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Brad 4th Ed Part 2 > Ch. 55 SCI > Flashcards

Ch. 55 SCI Flashcards

1
Q

Incidence of SCI by age

A

Lowest for < 15 yo
Highest for 16-30 yo
Average age of onset 40.2

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2
Q

Incidence of SCI by sex

A

80% male

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3
Q

Divorce rate in SCI

A

Increased in SCI in 1st 3 years post-injury compared to general pop

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4
Q

MCC of SCI in order

A

MVA
Falls
Violence
Sports

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5
Q

MCC of SCI in elderly

A

Falls

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6
Q

MCC of SCI in African Americans

A

Violence

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7
Q

MC time fore SCI

A

Weekends and Summer

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8
Q

MC level of plegia in order

A

Incomplete tetra
complete tetra
complete para
incomplete para

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9
Q

Predictors of mortality

A 
1st post-injury year
older
male
injured by violence
neuro complete
ventilator dependent
high neuro level
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10
Q

MCC of death

A 
Resp dz, esp PNA 
"other" heart disease
Infection/parasites
HTN/ischemic heart disease
Neoplasm
PE
GU dz
Suicide
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11
Q

SC terminates at level

A

L1-2

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12
Q

What does the posterior horns contain?

A

Cell bodies of sensory neurons

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13
Q

What does the anterior horn contain?

A

cell bodies of interneurons and motor neurons

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14
Q

Where is the gracilis located?

A

posterior medial column

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15
Q

What does the gracilis contain?

A

Fibers from T7-L5 dermatomes that real touch, vibration and position sense

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16
Q

Where is the cuneatus tract?

A

lateral posterior column rostral to T6

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17
Q

What does the cuneatus tract contain?

A

Dermatomes above T7 that relay touch, vibration, position sense

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18
Q

Where do the gracilis and cuneatus ascend?

A

Ipsilaterally to the medulla

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19
Q

What does the lateral spinothalamic tract contain?

A

Fibers that relay pain and temp sensation

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20
Q

Where does the spinothalamic tract ascend?

A

Contralaterally to the thalamus

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21
Q

Where is the lateral corticospinal tract?

A

Centrally and posterior in the lateral column

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22
Q

What does the corticospinal tract contain?

A

Fibers from motor cortex that are responsible for voluntary and reflex movement

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23
Q

Where does the corticospinal tract ascend?

A

90% ascend ipsilaterally and cross midline in the caudal medulla forming pyramidal decussations. 10% do not cross in medulla

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24
Q

What is Brown-Sequard synd?

A

Damage to one side of SC resulting in > ipsi weakness & position sense loss w/ contralateral pain & temp loss

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25
Q

What is an upper motor neuron?

A

corticospinal neuron

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26
Q

What is a lower motor neuron?

A

motor neuron that synapses in the SC & exits SC to innervate muscle

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27
Q

What is UMN synd?

A 
loss of voluntary movement
spasticity
hyperreflexia
clonus
Babinski's sign
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28
Q

What is conus medullaris synd?

A

Injury to sacral SC and lumbar nerve roots l/t areflexic bladder, bowel and lower limbs

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29
Q

What is Cauda Equina synd?

A

Injury to lumbosacral roots w/in spinal canal l/t arflexic bladder, bowel and lower limbs

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30
Q

What is spinal shock?

A

Transient suppression and gradual return of reflex activity below level of injury

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31
Q

Describe phase 1 of spinal shock

A

0-24 hrs post injury

Motor neuron hyperpolarization manifesting as hyporeflexia

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32
Q

Describe phase 2 of spinal shock

A

Days 1-3
Denervation super sensitivity and receptor upregulation
reflex return

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33
Q

Describe phase 3 of spinal shock

A

1-4 weeks post injury

interneuron synapse growth early hyperreflexia

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34
Q

Describe phase 4 of spinal shock

A

1-12 mo post injury
long axon synapse growth
late hyperreflexia

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35
Q

Where does the posterior spinal artery begin and supply?

A

Branch from vertebral a

suppl posterior 1/3 of SC

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36
Q

Where do the anterior spinal arteries begin and supply?

A

Branch from vertebral a
form single artery
supply anterior 2/3’s of SC

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37
Q

Where do the segmental radicular arteries travel?

A

from the aorta
through intervertebral foramina
divide into ant & post
anastomose w/ respective arteries

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38
Q

What is the artery of Adamkiewicz?

A

anterior radicular artery usually on left side that supplies T12-L2

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39
Q

Where does the artery of Adamkiewicz travel?

A

Divides into small ascending & large descending branches on anterior surface of SC. Descending branches anastomosic circule w/ terminal branches of posterior spinal arteries around the conus medullaris

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40
Q

What area of the SC is most prone to ischemia?

A

Anterior portion of T1-4 and T12-L2 as they are dependent on individual radicular arteries

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41
Q

What is the anterior cord syndrome?

A

Paraplegia w/ loss of pain & temp sensation w/ sparing of touch & position sense

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42
Q

MC location of fx or dislocation in the spine

A

T12 and L1 vertebrae

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43
Q

What is a Jefrerson fx?

A

Burst fx of atlas (C1)

caused by axial compression

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44
Q

What is a hangman’s fx?

A

Traumatic spondylolisthesis of the axis (C2)

caused by hyperextension & axial compression

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45
Q

What causes an odontoid fx?

A

Hyperflexion, hyperextensions or excessive lateral bending

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46
Q

What is a Chance fx?

A

Anterior wedge fracture of the vertebral body with horizontal fracture through posterior elements or distraction of facet joints and spinous processes

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47
Q

What causes a Chance fx?

A

Anterior force with hyperflexion

ex) passenger with lap belt but no cross body belt in a car accident

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48
Q

What is a clay shoveler’s fx?

A

avulusion fx of the SP of C6, C7 or T1 due to flexion w/ rotation

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49
Q

What is a flexion tear drop fx?

A

retropulsion of vertebral body into the spinal canal, detached from anterior fragment (teardrop)

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50
Q

What are flexion tear drop fx associated with?

A

incomplete anterior cord syndrome

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51
Q

What is central cord synd?

A

Cervical SCI d/t hyperext
sacral sparing
Weakness in UE>LE

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52
Q

Which is a more common cause of non-traumatic SCI, extradural or intradural tumors?

A

Extradural tumor (MC metastatic lesions)

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53
Q

What is an extradural tumor?

A

Arise from structures outside the dura, MC vertebral body

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54
Q

What the MC types of metastatic tumors to the spine?

A

Lung
Breast
Prostate
Kidney

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55
Q

What are the mech of metastasis to the spine?

A

Direct extension
Hemotogenous through Batson’s vertebral venous plexus
Valveless venous system draining through the thoracic, abdominal and pelvic viscera

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56
Q

What are primary spine tumors?

A 
Multiple myeloma
Ostoegenic sarcoma
Vertebral hemangioma
Chondrosarcoma
Chondroma
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57
Q

What are intradural space tumors?

A 
Ependmomas
Astrocytomas
Meningiomas
Schwannomas
Neurofibromas
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58
Q

Described the presentation of spinal tumors

A 
Pain worse in supine
Night sweats
Fevers
Unexplained weight loss
Anorexia
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59
Q

Treatment of acute SC compression by tumor

A

Steroids (dexamethasone) to dec inflam changes and prostaglandin production
Radiation
Surgery

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60
Q

Who is at risk for bacterial vertebral osteomyelitis?

A

IVDA
Immunocompromised
DM
Renal disease on HD

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61
Q

MC bacteria and location of vertebral osteomyelitis

A

Staph aureus

Lumbar spine

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62
Q

Clinic presentation of vertebral osteomyelitis

A

Spine pain
Fever
Neuro deficit
Elevated CRP, ESR

63
Q

What is Pott’s disease?

A

Mycobacterium tuberculosis to the spine

64
Q

What should be in the DDx of rapidly evolving myelopathy without history of trauma

A 
SLE
MS
Neuromyelitis optica
Paraneoplastic syndrome
Nutritional deficiency
Vascular insufficiency
Infection
Transverse myelitis
65
Q

What is transverse myelitis?

A

myelopathic process of unknown cause resulting in inflam of the SC

66
Q

How many tetraplegic ASIA A patients convert to ASIA D in 1 year

A

2-3%

67
Q

How man motor complete tetraplegic patients recover one motor level w/in 1 year of injur

A

30-80%

68
Q

What is the most important prognostic factor for single level motor recovery in complete tetraplegics?

A

Initial presence of nonfunctional strength grade 1 or 2 at that level

69
Q

What is a better sensory predictor of ambulation in an incomplete tetraplegic pt?

A

Presence of pinprick sensation near anus have >70% change of walking compared to light touch sensation

70
Q

What is recovery of lower limb function with paraplegia dependent on?

A

Level and completeness of injury

71
Q

What patient group has the best prognosis for ambulation in traumatic SCI?

A

Incomplete paraplegia

72
Q

What is the goal mean arterial pressure for acute SCI?

A

85 mmHg for 7 days

73
Q

What is neurogenic shock?

A

Hypotension and bradycardia due to sympathetic denervation

74
Q

How is neurogenic shock treated?

A

Intravascular volume repletion and vasopressors

75
Q

What is an ideal WC propulsive stroke?

A

Occurs at steady speed that maximizes handrim contact or push angle while keeping stroke frequency and force to a minimum

76
Q

What neurologic level of injuries cannot operate a car?

A

C1-4

77
Q

What are the leading causes of death in SCI?

A 
Pulmonary complications
Atelectasis
Pneumonia
Respirator failure
PE
78
Q

What is a Passy-Muir valve?

A

One-way airflow valve put in line with ventilator tubing to vocalize with exhalation. Used only with a deflated cuff

79
Q

When is the risk greatest for DVT in SCI?

A

Between 7-10 days after injury

80
Q

How long should motor incomplete SCI patients be on DVT ppx?

A

Until time of discharge

81
Q

How long should uncomplicated SCI patients be on DVT ppx?

A

8 weeks

82
Q

How long should motor complete SCI patients with additional risk factors be on DVT ppx?

A

12 weeks

83
Q

Which patients are affected by Autonomic dysreflexia?

A

T6 or above which is above major splanchinc outflow

84
Q

What are the symptoms of AD?

A 
Pounding headache
Systolic and diastolic HTN
Profuse flushing of face, beck and shoudlers
Nasal congestion
Pupillary dilation
Bradycardia
85
Q

Causes of AD

A 
Distended bladder
Fecal impaction
Ingrown toe nails
Labor &amp; delivery
Orgasm
Surgery
86
Q

Tx of AD

A 
Sit patient up
Remove restrictive clothing or garments
BP monitored ~2-5 minutes
Evacuation of bladder
Remove fecal impaction
Nitro paste or nifedipeine
Monitor BP for 2 hr after resolution
87
Q

What SCI level can have impaired thermal regulation?

A

T6 and above due to loss of supraspinal control

88
Q

What is poikilothermia?

A

Inability to regulate core body temperature. Have higher body temp in hot environments and lower temp in cold

89
Q

When is primary bone resorption most prominent in SCI?

A

First 7 months after SCI

90
Q

What are markers of bone resorption and when should they be monitored?

A

Urinary calcium and N-telopeptide elevated 8-12 weeks after SCI

91
Q

What are markers of bone turnover?

A

Parathyroid hormone & 25-hydroxyvitamin D low after SCI despite normal Ca

92
Q

What is a marker of bone formation?

A

Serum ostocalcin

Low after injury and inc after 6 mo

93
Q

What are risk factors for hypercalcemia in SCI?

A 
Children/adolescents
Recent injury
Male
complete injury
Tetraplegia
Dehydration
Prolonged immobilization
94
Q

What is treatment of hypercalcemia?

A

IVF
Diuretics
Bisphosphonates
Calcitonin

95
Q

How is secondary hyperparathyroidism treated?

A

Ca & vitamin D supplmentation

96
Q

Where is the greatest risk of loss of bone mineral density?

A

Lower limbs below level of lesion great from proximal to distal

97
Q

What should be spared in loss of bone mineral density?

A

weight bearing vertebral column. look for secondary causes of osteoporosis

98
Q

What can help protect against bone loss in SCI?

A

Passive weight-bearing in standing frame
FES cycle ergometry
Oral bisphosphonate
Ca & vitamin D supplementation

99
Q

What are factors that contribute to dysphagia in cervical SCI?

A

Immobilization of c-spine
ST swelling
nerve trauma after anterior spine surgery
Limited laryngeal elevation by trach tubing

100
Q

How long and what medications should be given in SCI for GI ppx?

A

histamine-2 receptor antagonist or PPI for 3 mo post-injury

101
Q

What is a GI complication associated with high paraplegia?

A

Gallblladder dz and pancreatitis d/t dec SNS stimulation

102
Q

When does adynamic ileus typically occur in SCI?

A

1-2 days post injury d/t loss of SNS and PNS tone during spinal shock
Resolves 2-3 days with bowel rest

103
Q

What does the vagus nerve innervate?

A

PNS innervation to Esophagus to splenic flexture of colon

modulates peristalsis

104
Q

What does pelvic nerve innervate?

A

S2-4 PNS innervation to descending colon to rectum

105
Q

What does the somatic pudenal nerve innervate?

A

External anal sphincter and pelvic floor mucles

106
Q

What is a reflexic or UMN bowel?

A

SCI above sacral segement
defecation cannot be initiated by voluntary relaxation of external sphincter
Reflex mediated colonic peristalsis

107
Q

What is an areflexic or LMN bowel?

A

Destruction of anterior horn cells of S2-4
no reflex-mediated colonic peristalsis
slow stool propulsion by myenteric plexus
Atonic anal sphincter prone to stool leakage

108
Q

What does PNS innervation of the bladder control?

A

modulates contraction of the urinary bladder with opening of bladder neck to allow voiding
Pelvic splanchnic nerve S2-4

109
Q

What does SNS innervation of the bladder control?

A

Relaxation of bladder body and narrowing of neck to inhibit voiding
Hypogastric nerves T11-L2

110
Q

What does the pudendal nerve control in bladder?

A

External urinary sphincter

S2-4

111
Q

What is a UMN bladder?

A

Unable to voluntary contract
Reflex voiding possible
Damage above sacral segments

112
Q

What is a LMN bladder?

A

Damage at S2-4
No reflex voiding
Bladder atonic and prone to leakage

113
Q

What is detrusor-sphincter dyssynergia?

A

simultaneous reflex contractile activity of bladder and external urinary sphincter

114
Q

What is the targeted cath volumes for I/O cathing?

A

500 ml for total fluid intake of 2,000 ml/day

115
Q

What medication can help to inhibit voiding between I/O cath?

A

Anticholinergics

Botox

116
Q

What is an augmentation cystoplasty?

A

Adding portion of small intestine to bladder to create high capacity low pressure reservoid

117
Q

What is reflex voiding?

A

Bladder tapping in males to stimulate urination

118
Q

What are risks of reflex voiding?

A 
high PVR
Vesicoureteral reflux
Hydronephrosis
Renal failure
UTI
Bladder stone formation
119
Q

What are risks associated with indwelling catheter?

A 
UTI
Bladder stone formation
Epidiymitis
Prostatitis
Hypospadias
Bladder cancer
120
Q

What can indicated at UTI in a SCI patient?

A 
Fever
Spontaneous voids between caths
Hematuria
AD
Increased spasticity
Foul smelling urine
Malaise
121
Q

What is needed to generate erection and lubrication psychogenically in SCI?

A

Some degree of LT and PP sensation in T11-L2 dermatomes

Bulbocavernous reflex

122
Q

In what patients are orgasms unlikely to occur?

A

Absent bulbocavernous reflex
Absent anocutaneous reflex
No sensation S4-5

123
Q

What is first line therapy for erectile dysfunction?

A

Type phosphodiesterase inhibitors

124
Q

What has been shown to decrease sperm quality?

A

Deteriorates 2 weeks post SCI
Ejaculatory frequency >1/week
Reflex bladder emptying compared to I/O cath

125
Q

When can women with SCI experience amenorrhea?

A

Post injury up to 4 months

126
Q

What functional complications are associated with pregnancy in SCI?

A 
Difficult transfers
WC propulsion
Respiratory compromise
Self cathing
Labor increasing spasticity
Not recognizing labor in Patients with T10 and above injury
127
Q

What is the distribution of pressure ulcers in acute hospitalization for SCI?

A 
Sacrum 39%
Calcaneus 13%
Ischium 8%
Occiput 6%
Scapula 5%
128
Q

What is the distribution of pressure ulcers 2 year after SCI?

A 
Ischium 31%
Trochanter 26%
Sacrum 18%
Calcaneus 5%
Malleolus 4%
129
Q

What is autolysis?

A

Moisture retentive barrier applied to superficial ulcer causing endogenous enzyme degradation of nectrotic tissue

130
Q

What is Chemical debridement?

A

Application of commercially available enzymes to selectively degrade necrotic tissue

131
Q

What is sharp debridement?

A

Excision o f necrotic tissue with sharp instrument

132
Q

What is mechanical debridement?

A

Hydrotherapy or application of wet to dry dressings

133
Q

What are the nutritional requirements in SCI with pressure ulcers?

A

25 kcal/kg/day

1.5-2g protein/kg/day

134
Q

What is nociceptive pain?

A

Pain arising from activation of peripheral nerve endings or sensory receptors encoding noxious stimuli

135
Q

What is neuropathic pain?

A

Pain arising due to lesion or disease affecting somatosensory system

136
Q

What is At-level SCI pain?

A

neuropathic pain in segmental pattern in dermatomes at NLI and 3 levels below but not lower

137
Q

What is Below-level SCI pain?

A

Neuropathic pain >3 dermatome levels below NLI d/t lesion of SC
Typically pain in region rather than dermatomal

138
Q

Tx of At-level and Below-level SCI pain

A 
Gabapentin
Pregabalin
Tramadol
Amitriptyline
SSRI or SNRI
Oipids
Itnrathecal ziconotide (neurotoxin)
Desensitization
CBT
139
Q

What is the 1st line tx of spinal spasticity?

A

Oral baclofen

GABA analog that binds to GABA B receptors, main inhibitory of the SC

140
Q

What is the maximum recommended dose of baclofen and side effects?

A

80 mg/day
Fatigue
Dizziness
Seizures

141
Q

What medications bind to GABA A receptors?

A

Benzodiasepines

142
Q

What is the MOA of tizanidine and its SE?

A

Central alpha2-adrenergic agonist
Sedation
Liver function ABN

143
Q

What is the MOA and SE of dantrolene?

A

Inhibits release of calcium from muscle sarcoplasmic reticulum inhibiting excitation-contraction coupling in muscle
SE: Hepatoxicity

144
Q

What is the MOA of botox?

A

Binds to receptor sites on presynaptic nerve terminal at NMJ inhibiting release of Ach

145
Q

When is intrathecal baclofen used?

A

Severe generalized spasticity

146
Q

What is Heterotopic ossification?

A

True bone in extraskeletal etopic sites

localized warm swelling with reduced ROM

147
Q

When does HO develop in SCI and what there the MC locations?

A 
W/in 4 mo of injury
Hips (90%0
Knees
Shoulders
Elbows
148
Q

How is HO diagnosed?

A

Elevated alkaline phosphatase
Bone scan
Xray positive when HO matures

149
Q

Tx of HO

A

IV etidronate 300 mg/day for 3 days
Oral etidronate 20 mg/kg/day for 6 months
Surgical removal once HO mature

150
Q

What are causes of SCI in children?

A

Lap belt injuries
Birth injury
Child abuse
Carnioverebral junction injury (RA, Down syndrome, skeletal dysplasia)

151
Q

What is the management of bladder and bowel emptying in children with SCI?

A

Infant: diaper
3-4 yo: I/O cath
5-7 yo: self caths
2-4 yo: bowel program

152
Q

What are common ortho problems in children with SCI?

A

Hip instablity

Scoliosis

153
Q

What are some characteristics of SCI in elderly?

A

Incomplete injury MC
Cervical stenosis
Women >men
Inc comorbidities & complications

Brad 4th Ed Part 2 (28 decks)

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