3.2 - Neuro PPT - Spinal Cord Injuries Flashcards
Week 3, Tuesday
Describe the UE & LE dermatomes
Describe the UE & LE myotoms
How is the level of SCI determined?
Named for the lowest functional level
“Functional” =
- Normal sensory
- MMT 3/5 and the immediately proximal level is at 5/5
What factors are directly correlated to the potential for recovery?
Level of lesion
Completeness of the injury (complete vs incomplete)
Preservation of pinprick sensation (due to proximity of spinothalamic & corticospinal tracts)
Describe the function of each of the primary spinal cord pathways
DCML
Spinothalamic Tract (ALS)
Lateral Corticospinal tract
DCML - fine touch & proprioception
Spinothalamic - pain & temp
LCST - primary motor pathway (motor for UEs & LEs)
Describe the ASIA Grading Scale
A) No motor or sensory function below the level of lesion
B) Sensory function preserved below the level of the lesion (atleast the sacral segments)
C) Sensory function + motor function <3 in most key muscles
D) Sensory function + motor function >3 in most key muscles
E) Motor and sensory function is normal
Describe spinal shock syndrome
Occurs acutely after a SCI
Dissipates after ~6-12 days
SCI -> acute inflammation & edema -> immediate, temporary loss of sensation, reflexes, & motor function below the lesion; b/b flaccidity
Need to weight until after this to accurately determine level of lesion and prognosis
Describe autonomic dysreflexia
Most common in those w/ SCI at or above T6
Noxious stimuli below the level of the lesion -> activation of sympathetic NS
SNS signal isn’t able to transmit up the spinal cord & be regulated by the CNS –> drastic SNS response below the level of the lesion
-> Increased BP
Increased BP detected by carotid baroreceptors –> activate PNS above the level of the lesion
Common triggers:
- Full bladder
- Pressure injury / area
- Fecal impaction
Describe the s/sx of autonomic dysreflexia
Severe & rapid elevated BP
Headache
Bradycardia
Sweating
Flushed Face
Distended neck veins
Describe the management if autonomic dysreflexia is suspected
Life-threatening!!
1) Sit patient upright
2) Remove noxious stimulus
3) Call EMS
“If the head goes red…”?
“If the head goes pale…”?
AD: if the head goes red, raise the head
OH: if the head goes pale, raise the tail
A patient displays autonomic dysreflexia and loses consciousness. What’s the next step?
Activate EMS
Describe Brown Sequard syndrome and it’s clinical presentation
Lesion through one half (R or L) of the spinal cord
Loss of fine touch, proprioception, and motor function ipsilateral to the lesion (DCML, LCST)
Loss of pain & temp sensation contralateral to the lesion (ALS)
Describe central cord syndrome
Clinical presentation
MOI
Known as “Walking SCI”
MOI: hyperextension injury (most often in the cervical spine)
Clinical Presentation:
- UEs affected > LEs
- Sensory & motor deficits
Describe Anterior Cord Syndrome
MOI
Clinical Presentation
MOI: Hyperflexion injury; CVA involving anterior spinal artery
Clinical Presentation:
- Loss of pain & temp, motor function below lesion (ALS, LCST)
- Preservation of fine touch & proprioception
At what spinal level does micturition control arise from?
S2-4
Describe how the lesion location can impact the clinical presentation of a bladder following a SCI
Lesion to S2-4 above conus medularis (at L1 vertebral level) –> develop a spastic / hypereflexic bladder
- Mimics an UMN lesion
- Reflex arc intact
- Bladder reflexively empties w/ adequate filling pressure
Lesion to S2-4 below conus medulllaris (below L1 vertebral level) –> develop a flaccid / areflexic bladder
- Mimics a LMN lesion
Describe the management of a spastic vs flaccid bladder
Both require intermittent catheterization initially
Spastic bladder - managed w/ suprapubic tapping to initiate bladder reflex
Flaccid bladder - managed w/ catheter or Valsalva maneuver straining
Describe how the location of the lesion can impact the bowel following a SCI
Bowel function controlled by S2-4
Lesion to S2-4 above the conus medullaris (L1) –> spastic / reflexic bowel
Lesion to S2-4 below the conus medullaris (l1) –> flaccid / areflexive bowel
Describe the management of a spastic vs flaccid bowel
Spastic bowel - reflexive defecation when rectum fills; digital stimulation
Flaccid bowel - manual evacuation; gentle Valsalva maneuver
Describe how a therapist can examine the strength of the diaphragm and intercostal muscles through observation
Normal: epigastric rise & chest wall expansion
Paradoxical:
- Occurs in pts w/ cervical or high thoracic SCI
- Upper rib cage moves inward during inspiration
- Decreased activity of the external intercostals & abdominal muscles -> diaphragm pull the rib cage down when it contracts and descends
How often should pressure-releif maneuvers be performed for individuals w/ SCI?
What may this include?
Every 15 min to prevent skin breakdown
Push-up maneuver
Leaning sideways
Leaning forward >45 deg
Tilt-in-space >65 deg
Describe the ROM considerations for the following:
Hamstring Length
Hand
Hamstring SLR to 100 deg
- Permits functional activities in long-sitting
- Do NOT overstretch
Hand:
- ‘Intrinsic-plus position’ - wrist in slight extension, MCPs in 90 deg flx, IP in extension
- Maintains tenodesis grip control
Describe considerations for improving tolerance to upright positioning following a SCI
Gradually increase angle of upright sitting / posture
Use abdominal binder
Use elastic compression stockings
Slow acclimation
What should be down if symptoms of orthostatic hypotension occur?
Bring patient immediately to supine or Trendelenburg position
Allow symptoms to completely subside before potentially continuing treatment at a lesser degree
Briefly describe how to communicate to individuals w/ a SCI about their expected prognosis
Be realistic
Provide a clear picture of costs / benefits of ambulation training
Describe the expected prognosis for function for each of the following SCI levels
C1-4
C5
C6
C7
C8
T1-T12
L1-3
L4-S1
C1-4: likely need mechanical assistance for breathing; dependent for ADLs; w/c motorized w/ sip/puff controls, head, chin, or tongue
C5: Require set-up (Mod I), dependent for transfers, w/c power w/ joystick, manual w/c possible w/ plastic-coated rimes & extensions, electronic tilt/recline, driving possible w/ modification
C6: some set-up required, but mostly independent, manual w/c w/ modifications, transfers w/ slide board, driving w/ adaptive equipment
C7: Independent w/ ADLs, manual w/c, manual pressure relief
C8: with full wrist/elbow control & most finger control, become more independent
T1-T12: independent or modified Independent
L1-3: Hip flexion & knee extension possible - ambulate w/ HKAFO or KAFO (AFO possible)
L4-S1: Full ambulation, possibly needing AFO or assistive device
Describe how rolling can be achieved following a SCI
Flexion of head and neck; BIL symmetrical rocking of the UEs
At what level can transfers be performed independently?
C6
Describe the head-hips relationship
Head moves one way, hips move the opposite
Describe the appropriate way to propel a w/c
Longer pushing strokes are most efficient
How can the w/c be modified to make a wheelie easier?
To make the w/c less “tippy”?
Shift the axle anteriorly –> makes wheelie easier
Shift the axle posteriorly –> makes the w/c less tippy
