Spinal Cord Injury Flashcards
1
Q
What is tetraplegia/quadriplegia? What parts of the body does it affect?
A
Impairment or loss of sensory and motor function in the cervical segments of the spinal cord
Affects UEs, LEs, trunk, and possibly respiratory
2
Q
What is paraplegia? What parts of the body does it affect?
A
Impairment or loss of sensory and or motor function in the thoracic, lumbar, or sacral segments of the spinal cord.
Affects LEs and trunk
UEs are spared
3
Q
What is the most common (highest incidence) type of SCI?
A
Incomplete tetraplegia = 45%
4
Q
How many pairs of spinal nerves are there?
A
31 pairs if spinal nerves
8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal
5
Q
At what level does the spinal cord end?
A
L1/L2
6
Q
What arteries provide blood supply to the spinal cord?
A
1 anterior spinal artery
2 posterior spinal arteries
7
Q
What are 3 causes of spinal cord injury?
A
Trauma
Disruption of the blood supply
Infection
8
Q
What can happen to the spinal and spinal cord as a result of trauma?
A
Compression, traction, or transection of the cord
Usually resulting in fracture / dislocation of vertebrae
9
Q
True or False: Cord does not need to be severed in order for permanent injury to occur
A
TRUE
10
Q
90% of traumatic injuries occur when the neck is _____.
A
FLEXED
11
Q
Flexion/Extension load trauma typically results in what? How are they typically treated?
A
Result in significant bone and ligamentous damage as well as neurological injury
Often require surgical stabilization
12
Q
What typically occurs as a result of an axial load trauma? Are these patients stable?
A
Burst fracture
Neurological damage as a result of splintering of vertebral bones into spinal cord
Patient is often orthopedically stable
13
Q
What are examples of a high velocity trauma? How much damage to the spinal cord is typically seen?
A
Gun shot, MVA, sports
Generally cause more damage to spinal cord
14
Q
What are examples of a low velocity trauma? How much damage to the spinal cord is typically seen?
A
Falls, sports
Associated with less damage and a brighter prognosis
15
Q
True or False: Most of the functional limitation seen following traumatic SCI is caused by transection of the spinal cord
A
FALSE
Transection of the SC is not the primary cause of functional limitations seen in SCI
16
Q
What is the primary injury that takes place within 18 hours of a SCI?
A
Death of axons directly disrupted by trauma.
***If spine remains unstable, additional traumatic injury may occur.
17
Q
What are the 5 things that take place secondary to SCI? (occurs within a few weeks of SCI)
A
- Ischemia/hypoxia: caused by disruption of ANS, damage to vessels, and presence of vasoconstrictors
- Biochemical: cell death (apoptosis) up to 4 spinal segments away from initial injury
- Demyelination: caused by damage to oligodendrocytes
- Edema
- Scarring: around lesion and dura
18
Q
What is spinal shock? When does it occur relative to the onset of a SCI? What does it cause?
A
Occurs immediately after traumatic SCI
Thought to be due to an abrupt loss of connections between the brain and spinal cord
19
Q
What reflexes are typically lost with areflexia following spinal shock? What system is impaired as a result?
A
- Loss of bulbocavernous reflex
Mediated at S2-S4
Tests internal/external anal sphincter - Loss of Babinski response
***Impairment of autonomic regulation
20
Q
Disruption of blood supply following an SCI can lead to what 5 phenomena?
A
- Trauma to the arterial spinal arteries
- Thrombosis/embolic (“spinal stroke”)
- Hematoma
- Cardiac arrest
- Aortic aneurysm
21
Q
What 4 inflammatory conditions can lead to SCI?
A
- Tuberculosis
- HIV
- Syphillis
- Transverse myelitis
22
Q
What is transverse myelitis? How long does it typically last? Is it recurrent?
A
Result of a viral infection that damages and destroys myelin
Occurs on both sides of one level
Can last several hours to several weeks
Usually not recurrent
23
Q
What is Syringomyelia ?
A
Development of a cavity (syrinx) in cord due to cyst formation and gliosis
May be post-traumatic
May be seen in other diseases and syndromes (eg: HIV, Chiari Malformation, Meningitis)
24
Q
What is the AIS Impairment Scale (ISNCSCI)? What does it assess?
A
Tool used to classify spinal cord injury
Assess motor/sensory impairment (sensation and MMT)
Assess different levels for left vs right impairment
Contains definition for Zone of Partial Preservation (“ZPP”) of sensory or motor function
25
What is the rationale behind AIS sensory testing?
Rationale: used to determine a complete versus incomplete injury, and to obtain the sensory level and sensory scores.
Key sensory points: There are 28 specific skin locations on each side of the body. (DERMATOMES)
Each site is reliably located in relation to bony anatomical landmarks
26
Why is a rectal exam needed? What are the components of a rectal exam?
Needed for determination of incomplete injury
1. Deep anal pressure (“DAP”)
2. Voluntary anal contraction
3. Bulbocavernosus reflex: determines conus integrity.
27
ASIA A Classification
Complete.
No motor or sensory function is preserved in the sacral segments S4-5.
28
ASIA B Classification
Incomplete.
Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5
29
ASIA C Classification
Incomplete.
Motor function is preserved below the neurological level, and more than 50% of key muscles below the neurological level have a grade of < 3.
30
ASIA D Classification
Incomplete.
Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a grade of >3
31
ASIA E Classification
Normal sensory and motor function
32
A complete SCI injury is characterized by the absence of _______
Absence of sensory or motor function in the lowest sacral segment (S4-5)
33
An incomplete SCI injury is characterized by _______
partial preservation of sensory &/or motor function in the lowest sacral segment (S4-5).
1. Sensory: at the anal mucocutaneous junction & deep anal sensation.
2. Motor: presence of voluntary contraction of the external anal sphincter
34
What is the zone of partial preservation (ZPP)? When is it used?
Refers to those dermatomes and myotomes below the neurological level that remain partially innervated
***Used only with complete injuries (absence of anal sphincter control and sensation)
35
What are the 5 recognized clinical syndromes of SCI?
```
Central Cord Syndrome
Brown Sequard Syndrome
Anterior Cord Syndrome
Conus Medullaris Syndrome
Cauda Equina Syndrome
```
36
What is the most common incomplete SCI?
Central Cord Syndrome
37
What is central cord syndrome? What occurs as a result?
Cervical lesion due to hyperextension of the neck
1. Produces sacral sparing
2. Greater weakness in UEs than in LEs.
3. May also produce bladder dysfunction
4. Various forms of sensory loss below the level of the lesion.
38
What are the outcomes for central cord syndrome?
75% walk
50% regain bowel and bladder control
25% regain UE function
39
What is Brown Sequard Syndrome? How will the patient typically present? What is the outcome?
Lesion that damages 1/2 of spinal cord (hemisection)
Ipsilateral proprioceptive and motor loss
Contralateral loss of sensitivity to pain and temperature beginning a few levels below the level of the injury
Patient presents with hemiparesis
Outcome: Generally expected to be positive
40
What is Anterior Cord Syndrome? What are 2 causes of anterior cord syndrome?
Injury affects anterior 2/3 of spinal cord
Causes:
1. Disrupted blood flow to that part of cord “Anterior Spinal Artery Syndrome”
2. Flexion injuries
41
What occurs as a result of anterior cord syndrome? What is the outcome?
Loss of motor function below level of injury
Loss of sensitivity to pain and temperature
Preservation of proprioception, light touch, and deep pressure.
Outcome: 10%-20% chance of muscle recovery
42
Conus medullaris syndrome is a _____ motor neuron injury
LOWER
43
What is conus medullaris syndrome? How do patients typically present?
Injury of the sacral cord (“conus”) and lumbar nerve roots within the spinal canal
(Neural segments S2 and below)
1. Presents with lower motor neuron deficits of anal sphincter and bladder
2. Areflexic bladder and lower extremities
44
Cauda Equina Syndrome is a _____ motor neuron injury
LOWER
45
What is Cauda Equina Syndrome ? How do patients typically present?
Injury to lumbosacral nerve roots within the neural canal (Below L1)
1. Areflexic bladder and bowel
2. Saddle region anesthesia
3. Flaccid lower extremities
46
What are 7 comorbidities that may occur at the time of a SCI?
1. Fractures
2. Amputations
3. Loss of consciousness
4. Traumatic brain injury
5. Pneumothorax
6. Hemothorax
7. Burns
47
What are the 2 goals for surgical management following an SCI?
1. Align spinal column and canal
| 2. Remove pressure on the spinal cord
48
What occurs with a fusion and ORIF following an SCI?
1. Most often done with an anterior approach
2. Bone graft may be taken from ASIS for fusion
3. Wiring of vertebral bodies
4. Plates, screws and rods
49
When is a thoracolumbosacral orthoses (TLSO) typically taken off?
Frequently taken off in bed as long as person lays with head of bed < 30 degrees
50
What is the purpose of a Jewitt brace?
Places the spine in slight extension
Tends to be uncomfortable
51
What neurologic symptoms does a patient experience immediately following an SCI?
1. Immediately after SCI, patients have surge in blood pressure (from adrenaline) followed by flaccid paralysis.
2. First few hours/days SCI patients are in neurogenic shock, characterized by triad of bradycardia, hypotension, and hypothermia.
3. Paradoxical breathing
52
What is paradoxical breathing? What population of SCI patients may this be seen in?
May be seen in tetraplegia
A condition when your chest moves inward during inhalation instead of moving outward. (keeps you from inhaling enough oxygen)
53
When should steroids be given following an SCI? When are they no longer effective?
Within the first 8 hours of an SCI to improve motor function
If >8 hours, steroids don't help
54
What happens to the neuromuscular system following an SCI injury? (5)
1. Paralysis or paresis of skeletal muscle
2. Hyperactivity of stretch reflexes
3. Spasticity and / or Spasms
4. Muscle atrophy with cellular degeneration and increased fibrosis
5. Muscle cells physiologically change into slow twitch fibers with slow contraction speeds.
55
What is autonomic dysreflexia? Where does it typically occur? What causes this to happen?
1. Acute, life threatening, syndrome of uncontrolled, massive reflex sympathetic discharge
2. Occurs in T6 injuries and above
3. Caused by noxious stimulus below the level of the injury (frequently bowel, bladder, pressure sore, electrical stimulation, ingrown toenails.)
56
What symptoms are associated with autonomic dysreflexia? (7)
1. Severe headache
2. Sweating above injury level
3. slow pulse
4. goose bumps
5. extremely high blood pressure (e.g. 300/160)
6. pallor
7. blurry vision
57
How is autonomic dysreflexia treated? (3)
1. Sit person up to decrease cerebral blood pressure
2. Try to remove noxious stimulus
3. Obtain medical assistance
58
What thermoregulatory dysfunction is seen in patients with SCI?
1. Decreased ability to regulate body temperature
2. Inability to sweat below the level of the injury (complete injuries)
3. Occasionally, excessive sweating is noted
59
What happens to the skeletal system following an SCI?
1. BMD decreases in the first 2. 4-6 months to 3 years post-injury
3. Up to three-fold decrease in load to failure
4. High incidence of pathological bone fractures
5. Joint instability (40% decrease)
6. DJD, overuse syndrome of UEs
60
What is heterotopic ossification? How does it appear on diagnostic images? Incidence?
1. Abnormal bone formation in the soft tissue and around joints (mostly in hip, knees ankles and elbows)
2. Histologically identical to callus seen in fracture healing
3. 20-30% incidence in SCI patients (4-12 weeks post injury)
61
How do patients with heterotopic ossification typically present?
May present with sudden onset of redness & swelling near large joint, decreased ROM, joint effusion, & pain.
Systemic reactions (fever, chills) are rare
62
How is heterotopic ossification diagnosed?
1. Elevated serum alkaline phosphatase (SAP) levels always precedes radiological evidence of HO
2. Routine x-rays are of no value in early stages
3. 3 Phase bone scans used to determine presence of and maturity of HO
63
How is heterotopic ossification treated? What should be avoided?
1. Medication management (Indomethacin, EDHP, Didronel)
2. ROM once inflammation diminishes
3. Splinting may be needed if total joint ankylosis is expected
***Forcible stretching and mobilization may worsen situation
64
What is the surgical intervention for heterotopic ossification? What are possible post op complications?
1. Best 12-18 months post onset, or when bone formation is mature
2. Excision usually followed by irradiation of the area to prevent recurrence
3. Post-op complications: delayed wound healing, excessive bleeding, infection, fracture, and recurrence
65
What postural deformities may be see in patients with SCI?
1. Scoliosis (dues to poor sitting posture/muscle imbalances)
2. Kyphosis/posterior pelvic tilt (poor sitting posture)
66
What is the primary cause of joint contractures in patient with SCI?
1. Loss of antagonist muscle contractions
| 2. Prolonged sitting/supine positioning
67
What causes pressure sores to develop? Where do they typically appear?
1. Caused by decreased circulation and sensation
| 2. Typically occur over bony prominences (scapula, greater trochanter, sacrum/ischium, heels/malleoli)
68
How often should one weight shift in bed and in sitting?
For every 20-30 minutes of sitting, need to weight shift for 1 minute
In bed, roll every 2 hours in order to weight shift
69
SCI patients have increased risk of _____.
BURNS
70
How is the cardiovascular systems affected post SCI?
1. Peripheral circulatory clamping of vessels (PVD
LE hairlessness, shiny skin)
2. Circulatory and Lymphatic Stasis
3. Venous Thrombosis & Risk of Pulmonary Embolus
4. Cardiac Muscle Atrophy( decrease in left ventricular mass)
5. Reduced volumes of whole blood and plasma
6. Decreased cardiac output
7. Unstable heart rate and blood pressure (arrhythmia)
71
What is orthostatic hypotension? How is managed?
1. A fall in blood pressure resulting from a change in position towards upright
2. Symptoms may include dizziness, pallor, numbness in face, loss of consciousness
3. Abdominal binder, meds, tilt table etc.
72
What gastrointestinal conditions may occur following an SCI?
1. Paralytic ileus lasts ~ 5-7 days post- injury (oral feeding needed)
2. Abdominal distension (due to lack of muscular support/GI complications)
3. B&B dysfunction and incontinence (use catheter)
* ** High risk for UTI
73
True or False: Women with SCI can become pregnant and give birth normally
TRUE
74
____% of SCI patients have persistent pain.
70%
75
What tool is used to classify and determine management of pain in SCI?
International Spinal Cord Injury Pain Dataset (ISCIPD)
76
What is nociceptive pain?
Pain that arises from actual or threatened damage to non-neural tissue and is caused by the activation of nociceptors
77
What is neuropathic pain? Incidence?
Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system
40% incidence in SCI
78
What are 4 types of neuropathic pain? What should be investigated?
1. Radicular Pain
2. Segmental Pain
3. Deafferentation Central Pain
4. Complex Regional Pain Syndrome
If develops months / years post-injury, should investigate via MRI to rule out syrinx formation
79
What are characteristics of neuropathic pain?
```
Burning
Pricking
Tingling
Itching
Shock-like
Stabbing
Continuous or intermittent
Spontaneous
Exaggerated
```
80
How is neuropathic pain treated?
1. Anticonvulsants, Antidepressants, Opioids (tramadol), Cannabinoid
2. Massage
3. Acupuncture (no really effective)
81
What is syrinx formation? What does it cause?
1. Cavity forms within the spinal cord
| 2. Causes pain, changes in motor and sensory function
82
What muscles make up the triad for normal ventilation?
1. Diaphragm (major for passive inspiration)
2. Abdominal muscles
3. Intercostal muscles
83
Innervation and purpose of diaphragm
Innervated at C3-C5
Passive inspiration
***Lesions above C4 result in paralysis of diaphragm and require artificial ventilation
84
Innervation and purpose of abdominal muscles
Innervated at T5 - L1
Needed for efficient cough / expiratory function
85
Innervation and purpose of intercostal muscles
Innervated at T1 - T12
1. Stabilize the rib cage and provide additional expansion of the chest
2. Needed for controlled exhalation and speech
86
What can happen to the respiratory system following an SCI?
1. Diaphragmatic, accessory, and intercostal muscle paralysis or paresis
2. Decreased chest expansion, vital capacity, & tidal volume
3. Reduced ability to cough effectively and to clear secretions
87
_____% of people with SCI show signs of acute or chronic pulmonary disease
80-85%
Atelectasis
Pneumonia
Respiratory Failure
88
What 5 muscles serve as accessory muscles for respiration?
1. Pectorals C5 - T1
Can substitute as rib cage stabilizers instead of intercostals
2. Serratus Anterior C5 - C7
Posterior chest expansion when arms are fixed
The only inspiratory muscle that works when trunk is flexed
3. Scalenes C3 - C8
Superior and anterior chest expansion
4. Sternocleidomastoid
Superior and anterior chest expansion
5. Erector Spinae C1 - L5
Spinal stability required for rib cage mobility and normal anterior chest wall motion
89
What is normal vital capacity? How much vital capacity is preserved at different levels of SCI?
1. Normal = ~ 4 liters
2. C1-2 expect 5-10% of normal (ventilator dependent)
3. C4 - 6 expect 50% of normal
4. C7-T4 expect 60-70% normal
5. T5-S5 expect relatively normal
90
What is a tracheostomy? What is it used for>
1. Artificial A/W that bypasses the upper airway and laryngeal structures
2. Used to relieve airway obstruction
3. Facilitates artificial ventilation
4. Facilitates suctioning
91
What does a pulse oximeter measure?
1. Measures percentage of oxygen in hemoglobin
| 2. Only truly indicative if hemoglobin levels are WNL.
92
What is the purpose of an abdominal binder?
1. Assists with venous return
| 2. Provides mechanical leverage for respiratory mechanisms
93
What is a mechanical in-exsufflator?
1. Works like a vacuum
2. Applies gradual positive pressure to the airway, then rapidly shifts to negative pressure, thereby stimulating a cough
3. Gets deeper than main bronchi
4. Is not invasive
94
What are the 4 advantages of phrenic nerve stimulation/pacing?
1. Increases mobility
2. Improves speech
3. Decreases nursing care, anxiety and health care costs
4. more cosmetic than ventilation
95
What are the 5 disadvantages of phrenic nerve stimulation/pacing?
1. Both phrenic nerves must be intact (capable of being stimulated)
2. Risk of phrenic nerve injury due to surgical dissection
3. Requires thoracotomy, neck disections, or laporoscopic surgery
4. Very expensive
5. Has had mixed outcomes
96
What is direct diaphragm pacing?
1. Percutaneous placement of electrodes over strategically located areas [motor points] of the diaphragm
2. Less invasive than phrenic nerve pacing
3. Only the inspiratory phase of breathing is facilitated by pacing
4. Cough remains impaired
97
What are the ROM guidelines for the shoulders, elbows and forearms?
Shoulders: In the absence of active or strong elbow extension, greater than normal elbow extension combined with shoulder external rotation is required.
Elbows: Full extension needed for stability
Forearms: Full supination is essential to assist in locking elbows into extension while weight bearing
98
What are the ROM guidelines for the wrist?
1. Full wrist flexion and extension must be preserved
2. If active wrist extension is <3/5, over-stretching may occur and further weaken these muscles.
3. Cock-up splints may be needed.
99
What is tenodesis? What does this allow for?
Natural kinematics of wrist and hand movement
1. Wrist extension results in finger flexion
2. Wrist flexion results in finger extension
3. Allows for functional grasp and release of objects in the absence of active finger movement
100
Weight bearing activities on hand should be performed in a _____ position
FISTED
101
What are the ROM guidelines at the neck and TMJ?
Neck: ROM should be obtained through gentle active exercise
TMJ: hypo mobility may be caused by halo immobilization, causes discomfort with chewing, and headaches
102
What are the ROM guidelines of the low back?
1. Prevent over-stretching in order to increase trunk stability in sitting
2. Mild tightness will allow transmission of head and shoulder motions to lower body and will enhance mobility
103
What are the ROM guidelines of the hamstrings?
1. Flexibility will facilitate long sitting, dressing, mat mobility, and floor transfers
2. Straight leg raise should ideally be 110o - 120o once orthopedically stable
3. Perform SLR stretch in supine to avoid over-stretching low back
104
What are the ROM guidelines of the ankles?
1. Dorsiflexion to neutral is needed for proper placement on wheelchair foot rests
2. Normal dorsiflexion is needed for ambulation
105
What are the functional expectations following a C1-C4 SCI?
1. Dependent in all functional position changes & weight shifting unless in power, tilt-in-space wheelchair
2. Independent wheelchair mobility in power wheelchair
3. Independent in giving instructions for self-care and transfers
106
What are the functional expectations following a C5 SCI?
1. Moderate assist bed mobility with bed rails
2. Moderate (occ min) assist pressure relief
3. Mod/Max assist sliding board transfers
4. Independent propulsion in power wheelchair; short distances in manual w/c
107
What are the functional expectations following a C6 SCI?
1. Independent in bed mobility (hospital bed)
2. Independent in pressure relief
3. Minimal assist / Independent sliding board transfers
4. Independent wheelchair mobility for basic skills, assist on uneven surfaces.
108
What are the functional expectations following a C7,C8,T1 SCI?
1. Independent bed mobility and pressure relief
2. Independent transfers wc to bed, car
3. Min assist floor transfers
4. Independent wheelchair mobility basic skills; some assist with advanced skills
109
What are the functional expectations following a T2-T6 SCI?
1. Independent in wheelchair level skills
| 2. May begin ambulation (household)
110
What are the functional expectations following a T8-T10 SCI?
1. Best candidates for ambulation with bilateral KAFOs
| 2. Independent in all functional mobility and ADLs
111
What are the functional expectations following caudal to T10 SCI?
1. Independent in wheelchair level skills, functional mobility and ADLs
