spinal cord injury Flashcards
define spinal cord injury
a complete or partial interruption of the sensory and motor tracts of the spinal cord
leading to loss of ability to feel or move below the level of the lesion
level of injury
C1-4 breathing head and neck mvmt C4-T1 = HR control UL mvmt T1-12 - trunk control temp reg abdominal muscles L1-S1- lower limb movement S2-S4/5 - bowel bladder and sexual function
SCI causes
non traumatic
traumatic
non traumatic vascular tumour infection degenerative cervical myelopathy
traumatic falls RTC sports assault / violence rarer - natural disaster self harm occupational injury
SCI prevalence
by age
male 71.5%
falls > half
age <1 medical / iatrogenic causes birth - young adult - RTC adults - high velocity trauma or violence men > women >60 years: falls, non traumatic SCI
financial cost of SCI
nature of injury timeliness of initial Rx length of stay hospital direct costs higher first year indirect costs - earning potential may exceed direct costs
diagnostic information
classification of LEVEL of injury
degree of completeness
level vertebral level neurological level sensory and motor levels zone of partial preservation mixed LMN and UMN presentation
neurological level
lowest segment of the spinal cord with normal motor function and sensory function
clinical assessment of SCI
(ISNCSCI)
motor and sensory function
to determine the neurological level of injury
degree of completeness to determine ASIA impairment scale AIS
motor assessment
10 muscle groups
Oxford scale
lowest intact myotome = motor level
sensory assessment - pinprick and light touch 28 dermatomes graded 0 - absent 1- partial or absent 2 - normal sensation lowest intact dermatome = sensory level
anorectal examination
assesses S4/5 dermatome and voluntary anal contraction
indentifies presence or absence of sacral sparing
determines if injury is complete or incomplete
classification of injury
complete
incomplete
Complete
No anal contraction or sensation (no
“sacral sparing”)
Complete loss of motor and sensory
function below the level of injury*
*Potential Zone of Partial Preservation
Incomplete
MUST have anal sensation or
contraction
Preservation of some motor or sensory fibres (or both) below the level of the injury
Further classified according to the extent of motor or sensory loss below the level of the injury
ASIA impairment scale score
A = Complete: No motor or sensory function is preserved in the
sacral segments S4-S5
B = Incomplete: Sensory but not motor function is preserved
below the neurological level and includes S4-S5
C = Incomplete: Motor function is preserved below neurological level, and more than half of key muscles below level have a grade less than 3
D = Incomplete: Motor function is preserved below neurological level, and at least half of key muscles below level have a grade 3 or more E = Normal: Motor and sensory function is normal
prognostic value of AIS
AIS score A have a 91.7% negative predictive probability for independent ambulation at one year
AIS D have a 97.3% positive predictive probability for independent ambulation at one year (Middendorp 2017)
2.1% of AIS A patients improve to an incomplete injury in 5 years (Kirshblum 2004)
incomplete SCI syndromes
Central cord syndrome Brown-Sequard syndrome Anterior cord syndrome Posterior cord syndrome Conus medullaris Cauda equina lesions
central cord syndrome
Incomplete SCI (usually cervical) causing weakness ULs > trunk > LLs
Hyperextension injuries
Cervical spondylosis or stenosis in older people can predispose
Compression of the cord anteriorly by osteophytes and posteriorly by ligamentum flavum
Associated with fracture dislocation and
compression fractures
outcomes
Good prognosis for independent walking with or without aids, though LL spasticity may persist
Good recovery often in hands but lack of proximal stability → limited selective movement
Depending on severity, some degree of motor deficit in trunk may persist → impaired posture and balance
Complications: shoulder pain, hand oedema, spasticity, neurogenic
pain
brown sequard syndrome
same side as lesion UMN weakness loss of position and vibration side opposite lesion loss of pain and temp A lesion that produces relatively greater ipsilateral proprioceptive and motor loss and contralateral loss of sensitivity to pain and temperature (Maynard et al 1997)
First described by Galen
Damage occurs to one side of the cord (hemi-section)
Gunshot or stab wounds, lateral vertebral fractures
Majority of people with this injury will walk
anterior spinal cord syndorme
clinical presentation
A lesion that produces variable loss of motor function and sensitivity to pain and temperature whilst preserving proprioception (Maynard et al 1997)
Traumatic
Forced flexion / compression injury, e.g. diving or RTC
Non traumatic
Vascular: anterior spinal artery thrombosis, aortic aneurysm, angioma
Severe motor loss due to anterior horn cell damage and damage to the motor tracts at ventral aspect of cord
Loss of temperature & pain sensation (LST)
Preservation of tactile, joint position sense and vibration (posterior column)
Preservation of proprioception → significant difference to rehabilitation
other incomplete
cancer - primary or secondary tumours
transverse myelitis
decompression sickness - usually produces an incomplete lesion
cauda equina syndrome
trauma management
- resp mimt
- CV
- Vertebral stability
- neuro-protection
vertebral stability
SCI may or may not be associated with structural damage and instability of the vertebral column
If no vertebral instability: generally mobilized within a few days if medically stable
If vertebral instability: conservative or surgical management
Surgery: spinal fusion, or halo traction and brace
early physio precautions
Surgeon / physician clearance required for:
Any rotation of the spine Rolling Unilateral arm movement Long sitting in the initial phases of rehabilitation Sitting out Standing
spinal shock
Acute reaction immediately post-injury Flaccid paralysis
Loss of reflex activity
Associated with hypotension and paralytic ileus
Extent of disruption is variable
Precise definition and duration is debated
Gradually resolves, takes days to months (Ditunno, 2004)
Duration of spinal shock is a potential indicator of outcome
CV complications
neurogenic shock
orthostatic hypotension
autonomic dysreflexia
neurogenic shock
Classic triad = Hypotension + Bradycardia + Hypothermia
Incidence 7%-45%
More commonly in injuries above T6 (disruption of sympathetic outflow)
Loss of sympathetic tone → ↓ systemic vascular resistance and dilation of venous vessels → ↓ cardiac preload
(Hypotension can also be contributed by severe haemorrhage at injury site or associated injuries)
BP restored by fluid administration + vasopressor drugs (avoid pulmonary oedema)
Atropine to treat bradycardia
orthostatic hypotension
Can occur in lesions above T6
Occurs with movement into gravity dependent positions
Signs: feel faint and loss of consciousness
Treatment: Lie down and raise the legs; or tilt the wheelchair backwards
Implications:
Use compression stockings and abdominal binders
Graduated programme against gravity is essential
Moderate evidence for use of FES
autonomic dysreflexia
Potentially life threatening complication of SCI (mortality 22%)
Dysregulation of the autonomic system in people with SCI above T6
Uncoordinated reflex sympathetic discharge in response to a noxious stimulus below the level of the SCI
Acute episode of systolic BP >25 mm Hg above baseline due to
vasoconstriction
Risk of stroke and cardiac arrhythmia or arrest
Can occur anytime throughout a patient’s lifetime
Triggers: The 6 B’s Bladder (over-distension, UTI) Bowel (constipation, impaction) Boils (skin – sores, pressure, breakdown) Bones (fractures) Babies (pregnancy) Back passage (haemorrhoid, fissure
treatment of autonomic dysreflexia
Position the patient upright
Remove tight clothing
Systematically check for 6 Bs and remove obvious triggers –
check catheter, skin
Monitor BP
Escalate to medical support – management of 6 Bs, vasodilation
If BP doesn’t drop after 10 mins or SBP > 150 mm Hg, medical team will administer vasodilators (nifedipine, GTN)
venous thromboembolisation
Deep vein thrombosis (DVT)
Increased vulnerability in first 2 weeks of injury
Common in veins of calf; more serious in veins of the thigh and groin Q: How do you recognise DVT?
Pulmonary embolism (PE) Dislodgement of DVT Life threatening
Q: How do you recognise PE?
DVTs likely to be dislodged during movement (active or passive) – implications for physiotherapy?
Interventions: Calf compressors, anticoagulants
pressure sores prevention
Positioning Changes of position Care of Skin Posture correction Correct seating Pressure relief (cushions and mattresses)
clinical predictors of outcome after traumatic SCI
Positive predictors (apart from level and completeness):
Sensory and motor zones of partial
preservation in complete SCI
Positive features of the upper motor neuron syndrome
Female*
Younger**
prognosis
Most neurological recovery occurs within the first 2 months (Waters et al., 1994)
Complete lesions have low probability of extensive neurological recovery (Marino, 2005), might regain one neurological level
Motor recovery following an incomplete lesion is more common (50% of AIS B/C improve over the 1st few months by 1 AIS level)
Predicting ability to walk is difficult and depends on level and completeness (unlikely in AIS A except low paraplegia, 30-45% AIS B walk short distances, most people with AIS C and D are community ambulators)
