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Neuro Midterm > Spinal Cord Injury > Flashcards

Spinal Cord Injury Flashcards

1
Q
  • 2500-3000BC:
A

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

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2
Q
  • 400BC:
A

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

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3
Q

SCI Epidemiology:

A

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

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4
Q

SCI and MVC:

A

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
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5
Q

SCI and Sports:

A

diving is the primary injury, followed by snow skiing, surfing, wrestling and football

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6
Q

Where/when do most SCI occur?

A
  • 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)
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7
Q

66% were employed at time of injury =

A

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

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8
Q

Mortality – Risk Factors

A
  • older age
  • male
  • violent etiology of injury
  • higher level of injury
  • vent dependence
  • increase risk of suicide
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9
Q

Tetraplegia:

A

In the cervical region

UE, Trunk, and LE involved

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10
Q

Paraplegia:

A

In the thoracic, lumbar, or sacral region

Trunk and LEs involved

Can include Conus Medullaris and Cauda Equina*

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11
Q

Classification of Injury with percentages =

A

Incomplete Tetra: 47.6%
Incomplete Para: 19.9%
Complete Para: 19.6%
Complete Tetra: 12.3%

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12
Q

Common Fractures of the Spine =

A

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

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13
Q

Dorsal Columns:

A

light touch, vibration, conscious proprioception – doccusate at pontomedullary junction

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14
Q

Lateral spinothalamic tract:

A

temperature, pain – doccusate within 2-3 levels of spinal cord

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15
Q

Spinocerebellar:

A

unconcious proprioception – do not doccusate, terminate in ispilateral cerebellum

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16
Q

Corticospinal tract:

A

motor control – doccusate at pontomedullary junction

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17
Q

Autonomic neurons:

A

are located laterally and exit by the ventral root, innervate smooth muscle

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18
Q

Blood Supply to Spinal Cord:

A

Artery of Adamkiewicz (arteria radicularis magna) clipped during AAA repair, most affecting T4-6 levels due to watershed zone

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19
Q

Defining SCI:ASIA Impairment Scale (AIS)

A

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

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20
Q

AIS - Complete =

A

Absence of sensory & motor function in the lowest sacral segments

Motor complete (AIS A & B)

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21
Q

AIS - Incomplete =

A

Preservation of sensory OR motor in the lowest sacral segments (sacral sparing)

Sensory Incomplete (AIS B)

Motor & sensory incomplete (AIS C & D)

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22
Q

ASIA Scores =

A

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

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23
Q

How to Score ASIA Exam

Q1.Is this injury complete vs incomplete?

A

Look for sensation at sacral levels

A (complete) vs B (sensory complete)

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24
Q

How to Score ASIA Exam

Q2. Is there motor preservation at the sphincter or >3 levels down from motor level of injury?

A

B vs C

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25
Q

How to Score ASIA Exam

Q3. Are the majority of muscles below NLI greather than or equal to 3/5?

A

C vs D

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26
Q

How to determine motor level:

A

At least 3/5 with ALL MOTOR ABOVE AT 5/5

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27
Q

Neurologic Level of Injury (NLI) =

A

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

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28
Q

Zone of Partial Preservation (ZPP)

A

Dermatomes & myotomes caudal to NLI that remain partially innervated

Used ONLY in complete (AIS A) injuries*

29
Q

Complete SCI =

A

Tetraplegia (C1-T1)

Paraplegia (T2 & below)

30
Q

Incomplete SCI Syndromes =

A

Anterior Cord
Central Cord
Posterior Cord
Brown-Sequard
Conus Medullaris
Cauda Equina

31
Q

Anterior Cord Syndrome =

A

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

32
Q

Central Cord Syndrome =

A

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

33
Q

Central Cord Syndrome =

A

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

34
Q

Brown Sequard Syndrome =

A

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

35
Q

Conus Medularis =

A

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

36
Q

Cauda Equina =

A

Lesion below L1

LMN deficits

LE motor weakness & atrophy (L2-S2)

Areflexia/hypotonia

Bowel & bladder involvement

Pain

May have spared perineum sensation - sometimes

37
Q

UMN lesion presentation =

A

hyperreflexia
hypertonia
spasticity and/or clonus
minimal atrophy
(+) babinski
absent fasciculations

38
Q

LMN lesion presentation =

A

hyporeflexia
hypotonia
flaccidity
severe atrophy
(-) babinski
present fasciculations

39
Q

SCI evaluation =

A

skin integrity
breathing and cough (respiratory)
hemodynamic response
ROM
Muscle tone

40
Q

SCI evaluation: skin integrity =

A

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

41
Q

SCI evaluation: breathing and cough (respiratory) =

A

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?

42
Q

SCI evaluation: hemodynamics =

A

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.

43
Q

SCI evaluation: ROM =

A

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

44
Q

SCI evaluation: muscle tone =

A

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
45
Q

Spinal Shock:

A

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

46
Q

Modified Ashworth Scale = 0

A

No increase in muscle tone

47
Q

Modified Ashworth Scale = 1

A

Slight increase in muscle tone, with catch and release or minimal resistance at end ROM

48
Q

Modified Ashworth Scale = 1+

A

Slight increase in muscle tone, with catch followed by min resistance through < ½ ROM

49
Q

Modified Ashworth Scale = 2

A

Marked increase in muscle tone throughout most ROM but affect part(s) easily moved

50
Q

Modified Ashworth Scale = 3

A

Considerable increase in muscle tone, passive movement difficult

51
Q

Modified Ashworth Scale = 4

A

Effected part(s) rigid in flexion or extension

52
Q

Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)

A

clonus (ankle DF)
flexor spasms (PinPrick)
extensor spasms (hip/knee extension)

53
Q

Clous (ankle DF) scale =

A

0 - no reaction
1 - mild, clonus maintained < 3 seconds
2 - moderate, clonus persisted 3-10 seconds
3 - severe, clonus persisted > 10 seconds

54
Q

flexor spasms (PinPrick) scale =

A

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

55
Q

extensor spasms (hip/knee extension) scale =

A

0 - no reaction
1 - mild, clonus maintained < 3 seconds
2 - moderate, clonus persisted 3-10 seconds
3 - severe, clonus persisted > 10 seconds

56
Q

Evaluation (Continued) =

A

sensation

voluntary muscle function

balance

seating/position

bracing

57
Q

Voluntary Muscle Function =

A

“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

58
Q

Trunk –

A

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

59
Q

Bracing =

A

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

60
Q

Typical Presentation by Level of Injury - Functional outcomes dependent on multiple factors =

A

Based on COMPLETE injury

Age
Body habitus
ROM
Arm : trunk length
Comorbidities
Motivation/psychological state

61
Q

Typical Presentation: C1-3

A

Muscle Available
> Facial muscles
> Limited neck control

Ventilator dependent
> May be able to wean for very short periods using glossopharyngeal breathing

62
Q

C3 with partial diaphragm innervation –

A

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

63
Q

Typical Presentation: C4

A

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

64
Q

Typical Presentation: C5

A

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

65
Q

Typical Presentation: C6

A

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

66
Q

Typical Presentation: C7

A

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

67
Q

Typical Presentation: C8-T1

A

Muscles Available
> Extrinsic finger flexors
> Flexor Carpi Ulnaris
> Flexor pollicis longus/brevis
> Intrinsic finger flexors

Movements Available
> FINE MOTOR SKILLS

68
Q
A

Neuro Midterm (7 decks)

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