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Patho II > Spinal Cord Injury > Flashcards

Spinal Cord Injury Flashcards

1
Q

Organization of the vertebral column

A 
VERTEBRAE
7 cervical
12 thoracic
5 lumbar
5 fused sacral
3/4 fused coccygeal

NERVES
Named for the vertebrae where they exit
8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal
C1-C7 nerves exit ABOVE the corresponding vertebrae
C8 and on exit BELOW the corresponding vertebrae

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2
Q

Intervertebral disks

A

Allow for flexibility and movement. Contain the nucleus pulposus (inner) and annulus fibrosus (outer)

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3
Q

Support in the spinal cord

A

provided by longitudinal ligaments connecting the bones: anterior, posterior longitudinal; supraspinal, interspinal, and ligamentus flavum.
Ligaments are not as strong on the backside–herniation more likely backwards

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4
Q

Major elements of central nervous system organization

A
  • White matter (internal in the brain, external on the SC) contain axons while Grey matter contains cells bodies (soma)
  • Efferent neurons move from the motor cortex=> SC => muscles. Most cross at medulla oblongata (contralateral)
  • Afferent: Sensory receptors => SC => sensory cortex. Some cross (contralateral) some don’t (ipsilateral)
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5
Q

Nerves innervating the ANS

A

PNS: cerebral and sacral nerves
SNS: T1 to L4ish

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6
Q

Causes of Spinal injury

A

Serious injury: car crashes, falls, gunshots/stab wounds, sports injuries (diving).
Less serious: lifting, minor falls

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7
Q

Plegia

A 
Paralysis
monoplegia = one limb
hemiplegia = both limbs on one side
paraplegia = both upper OR both lower limbs
quadriplega/tetriplegia = all four limbs
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8
Q

Paresis

A

Weakness. Can be ipsilateral (same side) or contralateral.

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9
Q

Muscle Tone related terminology

A 
Hypotonia = less than normal tone
flaccidity = absent tone
Hypertonia = excessive tone (ie drug addicted babies)
Spasticity = stiff, awkward movements
Rigidity = immoveable stiffness
Tetany = intermittent tonic spasms (Paroxysmal)
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10
Q

Vertebral column injuries

A 
Fracture = fragmentation of the bone: pedicle, lamina, process
Dislocation = displacement of the vertebral body
Subluxation = partial dislocation
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11
Q

Types of vertebral injuries

A

Flexion
extension
compression
axial rotation (ie in shaken baby syndrome)

Extent of injury d/o location and severity

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12
Q

Patho of SCI (initial)

A
  • Mechanical disruption of the neurons - vertebrae can grip onto them
  • injury-related ischemia and hypoxia => local infarction / necrosis of neural tissue
  • development of micro-hemorrhages or edema which interrupt neuronal function
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13
Q

Patho of SCI (Secondary)

A

Progressive neurologic damage due to initial injury

  • some can be reversible*
  • Vascular damage leads to ischemia, vascular permeability, edema
  • Neuronal injury leads to loss of reflexes below the level of injury (spinal shock)
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14
Q

Prevention of Secondary effects/damage

A

Immediate immobilization and steroids

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15
Q

Types of SCI

A
  • incomplete transection: partial preservation of sensory and motor function (central cord, anterior cord, brown sequard, conus medullaris)
  • Complete transection: absence of sensory and motor function (leads to quadriplegia above T1/ paraplegia below T1)
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16
Q

Effects of SCI at or above C5

A

Respiratory paralysis b/c diaphragm doesnt work, quadriplegia

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17
Q

Effects of SCI C5-C6

A
  • Paralysis of legs, wrists, and hands
  • weak shoulder abduction and elbow flexion
  • loss of brachioradialis reflex
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18
Q

Effects of SCI C6-C7

A
  • Paralysis of legs, wrists, hands
  • shoulder and elbow flexion usually possible
  • loss of biceps jerk reflex
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19
Q

Effects of SCI C7-C8

A

Paralysis of legs and hands

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20
Q

Effects of SCI C8-T1

A
  • Homer’s syndrome (constricted pupil, ptosis, facial anhidrosis)
  • Paralysis of legs
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21
Q

Effects of SCI T11-T12

A

Paralysis of leg muscles above and below the knee

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22
Q

Effects of SCI T12-L1

A

Paralysis below the knee

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23
Q

Effects of SCI at the Cauda Equina

A
  • Hyporeflex or areflexic paresis of the lower extremities
  • Usually pain or hyperesthesia in the nerve roots (increased sensitivity)
  • Loss of bowel and bladder control
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24
Q

Effects of SCI S3- S5 or Conus medullaris at L1

A

Complete loss of bowel and bladder control

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25
Q

Central Cord Syndrome

A

Damage to central gray or white matter of cord. Can happen in osteoperosis/ bone degradation or trauma.

  • Most affects motor function of upper extremities. Paresis or paralysis, loss of fine motor function
  • Less effect on LE motor fxn, bowel, bladder, sexual fxn.
  • Recovery: Can become ambulatory and control bowel and bladder, but often incapable of detailed work with hands.
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26
Q

Anterior Cord Syndrome

A

Infarction of anterior spinal artery. Damages anterior 2/3 of cord.
Most affected: loss of motor fxn, loss of pain and temp sensation. Reduction/loss of local reflexes and LMNs of the anterior horn.
Less affected: Posterior 1/3 of cord, which conveys position, vibration, and touch.
Recovery: tend to do poorly

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27
Q

Brown-Sequard Syndrome

A

Damage to a hemi-section of the anterior and posterior cord.
Most affected:
- loss of voluntary motor fxn from the corticospinal tract.
- Ipsilateral proprioception lost.
- Contralateral pain and temp sensations (below the lesion) lost.

Recovery: Can improve to point of ambulation and bowel and bladder control.

28
Q

Conus Medullaris Syndrome

A

Damage to the CM or the Sacral cord and lumbar nerve roots w/in neural canal.

Most affected:

  • flaccid bowel, bladder, and sexual function (ED, saddle anesthesia, Urinary and fecal incontinence, hypotonic anal sphincter, abnormal bulbocavernosus and anal wink reflexes)
  • motor fxn in legs and feet: Distal leg paresis

Less affected: reflexes are preserved if only CM is involved. May not have sensory impairment

29
Q

Cauda Equina Syndrome

A

Damage to lumbosacral nerve roots w/in the canal

Most affected: patterns of asymmetric flaccid paralysis, sensory impairment, pain

30
Q

Neuro exam for SCI

A

Should include:

  • Mental status and speech
  • cranial nerves
  • Central and peripheral sensory fxn
  • Motor fxn
  • Cranial and peripheral reflexes
  • cerebellar fxn and gait
31
Q

Diagnostics: X-Ray

A

Provides detail of the bone structures in the spine.

  • USED to rule out instability, tumors, fractures
  • Does NOT capture disc and nerve root structures.
  • Can’t be used to diagnose lumbar disc herniation/nerve pinching.
32
Q

Diagnostics: CT

A

Useful for imaging large disc herniations (but can miss smaller ones)

33
Q

Diagnostics: CT with Myelogram

A

Use a radiopaque dye into the sac around the nerve roots to light them up.

  • good info about nerve roots.
  • sensitive for nerve impingement and can pick up subtle lesions.
34
Q

Diagnostics: MRI

A
  • Most useful imaging study available for spine surgery (but expensive!)
  • Aids in assessment of certain conditions by providing detail of the disc and nerve roots
  • Provides refined detail of spine anatomy
35
Q

Diagnostics: EMG

A

Electromyography (more rare)
Like EKG but for nerves–assesses electrical activity
- used to distinguish neuropathy (nerve degeneration) from radiculopathy (nerve root compression)

36
Q

Diagnostics: SSEP

A

Somatosensory Evoked Potentials (more rare)

  • assesses speed of electrical conduction across spinal cord
  • if it’s pinched the electrical signals will travel slower
  • used to monitor SC during surgery
37
Q

SCI: Early Management

A

Immediate goal to reduce neuro deficits and prevent additional losses.

  • immobilize with neck collars and back boards
  • log roll and secure head
  • Cervical traction for cervical injury
  • Bedrest and log rolling for thoracic and lumbar injury
  • high dose methylprednisone w/in 8 hrs to stabilize (but watch out for pneumonia)
38
Q

Alterations in Spinal reflexes: UMN lesions

A
  • affected by any injury at or above T12
  • results in spastic paralysis of affected skeletal muscles groups and muscles that control bowel, bladder, sexual fxn.
  • Can still have a reflex arc but lack control
39
Q

Alterations in Spinal reflexes: LMN lesions

A
  • With injuries below T12
  • Result from damage to the peripheral nerves
  • Causes flaccid paralysis (no reflex arc) of involved skeletal and muscle groups
40
Q

Spinal or Neurogenic Shock

A

often the first complication of injury
- State of areflexia
- loss of most/all spinal reflexes below injury level
- manifestations: flaccid paralysis, lack of reflexes and autonomic fxn.
- can last minutes, hours, days, weeks but usually self limiting
(body may regain fxn)

41
Q

Innervation for Ventilation (when functioning)

A
  • Diaphragm innervated by phrenic nerves, C3-C5.
  • Intercostals innervated by T1-T7
  • Major muscles of expiration innervated by T6-T12
42
Q

Ventilation dysfunction r/t level of injury

A

C1-C3 injury: Lack of respiratory effort, requires ventilation
C3-C5 injury: allows partial diaphragmatic fxn but ventilation is diminished
Below C5: ability to take a deep breath and cough is less impaired

43
Q

Tools for meeting communication needs (patient is VERBAL)

A
  • they made need intubation*
  • Fenestrated tracheostomy tubes: provide airflow for vibration of the vocal cords
  • talking tracheostomy tubes
  • Diaphragmatic pacing
  • Electrolarynx-type devices
  • Mechanical ventilation w/ air leak (use vibration)
44
Q

Tools for meeting communication needs (patient is NON-VERBAL)

A
  • Communication boards or cards
  • computerized scanning programs
  • Mouth-stick control devices
45
Q

ANS Dysfunction

A
  • above level of injury - normal fxn*
  • Ascending and descending transmission below injury is blocked: uncontrolled spinal and autonomic reflexes
  • Biggest issues: Autonomic regulation of circulatory function and thermoregulation
  • Higher the level of injury the more profound the effect (especially above T6) – watch for diaphragm, IC muscles, baroreceptors in carotids.
46
Q

Vasovagal response

A

(Normal = vagus has inhibitory effect on HR/SNS)
Vagal stimulation => vasovagal response => bradycardia or asystole b/c SNS signal blocked
- If you need to deep tracheal suction, hyperoxygenate first in case they need O2
- Avoid rapid position change - if necessary to do so have anticholinergic drugs available to work against PNS

47
Q

Autonomic Dysreflexia: Causes

A

(stimulation that would normally be non-threatening become life threatening)

  • Visceral distension ie full bladder or rectum
  • pain: pressure ulcers, ingrowns, dressing changes, operative procedures
  • Visceral contractions: ejaculation, bladder spasms, uterine contractions
48
Q

Autonomic Dysreflexia: Description

A

Patients can’t feel stimulus but signals are still being sent.

  • Acute episode of exagg. SNS reflex response
  • Characterized by: Hypertension, bradycardia, headache from vasodilation
  • Does not occur until spinal shock has resolved and reflexes return (w/in 6 mo) but timing unpredictable and can occur throughout life
  • T6 and above injuries
49
Q

Autonomic Dysreflexia: Patho

A

Unregulated SNS activity =>
Vasospasm, hypertension, skin pallor, piloerection =>
baro-reflex mediated vagal bradycardia, vasodilation.
Skin flushed and profuse sweating above the injury (pallor below)

50
Q

Postural Hypotension

A
  • with injuries at T4-T6 and above*
  • related to descending control of sympathetic outflow to blood vessels in the extremities and abdomen
  • Blood pools without responding vasoconstriction => Low CO
  • SIGNS: dizziness, pallor, sweating above injury level, bblurred vision, fainting.
  • PREVENTION: change position slowly, promote venous return.
51
Q

Alterations in temperature Regulation

A
  • Again related to SNS helping regulate*
  • Central mechanisms for temp in hypothalamus
  • Sympathetic effector responses below level of injury are disrupted (can’t conserve or dissipate heat)
  • Higher level of injury = more disturbance
  • Poikilothermy: assuming the external temperature
  • Education: clothing choice and awareness of environment
52
Q

Circulatory System Dysfunction

A
  • Edema and DVT common b/c blood doesn’t return
  • Low PVR, areflexia and hypotonia lead to incr. venous pressure and pooling
  • Respond with Elevation and compression (AE Hose)
  • Respond to DVT: low dose heparin, ROM, compression devices
53
Q

Sensorimotor Dysfunction

A
  • Isolated reflex activity and muscle tone no longer under control of higher centers
  • Results in hypertonia/ spasticity below level of injury
  • May be tonic (sustained) or clonic (intermittent)
  • Occurs in injuries above T12 - below the response is damaged @ spinal cord or nerve level
  • Stimuli: stretching, infection, distension, pressure
  • Intervention: PROM, avoid stimuli, antispasmodics
54
Q

Skin

A
  • Skin injury is the most preventable complication from SCI*
  • innervation by nerves in dermatomes
  • SNS: control vasomotor and sweat glands, provide circulation, excretion, temp regulation

Factors of injury: pressure, shearing, trauma, irritation, sweat
Intervention: relieve pressure, encourage circulation, inspect for breakdown

55
Q

Pain

A
  • Diverse and unpredictable- could be none or lots*
  • Mechanical/Fracture pain: Dull, aching, at level of injury (from soft tissue damage)
  • Radicular or spinal nerve root pain: aching/shooting along distribution
  • Visceral: poorly localized, burning. r/t bladder distension or UTI
  • Central: diffuse burning sensationb elow level. Aggravated by touch, movement, distansion

Interventions: TENS, TCAs, Anticonvulsants, NSAIDs, PT

56
Q

Bladder Function

A

In health: sensory signals from stretch receptors to voiding center to motor neurons

  • SNS: detrusor relaxation (bladder filling)
  • PNS: detrusor contraction (voiding)
  • UMN injury: spastic bladder dysfunction. Lack awareness of filling/ voluntary control => incontinence
  • LMN injury: flaccid bladder dysfxn. Lack awareness of filling and tone. Cannot void => retention and overflow.

Intervention: drainage, external collection, manual techniques

57
Q

Bowel elimination

A

In health: SNS: T6-L3 = low motility and high sphincter tone.
PNS: S2-S4: high motility, low sphincter tone.

  • Injuries S2-S4: flaccid fxn of defecation reflex = loss of voluntary control
  • injuries above S2: spastic function of defectaion reflex => intrinsic contractile response intact but no defecation reflex.

Intervention: high fluid, high fiber diet, mobility, privacy, positioning, laxatives

58
Q

Sexual fxn

A

In health: T11-L2: mental stimuli or psychogenic sexual response
S2-S4: sexual touch or reflexogenic sexual response
Spinal cord injury at any level: disrupts neural pathways.
- UMN lesion (T10 and higher): reflex sexual response to touch but not mental stimuli
- LMN lesion (T12 and below): reflex center may be damaged. No response to touch, may have mental stimuli.

Intervention: erectile aids, lubricants.

May still have fertility!

59
Q

Herniated Disks- reasons

A
  • Trauma (50%): microfractures or microtears
  • Aging
  • Degenerative disorders (ie osteoperosis)
60
Q

Most common herniation

A

Posterior and oblique toward the intervertebral foramen.

61
Q

L5 nerve impingement

A

Can cause weakness in extension of big toe and ankle. Numbness and pain on top of foot and pain into buttocks

62
Q

S1 nerve impingement

A

May cause loss of ankle reflex or weakness in ankle push. Numbness and pain down the sole or outside of foot.

63
Q

Lumbar disk herniation

A

most comon L4 to L5 or L5 to S1

64
Q

Cervical Disk herniation

A

Most common = C6 to C7 and C5 to C6.

  • C5 = shoulder pain, deltoid weakness, possibly some numbness in the shoulder. Bicep reflex may be reduced
  • C6 = weak biceps and wrist extensors, pain/numbness down arm to thumb. Brachioradialis reflex may be diminished.
  • C7 = pain/numbness down arm to middle finger. Tricep reflex may be diminished
  • C8 = hand dysfunction (nerve to small muscles of the hand). pain/numbness to outside of little finger and impair reflex.
65
Q

Disk herniations: Manifestations

A
  • # 1 = pain
  • intensified by coughing, sneezing, straining, stooping, standing, jarring
  • radiating
  • slight motor weakness
  • paresthesias and numbness
  • lowered reflexes
66
Q

Disk herniations: management

A
  • analgesics: NSAIDS or short term opioids
  • Anti-inflammatories: steroids or cortisone injection
  • Muscle relaxants
  • conditioning exercise
  • PT
  • Chiropractic manipulation
  • Education: corrected mechanics for lifting and protection
  • Surgical indications: documented herniation, consisted pain or neuro deficit, failure to respond to other therapy, incontinence, foot drop

Patho II (12 decks)

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