Lecture 8 - SCI Flashcards
Where does the spinothalamic tract cross
What’s it do?
Anterior Commisure at same level it enters spinal cord
Pain and temp
Where does the DCML tract cross?
What does it do?
In medulla
Proprioception, fine touch
Where does the corticospinal tract cross?
What’s it do?
In medulla pyramids
Motor
Where is the sympathetic NS located
Where is the parasympathetic NS located
T1 to L3
Brainstem and S2-S4
What is the most common cause of SCI
Vehicular accidents
Mainly affects males
Most common outcome: incomplete tetraplegia
How do you manage an emergent case of SCI
Immobilization of head and neck
Airway protection
Avoid hypotension
Emergent plain films and CT scan of spine
Surgical decompression (needed within first 24 hours)
Most traumatic injuries occur where in the spine?
50% cervical. Most commonly C5 followed by C4.
Thoracic next most common, then lumbar
A lesion around what level will cause quadriplegia vs paraplegia
Below cervical (C8) - paraplegia
Above cervical- quadriplegia
What is considered the gold standard of spinal cord injury assessment
ASIA international standards for neurological classification of spinal cord injury ISNCSCI
What does someone’s “motor level” and “sensory level” mean in a SCI
The lowest level still intact
Muscle groups in ASIA:
C5
C6
C7
Elbow flexor
Wrist extensor
Elbow extensor
Muscle groups in ASIA:
C8
T1
L2
Finger flexors
Small finger abductors
Hip flexors
Muscle groups in ASIA:
L3
L4
L5
S1
Knee extensors
Ankle dorsiflexors
Long toe extensor
Ankle plantarflexors
How is sensory graded in ASIA?
0- absent
1 altered/ impaired/ hypersensitive
2 - normal
NT- not testable
What does A mean on the ASIA impairment scale?
Complete (cord injury): no sensory or motor preserved in s4 s5
What does B mean in the ASIA scale?
Sensory incomplete
What does C mean in the ASIA scale?
Motor incomplete (more than half)
<3 on MMT
What does D mean in the ASIA scale?
Motor incomplete: less than half (less than half of function is gone)
>3 on MMT
What does E mean on the ASIA scale
Normal
What is spinal shock?
Immediate flaccidity and loss of sensory and automatic function below the level of a lesion
What does spinal shock present like?
How long does it last
Atonic bladder with overflow incontinence
Atonic bowel with gastric dilation
Loss of vasomotor control
Lasts days to several weeks
After spinal shock, what normally happens in a SCI?
Increased reflexes and spasticity below the level of the lesion
pathological pyramidal reflexes(Babinski and hoffman)
Spastic bladder
Paralyzed legs w/ flexion contracture
autonomic dysreflexia (depending on level)
SCI above what level causes babinski reflex? Hoffman?
Babinski - S1
Hoffman - C7
Autonomic Dysreflexia happens with spinal cord injuries above _____
T5
Disabilities associated w/ C1-C5 tetraplegia:
at what level do you have independent verbal communication?
- Bathing and dressing: dependent
- communication: independent w/ assistive device C1-C3
Independent verbal communication C4-C5
Assistive device necessary for keyboarding, writing, page turning, use of telephone
Disabilities associated w/ level of C6-C8 tetreplegia
At which level of injury can they use a wheelchair?
How is dressing?
- Dressing: independent with AD in bed (C7) or wheelchair C8
- Minimal assistance dressing
- moderate assistance undressing
- those w/ C8 injury can dress and undress in wheelchair
Disabilities associated w/ level of C6-C8 tetreplegia
How is Bathing? Upper body? Lower body?
- Minimal assistance for upper body bathing and drying
- Moderate assistance for lower body drying
- C7 and C8 are independent w/ use of assistive devices
- AD include tub chair
Disabilities associated w/ level of C6-C8 tetreplegia
How is communication?
- Independent verbal communication
- AD necessary for keyboarding, writing, use of phone
- C6 may require set up
Disabilities associated w/ T1 injury
How is Dressing, bathing and communication
Dressing: independent w/ assistive device
Bathing - Independent w/ use of assistive device
communication - independent
(arms are fine)
What are symptoms of autonomic dysreflexia
Hypertension (up to 300mmHg systolic)
sweating (above the injury)
Flushing (above the injury)
Bradycardia (vagus nerve is still working
note: usually due to complete transverse cord lesion, risk increases after recovery from spinal shock when transfering to rehab
Autonomic dysreflexia triggers:
Full Bladder
Full or impacted bowel
Scrotal compession
kidney stones
gastritis
onset of menses
DVT
Pulmonary Embolism
Pressure ulcers
change in temp
pain or irritation below level of lesion
basically they cannot feel these things to address them
Autonomic dysreflexia is a sudden increase in BP by _____________ resulting from harmful, painful, or injurous stimulus below the level of a spinal cord lesion
How should you position a patient whos having autonomic dysreflexia?
20-40mmHG
Sit patient upright (90 degrees) Monitor BP every 2-3 minutes
What are cardiovascular complications of a SCI?
Arrhythmias, fluctuating BP, orthostatic hypotension
thrombophlebitis, pulmonary embolisms, edema (this is why these patients need compression, exercise, and early mobility)
What are respiratory complications of a SCI?
impaired cough and reduced ability to mobilized secretions (making them more suseptible to pneumonia)
increased risk of obstructive sleep apnea
reduced exercise tolerance
What are nutritional complications of a SCI?
high catabolic state
prone to poor wound healing and infection
associated paralytic ileus which may prevent oral feeding
gastritis and stress ulcers (prevented with medications)
What are skin complications w/ SCI?
Ulcers, Osteomyelitis, Sepsis
Bony Prominences
Prevent with scheduled position changes
What are sexual complications of a SCI
Men: impaired libido, potency, fertility
women: impaired libido and sexual response, fertility is maintaned
What are the leading causes of death for SCI patients
sepsis
pneumonia
respiratoy failure
highest death rate is in first year
Cervical spondylosis is most common at what disc levels?
C5 C6
due to bulging discs, bone spurs. thickening of ligaments, compromise of cord and roots
If nerve roots are involved we might treat w/ ______
but if theres spinal cord involvement then you ________
Physical therapy
Need a surgery
What are cervical spondylotic myelopathy symptoms
Pain
Burning
Weakness
Numbness
Tingling
Bowel and bladder
Lhermitte phenomenon
How does spondylotic myelopathy progress?
Gait impairment often happens early
Lower limb will have sensory problems if dorsal column is compressed
lateral arm weakness and loss of finger dexterity
cervical radicular dysfunction
Where is an intramedullary spinal cord tumor?
Within the spinal cord
where is an extramedullar-intradural spinal cord tumor?
lying on the surface of the cord
arising from roots or meninges
where is an extradural spinal cord tumor located?
in the extra dural space but can compress spinal cord
Where at the majority of spinal cord metastases located?
70% thoracic
20% lumbar
10% cervical
What cancers most often spread to the spinal cord?
Lung, breast, prostate, kidney, thyroid, gut
symptoms: back pain, tenderness, paraparesis, incontinence
What are the symptoms of an epidural abscess?
How is it diagnosed and treated?
Fever, local pain, radicular pain, rapid progressive paraparesis and sensory loss
diagnosis: emergency MRI
Treatment: laminectomy, drainage, antibiotics
What can cause Posterolateral column syndrome?
B12 deficiency
Copper deficiency
cervical spondylosis
paraneoplastic myelitis
HTLV1 myelopathy
What is subacute combined degeneration?
What vitamins are deficient?
What tracts does it involve?
Spinal cord syndrome resulting from deficiency of vitamin B12 or copper
involved posterior columns and corticospinal tracts
What are the symptoms of subacute combined degeneration
DCML and corticospinal tracts r involved
resulting in weakness
paresthesias
sensory ataxia
gait unsteadiness
What causes B12 deficiency?
where is B12 found?
Impaired absorption d/t gastric bypass, anemia, or IBS
found in meat, eggs, milk, fortified foods
What can cause posterior column syndrome?
Neurosyphilis (tabes dorsalis)
early cervical spondylotic myelopathy
radiation induced myelopathy
What is syphilis(Tabes dorsalis)?
How does it present?
Sexually transmitted infection
causes dorsal column demyelination in chronic untreated infections
-rare today
-impaired sensory and gait imbalance/ataxia
-absent reflexes with normal strenght
What causes hemicord syndrome?
Gunshot/knife
MS
Epidural abscess
Hemicord syndrome affects the
________ corticospinal tracts
__________ DCML tracts
_____________ spinothalamic tracts
Ipsilateral corticospinal - UMN weakness below lesion
Ipsilateral DCML - loss of sensory and proprioception below level of lesion
Contralateral spinothalamic- loss of pain and temp 1-2 levels below the lesion
Hemicord syndrome affects the _______ anterior horn
the _______ nerve root
and the ________ descending autonomic fibers
ipsilateral anterior horn - ipsilateral lower motor neuron weakness
ipsilateral nerve root- ipsilateral nerve pain
ipsilateral autonomic fibers- impaired sweating
What can cause central cord syndrome?
Syringomyelia
intramedullary tumors
neuromyelitis optica (NMO)
cervical hyperextension
What is central cord syndrome?
Swelling in middle of spinal cord, often from cervical myelitis
What is syringomyelia?
Central cavitation in spinal cord
most commonly in cervical region
-idiopathic
-associated w/ tumor or hemorrhage
-associated w/ brain malformatin
-late complication of spinal cord trauma
How does syringomyelia present?
segmental weakness and atrophy of hands and arms w/ loss of tendon reflexes
“cape distribution”
may need surgical drainage of cyst
What is a common cause of anterior cord syndrome?
anterior spinal artery stroke
What is usually preserved in anterior spinal cord syndrome?
what is normally affected?
Pain and temp preserved, DCML preserved
mainly motor loss
What are the symptoms of conus medullaris/ cauda equina syndromes?
______
_______ UE strength and sensation
______ reflexes in legs
sensory loss in ___________
___________ leg weakness
impaired ________________ function
Pain unilateral/bilateral radicular
preserved UE strength and sensation
absent reflexes in legs
sensory loss in proximal legs/ saddle anesthesia
proximal lower leg weakness
impaired B&B function
What can cause conus medullaris/cauda equina syndromes?
Disc herniation
Vascular
infections
radiation
neoplastic disorders
inflammatory disorders
