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KINE 3P92 > Lecture 2 > Flashcards

Lecture 2 Flashcards

1
Q

What is a level of injury and the 2 (/3) forms?

A

Where the injury occurs and the restrictions due to this

  1. Tetraplegia
    - Impairment or loss of motor and/or sensory function in upper and lower extremities, trunk, and pelvic organs
    - Damage to segments C8 or higher (Cervical)
  2. Paraplegia
    - Impairment in both legs and pelvic organs
    - Motor and sensory function normal in upper extremities
    - Damage to thoracic, lumbar or sacral segments T1 or lower

*3. Cauda equina
- Technically not a spinal cord injury, but can fall under paraplegia since will look similar, and falls under the T1 spinal cord

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2
Q

What is the difference between an upper and lower motor neuron injury?

A

Upper:
- Damage to the descending tracts
- Either tetraplegia or paraplegia
- Upper motor neurons are from brain/stem to spinal cord where they synapse with the lowers
- Spinal cord injury*****

Lower:
- Lower motor neurons are those that come off spinal cord going towards effector muscle/organs
- Damage that occurs to the peripheral nerves in vertebral column
- Cauda equina injury*****

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3
Q

Is it possible to have lower motor neuron injury in spinal cord?

A

Yes, since possible for injury site to be cauda equina, with slight blow to the spinal cord as well.

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4
Q

What are the 2 functional differences between Upper and Lower motor neuron injuries?

A

Upper motor injury:
- Has spasms due to lower motor neurons being in tact to form somatic motor reflexes (even if not able to feel it)
- Some maintenance of muscle (Since even though no voluntary control, still has spasms)

Lower motor injury:
- Flaccid paralysis, meaning no spasms present since that reflex is cut off due to injury
- Profound atrophy since muscle cannot contract ever

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5
Q

What is muscle spasticity?

A

Being able to spasm due to slight passive stretch, or increase in muscle tone, sending afferent response to cauda equina and sending motor response back to contract/spasm

Upper motor neuron injury:
- Spastic paralysis below level of injury

Lower motor neuron injury:
- Flaccid paralysis

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6
Q

What is the difference between a complete and incomplete injury?

A

Complete:
- Both sensory and motor function are absent in the lowest sacral segments of the spinal cord (S4, S5)
- At some point in cord, no sensory or motor use (Not always at injury site)

Incomplete:
- Some sensory and/or motor function preserved below injury site, including sensory and/or motor function at S4 and S5 spinal cord segments

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7
Q

Complete vs. Incomplete innervation test of S4 and S5?

A

Finger in the anus, test if they can feel, and contract the sphincter
- If no motor or sensory, then complete
- If one or both, injury is incomplete

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8
Q

What are the 4 general classifications are spinal cord injury?

A
  1. Complete tetraplegia
    - Absent motor and sensory function at some point before C8
  2. Incomplete tetraplegia
    - Partial motor and sensory function beginning before C8
  3. Complete paraplegia
    - Absent motor and sensory function at some point after T1
  4. Incomplete paraplegia
    - Partial motor and sensory function somewhere after T1

Cauda equina/LMN injury would be paraplegia appearing similarly to complete

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9
Q

What is the neurological level in an ASIA exam?

A

The most caudal/lowest segment of the spinal cord with normal sensory and motor function on both sides of the body

  • There may be different values for sensory vs. motor, and left vs. right
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10
Q

What is the sensory level in an ASIA exam?

A

The most caudal/lowest segment of the spinal cord with normal sensory function on both sides of the body

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11
Q

How would you perform the sensory function portion of the ASIA exam?

A

Test on the cheek at first since above spinal cord so will feel difference between sharp and dull

Eyes closed, start at c2 and ask whether sharp or dull, with 3 ways to answer:

  1. Can feel, and can tell whether sharp or dull (2/2)
  2. Can feel, but not as sharp of a feeling, or feel but dull not sharp, then 1/2
    - 1/2 could also be hypersensitive at the area of injury, so could be dull feeling sharp
  3. No feeling 0/2

Not testable:
- Possible severe injury (burns, casts, amputation, etc)

Test all 28 points on the left, and all 28 on the right, for both light touch with cotton ball and the pin prick for a max of 112

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12
Q

How do you interpret scores to determine the real sensory level?

A

Find the most caudal segment with normal sensory function on both sides
- Last segment with a 2/2 score for both sides

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13
Q

What is the motor level in the ASIA exam?

A

The most caudal/lowest segment of the spinal cord with normal motor function on both sides of the body
- May differ from one side to the other

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14
Q

What issue is presented with the motor level portion of the ASIA exam?

A

The functional test only provides information for the key 10 myotomes for both the right and left sides being
- Elbow flexors
- Wrist extensors
- Elbow extensors
- Finger flexors
- Finger abductors

  • Hip Flexors
  • Knee Extensors
  • Ankle dorsiflexors
  • Big toe extensors
  • Ankle plantar flexors

This means that the trunk muscles aren’t tested (Would be too difficult) but therefore difficult to make very accurate reading of motor level

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15
Q

How would you perform the motor function portion of the ASIA exam?

A

Six point strength grading scale of each of the 10 myotomes:

0 - total paralysis/no contraction felt or seen

1 - palpable or visible contraction/flicker

2 - Active movement with full ROM, gravity eliminated/laying down

3 - Active movement with full ROM, against gravity/standing, off the body fighting gravity

4 - Active movement with full ROM, against moderate resistance/can fight slightly with resistance, not enough for full range resisted

5 - (Normal) Active movement with full ROM, against full resistance

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16
Q

How do you interpret scores to determine the real motor level?

A

Since one nerve can innervate multiple muscles and muscles are innervated by multiple nerves:

Segment is still defined as intact if graded as 3/5 or greater as long as the previous level was a 5/5 for both sides.

17
Q

What needs to be done if the injury appears to affect the area between T1-L2 therefore motor level cannot be calculated?

A

It would be determined that although not fully accurate, the motor level is the same as the sensory level

18
Q

What is the zone of partial preservation in the ASIA exam, and how do you determine it?

A

Only applicable for complete injury
- Since if incomplete, whole body is zone of partial preservation

Refers to dermatomes and myotomes caudal/lower than the neurological level that remain partially innervated

For example, if the right sensory level is C5, but some sensation extends to C8, then C8 is determined to be the right sensory ZPP block.

19
Q

What are the 5 levels of severity in the ASIA impairment scale, and what are their descriptions (Most impaired/severe to least)

A

ASIA A:
- No sensory or motor function is preserved in the sacral segments S4-S5 (COMPLETE)

ASIA B: Sensory but not motor function is preserved below the neurological level and includes the sacral segments (INCOMPLETE)

ASIA C: Sensory and motor function is preserved below the neurological level (Including S4-5) and more than half of the muscles below the neurological level have a muscle grade LESS THAN 3 (INCOMPLETE) 1, or 2

ASIA D: Sensory and motor function is preserved below the neurological level (Including S4-5), and at least half of the muscles below the neurological level have a muscle grade MORE THAN OR EQUAL TO 3 (INCOMPLETE) 3, 4, or 5

ASIA E: Normal sensory and motor function

20
Q

What are primary mechanisms of spinal cord injury?

A

Traumatic accident which causes damage to the
- vertebrae
- spinal cord
- blood supply to the spinal cord

Non-traumatic causes
- infection
- loss of spinal cord blood supply
- radiation

21
Q

What are secondary mechanisms of spinal cord injury?

A

Within hours following the initial trauma the spinal cord undergoes progressive tissue destruction
- May last several days to a month

Results in spindle shaped area of necrotic/dead tissue (Cyst) that may span over several cord segments
- Can make injury go from incomplete to complete, or just bad to worse

22
Q

What are the 4 types of secondary mechanisms in spinal cord injury?

A
  1. Ischemia
  2. Inflammation
  3. Ion-derangement
  4. Apoptosis
23
Q

What are the characteristics of Ischemia? (Secondary mechanisms of SCI)

A
  • Damage to arteries and arterioles that supply the cord
  • Vasospasm due to neuron contents bursting, causing loss of norepinephrine (Vasoconstrictor) causing a spasm, and cutting blood supply
  • Edema
  • 15–30 seconds of lack of O2 (Anoxia) may cause irreversible damage
23
Q

What are the characteristics of inflammation? (Secondary mechanisms of SCI)

A

Acute inflammation causes inflammatory cells to attract to the initially injured tissue

-This causes phagocytosis (eating dead tissue)

  • Causes free radical production filling area (Healing cells, end up eating healthy tissue)
  • This causes damage to surrounding healthy tissue

Makes injury larger than at the start

23
Q

What are the characteristics of Ion derangement? (Secondary mechanisms of SCI)

A

Cell membrane damage leads to:

Increase in extracellular K+ and Intracellular Na+

Leads to: Increase intracellular Ca++

Leads to breakdown of phospholipids (Cell membrane) and proteins (Cell cytoskeleton)

Which all leads to cell death

24
Q

What are the characteristics of apoptosis? (Secondary mechanisms of SCI)

A

Preprogrammed cell death (Cell suicide)
- cell shrinks, and is engulfed by phagocytes
- No inflammatory response, no escape of cellular contents

25
Q

What is necrosis?

A

Unintended cell death (Cell murder)
- cell swells, membrane bursts
- release of intracellular contents
- provokes inflammatory response

26
Q

What is the results of secondary mechanisms of spinal cord injury?

A

Astrocytes form the “egg shell”
- stop the growth of the cyst/astrocytic scar

Cut off of nerve pathways due to this cyst
- some may still be functional but only if still fully myelinated, some nerves may be in tact without this myelination

27
Q

What is spinal shock?

A

A temporary period of no spinal cord function below the level of the injury site
- No motor, reflexes, or sensory info functioning
- Usually resolves in a few weeks, and is not fully understood why it occurs

Some neurological return may be made due to prolonged slight nerve regeneration for approximately 2 years

ASIA exam would be completed AFTER the initial spinal shock

28
Q

Which ASIA exam levels are most likely to progress to a higher grade within a year, and which are more likely to progress to a lower level (D or E) after tested 24 hrs after injury

A

C has highest change of moving up to higher grade (54%) and also a 54% chance to progress to a D or E

Followed by B, with 43% to progress to more severe, and a 28% to improve to a D or E

A has 10% to get worse, and 3 % to reach D or E

29
Q

What is the ratio of traumatic to non-traumatic spinal cord injuries?

A

Almost 50/50

(49 Non-traumatic, 51 traumatic)

30
Q

What is the 1 year case fatality rate of specifically receiving a spinal cord injury (Not resulting factors like a heart attack)

A

46% of all individuals who sustain a SCI
13% for those who reach hospital

31
Q

What is the ratio of males to females with spinal cord injuries?

A

In Ontario, 68.4% of traumatic SCI are male

In US males represent 61% of traumatic SCI

32
Q

What are the top causes of injury in Ontario?

A
  1. Unintentional falls (43%)
  2. Motor vehicle accidents (42.8%)

Other notable causes include:
- Medical conditions
- Sports
- Diving

33
Q

What is the relation between age when the injury occurred, and the current age distribution of those with SCI?

A

50% of injuries occurred between 15-24
27% occurred between 25-34

Currently, 30% of population are 40-49
25% of population are 50-59

Therefore injuries usually happen at a young adult age, to about 40
- Not many injuries occur to the elderly, but is still reporting higher rates as the years go on

34
Q

What are the percentages of ASIA severity levels, and the level of injury?

A

50% of injuries were lumbosacral
29% were cervical
21% were thoracic

ASIA A - 45%
ASIA B - 15%
ASIA C - 10%
ASIA D - 30%

In 25% of all SCI, alcohol played a major role

35
Q

What are some examples of costs for those who just sustained SCI?

A
  • Medical bills
  • Home modifications
  • Vehicle modifications
  • Wheelchairs, accessories and other supplies
  • Medications
  • Personal assistance/practitioner services

The worse the injury, the higher the cost of these, and can cost anywhere from 150-500 thousand dollars
- 7-35 thousand annually

36
Q

What are the common life expectancies of those with SCI at each of the varying levels?

A

C1-C4 ASIA A-C - 64-69% life expectancy compared to general population

C5-C8 ASIA A-C - 65-74%

T1-S5 ASIA A-C - 88-91%

All ASIA D - 96-97%

37
Q

What are SMR ratings, and what are some examples of the top causes of death from SCI

A

Standardized mortality ration
- How more or less likely one is to pass due to a condition (SMR of 2.0 = double/twice the mortality)

Depending on the severity of the injury (Incomplete vs. complete and paraplegia vs. tetraplegia)
- Septicemia can be 45-250x as likely
- Pulmonary disease 23-105x
- Pneumonia and influenza 10-150x

Note the SMR limits
- If it includes the value of 1 in the range, means there isn’t a “true” increased risk
- The above three all have ratings above 1 in the scale (ex. 11.5-78) meaning increased

KINE 3P92 (10 decks)

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