Spinal Cord I Flashcards
4 Aspects of SCI Body Structure Function Exam and Eval
- Sensation
- Strength
- Muscle spasticity/ tone
- Range of motion
What are the 3 components of the International Standards for Neurological Classification of Spinal Cord Injury?
Sensory Testing
Motor Testing
Anorectal Exam
What does the ISNSCI determine?
- Sensory level
- Motor level
- Neurologic level
- Severity (complete vs. incomplete)
- ASIA Classification
What must you do in order to get an accurate classification?
Test ALL aspects of the exam
Two parts of sensory testing
- Light touch (DCML)
- Pin Prick (ALS)
How to do light touch sensory testing
Identify reference point on cheek
Use key sensory points at each dermatome from ISNSCI worksheet (move C2→S4, single side) Each key point assessed with single small swipe with wisp of Q tip
Grading for light touch
2: Intact
1: Impaired - can feel touch by feels different that reference
0: Absent
Instruction for light touch sensory testing
“Tell me when you feel me touch you, and if it feels the same or different than your cheek”
How to perform pin prick sensory testing
- Each key point is assessed with 4-6 touches in random order of sharp/dull with safety pin
Instruction for pin prick sensory testing
“tell me if you feel sharp or dull after each touch”
*after series of touches at each sensory point…
“Did that feel the same or different than your cheek?”
Pin prick grading
2: Intact
1: Impaired - can distinguish between sharp/dull but feels different than reference
0: cannot distinguish between sharp/dull
What position should the patient be in for sensory exam?
Supine
It is standardized and reproducible
Sensory exam considerations
Eyes open for instruction & demonstration (on own hand), eyes closed for exam
Differentiate between patient lacking sensation vs not understanding task
No leading questions – “did you feel that?”
MUST ask for comparison to reference to be able to distinguish between 1 or 2 grading
Pause exam if repositioning limb to access sensory point and explain to patient
What is the sensory level?
The most caudal level on each side with intact sensation for BOTH light touch and pinprick with all 2s above
ASIA Key Muscle Groups
- C5: Elbow Flexors
- C6: Wrist Extensors
- C7: Elbow Extensors
- C8: Long Finger Flexors
- T1: Small Finger Abductor
- L2: Hip Flexors
- L3: Knee Extensors
- L4: Ankle Dorsiflexors
- L5: Great Toe Extensors
- S1: Ankle Plantarflexors
ASIA Motor Grading
- 5 - Anti-gravity, full resistance
- 4 - Anti-gravity, partial resistance
- 3 - Anti-gravity, no resistance
- 2 - Gravity-eliminated, full ROM
- 1 - Gravity-eliminated, partial ROM or trace muscle contraction
- 0 - no trace muscle contraction
5 ISNSCI Motor Testing Considerations
Demonstrate task by moving patient through PROM first OR demo on self in patient’s line of vision – remember, they are supine!
Ask patient to move through AROM in anti gravity position first and then move to gravity eliminated if needed
Palpate over muscle belly of muscle being assessed in case you don’t see AROM
Support or “float” limb to eliminate effects of friction when moving in gravity eliminated position
Starting position accounts for restrictive antagonist muscles or extensor spasm/tone (see motor exam guide)
What if they have a motor grade of 0?
- Cue for muscle contraction regardless of whether it is happening or not
How do you determine the motor level?
- Most caudal level on each side with intact motor function with all 5s above
- Intact motor function = at least 3/5
How to determine Neurologic Level of Injury
Most caudal level with intact sensation and motor function bilaterally
How do you determine the neurologic level of injury if it is a thoracic level injury?
Go based on the sensory level
2 Parts of anorectal exam:
SENSORY: Includes S4-5 sensory point + Deep Anal Pressure (DAP)
MOTOR: Includes Voluntary Anal Contraction (VAC)
Why is the anorectal exam important?
Represents the most caudal segments of the spinal cord
Determines patient’s bowel/bladder function
Key determinant of severity of SCI – complete vs incomplete
What defines a complete vs incomplete spinal cord injury?
Absence or presence of sacral sparing
- Complete: No VAC, DAP, or S4-S5 sensation on either side
- Incomplete: If VAC, DAP, or or any S4-S5 sensory scores are >0 on either side
AIS A
No Sacral sparing in sacral segments
Complete SCI
AIS B
Sacral Sparing Present
Neither VAC present NOR motor function more than 3 levels below motor level on a given side
(Sensory incomplete/motor complete SCI)
AIS C
Sacral Sparing Present
There is VAC present OR there is motor function more than 3 levels below the motor level on a given side
Half of the key muscles below the NLI are NOT a grade 3 or better
AIS D
Sacral Sparing Present
There is VAC present OR there is motor function more than 3 levels below the motor level on a given side
Half of the key muscles below the NLI ARE a grade 3 or better
C5
Elbow flexors
C6
Wrist Extensors
C7
Elbow extensors
C8
Finger Flexors
T1
Finger abductors (little finger)
L2
Hip Flexors
L3
Knee extensors
L4
Ankle DFs
L5
Big Toe Extensors
S1
Ankle PFs
What are zones of partial preservation?
Most caudal innervation below sensory/motor levels in a sensory or motor complete injury (any innervation)
Sensory ZPP –in absence ofDAP (can be on one side only if S4-5 present unilaterally)
Motor ZPP – in absence of VAC
Central Cord Syndrome
Most common form of incomplete SCI
Commonly occurs from hyperextension injury or a fall by an older adult with underlying cervical disease
Greater motor deficits due to medial aspect of
corticospinal tract involvement (hands and forearms)
Pain and temperature sensation lost mainly in UE and trunk due to spinothalamic somatotopic organization
Bladder dysfunction but sacral sensation usually
preserved
Anterior cord syndrome
Sometimes referred to as anterior spinal artery syndrome or ventral cord syndrome
Caused by hyperflexion injuries of cervical spine resulting in infarction of anterior 2/3 of spinal cord or its vascular supply from ASA
Characteristic of motor paralysis below level of lesion
Loss of pain and temperature below level of lesion
Light touch, vibration and proprioception is typically preserved due to sparing of DCML
Brown-Sequard Syndrome
Characterized by a hemisection of the spinal cord
Presents as ipsilateral motor deficits and light touch, proprioception and vibration
Contralateral pain and temperature sensation loss
Most often caused by a trauma (GSW or stabbing to neck or back), and less commonly non- traumatic from a spinal tumor, inflammatory
disease process (MS, infectious disease process (TB, Meningitis) or blocked blood flow to spine
Posterior Cord Syndrome
- Uncommon
- Bilateral loss of proprioception and vibration sense DCML affected)
Cauda Equina Syndrome
nerve root compression/damage after
exiting spinal cord often leading to incontinence and LE weakness (LMN presentation)
Conus Medullaris Syndrome
similar presentation to Cauda Equina Syndrome w/ UMN signs as well
