Spinal Cord Injury Flashcards
Mechanisms of Injury for SCI
List + 1 Example
- Flexion (most common in L/S)
- Flexion-Rotation (most commin in C/S)
- INC risk of SCI
- Ex. Passenger turning to talk to driver & gets rear-ended - Axial Compression
- Heavy falls onto someones head OR driving into a pool head first - Hyperextension
- Rear end collision or elderly person falls & chin clips something ie. counter - Penetrating injuries
- Gunshot OR stab wound
Spinal Shock
Defintion & Characteristics
A transcient period of arereflexia immediately following SCI
Characterized by:
1. Absense of all reflex activity (approx 24 hr)
2. Impaired autonomic regulation
- Hypotension
- Loss of control of sweating
- Piloerection (goosebumps)
Spinal Shock Recovery
Total Areflexia = approx 24 hr
Gradual Return of Reflexes = 1-3 days
Increasing Hyperreflexia = 1-4 weeks
Final hyperreflexia = 1-6 months <- UMNL
ASIA Impairment Scale: A
ASIA A = Complete
No sensory or motor function in the lowest sacral segments (S4/5)
ASIA Impairment Scale: B
ASIA B = Sensory Incomplete
Sensory but not motor function is perserved below the neurological level (NLI) including sacral segments
Have sensory but motor loss
ASIA Impairment Scale: C
ASIA C = Motor Incomplete (Non-functional)
Motor function is perserved below the NLI & more than half of key muscles below the NLI have a muscle grade less than 3
Majority of key muscles below this level are grade <3
ASIA Impairment Scale: D
ASiA D = Motor Incomplete (Functional)
Motor function is perserved below NLI & more than half of key muscles below the NLI have a muscle grade of 3 or more
Majority of key muscles below this level are grade >3
ASIA Impairment Scale: E
ASIA E = Normal
Motor and sensory function is normal
Brown-Sequard Syndrome
Definition & Losses
Damage to one side of the spinal cord (hemi-section). Typically d/t penetrating wound
IPSI-lateral loss
1. Motor function (descending: lateral corticospinal tract)
2. Proprioception, discriminative touch, vibrations (ascending: dorsal column)
CONTRA-lateral loss
1. Pain & temperature (ascending: spinothalamic tract - crossed @ lvl of the spinal cord)
Anterior Cord Syndrome
Damage to the anterior portion of SC - commonly d/t cervical flexion injuries (damage to the ant portion of the cord &/or its vascular supply = anterior spinal artery)
Loss:
1. Motor function (corticospinal tract)
2. Pain & temperature (spinothalamic tract)
Below NLI
** Almost everything EXCEPT Dorsal Column
Central Cord Syndrome
Damage to central portion of the spinal cord with peripheral portions spared - commonly d/t hyperextension injury in C/S region
Compressive forces cause hemorrhage & edema damaging the central portion of the cord
Loss:
1. Motor > sensory
2. UE > LE
- L/E & sacral tracts are more LATERAL = less likely to be affected (spared)
- Sacral sensation spared. Sacral motor function often spared.
Posterior Cord Syndrome
Damage to the posterior portion of SC - very rare
Loss:
1. Proprioception, discriminative touch, vibration sense (ascending: dorsal column)
No motor loss - corticospinal tract is NOT affected - lateral
What is the most common spinal cord syndrome?
Central Cord Syndrome
Difference b/t FLACCID bladder & SPASTIC bladder?
FLACCID
- Detrusor mm does not have innervation - no tone
- Will not respond to stretch in the bladder > as it fills - pt does not get sensation that they need to pee (full) > so overfilled that it begins to dribble out = WET & pt cannot feel it
SPASTIC
- Detrusor mm reflexively contracts & bladder empties to a certain filling pressure (less than what is normal) = essentially HYPERreflexia & does not take a lot of volume before it starts reacting & contracting
- Dysenergy b/t mm & spincter = INC urinary frequency & urgent incontinence
AUTONOMIC DYSREFLEXIA
A pathological autonomic reflex xausing sympathetic over-activity in the body
Typically occurs in lesions above T6
More common in complete or near complete injuries
Usually occurs in first 3-6 months post-SCI
ASIA Impairment Scale: Pathophysiology
- Noxious stimulus below level of lesion
- May not be a true noxious stimulus. Ie tight or wrinkled clothing - INC sympathetic outflow (mass reflex response)
- Wide spread vasoconstriction, INE BP, INC HR
- HR the behins to DEC even though there is sympathetic activity that is overactive
- Bradycardia & hypertension @ the same time - Baroreceptors stimulated leading to INC vagal output causing DEC HR, but insufficient to counteract INC BP
- Vagus nerve is acting on th heart - slowing down its electrical impulses > effort to normalize BP (dangerous)
- Body’s mechanism of trying to normalize things & bring it back to homeostatis
Autonomic Dysreflexia: Triggers
(9)
- Bladder distention/ irritation **
- Bowel distention/irritation **
- Stimuli that would be normally be painful below NLI
- GI irritation
- Sexual activity
- Labor
- Skeletal fracture below NLI
- Electricial stimulation below NLI (careful w/ TENS/ IFC)
- Pressure sores ** (even more important they do not get pressure sores)
Primary & Secondary Complications of SCI
(7) + (7)
- Autonomic Dysreflexia
- Postural HYPOtension (loss of SNS - vasoconstriction & mm tone = more venous pooling = DEC cerebral BF = lightheadness, dizzy, etc)
- Impaired Temp Control (depends on lvl - more likely with C/S)
Impacts hypothalamus ability to regulate BF - ex. heat to skin to sweat - not able to let off heat = impairment in themoregulation - Respiratory Impairment - weakness of inspiratory & expiratory mm makes it difficult to clear secretions > infection. Also, acts as a restrictive disease b/c unable to take a deep breath > atelectasis.
- Spasticity
- Bladder & bowel dysfunction
- Sexual dysfunction
Secondary Complications:
1. Respiratory complications
2. Pressure sores
3. DVT
4. Contractures
5. Hetertropic Ossification - most common = hip & brachialis
6. Pain - repetitive use (W/C)
7. Fracture/ Osteoposis
NLI C1-4
(6)
- Most severe of the SCI lvls - greatest amount of impairments
- Patient requires assistance with breathing, secretion clearance (all respiratory muscles are affected)
- C1-3 requires ventilation - C4 is main innervation for DIAPHRAGM * Not strong enough on C3 alone
- Dependent for ADLs
- Totally dependent in transfers (mechanical lifts)
- Power wheelchair (tilt in space or reclining to help with pressure relief)
NLI C5
(4)
- NLI past this lvl can breath independently, may be laboured; abdominal binder may improve breathing (acts like INC tone = mechanical advantagous for the diaphragm - piston affect (push against))
- Dependent in transfers
- Manual W/C w/ propulsion aids for short distances (flat surfaces)
- Power W/C with adapted joystick for community
NLI C6
(6)
- Able to perform limited self-care activities with use of tenodesis grasp
- Independent to min. assist wtih sliding board - locked elbow (CCP), shoulders can flex b/c elbow locks & uses depressors of scapulas to lift up
- Independent w/ manual cough - hemlick manuever
- W/C propulsion for short distances / Power W/C for community
- Independent with pressure relief manuevers in W/C - arms into loops to pull themselves from side-to-side
- Capable of living independently
NLI C7
(3)
- Can extend elbow allowing for easier use of sliding board transfers
- Can do most ADLs by themselves, bed mobility much easier
- Manual W/C with fricton surface hand rims - may require assistance with ramps, curbs, etc b/c pt do not have use of intrinsic hand mm - need it for “wheelies” to get over obstacles
NLI C8
- Full use of hand instrinic mm, allowing for grapsing of objects w/ ease and less need for adaptive equipment
- Independent in all ADLs; may require adaptive equipment
- Manual W/C with standard hand rims
NLI T1-T12
(3)
- The lower the level of injury in the T/S, the better the trunk control as more abdominals and paraspinals will be functional
- May use orthoses (prescribed based on function) w/ assistive devices for short distances
- W/C for community
NLI L1-3
- May use orthoses (HFAFO, KAFO, AFO) with assistive devices for short distances
- W/C for community
L3 & > - using an AFO b/c it is less bulky
NLI L4-SI
- AFO w/ assistive device.
- NLI L4 may choose to use W/C for long distances
What is Glossopharyngeal Breathing (high cervical lesions)?
“Frog Breathing” = gulping the air.
Strategy to get bigger breaths
- Emergency situation where they are not on a ventilator
When should positioning and pressure relief manuevers be conducted?
Positioning = every 2 hours
Pressure relief = every 15 minutes when in a W/C & should be held for 2 minutes
Why should the pelvic be kept in neutral during the ACUTE/ EARLY phase?
L/S Posterior pelvic tilt can put tension on the SC & cause damage / irritation
LSP injury & Tetraplegia contraindications until orthopedic clearance?
LSP = SLR > 60 & hip flexion > 90 should be avoided
Tetra = mvmts of head/neck & shoulder flexion/abduction > 90 (spine stability & fully healed)
Selective Stretching: what do you stretch/ not stretch
Tightness in certain mm can enhance function
- Tight lower trunk muscles may INC trunk stability & sitting positions
- Tight long finger flexors will improve tenodesis grasp
Adequate length in certain mm can enhance function
- SLR ~100 needed for long sitting & LE dressing
- Functional:
1. Helps w/ assisted cough - lean forward fast = rapid flexion - INC intraabdominal pressure & this assist w/ the cough
2. Functional position to help put on their pants
Splinting (Intrinsic-plus splint)
- Wrist: 20 extension
- MCP: full flexion
- IP: full extenstion or slight flexion
- Thumb: natural opposition
Think: hamburger hands about to eat a burger
