Spinal Cord Injury Flashcards
- 2500-3000BC:
First documented on the “Edwin Smith Surgical Papyrus,” described as “an ailment not to be treated”
Described a patient that we would now call a complete cervical spine injury
- 400BC:
Hippocrates correlated visceral dysfunction with SCI
Constipation, bladder difficulty, bed sores, venous stasis
Poor outcomes associated with obstruction of visceral organs
Promoted special diets for SCI
Credited with first treating deformities with traction
SCI Epidemiology:
17,730 new cases per year
~291,000 persons living with SCI
> 50%: 16-30 year old at time of injury
Men to women: 4:1
SCI and MVC:
MVC is leading cause until age 45, when falls take over
In children, 2/3 of MVC SCI is due to children not wearing seat belt (properly or at all)
- MVC percentage is dropping due to improvements in car safety (was 40% in 2005)
- Violence is higher in minority groups
- MVC data includes cars, motorcycles and bicycles with prevalence in that order
SCI and Sports:
diving is the primary injury, followed by snow skiing, surfing, wrestling and football
Where/when do most SCI occur?
- More injuries occur in the South and Midwest
- Most occur on weekends (especially Saturday night)
- Peak amount of injuries in July
- Most are single at the time of injury (larger divorce rate as well)
66% were employed at time of injury =
Less than half of that remain employed
Predictors of return to work:
> Higher education
> Young age
> White
> Married
> ASIA D
> Non-violent etiology
> Able to drive
Mortality – Risk Factors
- older age
- male
- violent etiology of injury
- higher level of injury
- vent dependence
- increase risk of suicide
Tetraplegia:
In the cervical region
UE, Trunk, and LE involved
Paraplegia:
In the thoracic, lumbar, or sacral region
Trunk and LEs involved
Can include Conus Medullaris and Cauda Equina*
Classification of Injury with percentages =
Incomplete Tetra: 47.6%
Incomplete Para: 19.9%
Complete Para: 19.6%
Complete Tetra: 12.3%
Common Fractures of the Spine =
C5 Burst Fracture
> C5 Burst: sagital CT scan, note narrowed spinal canal
“Chance” Fracture @ T12, L1, or L2
> Chance fx = seat belt fracture from hyperflexion injury. Decreased incidence with shoulder belt
Utilize stabilizing orthosis for 3-4 months typically, depending on surgical fixation
Dorsal Columns:
light touch, vibration, conscious proprioception – doccusate at pontomedullary junction
Lateral spinothalamic tract:
temperature, pain – doccusate within 2-3 levels of spinal cord
Spinocerebellar:
unconcious proprioception – do not doccusate, terminate in ispilateral cerebellum
Corticospinal tract:
motor control – doccusate at pontomedullary junction
Autonomic neurons:
are located laterally and exit by the ventral root, innervate smooth muscle
Blood Supply to Spinal Cord:
Artery of Adamkiewicz (arteria radicularis magna) clipped during AAA repair, most affecting T4-6 levels due to watershed zone
Defining SCI:ASIA Impairment Scale (AIS)
Level of Injury
Skeletal level
> Radiologically greatest vertebral damage
Neurologic level of injury
> Most caudal level where both motor & sensory modalities intact bilaterally
Motor and sensory levels are the same in less than 50% of complete injuries. Can be up to 4 “levels” – R/L sensory, R/L motor
AIS - Complete =
Absence of sensory & motor function in the lowest sacral segments
Motor complete (AIS A & B)
AIS - Incomplete =
Preservation of sensory OR motor in the lowest sacral segments (sacral sparing)
Sensory Incomplete (AIS B)
Motor & sensory incomplete (AIS C & D)
ASIA Scores =
A. Complete
B. Sensory Incomplete
C. Motor Incomplete (strength < 3/5)
D. Motor Incomplete (strength greater than or equal to 3/5)
E. Neurologically Intact
How to Score ASIA Exam
Q1.Is this injury complete vs incomplete?
Look for sensation at sacral levels
A (complete) vs B (sensory complete)
How to Score ASIA Exam
Q2. Is there motor preservation at the sphincter or >3 levels down from motor level of injury?
B vs C
How to Score ASIA Exam
Q3. Are the majority of muscles below NLI greather than or equal to 3/5?
C vs D
How to determine motor level:
At least 3/5 with ALL MOTOR ABOVE AT 5/5
Neurologic Level of Injury (NLI) =
Most caudal segment with intact sensory (both modalities) and motor without deficits above
Translation:
> Sensation 2/2 across, intact above
> Motor level
> Whichever is higher is the NLI
Zone of Partial Preservation (ZPP)
Dermatomes & myotomes caudal to NLI that remain partially innervated
Used ONLY in complete (AIS A) injuries*
Complete SCI =
Tetraplegia (C1-T1)
Paraplegia (T2 & below)
Incomplete SCI Syndromes =
Anterior Cord
Central Cord
Posterior Cord
Brown-Sequard
Conus Medullaris
Cauda Equina
Anterior Cord Syndrome =
Etiology =Lesions of anterior spinal artery
Presentation:
> Loss of motor
> Loss of pain & temperature
> Relative preservation of position sense & vibration
Prognosis:
Generally poor (10-20%) for motor recovery
Central Cord Syndrome =
Etiology = Most common in older people following extension injuries
> Damage to central aspect of cord, sparing peripheral aspects
Presentation
> Motor & sensory loss in UEs
> Trunk & LEs may be affected dependent on severity
Prognosis
> 50 y.o. only 41% (I) community ambulators
< 50 y.o., 97% (I) community amb
Central Cord Syndrome =
When process of central hemmorhage/necrosis due to tissue damage
does not progress to full destruction of cord segment
peripherally located fiber tracts intact
Spatial orientation of tracts – cervical segments located closer to central gray matterT, L, S segments located progressively more peripherally in cord
Brown Sequard Syndrome =
Etiology = damage to ½ of the cord (hemi-section)
Most common cause = stab/gunshot wound
Presentation:
Ipsilateral side
> motor loss
> sensory loss of proprioception, vibration
Contralateral side
> sensory loss of pain & temp
Prognosis:
Good for recovery – most will regain bladder/bowel function; most will become ambulatory
Conus Medularis =
Terminal segment of spinal cord at bony level of L1
Affects S2 to S4-5
UMN lesion (likely LMN component)
Bowel and bladder dysfunction
Sexual dysfunction
LE strength may remain intact
Saddle anesthesia
Cauda Equina =
Lesion below L1
LMN deficits
LE motor weakness & atrophy (L2-S2)
Areflexia/hypotonia
Bowel & bladder involvement
Pain
May have spared perineum sensation - sometimes
UMN lesion presentation =
hyperreflexia
hypertonia
spasticity and/or clonus
minimal atrophy
(+) babinski
absent fasciculations
LMN lesion presentation =
hyporeflexia
hypotonia
flaccidity
severe atrophy
(-) babinski
present fasciculations
SCI evaluation =
skin integrity
breathing and cough (respiratory)
hemodynamic response
ROM
Muscle tone
SCI evaluation: skin integrity =
Skin: Surgical incision, abrasions from injury, protection 2/2 loss of sensory and motor function
-Start thinking about seating systems, posture, ability to perform pressure relief, and equipment to assist with skin inspection
SCI evaluation: breathing and cough (respiratory) =
Respiratory: Level of injury and effect on diaphragm/abdominal function. A
ny period of intubation?
May experience with speech, swallowing, and limited activity tolerance secondary to impaired lung excursion.
Any rib fractures?
SCI evaluation: hemodynamics =
Hemodynamics: Impaired HDR s/p injury, particularly presenting with symptomatic/asymptomatic hypotension and tachycardia initially at rehab.
Managed with compression garments (abdominal binder, TEDS, Ace wraps, and medication) in addition to improving upright tolerance via tilt-in-space chair, tilt table, etc.
Initial goal is to increase sitting and OOB tolerance to be able to trial appropriate equipment.
SCI evaluation: ROM =
GH/elbow/wrist extension, GH ER
Hamstring >110*, IR/ER – bed mobility, advanced transfers & dressing
ROM: Profound impact on functional ability – even mild restrictions can be detrimental (ex. Elbow ext in tetra)
Shoulder, elbow wrist ext, forearm pronation and ER for C6 mobility
Hamstring length for leg management and bed mobilityhip flexion and rotation for floor transfers
SCI evaluation: muscle tone =
Time since injury (spinal shock = flaccid)
UMN v LMN
Effect on mobility
+ = ms bulk, bone/ms health, venous return, may assist function
- = interfere with function, jt contractures, discomfort
Spinal Shock:
When this dissipates spasticity will begin to present, which needs to be closely assessed, monitored, and managed as it may begin to impede functional mobility
Hypertonicity – some good for bone and muscle health, too much interferes with function and impacts ROM and skin
Modified Ashworth Scale = 0
No increase in muscle tone
Modified Ashworth Scale = 1
Slight increase in muscle tone, with catch and release or minimal resistance at end ROM
Modified Ashworth Scale = 1+
Slight increase in muscle tone, with catch followed by min resistance through < ½ ROM
Modified Ashworth Scale = 2
Marked increase in muscle tone throughout most ROM but affect part(s) easily moved
Modified Ashworth Scale = 3
Considerable increase in muscle tone, passive movement difficult
Modified Ashworth Scale = 4
Effected part(s) rigid in flexion or extension
Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)
clonus (ankle DF)
flexor spasms (PinPrick)
extensor spasms (hip/knee extension)
Clous (ankle DF) scale =
0 - no reaction
1 - mild, clonus maintained < 3 seconds
2 - moderate, clonus persisted 3-10 seconds
3 - severe, clonus persisted > 10 seconds
flexor spasms (PinPrick) scale =
0 - no reaction
1 - mild, <10 deg. excursion in flexion at knee and hip or extension of great toe
2 - moderate, 10-30 deg. of flexion at knee and hip
3 - severe, >30 deg. of knee and hip flexion
extensor spasms (hip/knee extension) scale =
0 - no reaction
1 - mild, clonus maintained < 3 seconds
2 - moderate, clonus persisted 3-10 seconds
3 - severe, clonus persisted > 10 seconds
Evaluation (Continued) =
sensation
voluntary muscle function
balance
seating/position
bracing
Voluntary Muscle Function =
“Key muscles” UE & LE
Trunk - palpation and visual assessment
substitution (Common substitutions - important for function but hurts eval - eliminate motions at other jts and palate)
stabilization (Stabilizing ms can beweak or absent - making testing ms seen weaker - therefore provide stabilituty- honk about this functionally too. May have strong delta but if not in a stable seated position unable to use strength effectively)
Muscle strength/function: LEMS, UEMS, still test other muscles than key muscles that are important for function
Trunk –
standard tests assume abs and back extensor function along entire spine
Abs – use umbilicus + palpation – remains central = even pull all sides – absent or uniform along entire length above T5 or below T12
if moves up = > strength above (T5-T12)
laterally = toward stronger sideBack extensors – palpation
Bracing =
Halo
> No pillow
> No pulling on bars or vest
Cervical Collar
> Miami J, Aspen
Cervical Thoracic Orthosis (CTO)
TLSO
> Don in supine via log rolling
> HOB >30 and OOB
Typical Presentation by Level of Injury - Functional outcomes dependent on multiple factors =
Based on COMPLETE injury
Age
Body habitus
ROM
Arm : trunk length
Comorbidities
Motivation/psychological state
Typical Presentation: C1-3
Muscle Available
> Facial muscles
> Limited neck control
Ventilator dependent
> May be able to wean for very short periods using glossopharyngeal breathing
C3 with partial diaphragm innervation –
therefore longer weans (full focus on breathing)
Able to talk with leak speech (cuff deflated some to allow air thru)mastication, sip/puff
(I) power w/c mobility with specialty controls at household level (S in community)
(I) pressure relief in power w/c via specialty controls
(I) with ECU (environmental control unit)
(I) directing all positioning, pressure relief, skin inspection
(I) directing pulmonary management
(I) directing management of all equipment
Typical Presentation: C4
Typical Presentation: C4
> Diaphragm
> Trapezius
> Levator scapulae, Rhomboids
Available Movements
> BREATH INDEPENDENT of VENT!!!
> Scapular elevation
Still limited respiratory function (may require permanaent trach, likely will need MIE for home for secretion management
Typical Presentation: C5
Muscles Available
> Deltoid
> Biceps brachii
> Brachialis
> Brachioradialis
> Infraspinatus/teres minor
> Supinator
Operate power w/c with joystick
Also beginning to get other muscles activating but very little due to multiple nerve root segments.
Movements Available
> Elbow Flexion & forearm supination
> Shoulder ER, abd
Typical Presentation: C6
Muscles available
> Pectoralis major – clavicular portion
> Serratus anterior
> Latissimus Dorsi
> Extensor Carpi Radialis
> Pronator Teres
Significantly > functional potential than above levels
Movements Available
> Wrist Extension
> Forearm Pronation
> Shoulder/scap stability/strength
Typical Presentation: C7
Muscles Available
> Pec major – sternal portion
> TRICEPS
> Flexor carpi radialis
> Extensor pollicis longus/brevis
> Extrinsic finger extensors
Potential for independent function
Movements Available
> Elbow Extension
> Wrist Flexion
> Finger Extension
Typical Presentation: C8-T1
Muscles Available
> Extrinsic finger flexors
> Flexor Carpi Ulnaris
> Flexor pollicis longus/brevis
> Intrinsic finger flexors
Movements Available
> FINE MOTOR SKILLS
