SPINAL CORD INJURY Flashcards
SCI
Average age at the time of injury =
42 yo
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80% of SCI patients are
males
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Causes of SCI:
- 38% = MVA
- 30.5% = falls
- 13.5% = Violence
- 9% = sports
- 5% = medical/surgical
- 4% = other/unknown
(last 2 categories used be classified as “others”)
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which is the most common type of SCI?
- Incomplete tetraplegia = 45%
- Incomplete paraplegia = 21.3%
- Complete paraplegia = 20%
- Complete tetraplegia = 13.3%
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Most common ocurrence of SCI is?
Incomplete tetraplegia = 45%
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results in impairment of function in the arms as well as trunk, legs, and pelvic organs. It does not include brachial plexus lesions or injury to peripheral nerves outside the neural canal.
Tetraplegia (AKA quadriplegia)
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Impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal.
Tetraplegia (quadriplegia)
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arm functioning is spared, but depending on the level of injury, the trunk, legs, and pelvic organs may be involved.
paraplegia
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Impairment or loss of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord secondary to damage of neural elements within the spinal canal.
Paraplegia
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No sensory or motor function is preserved in the sacral segments S4-5.
ASIA: A
complete
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- Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5 (light touch or pin prick at S4-S5 or deep anal pressure)
- AND no motor function is preserved more than three levels below the motor level on either side of the body.
ASIA B = Sensory Incomplete
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The sensory level is the most ______, intact dermatome for both pin prick and light touch sensation.
caudal
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- The motor level is defined by the________________________ (on supine testing), providing the key muscle functions represented by segments above that level are judged to be intact (graded as a 5).
- Note: in regions where there is no myotome to test, the motor level is presumed to be the same as the sensory level, if testable motor function above that level is also normal.
lowest key muscle function that has a grade of at least 3
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How do you determine whether the injury is complete or incomplete?
- (i.e. absence or presence of sacral sparing)
- If voluntary anal contraction = No
- AND all S4-5 sensory scores = 0
- AND deep anal pressure = No
- then injury is Complete.
- Otherwise, injury is Incomplete.
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- Headache
- Flushing of the face
- Sweating
- Skin rash
- Hypertension
- Bradycardia
autonomic dysreflexia
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treatmnent of autonomic dysreflexia
- Identify noxious stimuli and remove it
- Monitor BP and HR
- Keep patient sitting up!
- Notify MD – the may need to be medicated to decrease BP
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Common sources of noxious stimuli leading to Autonomic Dysreflexia:
- Bladder or bowel distention
- Decubiti (pressure ulcer)
- Bladder infection or UTI
- In-grown toe nail
- leg strap is too tight
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The afferent stimuli (or strong sensory input) leads to sympathetic response that causes significant local vasoconstriction and life-threatening hypertension. Inhibitory input is blocked and hypertension persists.
autonomic dysreflexia
AKA hyperreflexia
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Impairment or loss of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord secondary to damage of neural elements within the spinal canal. Arm functioning is spared, but depending on the level of injury, the trunk, legs, and pelvic organs may be involved.
Paraplegia
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A collection of muscle fibers innervated by the motor axons within each segmental nerve root.
MYOTOME
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Area of skin innervated by the sensory axons within each segmental nerve root.
DERMATOME
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Tetraplegia key muscles:
(C5 to T1 injury)
- C5: biceps – elbow flexors
- C6: wrist extensors
- C7: triceps - elbow extensors
- C8: finger flexors (distal phalanx of middle finger)
- T1: finger abductors (5th digit)
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Paraplegia key muscles:
(L2 to S1)
- L2: hip flexors
- L3: knee extensors
- L4: ankle dorsiflexors
- L5: long toe extensors
- S1: ankle plantarflexors
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What are the results of Brown-Sequard syndrome?
Hemisection of the spinal cord:
- Ipsilateral proprioception loss at and below that level
- Ipsilateral motor control loss at and below the level of lesion
- Contralateral Pain & temperature loss from side below that level
- Abnormal or absent reflexes on the same side at the level of lesion
- Babinski sign ipsilaterally
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What are the results of anterior cord syndrome?
- loss of motor function (complete paralysis) below level of lesion
- loss of pain & temperature below level of the lesion
- intact 2-point discrimination, proprioception and vibratory senses due to intact posterior column
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What are the results of central cord syndrome?
- Hyperextension injury
- Bilateral motor paresis, UE > LE
- varying degree of sensory loss
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What are the results of posterior cord syndrome?
- Rare
- loss of proprioception, two-point discrimination, graphesthesia, sterognosis below level of the lesion
- wide-based steppage gait pattern typical preservation of motor, pain & light touch
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What are the results of CAUDA EQUINA SYNDROME?
- Bowel, bladder, sexual dysfunction
- Saddle +/- genital sensory loss
- LE weakness
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“Critical PROM” Guidelines: Hamstrings = ______ deg for dressing, transfers, etc
110
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Hip extension = ____ deg for gait training
10°
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Hip flexion = greater than _____ deg for sitting
90°
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Hip abduction = important for _____
self-care & bed mobility
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Ankle DF = ____ for gait, minimal neutral for positioning in WC
10°
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slight tightness in finger flexors for functional use of the hand
Tenodesis
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Shoulder extension & ER with scapula adduction, elbow extension, wrist extension and supination WFL for
UE weight bearing activities
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Providing _____________ is crucial to MMT
proper proximal stabilization
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What are the 2 additional clinical considerations when treating patients with SCI?
- Orthostatic hypotension
- Autonomic dysreflexia
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Sudden drop in BP caused by a change from lying to sitting or standing position
ORTHOSTATIC (POSTURAL) HYPOTENSION
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Orthostatic hypotension is more common in SCI lesions at the level of
T6 & above = loss of sympathetic control of peripheral vasoconstriction leads to hypotension.
Loss of muscle tone = poor venous return to heart and brain
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ways to prevent orthostatic hypotension
- Change to upright positions slowly and monitor patient closely
- Abdominal binder
- Compression stockings
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Signs and symptoms of orthostatic hypotension
- Lightheadiness or dizziness
- Loss of vision or blurred vision
- Fainting
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gait training: gait pattern and bracing options are dependent on muscles available, T12 – L4/5 injury: usually _____
KAFO
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gait training: gait pattern and bracing options are dependent on muscles available:
L4/5 injury: usually _____
AFO
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indications for gait training in patients with SCI
- no contractures
- adequate UE strength
- motivation
- endurance
- realistic expectations.
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describe three benefits of gait training for SCI patients
- mobility
- skin care
- cardiac & respiratory function
- B & B function
- morale
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important functional activities for patients with SCI
- Rolling: for bed mobility
- Prone: skin relief & stretching of hip flexors
- Prone on elbows: sh girdle stability
- Balance: long and short sitting (CRUCIAL)
- Gait training
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Treatment principles crucial to working with the SCI population:
- Trunk-arm relationship (body type)
- Relationship between balance and speed: momentum
- Head-hips relationship (movement strategy)
- Unweighting of body part is necessary for moving it
- Muscle endurance: often using small muscles to move heavy loads
- Awareness of COM over BOS within new functional body
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Shoulder ER for
triceps
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ER for
supination
SCI compensations
Scapula adduction for
latissimus
SCI compsensations
Hip flexion for
knee flexion
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C2
Occipital protuberance
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C3
Supraclavicular fossa
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C4
Top of acromioclavicular jt
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C5
Lateral side of antecubital fossa
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C6, C7, C8
- C6 → Thumb
- C7 → Middle finger
- C8 → Little finger
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Medial side of antecubital fossa
T1
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Apex of axilla
T2
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Third intercostal space
T3
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Fourth intercostal space(nipple line)
T4
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Fifth intercostal space
T5
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Sixth intercostal space
T6
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Inguinal ligament at mid-pt
T12
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Half the distance between T12 and L2
L1
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Mid-anterior thigh
L2
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Medial femoral condyle
L3
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Medial malleolus
L4
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Dorsum of foot at 3rd metatarsal phalangeal joint
L5
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Lateral heel
S1
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Popliteal fossa
S2
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Ischial tuberosity
S3
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Perianal area
S4-5
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Respiration, C3-5 innervates the
diaphragm
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Respiration, T1 to T6 innervates the
intercostals
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Respiration, T6 to T12 innervates the
abdominals
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a T3 SCI patient will breathe using
diaphragm and some intercostals
(no abdominals)
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Decubiti develop when capillary pressure exceeds ___ mmHg
30
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A patient with a decubiti ulcer in one heel shows Reactive Hyperemia (redness)
What is the decubiti ulcer stage?
Stage I
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A patient with a decubitus ulcer shows present with dermis involvement in one heel.
What is decubiti ulcer stage?
stage II
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A patient with a decubiti ulcer in one heel shows subcutaneous fatty tissue is involved
What is the decubiti ulcer stage?
STAGE III
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A patient with a decubiti ulcer in one heel shows muscle and bone that are destroyed….
What is the decubiti ulcer stage?
Stage IV
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Skin integrity: ________ IS KEY!!!!
prevention
- Pressure Reliefs
- Weight shifts for pressure reliefs
- Appropriate sitting surfaces (cushions)
- Appropriate sleeping surfaces (mattresses)
