Clinical Assessment of the Spine and Spinal Cord 2 Flashcards
Additional Sensory Testing
two-point discrimination
Double simultaneous stimulation (looking for extinction)
Testing higher order (cortical) sensory processing:
Graphesthesia
Stereognosis- ability to recognize based on texture, size, temperature
Clinical Assessment of Motor Function
Inspection Observation Palpation Individual muscle group testing pronator drift fine motor movements
The abdominal reflex (special)
elicited by drawing a line away from the umbilicus along the diagonals of the 4 abdominal quadrants. A normal reflex draws the umbilicus toward the direction of the line that is drawn.
cremasteric reflex (special)
elicited by drawing a line along the medial thigh and watching the movement of the scrotum in the male. A normal reflex results in elevation of the ipsilateral testis.
anal wink reflex (special)
elicited by gently stroking the perianal skin with a safety pin. It results in puckering of the rectal orifice owing to contraction of the corrugator-cutis-ani muscle.
- Complete Cord Transection
Tracts: All ascending sensory & descending motor/autonomic tracts.
Deficit: Sensory + motor levels below lesion; may also have root signs at site.
Note: Spinal shock followed by UMN signs.
- Central Lesions:
Tracts:Initially involve crossing ST
E.g.s: Syringomyelia (fluid-filled cavity in cord), ependymomas, cord contusion.
Deficit: PP/Temp loss at level of lesion, with
sparing of position sensation.
Note: Cape-like distribution if in C-spine.
- Posterior Column Syndrome:
Tracts: PC
E.g.s.Tabes dorsalis (form of neurosyphilis)
Deficit: Bilateral loss of position & vibration
sensation
- Combined Anterior Horn Cell-Pyramidal Tract Syndrome:
Tracts:CS and LMN cells in cord.
E.g.s:Amyotrophic lateral sclerosis (Lou Gehrig’s disease)
Deficit: Loss of bilateral strength.
Note: Fasciculations, atrophy, ↑ or ↓DTR,
normal sensation
- Brown-Sequard (Hemi-Section):
Tracts: Crossed ST + uncrossed PC + crossed CS
E.g.: Compression by herniated discs, tumor extramedullary abscess, etc.
Deficit: Below lesion, loss of
CL PP/Temp
IL Position
IL strength.
- Posterolateral Column Syndrome:
Tracts: PC + CS
E.g.: B12 deficiency (aka subacute combined degeneration)
Deficit: Bilateral loss of position & vibration, and strength.
- Anterior Horn Cell Syndrome:
Tracts: None - lower motor neuron (cell).
E.g.: Spinal muscular atrophy, polio virus
Deficit: Bilateral loss of strength.
Note: Fasciculations, ↓ tone + ↓ DTRs
with sparing of all sensory tracts and bladder functions.
- Anterior Spinal Artery Occlusion:
Tracts: ST + CS
E.g.: Anterior spinal artery occlusion.
Deficit: Bilateral loss of strength + PP/Temp,
with sparing position sense.
- Pyramidal Tract Syndrome:
Tracts: CS
E.g.: Primary lateral sclerosis.
Deficit: Bilateral UMN weakness with spastic gait, ↑ DTRs, but complete sparing of all sensory tracts and bladder function.
- Myelopathy with Radiculopathy:
Tracts: Any or all 3 tracts (esp. CS)
E.g.s:Cervical spinal stenosis, may be congenital or degenerative.
Deficit: Bilateral UMN syndrome with spastic gait, ↑ DTRs + IL or CL root signs + possible bladder dysfunction.
CAUDA EQUINA Syndrome
-EARLY root pain radiating to legs Leg weakness & ↓ DTRs (LMN) -Patchy, asymmetric "saddle" Late bladder dysfunction Late bowel & sexual dysfunction
CONUS MEDULLARIS
Late pain in thighs & buttocks Pelvic floor muscle weakness SYMMETRIC "saddle" anesthesia, numb -EARLY bladder dysfunction -EARLY bowel & sexual dysfunction
Lhermitte’s Sign
Neck flexion results in “electric shock” sensation down the back and/or into arms.
Attributed to posterior column disease (MS, disc, B12 def, mass).
Cervical Stenosis
Congenital or acquired narrowing of central cervical spinal canal.
Can result in UMN signs in legs +/- bladder dysfunction.
Immediate muscle weakness and hypotonia, hyporeflexia or areflexia (“Spinal Shock”)
Followed by spasticity and HYPERreflexia in days to weeks (including extensor plantar response: Babinski’s sign)
SPASTIC PARESIS
UMN:
Muscle weakness, hypotonia, hyporeflexia, areflexia are all immediate and long-lasting
FLACCID PARESIS
FASCICULATIONS
ATROPHY
LMN
Detrusor (smooth) muscle, activated by the preganglionic parasympathetic outflow from the
S2-S4 segments.
The involuntary (smooth) sphincter, controlled by sympathetic outflow from the ________ of the spinal cord
T10-L2 segments
Skeletal muscle of the pelvic floor, innervated by alpha motor neurons from the ________
S2-S4 segments
Late bladder/ sex problem
Early Pain
Cauda Equina
Early Bladder
Late pain
Conus Medullaris
Traumatic Spinal Cord Injury (SCI)
Spinal Shock following spinal cord injury is a specific term that relates to the loss of all neurological activity below the level of injury, including loss of motor, sensory, reflex, and autonomic function. Physiologic disruption of cord
Neurogenic Shock:
low blood pressure, slowed heart rate that results from the disruption of the autonomic pathways within the spinal cord.
Hypotension results from decreased systemic vascular resistance from loss of sympathetic tone.
Bradycardia results from unopposed vagal tone.
Spinal Shock
48- 72 hours transient disruption
return bulbo-cavernouses reflex shows ending
(anal contraction)
Primary vs Secondary injury
primary: cannot repair
Sequelae of SCI
bladder, DVT, pressure ulcer, pneumonia, gi hemorrhage, autonomic dysreg
Lhermitte’s Sign:
Neck flexion results in “electric shock” sensation down the back and/or into arms. Attributed to posterior column disease (MS, disc, B12 def, mass).
Radiculopathy
Sensory and/or motor dysfunction due to injury to a nerve root. Can be caused by herniated disk
s/s:
Lhermitets
nerve pain
reliefe: rest, nsaids
