SCI Pathophys and Clinical Presentation Flashcards
1
Q
What is found in the central gray matter?
A
- dorsal horn (sensory)
- intermediate zone (interneurons)
- ventral horn (motor)
2
Q
What is found in white matter?
A
ascending and descending columns
3
Q
Which part of the spine is preganglionic sympathetic?
A
T1-L2 lateral horn
4
Q
Which part of the spine is preganglionic parasympathetic?
A
S2-S4 lateral horn
5
Q
White matter ______ from caudal to cranial. Where is the volume of gray matter the highest?
A
increases
volume of gray matter highest in cervical and lumbosacral regions
- for UE and LE
6
Q
What are the major sources of vascularization for the spinal cord?
A
- Anterior spinal artery – ventral surface and supplies 2/3 of spinal cord
- Posterior spinal artery – posterior surface and supplies 1/3 of spinal cord
7
Q
What is the region of vulnerability (susceptible to infarct) in the spine?
A
T4-T8
8
Q
Functions of the dorsal column - medial lemniscus pathway
A
- conscious proprioception
- vibration
- light and discriminative touch
9
Q
Where does the dorsal column - medial lemniscus pathway decussate?
A
2nd order neurons cross in caudal medulla in internal arcuate fibers
10
Q
Location of the dorsal column - medial lemniscus pathway?
A
center posterior white matter
11
Q
function of anterolateral pathways
A
- pain
- temperature
- crude touch
12
Q
point of decussation of anterolateral pathway
A
2nd order neurons cross at level of spinal cord through anterior commissure
13
Q
location of anterolateral pathway
A
near ventral horn
- lateral and more anterior side
14
Q
functions of spinocerebellar pathway
A
unconscious proprioception from trunk and limbs
15
Q
point of decussation of spinocerebellar pathway
A
ascends ipsilaterally and contralaterally
- terminates in ipsilateral cerebellum
16
Q
location of spinocerebellar pathway
A
lateral edges of white matter
17
Q
function of lateral corticospinal tract
A
volitional movement of contralateral limbs
18
Q
point of decussation for lateral corticospinal tract
A
cross at pyramidal decussation and descend contralaterally
19
Q
location of lateral corticospinal tract
A
by posterior horn
20
Q
function of anterior corticospinal tract
A
controls bilateral axial and girdle muscles
21
Q
point of decussation for anterior corticospinal tract
A
descends ipsilaterally until level of spinal cord, then bilateral innervation
22
Q
location of anterior corticospinal tract
A
along ventral median fissure
23
Q
functions of rubrospinal tract
A
assists lateral corticospinal tract with descending drive for movement of contralateral limbs (flexors)
24
Q
point of decussation of rubrospinal tract
A
midbrain and descends contralaterally
25
location of rubrospinal tract
midpoint and towards lateral edge
26
functions of vestibulospinal tracts - medial and lateral
medial - control positioning of head and neck
lateral - truncal control and balance
27
point of decessation of vestibulospinal tracts - medial and lateral
medial - none (descends bilaterally)
lateral - non (descends ipsilaterally)
28
location of vestibulospinal tracts - medial and lateral
most ventral next to ventral median fissure
29
functions of reticulospinal tract
aids in posture and gait-related movements
30
point of decussation of reticulospinal tract
none - descends ipsilaterally
31
location of reticulspinal tract
midpoint near lateral horn and middle at endpoint of ventral median fissure
32
functions of tectospinal tract
assists with coordination of head and eye movements
33
point of decussation of tectospinal tract
crosses in midbrain and descends contralaterally to upper cervical cord
34
location of tectospinal tract
along ventral horn
35
Where are the most common sites of SCI overall?
- most mobile parts of the spine
Cervical - C5 and C7 - most common due to highest degree of mobility
- C4-C7 most frequently involved areas
Thoracolumbar - T12-L1
36
Function of methylprednisone and how is it used/impact prognosis?
- stabilizes cell membranes
- decreases inflammation
- increases nerve impulse generation
- improves blood flow to damaged area
small window of opportunity - 3-8 hours after injury
Incomplete - enhances return of some function below level
Complete - increases chances of return of function of the last preserved spinal level
37
What is spinal shock? Symptoms? What levels does it occur in?
- spinal cord ceases to function
- absent spinal reflexes, voluntary motor control, sensory function, and autonomic control
- dangerous high increase in BP followed by decrease in BP, HR, hypothermia, venous stasis
occurs with T6 injuries and above
38
How long does spinal shock last and what is the 1st thing to return?
- resolves within 24 hours to several days
- 1st thing to return - sacral/anal reflexes
39
What is autonomic dysreflexia? What causes it? Which injury levels?
- over-activity of autonomic nervous system due to irritating stimulus
- caused from full bladder, full bowel, burns, kinked clothes, ingrown nails, foreign object against skin
- T6 injuries and up
40
symptoms of autonomic dysreflexia
- pounding headache due to increase in BP
- goose bumps
- sweating above level of injury
- bradycardia
- skin blotching
41
What should you do if your patient is having an autonomic dysreflexia crisis?
1) Sit them up immediately if lying down
2) If already sitting, remain sitting
3) Check catheter
4) Check clothing
5) Check skin
6) Initiate emergency response if not resolved within 10 min
- Patient education is crucial
42
What level injuries is spasticity common?
cervical lesions
43
At what level and below will the patient have normal ventilatory and respiratory function?
T10 and below
44
C1-C2 respiratory muscles
- SCM
- upper trap
- cervical extensors
45
C3-C4 respiratory muscles
- partial diaphragm
- scalens
- levator scapulae
46
C5-C8 respiratory muscles
- diaphragm
- pec major and minor
- serratus anterior
- rhomboids
- lat dorsi
47
T1-T5 respiratory muscles
- some intercostals
- erector spinae
48
T6-T10 respiratory muscles
intercostals and abdominals
49
How does bladder dysfunction differ between SCI levels?
- Above conus medullaris/sacral segments (L1) – spastic/hyperreflexic bladder
o Voiding is involuntary and incomplete
- Lesion to conus medullaris/sacral segments – flaccid/areflexic bladder
o Bladder overfills and over-distends
o Overflow and stress incontinence may occur
50
How does bowel dysfunction differ between SCI levels?
- Above S2 – spastic/reflex bowel
o Excrement is involuntary and incomplete
- S2-S4 – flaccid/areflexive bowel
o Bowel overfills and over-distends
- overflow and stress incontinence can occur
51
Symptoms of bladder and bowel dysfunction
- fever
- chills
- nausea
- headache
- increased spasticity
- autonomic dysreflexia
- dark or bloody urine
52
What are some of the more common presentations of sexual dysfunction post SCI for males and females?
Males
- directly related to level and completeness of injury
- erectile capacity spared w/ UMN lesions, but fertility impacted
Females
- menstruation and fertility most likely spared
- pregnancy is high risk
53
What are common issues seen regarding blood pressure management post SCI? Why do we see this?
- T6 and up – bradycardia, excessive peripheral vascular dilation
- Orthostasis common at all levels
o Lack of muscle tone AND loss of sympathetic vasoconstriction response in the LE’s causes venous pooling in LE’s
54
What types of pain do we see with SCI?
- Neuropathic
o Poorly localized
o Can be exaggerated by noxious stimuli, UTO, spasticity, bowel impaction, and smoking
- Orthopedic
o Common – shoulder overuse injuries and low back pain
55
How do we manage OP and renal calculi?
- Early mobilization
- Therapeutic standing
- Administration of calcium supplements
- Good dietary management
56
What is Anterior Cord syndrome and what are the common causes?
- damage to cord itself, damage to Anterior Spinal Artery, or both
Caused by flexion or burst injuries
57
What will be the clinical presentation of a patient with anterior cord syndrome? What will their ASIA exam look like?
- loss of motor function and pain/temp below level of injury bilaterally
- Light touch sensory intact
o Asia exam will have all 2’s for both light touch (dorsal column) but abnormal motor and pin prick (anterolateral)
58
At what level does central cord syndrome usually occur at?
cervical
59
What are the typical mechanisms of injury that can lead to central cord syndrome?
- Damage to central aspect of spinal cord – almost exclusively a cervical injury
- Elderly patient, or prior spondylosis/stenosis – extension injury
o Minor trauma like a fall
- Younger patient – flexion and compression
o + vertebral trauma, herniated disc
60
What will be the clinical presentation of a patient with central cord syndrome?
- UE > LE involvement – reverse spinal cord injury
- UE motor loss > LE motor loss
- Sparing sacral sensation and may have sparing sacral motor
- variable sensory loss (UE > LE)
61
What are the typical mechanisms of injury that can lead to Brown-Sequard syndrome?
- Damage to one side of spinal cord
- Knife wound, gun shoot wound
62
What will be the clinical presentation of a patient with Brown-Sequard syndrome? What will their ASIA exam look like?
- Ipsilateral motor and dorsal column symptoms and contralateral anterolateral pathway symptoms
- Ipsilateral spasticity common below level of lesion
- ASIA exam
o Side of injury – normal pin prick and abnormal motor and light touch
o Opposite side – abnormal pin prick and normal motor and light touch
63
What are the typical mechanisms of injury that can lead to posterior cord syndrome?
- Compression by disc or tumor
- Posterior spinal artery infarct
- Vitamin B12 deficiency
64
What will be the clinical presentation of a patient with posterior cord syndrome?
- Dorsal column lost bilaterally below level of lesion
o Completely lose proprioception, light touch vibration
- Motor and pain/temp are normal
- ASIA exam
o Light touch abnormal bilaterally with motor and pin prick normal
65
What do we know about the prognosis for functional return for anterior cord syndrome?
- Extremely poor prognosis for bowel/bladder function, hand function, and ambulation
- 10-20% chance of motor recovery
o Demonstrate poor power and coordination even with recovery
66
What do we know about the prognosis for functional return for central cord syndrome?
- Most people regain some ambulatory function
- > 50% recover bowel and bladder control
- Intrinsic hand function last to return
67
What are some known positive prognostic indicators for functional return for central cord syndrome?
- Good hand function
- Evidence of early motor recovery
- Young age
- Absence of spasticity
- Pre-injury employment
- Absence of LE neurologic motor impairment at rehab admission
68
What do we know about the prognosis for functional return for Brown-Sequard syndrome?
- Very good prognosis
- Nearly all patients attain some level of ambulatory function
- 80% regain hand function
- 100% regain bladder control and 80% regain bowel control
69
What are the typical mechanisms of injury that can lead to conus medullaris syndrome?
- Damage to sacral cord and lumbar nerve roots
o Trauma
o Tumors
o Infections
o stenosis
70
What will be the clinical presentation of a patient with conus medullaris syndrome?
- Sudden onset of UMN and LMN symptoms
- Symmetrical saddle anesthesia
- Symmetrical weakness/flaccidity
- Hypotonicity
- Distal LE areflexia – may see intact sacral reflexes
- Sexual dysfunction
- Mild low back pain with mild radicular symptoms
- Bowel and bladder dysfunction (urinary retention and atonic anal sphincter)
71
What is the typical treatment for conus medullaris syndrome?
- surgical decompression
- Do not have PT until they have their surgical decompression
72
What are the typical mechanisms of injury that can lead to cauda equina syndrome?
- Injury below L1 to lumbosacral roots of peripheral nerves – LMN injury (cord spared)
- Lumbar burst fracture or herniated disc
73
What will be the clinical presentation of a patient with cauda equina syndrome?
- Asymmetrical saddle anesthesia, bowel and/or bladder dysfunction, asymmetrical LE weakness
- Variable sensory loss – partial vs complete loss
- Flaccid paralysis, areflexia – loss of sacral reflexes
- Flaccid paralysis of bowel and bladder
- Severe low back pain often with severe radicular pain
74
What is the typical treatment for cauda equina syndrome?
surgical decompression
75
Which has the better prognosis: conus medullaris or cauda equina syndrome?
cauda equina because its a peripheral nervous issue
76
How do prognoses compare for conus medullaris and cauda equina syndromes?
Cauda equina – best prognosis b/c peripheral nervous issue
- Bladder outcomes worsen the longer the cauda equina is compressed
- Prognosis improves when surgery is withing 48 hours of presentation
- Better prognosis for nerve regeneration since it is a PNS injury
Conus Medullaris
- Similar to cauda equina but have less favorable prognosis due to UMN injury
- 10% regain function
77
T/F: Conus Medullaris syndrome has severe pain.
false - cauda equina syndrome has severe pain
- conus medullaris has mild pain
