Spinal Cord Injury Flashcards
What causes a spinal cord injury
insult to the spinal cord resulting in a change, either temporary or permanent
- widely accepted system describing the level and extent of injury based on a systematic motor and sensory exam or neurological function
Tetraplegia and paraplegia
Tetraplegia- injury to the spinal cord in the cervical region associated with loss of muscle strength in all 4 limbs
paraplegia- injury to the spinal cord in the thoracic, lumbar or sacral segments including the cauda equina and conus medullaris
Traumatic causes vs. non- traumatic causes
Traumatic= MVA, falls, sports injuries
Non-Traumatic= a minor injury can cause spinal cord trauma if the spine is weakened or if the spinal canal protecting the spinal cord has become too narrow ex. spinal stenosis
Physiological Reactions- spinal shock
- Spinal Shock
- the first several weeks after spinal cord injury
- a state of transient physiologic (rather than anatomic) reflex depression
- an initial increase in blood pressure
- flaccid paralysis, including of the bowel and bladder
Notes
- 1st few week to 1-2 months- spinal segments at level of injury has lots of fluid no movement, completely non-functioning
- test reflex arc to see if patient is in this phase
Physiological reaction- Neurogenic Shock
- disruption of the autonomic pathways within the spinal cord
- resulting in hypotension, occasionally with bradycardia
- Shock tends to occur more commonly in injuries above T6
- Disruption of the sympathetic outflow from T1-L2
- Neurogenic shock can lead to organ dysfunction and need immediate treatment
In more simple terms: the trauma causes a sudden loss of background sympathetic stimulation to the blood vessels. This causes them to relax (vasodilation)[3] resulting in a sudden decrease in blood pressure (secondary to a decrease in peripheral vascular resistance).
Physiological Reaction- Autonomic dysreflexia
- Life threatening condition occuring in the SCI above the T5 level
- Resulting from noxious stimulus ex. kinked catheter that sends pain signals towards the brain
- signs and symptoms
- pounding headache, a sudden increase in BP, sweating above the level of injury, flushed face
Acute AD is a reaction of the autonomic (involuntary) nervous system to overstimulation. It is characterised by severe paroxysmal hypertension (episodic high blood pressure) associated with throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, bradycardia, apprehension and anxiety, which is sometimes accompanied by cognitive impairment.[2] The sympathetic discharge that occurs is usually in association with spinal cord injury (SCI) or disease (e.g. multiple sclerosis).
AD is believed to be triggered by afferent stimuli (nerve signals that send messages back to the spinal cord and brain) which originate below the level of the spinal cord lesion. It is believed that these afferent stimuli trigger and maintain an increase in blood pressure via a sympathetically mediated vasoconstriction in muscle, skin and splanchnic (gut) vascular beds.[3]
Clinical Syndromes- Central Cord Syndrome
Can result from a cervical region injury and leads to greater weakness in the upper limbs than in the lower limbs with sacral sparing (bowel and bladder sensation and function)
More common with older age- such as due to spinal stenosis then hyperextension injury
focus of injury is the central grey matter
results in:
UE weaker than lower extremity- lower limb function is less severely impacted
Anterior Cord Syndrome
decreased or absent blood flow to the anterior spinal artery causing loss of function to the anterior spinal artery
- focus of injury: anterior 2/3 of cord
- the dorsal columns are spared but the spinothalmaic and corticospinal tracts are compromised
- Loss of motor function, Loss of pain and temperature sensation, preservation of light touch and joint position sense
- Traumatic bending or narrowing the vertebral canal
- Poor prognosis for neural recovery
Posterior cord syndrome
- Posterior spinal artery to posterior columns
- Loss of proprioception (sparing of motor and pain)
- Poor prognosis for ambulation due to problems with balance
Brown-sequard Syndrome
- Cord hemi-section
- ipsilateral motor and proprioceptive loss and contralateral pain/temperature loss
- Ipsilateral flaccid paralysis at the level of injury
- ipsilateral spastic paralysis of muscle below the lesion site
- Favorable prognosis for ambulation, ADL independence and bladder
Conus Medullaris syndrome
- associated with injury to the sacral cord and lumbar nerve roots leading to areflexic bladder, bowel and lower limbs
- S1-S5
- bladder, bowel and sexual dysfunction
more often complete
poor prognosis
Cauda Equina Syndrome
- Injury to the dorsal and ventral nerve roots in the cauda equina
- loss of sensation, flaccid paralysis and loss of sympathetic and parasympathetic responses in the pelvis
- loss of bowel and bladder control
- more often associated with pain
- more often incomplete- recover in approx. 12-18 months
Physical Assessment- ASIA Examination
ASIA impairment scale
- A= complete- no sacral motor or sensory sensation and no change below lesion
-B= Sensory incomplete; preservation of sensation below the injury level extending through sacral segments
C= Motor incomplete: voluntary anal sphincter or sensory sparing and motor function 3 levels below injury with majority of muscles grade 3
D= Motor imcomplete: same as C but majority of key muscles great than grade 3
E= normal motor and sensory recovery
Functional Expectations C1- C3
C1-C3
- Typically on a ventilator dependent
- Limited head and neck movement, limited speech
- important for effective communication with caregivers
- AT
- WC access and selection
- Transportation
- ramps/access
- pain/spasticity
- skin/contractures
- pulmonary issues
- 24 hour care
Functional Expectations C4
- some respiratory issues- unable to cough, but usually not on a ventilator
- have control of diaphragm, trapezius
- communication (mouthstick, environmental control unity, page turner, computer)
- transportation and access
- still need 24 hour care
Functional Expectations C5
have head, neck and shoulder control
- to establish functional goals at this level, motor function of the elbow flexors, or biceps must score 3 or better on the classification form
Functional Goals:
-independence with eating, drinking, face washing, tooth brushing, shaving, hair care, with setup equipment
-personal care atleast 10 hours per day
home care 6 hrs per day
Functional Expectations C6
to establish function goals, motor function of the wrist extensors, must score a 3 or better on the classification form
Functional goals include:
- can self assist cough
- bed mobility, transfers, and functional ADL transfers moderate to min. assistance
- Pressure relief management
- Feeding, dressing, grooming
- WC propulsion
- driving with hand controls
- homemaking
- requires personal care 6 hrs per day and homecare 2-4 hours per day
Functional Expectations C7
Has wrist flexors, triceps, extensor digitorum
- to est. functional goals, motor function of the elbow extensors or triceps must score 3 or better
Functional Goals
- same as C6 but now has elbow movement
- manual wheelchair realistic
- more ease with transfers, wheelchair pushups and pressure relief
- less adaptive equ.
still fatigue easily
still requires 6 hours of personal care and 2 hours of homecare
Functional Expectations C8
Add strength and precision of fingers
- to est. function goals, motor function of the flexor digitorum, middle finger score 3 or better
Functional Expectations T1
More hand function
Functional goals for C8 and T1
live independently
feeding, grooming, oral and facial hygiene, dressing, transferring, bowel and bladder management with little to no hand devices
- still needs home and personal care 6-8hours per day
Functional Expectations T2-T6
Better rib, chest and trunk control as higher thoracic levels innervated
- Functional goals and upper extremity control for T2 and above
Functional Expectations T2-T12
paraplegic ambulation- have capability of some walking but energy demands and stress on upper extremities provide no functional advantage
- using future technology
Functional Goals for T7-T12
added function with increased abdominal muscle control
- improved pulmonary cough
- increased ability to perform unsupported sitting activities
Functional Expectations L1-L5
to be classified at any of these levels, the person must score 3 or better on the classification form at that level
L3- motor function in the quads
L4- Motor function in the tibialis anterior
L5- Motor function in the extensor hallucis longus
Functional Goals for L1-L5
more functional benefit to walking
-may have cauda-equinas syndrome
- more likely to employ braces and assistive devices for gait
may require 1-2 hours per day of care
Functional goal for S1-S5
est. function goals, motor function of the ankle plantar flexors must score 3 or better
