- Fracture is osteopenic extremities
- NMR scoliosis
- Pseudo hip flexion contractures if flaccid
What children with SCI develop scoliosis?
Almost all children, 67% will progress to require fusion
What are four components of initial management of SCI in acute care?
- ABC (airway, breathing, circulation)
- Management of life threatening injuries
- Spinal stabilization
- Transportation
Why are spine boards for infants and toddlers modified?
Allow for neutral alignment of c-spine
How are spine boards modified for infants and toddlers?
Occipital cut out or elevating torso
What radiographs are indicated following SCI?
Whole spine - C1 to sacral vertebrae
When is MRI indicated for children with SCI?
All children
What is there a high incidence of in MRI’s of children < 10?
SCIWORA (radiologic abnormalities)
What % of children will have multiple, non contiguous fractures?
30%
What is monitored in the ICU following SCI?
Respiratory status, organ function, cardiovascular status, bowel and bladder management, integument
What is acute pharmacologic management for SCI?
High dose steroids and other medications for secondary complications
How are fractures stabilized?
Open reduction, or closed reduction with traction devices and immobilization
When is surgical decompression and stabilization recommended?
Within 24 hours
When is immobilization indicated?
Both open and closed reduction
What orthotics can be used for immobilization?
Halo, Minerva, Miami J collar, Jewett, custom body jacket
When does cervical traction have increased risk?
Increased risk in children < 12 when compared to adults
What type of traction is preferred in children?
Halo
How is halo traction modified in children?
Increased number of pins to decrease the torque on each pin
