SCI Flashcards
SCI
SPINAL CORD INJURY:
A lesion or injury of the spinal cord due to bleeding, strain, bruising or total disruption of the spinal cord resulting in partial or complete loss of motor and/or sensory function below the site of the injury.
Causes
Direct injury to the spinal cord (e.g. stab wound to the spinal cord)
Indirect (e.g. fracture dislocations)
• Traumatic causes > non-traumatic
– 50% of traumatic cases are through road traffic accidents
– 26% industrial accidents
– 10% sporting accidents
– 10% accidents at home
– Other causes include falls from a height and tu
Primary traumatic Causes
o 84% of all cases o 25% of the cases = dislocations • Motor vehicle accidents • Pedestrian-vehicle Accidents • Motorbike accidents • Quadbike accidents • Violence/ Assault - Gunshots - Stab injuries • Diving accidents Falls • Agricultural accidents
Secondary traumatic causes
Usually occurs over days or weeks because of • bleeding, • swelling, • inflammation and • fluid accumulation in and around SC
Fragile SC
Lower cervical region (C5 – C7)
o Mid thoracic region (T4 – T7)
o Thoracolumbar junction (T10 – L2).
Non traumatic causes
Non-traumatic causes
• TB spine
• Inflammatory (e.g. poliomyelitis, GBS)
• Neoplasia (benign or malignant)
• Degenerative diseases (e.g. disc prolapse, spinal stenosis)
• Developmental (e.g. Spina Bifida, Scoliosis)
• Demyelinating diseases (e.g. Multiple Sclerosis)
• Infection
• Vascular accidents especially with involvement of the
anterior vertebral artery
• Cysts (e.g. Syringomyelia)
gray matter.
Tetraplegia
Refers to impairment (or loss of) motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal.
• Results in impairment of upper limbs (ULs), trunk and lower limbs (LLs).
NB
It does NOT include brachial plexus injuries or injuries to peripheral nerves outside the neura
Paraplegia
Refers to impairment (or loss of) motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord, due to damage of the neural elements within the spinal cord.
Results in the preservation of UL function, but depending on the level of injury, the trunk and LL’s may be impaired.
Note: This includes cauda equina and conus medullaris injuries, but not lumbo-sacral plexus injuries or injuries to
Haematomyelia
Acute haemorrhage into the central grey matter – is followed by loss of function below level of lesion
• As oedema subsides and the bleed is absorbed -
function returns in the posterior and lateral columns
white columns.
• Patient has segmental flaccid paralysis and muscle
atrophy.
• Gradual increase of spastic paralysis with segmental loss of pain and temperature sensation.
• Preservation of pain and temperature sensation and posterior column function above and below level of bleed
Asia class
ASIA A = Complete: No motor or sensory function is preserved in the sacral segments S4-S5.
• ASIA B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
Asia class cont
ASIA C = Incomplete: Motor function is preserved below the neurological level and the majority of key muscles below the neurological level have a muscle grade of less than 3.
- ASIA 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 greater than or equal to 3.
- ASIA E = Normal: Motor and sensory function are norma
Anterior cord syndrome
Damage of the front two- thirds of spinal cord (& preservation of the posterior columns) -results from compression of anterior spinal artery. • Often caused by: – flexion injuries where anterior segment is directly injured. – Retropulsed disc or bone fragments
• Damages the Corticospinal and Spinothalamic tracts.
SYMPTOMS
Variablelossofmotor function (muscle power), pain & temperature sensation below the lesion.
• Proprioception, light touch and deep pressure is preserved.
Prognosis
• Poorprognosisfor recovery of LL function &
Central cord
Usually due to unbelted MVA’s and falls from the elderly
Common in elderly with pre-existing spondylosis/stenosis
Occurs almost exclusively in the cervical region
(due to hyperextension with simultaneous compression of the spinal cord)
Main symptoms • Motor loss UL’s (including hands)>LL’s • Sensory loss varies, but more severe in the UL • Flaccid paralysis (LMN) of the arms • Relatively strong but spastic (UMN) leg function • Sacral sensation and bowel and bladder function partially spared. Prognosis • Favourable for ambulation and ADLs • Recovery occurs first in legs, then bladder, then UL extremity before intrinsic had fx
Posterior cord
Incidence rate <1%)
• Commonly seen in hyperextension injuries.
• Causes contusion in the
posterior columns.
• Motor function, pain and temperature less affected
• Walking is difficult due to:
– Profound sensory and proprioception loss
– Difficulty with coordination
Brown sequard syndrome
Hemisection of the spinal cord
Mostly due to penetrating (stab) injuries or GSW
– (Due to interruption of posterior column)
• Ipsilateral: Hemiplegia
– loss of vibration
– loss of form perception
– loss of two point discrimination
– loss of proprioception/position sense
– Motor loss below the lesion
• Contralateral: Hemianaesthesia / hemianalgesia
(Due to interruption of the spinothalamic tract)
– Loss of pain, temperature sensation
and light touch below the lesion
Compression of conus medullaris
• Usually occurs with compression fracture of L1.
• Causes contusion and haemorrhage with damage to sacral segments of the
cord.
• In high conus injuries, the sacral segments may show preserved
bulbocavernosus reflexes & ultimately an upper motor neuron presentation (i.e. spaticity)
Signs and symptoms
• Motor
– usually no persistent motor involvement
– can have upper and lower motor neuron signs.
– can also have a patulous anus leading to faecal incontinence.
• Sensory
– sensory loss occurs in the sacral segments
• Autonomic
– produces urine retention with overflow
– complete loss of sexual function in the male (impotence)
Cauda equina compression
Symptoms depend on the extent of damage of the nerve roots in the cauda equina
• Lesion results in mainly lower motor neuron damage.
• There is progressive recovery although limited. Cauda equina has
better ambulation prognosis than conus medullaris.
Signs and Symptoms
• Flaccid paralysis
• Muscle wasting
• Sensory loss corresponding to the involved dermatomes
• Partial nerve root destruction = pain and hyperaesthesia
• Compression of S2, S3, S4 nerve roots = disturbance of bladder
function
• Disturbances of sexual function and faecal incontinence
• Muscle fasciculations – in the affected muscles
• Loss of stretch reflexes
Aims of PT Rx
Acute phase
• Maintenance of an adequate airway
• Maintenance of MSK integrity (joint ROM and
muscle strength)
• Prevention of secondary health complications
• Relieve pain
• Prepare patient to get out of bed.
• Psychological support
• Educate patient, caregiver, family and staff
Autonomic dysreflexia
Autonomic Dysreflexia (AD)
• A syndrome of massive imbalanced reflex sympathetic discharge occurring in patients with spinal cord injury (SCI) above the splanchnic sympathetic outflow (T5-T6).
• It is an exaggerated response to stimuli resulting in an acute emergency.
• The increase in ICP and blood pressure can lead to cerebral hemorrhage and death.
• Occurs only after spinal shock has resolved
• Sex: male-to-female ratio for sustaining SCI is 5:1
• Age: No specific relationship has been documented between
Signs of AD
pounding headache, marked hypertension, excessive sweating (particularly of the forehead), bradycardia, flushing of the skin, piloerection (raising of hair / goosebumps), nausea and nasal congestion, blurry vision, spots in patient’s visual fields.
• Sometimes no symptoms may be observed
Causes of sympathetic AD
Anythingthatcancausediscomforttoa neurologically intact person can trigger autonomic dysreflexia in a patient with a spinal cord injury.
• Themostcommonstimulusisadistendedbladderor rectum.
• Other causes include: Stimulation of the skin from pressure, pain, heat or cold.
• Bowel-overdistentionorirritation • Skin-relatedDisorders
• SexualActivity
• Other
- Heterotopic ossification
- Acute abdominal conditions
- Skeletal fractures
Management
General Management of Autonomic Dysreflexia:
The goal of treatment is to identify and remove the cause of the dysreflexia and thus lower the BP.
• Checkthepatient’sbloodpressure.
• If blood pressure is elevated sit them up
immediately with feet down to promote orthostatic reduction of blood pressure. If patient unable to sit, elevate head of bed to 90 degrees.
• Loosen any clothing or constrictive devices
• Monitor the urinary catheter for any blockage or
twisting during treatment
Rehabilitation Phase Physiotherapy program must consist of: • Matwork • Muscle building exercises • Endurance training • Exercises for joint suppleness • Functional activities • Balance training • Self – care • Education on SCI and complications
Aims of functional rehab
• Reduce the occurrence of dizziness
• Re-educate balance
• Hyper-develop normal parts of the body to
compensate for the impaired parts.
• Increase endurance
• Educate transfer/ gait skills
• Empower patients through auto-exercise training
• Home program and carer training
• Psychological support and SCI education
• Education on preventing complications
Subacute to chronic stage physiotherapy management…
• Muscle strengthening • Home adjustments
• Sexual education
• Social services
• Vocational training and job placement
