Lecture 4: Spinal Cord Injury Flashcards
At what level does the spinal cord end?
L1-L2
What what spinal level os Conus Medullaris present?
~T12
What what spinal level is Cauda Equina present?
L3
What is the significance of knowing where Cauda Equina is?
This represents the change from UMN to LMN
the dorsal end of the spinal cord is known as?
Cauda Equina
What regions represent the UMN?
- Motor Cortex
- Internal Capsule
- Brainstem
- Spinal Cord
What regions represent the LMN?
- Interneurons
- Anterior Horn Cell
- Peripheral Nerve
- Motor End Plate
What is the most important motor tract in the UMN?
Lateral Corticospinal tract
Where can the sensations of pain, temperature, and itch be found in the spinal cord?
Anterolateral system
Where can the perception of proprioception be found in the spinal cord?
In the Gracile and Cunate Fasciles
The anterior horn cells are part of what system?
A. UMN
B. LMN
C. Both
B. LMN
List the different types of Spinal cord Syndromes (8)
- Lateral Cord (Brown-Sequard)
- Compete Cord
- Central Cord
- Anterior Cord
- Posterior Cord
- Pure Motor
- Conus
- Cauda Equina
The spinal thalami tract can be found where in the Spinal Cord?
Anterior lateral aspect
The Corticospinal tract can be found where in the spinal cord?
Posterior lateral aspect
Loss of motor and sensation of the legs bilaterally will be classified as what?
Complete spinal cord lesion
If the contralateral side experiences loss of pain, temperature and itch, and the Ipsilateral side experiences loss of proprioception, what is true in this case?
DCML on the ipsilateral side will be impaired
ALS on the contralateral side will be impaired
Where is the lateral corticospinal tract in the spinal cord?
Posterior lateral aspect of the spinal cord
Where are the anterior horn cells located in the spinal cord?
Anterior lateral aspect
What are of the spinal cord is responsible for vibration and position sense?
Posterior columns: Gracile and cunate fasciculus
What are the most common cases of spinal cord injuries?
MVA
Falls
Violence
Who is affected more by spinal cord injuries, males or females?
Males 4:1 Females
What are the 4 different mechanisms of injury for a spinal cord injury?
- Impact w/persistent compression (burst fracture)
- Impact w/transient compression post hyper/injury
- Distraction: Forcible stretching of spinal cord or blood supply
- Laceration from miss LE injury, sharp bone fragment dislocation, or severe distraction
When it comes to spinal cord injuries, what are the two types of injures classified as?
- Primary Injury
2. Secondary Injury
With a primary spinal cord injury, what is the cause?
- Fracture
- Vascular disruption
- Axonal shearing/disruption
With secondary spinal cord injury, what is the course?
- Spine Trauma
- Inflammatory activation of microglia and astrocytes
- Chemoattraction of Neutrophils, macrophages, lymphocytes
- Release of Cytokines/Chemokines, RNS, ROS, Complete components, Proteases
With primary and secondary spinal cord injuries, they both lead to …
=>Blood-Spinal cord barrier break-down
===>Spinal edema
When someone experiences a spinal cord injury, what is the most critical component to consider during the acute stage?
Microenvironment is critical to prevent secondary injury
Inflammation at the lesion site in the spinal cord is well-known, however less is known about what?
What level the inflammation is occurring
When a spinal cord injury, inflammation could occur up to how many segments away?
10 segments
What is the most important aspect to reduce the effects of secondary spinal cord injury?
Reduce inflammation
Inflammation in the spinal cord post injury can produce what? Specifically in the L/S region? (2)
- Maladaptive Neuroplasticity
2. No Motor Learning
Signs of UMN and LMN Lesions with respect to Spinal cord injury. Determine if UMN, LMN, or both are affected and how
Weakness
Atrophy
Fasciculations
Reflexes
Tone
Weakness: UMN & LMN
Atrophy: LMN
-UMN lesion may lead to atrophy from lack of muscle use
Fasciculations: LMN
Reflexes: Increased w/UMN; Decreased w/LMN
-w/acute UMN lesions, reflexes may be decreased
Tone: Increased with UMN; Decreased w/LMN
-w/acute UMN lesions, tone may be decreased
Describe the disease course of a Spinal cord injury
- Acute Onset
2. Progressive to stable
Describe the timeline for a Spinal Cord Injury
- Initial Traumatic Event
- Spinal Shock/Flaccid Paralysis, Loss of sensation, Loss of motor function
- Emergency response: Immobilization/Stabilization. Diagnose via MRI
- Stable: Possible UMN signs, Spasticity, Hyperreflexia
- Neurological return: Most recovery in 1 year. Most rapid recovery 1st 6 months, then slower pace up to 2 years.
What are the key diagnostic studies for determining a spinal cord injury?
(6)
- MRI (Gold Standard)
- X-Rays
- CT
- Somatosensory-Envoked Potentials
- EMG
- NCV
Describe the standard medical care for a patient that presents with a SCI
- Immobilization: Halo TLSO (Avoid Prolonged Immobilization)
- Early Inervention: Closed Reduction, Spinal Decompression
- Corticosteroids: Early Methylprednisolone IV Bolus
- BP Management
- General Care
- Nutritional Support
This drug, if given within 8 hours of injury, has been shown to have a significant effect on improvement with motor and sensation function within the first 6 months of therapy.
Corticosteroids: Early Methylprednisolone IV Bolus
What are the experimental medical management protocols for SCI?
- Therapeutic Hypothermia
2. Human Embryonic Stem Cells
What is the mortality rate for someone with a SCI?
4-17%
What are the predisposing factors for a SCI?
- Age
- Higher levels
- Pulmonary Embolism
- Medical Co-Morbidities
- Suicide
Which SCI patients have the greatest potential for recovery?
Those who suffer from Brown-Sequard syndrome
With this SCI, the LE can recover, and bowel and bladder function is seen early
Central Cord Syndrome
What is the age cut off for faster, more successful recovery for SCI?
<50 years
What are the 7 issues in Rehab for patients who present with Spinal Cord Injuries?
- Bladder Dysfunction
- Bowel Dysfunction
- Decubitus Ulcers
- Autonomic Dysfunction
- Sexual Dysfunction
- Wheelchair Seating & Positioning
- Spasticity
UMN lesions of the spinal cord are from what regions?
C1-L1
LMN lesions of the spinal cord are from what spinal levels?
L2-S5
With respect to the bowels, UMN lesions (C1-L1) can cause…
Hyperreflexia (Spastic paralysis, reflex is intact)
With respect to the bowels, a LMN lesion (L2-S5) can produce what effect?
Areflexia (flaccid paralysis)
-No Tone in the muscles
With respect to the bladder, and UMN lesion (C1-L1) has what effect?
Spastic (Urinary bladder and sphincter are overactive)
With respect to the bladder, a LMN lesion (L2-S5) has what effect?
Areflexia (Detrusor is unable to contract)
What are the symptoms associated with an UMN lesion in the spinal cord (C1-L1) for bowel and bladder?
Bowel: Constsipation, difficulty w/evacuation & Incontinence
Bladder: Increased frequency of urination/failure to store urine
-Inability to fully empty the bladder (Excessive spasms of the bladder)
What are the symptoms associated with a LMN spinal cord lesion (L2-S5) on the bowel and bladder?
Bowel: Constipation, difficulty w/evacuation & Incontinence
Bladder: Retention/Failure to empty urine
-Possible damage to kidneys and bladder wall
Clinical management of an UMN spinal cord lesion (C1-L1) for the bowels include… (5)
- Reflex defecation
- Stool Softener
- Laxative
- Suppository
- Rectal Stim
Clinical management of the bladder with UMN lesion (C1-L1) includes…
- Catheterization
- Prevention of urinary tract complications
- Pharmacological management
Clinical management of a spinal LMN lesion (L2-S5) includes what for the bowels?
- Stool Softener
2. Minimal Strain to void
Clinical management of a spinal LMN lesion (L2-S5) includes what for the bladder?
- catheterization
- Prevention of urinary tract complications
- Pharmacological Management
This is known as an exaggerated, massive autonomic response to noxious stimuli.
Autonomic Dysreflexia
What are some causes for Autonomic Dysreflexia? (5)
- Constrictive clothing
- Tight shoes
- Kinked Catheters
- Bowel and bladder distention
- Ingrown Toe-nails
Autonomic Dysreflexia is can described as a …
Loss of inhibitory control of sympathetic neurons
For Autonomic Dysreflexia, the lesions are typically at what spinal level(s)?
T6 and above
What are some common causes of Autonomic Dysreflexia?
- Bladder and Bowel Distention
- Ulcers
- Constrictive Clothing
- Ingrown Toenails
How should one treat and individual who may be preventing with Autonomic Dysreflexia?
- Remove Noxious Stimulus
- Medical Emergency!
- Keep patient upright to reduce blood pressure
- Do not place them in supine - Reduce blood pressure which is likely to be elevated
The sacral region of the parasympathetic nervous system is responsible for what autonomic functions?
- Reproductive organs
- Bladder
- Large Intestine (rectum)
What are the sign and symptoms associated with Autonomic Dysreflexia? (10)
- Pounding headache (Caused by increased BP)
- Hypertension (BP > 200/100mmHg)
- Diaphoresis (Sweating) above the level of injury
- Red Blotches on the skin above level of spinal injury
- Goose Pimples
- Flushed (Red Face)
- Nausea
- Slow Pulse (<60bpm)
- Cold, clammy skin below level of spinal injury
- Nasal Congestion
What system is essential to penile erections?
Autonomic nervous system
What system initiates erectile response and what spinal levels contribute to this?
- Parasympathetic nervous system: Erectile response
2. Spinal level S2-S4
This autonomic nervous system is essential for ejaculation. What spinal levels contribute to this?
- Sympathetic nervous system: Ejaculation
2. L1-L3
What are the 3 most common issues with sexual dysfunction?
- erectile Dysfunction
- Ejaculation
- Fertility
What are the 3 most common treatment options for Erectile Dysfunction?
- Surgical prosecutes (Penile Prosthesis)
- Vacuum Devices
- Pharmacology
This is copied as “Velocity-Dependent increase in tonic stretch reflexes with passive movement”
Spasticity
For a Spinal cord injury to be classified as an UMN lesion, where does the injury have to occur?
Above Cauda Equina (UMN Lesion)
How long does it take for spasticity to be evident post spinal cord injury?
Initially absent immediately post acute injury
-Develops over weeks
How should a PT manage a patient who presents, or may not yet present with spasticity?
Stretching to prevent contracture
What medications are there available for Spasticity management?
- Baclofen
- Tizanidine
- Diazepam
- Dantrolene
- Clonodine
Botox, Xeomin, phenol nerve blocks, and intrathecal baclofen pumps are used to treat what?
Spasticity
For severe cases of spasticity, what medical treatment can be used to reduce pain and other related symptoms?
Intrathecal Baclofen Pump
-Can decrease pain and spasticity, but not very common. Only used in severe cases.
When using the ASIA form, how do you determine sensory level loss?
The most caudal level normally innervated dermatome for both pin prick and light touch (grade 2)
-May Differ from right to left
When using the ASIA form, how do you determine the motor neurological level effected?
The most caudal level, normal or intact innervated spinal nerve
-Must be a grade ≥3, provided the next most rostral key muscle tests are normal
ASIA Impairment Scale
A = ?
Complete: No motor or sensory function is preserved in the sacral segments S4-S5
ASIA Impairment Scale
B = ?
B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5
ASIA Impairment Scale
C = ?
C = Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade of 3 or more.
ASIA Impairment Scale
D = ?
D = Incomplete: Motor function is preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more.
ASIA Impairment Scale
E = ?
E = Normal: Motor and sensory function are normal
What are the 6 Non-Traumatic disorders of the spinal cord?
- Syringomyelia
- Myelitis
- SC Infarction
- Spinal Epidural Abscess
- Spinal Epi/Subdural Hematoma
- Spina Bifida
This is a fluid-filled gliosis-lined cavity
Syrungomyelia
Syringomyelia is a fluid filed gliosis-lined cavity. It is an irregular cavity and disrupts ___________
Anterior horns of Grey Matter
Syringomyelia is associated with …
Spinal column or Brainstem abnormalities
Patients with Scoliosis, Klippel-Feil syndrone, and arnold chairs malformation are at risk for what SC non-traumatic injury?
Syringomyelia
At what decade in the human life does someone experience Syringomyelia?
3rd or 4th decade
What is the key diagnostic(s) study for determining if someone has syringomyelia?
MRI & CT Scane
What is the general progression Syringomyelia?
- Long motor tracts affected
2. Sensory tracked affected
What are the 4 signs and symptoms associated with Syringomyelia?
- Segmental Atrophy
- Loss of pain and temperature (ALS system)
- Areflexia (LMN)
- Proprioception Intact
What are the conservative measures for someone who presents with Syringomyelia? (4)
- Avoid High-Force isometric contractions
- Avoid Valsalva Expiration
- Head Elevation at night
- Maintain neutral neck
What are the 3 surgical interventions for Syringomyelia?
- Decompression
- Shunt Replacement
- Tumor resection & Radiation (Intra-Medullary Spinal cord tumors)
This is a birth defect with incomplete closure of the spine and membranes
Spina Bifida
What are the two types of Spina Bifida?
Spina Bifida Aperture
Spina Bifida Occulta
This type of Spina bifida is visible or open
Spina Bifida Aperta
This type of Spina Bifida is hidden or not visible
Spina Bifida Occulta
What are the two sub-types of Spina Bifida Aperta?
- Myelomeningocele
2. Meningocele
This type of Spina bifida is a clear bump on the individuals back with a visible lesion. the spinal cord and membranes are protruding out.
It is a visible open lesion
The extent of damage depends on where and how much the nerves are protruding out
Spina Bifida Aperta: Myelomeningocle
This type of Spina bifida has the spinal cord protruding out away from the vertebral body towards the bump on the skin
Spina Bifida Aperta: myelomeningocle
This type of spina bidifa just has the subarachnoid space protruding out towards the skin
Spina Bifida Aperta: Meningocele
What is the most Mormon form of Spina Bifida?
Myelomeningocele
This type of Spina Bifida has protrusions of the spinal meninges and spinal cord through a defect in the vertebral column
Myelomeningocele
Spina Bifida Aperta is an OPEN SPINAL CORD DEFECT, which means it is ….
Not Skin Covered
This type of Spina Bifida is associated with nerve paralysis, but not always
Spina Bifida Aperta
What are the 3 clinical findings for Spina bifida Aperta: Myelomeningocele
- Multi-system involvement
- Degree motor and/or sensory loss varies
- Extrusion of neural tissue
- Musculoskeletal deformities - No two patients are clinically identical
- High risk for loss of function over time
What are the surgical and medical managements for Spina Bifida Myelomeningocele? (4)
- Surgical closure of the Myelomeningocele
- Surgical correction of orthopedic deformities
- Placement of VP Shunt
- Medications for management of Bowel and Bladder function
What is the prognosis of Spina Bifida Aperta: Myelomeningocele
(2)
- Despite surgery, affected nerves may not function normally.
- Higher the location of the defect on the baby’s back, the more nerves will be affected
What is true of a child with Spina Bifida Aperta: Myelomeningocele with respect towards intelligence?
- Typically normal intelligence
What are the two risks with respect to intelligence for a child with Spina Bifida Aperta: Myelomeningocele?
- Hydrocephalus
2. Meningitis
Children with Spina Bifida Aperta: Myelomeningocele are prone to what two issues?
- Learning Disabilities
2. Seizure episodes
Spinal cord issues with Spina Bifida Aperta can occur later in life. What are the 3 most common ones?
- Rapid growth during puberty
- Possible increase loss of function
- Orthopedic problems
- Scoliosis, Foot or ankle deformities, dislocated hips, and joint tightness or contractures
Where does the spinal cord end for UMN?
L1-L2 (UMN Ends)
The (Blank) is a collection of nerve roots that begins at the end of the spinal cord and exits from the third lumbar vertebrae to the 5th sacral vertebra
Cauda Equina (LMN)
Where does the LMN begin in the spinal cord?
Cauda Equina (L2-S5
This is an exaggerated autonomic response to a noxious stimuli that is a medical emergency typically for SCI levels T6 and above.
Autonomic Dysreflexia
What is the etiology of an UMN Lesion and what are the spinal levels associated with it?
Trauma
Spinal Level C1-L1 UMN
What is the etiology of a LMN injury and what is its associated spinal cord level?
Trauma
L2-S5
What is the etiology of Syringomyelia?
Non-Traumatic
What is the etiology of Myelomeningocele?
Non-Traumatic
What are the signs and symptoms associated with an UMN Lesion (C1-L1)? (4)
- Atrophy
- Weakness
- Hyperreflexia
- Spasticity
What are the signs and symptoms associated with a LMN lesion in the spinal cord (L2-S5)? (3)
- Atrophy
- Weakness
- Areflexia
Where are lesions typically in the spinal cord for one to experience spasticity?
UMN C1-L1
What are the signs and symptoms associated with Syringomyelia (4)
- Segmental Atrophy
- Areflexia
- Pinprick impaired
- Vibration intact
What are the signs and symptoms associated with Myelomeningocele? (3)
- Multisystem involvement
- Degree of motor and sensory loss
- Musculoskeletal deformities
What are the Key Diagnostic tests for UMN/LMN lesions in the spinal cord, Syringomyelia, and Myelomeningocele?
What is the extra test for Myelomeningocele?
MRI and CT Scan
Myelomeningocele has the addition of an X-Ray
What is the typical progression of an UMN/LMN lesion in the spinal cord?
varies expending on predictive factors
What is the prognosis and progression of Syringomeyelia?
Varies depending on
- Classification
- Expansion
- Treatment
What is the prognosis and progression of Myelomeningocele?
- Varies depending on
A. Extend of damage
B. Surgical Intervention
C. Therapeutic Intervention
What is the typical treatment plan for one who presents with a n UMN lesion (C1-L1)? (5-6)
- Immobilization
- Surgical Intervention
- Corticosteroids
- Neuro protective Strategies
- BP Management
- General Care
What is the general treatment plan for someone who presents with a LMN lesion (L2-S5)? (5-6)
- Immobilization
- Surgical Intervention
- Corticosteroids
- Neuro protective strategies
- BP Management
- General Care
What is the general treatment plan for someone who presents with Syringomyelia? (2)
- Conservative
2. Surgical Decompression
What is the general treatment plan for someone who presents with Myelomeningocele? (4)
- Surgical closure of Myelomeningocele
- Surgical Correction of Orthopeadic Deformities
- Placement of VP Shunt
- Medications: Bowel and Bladder Management
