Spinal Cord Injuries Flashcards by Mia Pirouet

brief CNS and sc refresher -

Sc is our motor way of information
Sc sits within the bony protection of the spinal column surrounded by protective tissue - dura
Nerve roots emerge from the vertebral foramen at each segment level
Ascending and descending pathways/tracts

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Afferent sensory tracts
Dorsal column -

Fine touch
2 point discrimination
Vibration
Conscious
Proprioception

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Afferent sensory tracts
Spinothalamic -

Pain
Course touch/ pressure
Temperature

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Afferent sensory tracts
Spinocerebellar -

Proprioception (unconscious)
Coordination

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Descending motor tracts
Corticospinal tract -
Rubio spinal -

Cortico - voluntary conscious movement

Rubio - tone-manly flexors of upper limb

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Descending motor tracts
Retiiculopsinal -
Vestibulospinal -
Tectospinal -

Reticulopsinal - tone, postural axial tone, resp/circulator systems

Vestibulospinal - extensor activity
Balance and posture

Tectospinal - auditory and visual stimuli

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Autonomic NS
Parasympathetic, what does it do?

Rest and digest
Constricts pupils
Stimulates saliva flow
Slows heart rate
Constricts bronchi
Stimulates stomach, pancreas and intestines
Stimulates bile release
Contracts bladder

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Autonomic NS
Sympathetic - what does it do?

Fight or flight
Dilates pupils Stimulates saliva
Inhibits saliva flow
Accelerates hr
Dilates bronchi
Stimulates stomach, pancreas and intestines
Converts glycogen to glucose
Secretes adrenaline
Inhibits bladder contraction

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Background and stats of SCI in the uk:

Approx 105,000 people in uk live with a SCI
Previously, predominantly young male individuals
1.5:1 male:female

Demographics are changing, seeing an increase in proportion of elderly population

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Causes of SCI
Traumatic: 3 different mechanisms -

1) destruction - from direct trauma
2) compression - by bone fragment, hematoma or disc material
3) ischaemia - from damage or impingement on spinal arteries

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Causes of SCI
Non-traumatic -

Degenerative disc disease and spinal canal stenosis
Spinal infarction
Tumour
Inflammation of spinal cord
Viral infection
Developmental/ congenital abnormalities

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Types of SCI
Complete -

Complete loss of function below the injury
Motor
Sensory
Auntonomc dysfunction
- postural hypotension - vast motor control
Autonomic dysreflexia - medial emergency, response to stimuli resulting in sudden increase in BP and decrease in HR
- problems with bladder and bowel function
- problems with sexual function

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Types SCI
Incomplete -

Some sparing of neural activity below the level of the lesion
4 main types

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Types SCI
Tetra/quadraplegia -

Impairment at cervical segments of the cord
Affects all four limbs - upper and lower

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Types SCI
Paraplegia -

Impairment at thoracic, lumbar or sacral segments of the cord
Involving lower limbs
Depending on level of injury , trunk, legs and pelvis may be involved

What are the vulnerable areas of the vertebral column?

Cervical spine - typically C5-7, bc of weight of head and pivot point

Thoracolumbar, typically T12 - often from falling

Majority of traumatic cases are due to dislocation

Incomplete SCI
Central cord syndrome -

Motor dysfunction in upper limbs
Bladder dysfunction
Corticospinal and spinothalamic tracts

Cause - hyperextension injury to neck

Incomplete SCI
Anterior cord syndrome -

Motor paralysis below leison
Loss of pain and temperature sense
Retained proprioception and vibration
Cause - disc herniation

Incomplete SCI
Brown-sequard syndrome -

Motor deficit and numbness to touch and vibration on same side of leison
Loss of pain and temperature sensation on opposite side (because of tracts crossing at different levels)
Most common cause - stab or gunshot wound to cervical or thoracic spine

Incomplete SCI
Posterior cord syndrome -

Sensory disturbance and less motor loss
Compression to posterior/sensory section of spinal cord
Cause - posterior impact or hyperextension trauma

InComplete SCI
‘Special one’ to make a 5th type - Cauda equina syndrome -

Lower motor neurone lesion
Motor and sensory loss in lower limbs Bladder dysfunction
Saddle anaesthesia, bilateral lower limb sensory changes
Causes - lumbar stenosis, spinal trauma, metastatic tumour

Incomplete SCI
Cauda equina - immediate medical management -

Following trauma, treatment begins with stabilisation
Need to have normal oxygenation, perfusion and acid/base balance to aid management of the injury
Vasogenic oedema and altered flow account for clinical deterioration - hypotension and shock can aggravate SCI
Surgical intervention - possibly decompression, removal of foreign body stabilise the spine
Alongside medical management of any other trauma sustained

Post acute management of CES - (of complications)

Urinary and bowel management
Skin integrity (pressure sores)
DVT
Autonomic dysreflexia (at or above T6)
Orthostatic hypotension (postural hypotension)

What is autonomic dysreflexia? S+s -

Life threatening condition It is an uninhibited sympathetic nervous system response to a variety of noxious stimuli occurring in people with spinal cord injury at T6 level or above S+s - raised BP, bradycardia, pounding headache, flushing, sweating or blotching above level of injury: pale, cold, goosebumps below level of injury, anxiety or apprehension Seek urgent medical support and remove/ relieve noxious stimulus if possible

Defining the level of the lesion - Eg, with loss of biceps -

Define the level of injury as the first spinal segmental level that shows abnormal neurological loss Eg person has loss of biceps (C5), the motor level of injury is often said to be C4

What scale can be used asses sensory and motor levels? How does it work?

ASIA impairment scale (American spinal injury association scale) 5 levels - A-E A- complete, no motor or sensory function is preserved in sacral segments S4-S5 B- incomplete, sensory but not motor function preserved C- imcomplete, motor function preserved below neurological level and more than half of key muscles below grade less than 3 D- incomplete, same as above but muscles grade more than a 3 E - normal - motor and sensory function are normal

ASIA and Myotomes and Dermatomes C5 - C6 - C7 - C8 - T1 -

C5 - shoulder abd/LR, elbow flexors C6 - wrist extensors/flexors, pron/sup C7 - shoulder add/MR, elbow extensors C8 - finger flexors/ext T1 - finger abduction

ASIA Myotomes and Dermatomes L2 - L3 - L4 - L5 - S1 - S4-5 -

L2 - hip flexors L3 - knee extensors L4 - ankle dorsiflexion L5 - long toe extensors S1 - ankle plantar flexors S4-5 - anal sphincter

Diagnosing SCI Differential diagnosis - What presents in a similar way?

Diagnosis is based on patients presentation However, broader differential must be considered for sensorimotor weakness when the insert and preceding events are unclear Other pathologies leading to sensorimotor loss/weakness: Central NS pathologies - stoke, MS Neuromuscular junction - myasthenia gravis and botulism Peripheral nerve - Gillian-barre syndrome, transverse myelitis Other - hypoglycaemia and diabetic neuropathy

Spinal nerve root action in relation to vertebrae C1-3 - C4 -

C1-3 - limited head control C4 - breathing and shoulder shrug

Spinal nerve root action in relation to vertebrae C5 - C6 - C8 -

C5 - lift arm with shoulder, elbow flex C6 - elbow flex and wrist ext C8 - finger flexion

Spinal nerve root action in relation to vertebrae T1 - T2-T12 - T6-L1 -

T1 - finger movement T2-12- deep breaths, deep breathing T6-L1 - deep exhale of breath, stability whilst sitting

Spinal nerve root action in relation to vertebrae L1-2 - L2-3 - L3-4 -

L1-2 - hip flexion L2-3 - hip movement towards middle of body L3-4 - knee extension

Spinal nerve root action in relation to vertebrae L4-5 - L5 -

L4-5 - ankle extension L5 - extension of big toe

Spinal nerve root action in relation to vertebrae S1 - S1-2 - S2-4 -

S1 - movement of foot and ankle S1-2 - toe movement S2-4 - function of bladder and bowel

Ascending tracts transmit - Descending tracts transmit - The two sections of autonomic NS-

Ascending - sensory Descending - motor Autonomic sympathetic and parasympathetic

What are the sages of autonomic dysreflexia?

SCI level t6 or above 1) catheter blockage for eg, stimulus below level of injury, too much urine in bladder 2 stretched bladder sends nervous impulses to the spinal cord 3) when impulses reach level T6,sympathetic neurones become activated and release chemicals called norepinephrine. 4) causes blood vessels in skin and abdomen to constrict. BP rises *sudden increase in BP is medica emergency as can lead to strokes, seizures or even sudden death 5) rise in BP detected by sensors in heart and neck (baroreceptors) these send signals to brain 6) 2 ways brain can oppose rise in BP. First, sends messages via parasympathetic vagus nerve to heart to slow is down 7) brain sends messages down SC making blood vessels open up Cord injury prevents messages, only blood vessels above injury dilates. It’s not enough to overcome constricted vessels below injury level, therefore BP continues to rise and HR remains slow