3.2 - Neuro PPT - Spinal Cord Injuries

Question 1

Describe the UE & LE dermatomes

Question 2

Describe the UE & LE myotoms

Question 3

How is the level of SCI determined?

Answer 3

Named for the lowest functional level

“Functional” =
- Normal sensory
- MMT 3/5 and the immediately proximal level is at 5/5

Question 4

What factors are directly correlated to the potential for recovery?

Answer 4

Level of lesion
Completeness of the injury (complete vs incomplete)
Preservation of pinprick sensation (due to proximity of spinothalamic & corticospinal tracts)

Question 5

Describe the function of each of the primary spinal cord pathways

DCML
Spinothalamic Tract (ALS)
Lateral Corticospinal tract

Answer 5

DCML - fine touch & proprioception
Spinothalamic - pain & temp
LCST - primary motor pathway (motor for UEs & LEs)

Question 6

Describe the ASIA Grading Scale

Answer 6

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

Question 7

Describe spinal shock syndrome

Answer 7

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

Question 8

Describe autonomic dysreflexia

Answer 8

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

Question 9

Describe the s/sx of autonomic dysreflexia

Answer 9

Severe & rapid elevated BP
Headache
Bradycardia
Sweating
Flushed Face
Distended neck veins

Question 10

Describe the management if autonomic dysreflexia is suspected

Answer 10

Life-threatening!!

1) Sit patient upright
2) Remove noxious stimulus
3) Call EMS

Question 11

“If the head goes red…”?

“If the head goes pale…”?

Answer 11

AD: if the head goes red, raise the head

OH: if the head goes pale, raise the tail

Question 12

A patient displays autonomic dysreflexia and loses consciousness. What’s the next step?

Answer 12

Activate EMS

Question 13

Describe Brown Sequard syndrome and it’s clinical presentation

Answer 13

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)

Question 14

Describe central cord syndrome

Clinical presentation
MOI

Answer 14

Known as “Walking SCI”

MOI: hyperextension injury (most often in the cervical spine)

Clinical Presentation:
- UEs affected > LEs
- Sensory & motor deficits

Question 15

Describe Anterior Cord Syndrome

MOI
Clinical Presentation

Answer 15

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

Question 16

At what spinal level does micturition control arise from?

Answer 16

S2-4

Question 17

Describe how the lesion location can impact the clinical presentation of a bladder following a SCI

Answer 17

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

Question 18

Describe the management of a spastic vs flaccid bladder

Answer 18

Both require intermittent catheterization initially

Spastic bladder - managed w/ suprapubic tapping to initiate bladder reflex

Flaccid bladder - managed w/ catheter or Valsalva maneuver straining

Question 19

Describe how the location of the lesion can impact the bowel following a SCI

Answer 19

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

Question 20

Describe the management of a spastic vs flaccid bowel

Answer 20

Spastic bowel - reflexive defecation when rectum fills; digital stimulation

Flaccid bowel - manual evacuation; gentle Valsalva maneuver

Question 21

Describe how a therapist can examine the strength of the diaphragm and intercostal muscles through observation

Answer 21

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

Question 22

How often should pressure-releif maneuvers be performed for individuals w/ SCI?

What may this include?

Answer 22

Every 15 min to prevent skin breakdown

Push-up maneuver
Leaning sideways
Leaning forward >45 deg
Tilt-in-space >65 deg

Question 23

Describe the ROM considerations for the following:

Hamstring Length
Hand

Answer 23

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

Question 24

Describe considerations for improving tolerance to upright positioning following a SCI

Answer 24

Gradually increase angle of upright sitting / posture
Use abdominal binder
Use elastic compression stockings
Slow acclimation

Question 25

What should be down if symptoms of orthostatic hypotension occur?

Answer 25

Bring patient immediately to supine or Trendelenburg position

Allow symptoms to completely subside before potentially continuing treatment at a lesser degree

Question 26

Briefly describe how to communicate to individuals w/ a SCI about their expected prognosis

Answer 26

Be realistic
Provide a clear picture of costs / benefits of ambulation training

Question 27

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

Answer 27

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

Question 28

Describe how rolling can be achieved following a SCI

Answer 28

Flexion of head and neck; BIL symmetrical rocking of the UEs

Question 29

At what level can transfers be performed independently?

Answer 29

C6

Question 30

Describe the head-hips relationship

Answer 30

Head moves one way, hips move the opposite

Question 31

Describe the appropriate way to propel a w/c

Answer 31

Longer pushing strokes are most efficient

Question 32

How can the w/c be modified to make a wheelie easier?

To make the w/c less “tippy”?

Answer 32

Shift the axle anteriorly –> makes wheelie easier

Shift the axle posteriorly –> makes the w/c less tippy