Spinal Cord Injury Flashcards
Conduit for crucial information from the brain to most of the body
Spinal Cord`
Length of SC
42-45cm long
Width of SC
10-15mm
Width of Spinal Canal
17mm
Where the SC ends in children
L3
Where the SC ends in adult
L2
How many segments SC has?
31 segments
“Horse’s Tail”
Cauda Equina
Prolongation of pia mater
Filum Terminale
Center for micturation
Conus Medullaris
Bundle of nerve roots after the inferior of SC
Cauda Equina
Connects the distal tip of SC to the distal dural sac to coccyx
Filum Terminale
Distal tip of the SC
Conus Medullaris
Three blood supply of spinal canal
Anterior Spinal Artery, Posterior Spinal Artery, Radicular artery of Adamkiewicz
What area does ASA supplies in the SC?
Anterior upper 2/3
What area does PSA supplies in the SC?
Posterior upper 1/3
What area does Adamkiewicz supplies in the SC?
Lower 2/3
Area in the SC with the least blood supply
Watershed areas
Level of watershed area in the SC
T4-T6
Drainage of SC
Internal vertebral venous plexus
Sensory Neurons
1ON, 2ON, 3ON
Motor Neurons
UMN and LMN
Axons for ascending tracts
2ON
Axons for descending tracts
UMN
Neuron for pain modulation and reflexes
Interneuron
Inhibitory interneuron that controls message that presynaptic neuron will relay
Pre-synaptic interneuron
Interneuron that inhibits gamma motor activity
Renshaw cell
Inhibitory and excitatory internueron
Post-synaptic interneuron
True or False: Is the autonomic neurons afferent?
False, efferent
Four target organs signaled by post-ganglionic neurons
Cardiac Muscle, Adipose Tissue, Smooth Tissue, Glands
Part of SC that composed of cell bodies of neurons and Rexed lamina
Gray Mater
Part of SC that is composed of axons and tracts
White Mater
Rexed Lamina: For Pain
RL I and II
Rexed Lamina for Sensory
RL I - VII
Rexed Lamina for Motor
RL VIII - X
Rexed Lamina: For posture and balance
RL VII
Rexed Lamina: For touch and pressure
RL III - IV
Rexed Lamina: For joint activity
RL VI
Rexed Lamina: Connects R and L sides
RL X
Rexed Lamina: For visceral sensation and pain
RL V
Rexed Lamina: Motor function
RL VIII and IX
Rexed Lamina I
Lissauer’s tract
Rexed Lamina II
Substantia Gelatinosa
Rexed Lamina III and IV
Nucleus Proprious
Rexed Lamina V
Visceral Nucleus
Rexed Lamina VI
Deep Nucleus
Rexed Lamina VII
Clarke’s Column
Rexed Lamina VIII and IX
Motor Pools
Rexed Lamina X
Central Gray Commissure
Three Ascending tracts
Dorsal Column, Spinothalamic, Spinocerebellar
Five Descending tracts
Corticospinal, Rubrospinal, Vestibulospinal, Reticulospinal, Tectospinal
Transmits discriminative touch, proprioception, 2-point discrimination, epicritic sensation
Dorsal Column
Transmit crude touch, pain, and temperature
Spinothalamic tract
Transmit information about posture, coordination, balance
Spinocerebellar
3 epicritic sensations
Barognosis, Sterognosis, Graphesthesia
Rexed lamina of DCML
3&4: Nucleus Proprious
Decussation of DCML
Lower dorsal MO
Funiculus for LE
Gracilis (Below T6)
Funiculus of UE
Cuneatus (Above T6)
STT for crude touch
Anterior STT
STT for pain and temperature
Lateral STT
Rexed lamina of Lateral STT
I, II, and V: Lissaeur’s, Susbtantia Gelatinosa, Visceral Nucleus
Rexed lamina for Anterior STT
3&4: Nucleus Proprious
Decussation of STT
2 segments above
Spinocerebellar that decussates
Ventral SCT
Spinocerebellar that not decussates
Dorsal SCT
Rexed lamina of Spinocerebellar Tract
7: Clarke’s column
2 Decussation of SCT
At level of SC and Before cerebellum
CST that decussates
Lateral CST; 90%
CTS that does not decussates
Anterior CST: 10%
Controls tone of flexor muscles
Rubrospinal Tract
Controls postural muscle
Reticulospinal Tract
Controls posture and coordination
Vestibulospinal tract
Controls bright and sudden movements
Tectospinal
Area of the brain that is for processing of visual information
Tectum of Midbrain
Facilitatory tract for Flexion
CST and Rubrospinal
Facilitatory tract for Extension
Vestibulospinal and Reticulospinal
Inhibitory tract for Flexion
Vestibulospinal and Reticulospinal
Inhibitory tract for Extension
CST and Rubrospinal
True or False: Posture is more maintained by extensors to fight against gravity
True
Injury above the midbrain will result into?
Decorticate
Injury below the midbrain will result into?
Decerebrate
Flexor predominate extremities
Decorticate
Extensor predominate extremities
Decerebrate
Facilitate or inhibit movement or reflexes
Reticulospinal
Reflex postural movements in response to visual stimulus
Tectospinal
Ascending tract for pain and arousal
Spinoreticular
Ascending tract for cutaneous sensation
Spino-olivary
Ascending tract for spinovisual reflex
Spinotectal
Three sensory fiber type for proprioceptive touch
A-alpha, A-beta, A-delta
Two sensory fiber type for crude touch and pain
A-delta and C
The function of Merkel’s disc
Light touch information
The 2 functions of Meissner’s Corpuscle
Discriminative touch and texture
The 3 functions of Ruffini’s ending
Heat, joint activity, skin stretch
The 3 functions of Krause end bulb
Cold, touch, pressure
The 2 functions of Pacinian Corpuscle
Pressure and Vibration
The 3 functions of Free Nerve Endings
Tickle, Itch, Pain
Two motor fiber type
A-alpha and A-gamma
Motor fiber type for voluntary action
A-alpha
Motor fiber that facilitates contraction of muscle due to activation of muscle spindle
A-gamma
Sensory organ for reflex
GTO
Sensory organ for stretch stimulus
Muscle spindle
Pre-ganglionic autonomic neuron
B fibers
Post-ganglionic autonomic neuron
C fibers
4 target organs of Autonomic neuron
Cardiac muscle, smooth muscle, adipose tissue, glands
What kind of outflow does the sympathetic and parasympathetic nervous system have?
Efferent system
Level of PSNS
Craniosacral
Level of SNS
Thoracolumbar
Cranial level of PSNS
Brainstem
Thoracolumbar of SNS
T1-L2
Sacral level of PSNS
S2-4
PSNS proportion
1 pre-ganglionic: 4 post-ganglionic
SNS proportion
1 pre-ganglionic: 20 post-ganglionic
Superficial Reflex: Upper Abdominal
T7-T9 or T10
Superficial Reflex: Lower Abdominal
T10 or T11-T12
Superficial Reflex: Cremasteric
T12-L1
Superficial Reflex: Plantar
S1-S2
Superficial Reflex: Gluteal
L4-L5 or S1-S3
Superficial Reflex: Anal
S2-S4 or S4-S5
Three visceral reflexes
Bulbocavernosus, rectal, micturation
Reflex level of visceral reflexes
S2-S4
Babinski Reflex
L3-L5, S1
DTR Grading: Absent
0
DTR Grading: Hyperreflexive
3
DTR Grading: Normal
2
DTR Grading: Hyporeflexive
1
DTR Grading: Clonus
4
Law that states: “once the agonist is stimulated, the antagonist relaxes”
Sherrington’s Law of Reciprocal Innervation
Monosynaptic reflex flow
Afferent neuron to efferent neuron
Polysynaptic reflex flow
Afferent neuron to interneuron to efferent neuron
Insult to the spinal cord that may result in alterations in the sensory, motor, and/or autonomic function below the level of the lesion
Spinal Cord Injury
What gender is more affected by SCI?
Males
What age range is predisposed to SCI?
16-30 years old (26 y.o)
Most common MOI of SCI
MVA
The most common injury that results from SCI
Hyperextension injuries
The most common MOI of SCI in older adults
Falls
Two etiology of SCI
Traumatic and Non-traumatic
4 causes of traumatic SCI
MVA, Falls, Violence, Sports
The most common sport that results from SCI
Diving
6 causes of non-traumatic SCI
Tumors/neoplasm, infections, toxins, degenerative processes, congenital malformation, vascular disorder
The common type of SCI among infants or children
SCIWORA (SCI without radiographic abnormality)
MOI of SCIWORA in infants
Mishandling or improper handling of infants
MOI of SCIWORA in a teenager
Motor Accidents
Incontinence seen in UMNL
Urge
Erection seen in LMNL
Psychogenic (Sympathetic)
Ejaculation seen in UMNL
Present but may need stimulation
Incontinence seen in LMNL
Urinary Retention
Paralysis and bladder seen in UMNL
Spastic
Ejaculation seen in LMNL
Present without stimualtion
Erection seen in UMNL
Reflexogenic (Parasympathetic)
Is UMNL/LMNL complete or incomplete SCI?
Incomplete
3 stimulatory techniques to improve Urge Incontinence
Suprapubic tapping, Lower abdominal stroking, Hair pulling
2 stimulatory techniques to improve Urinary Retention
Crede Maneuver, Valsalva Maneuver
(+) Reflexogenic Erection indicates what?
(+) Sacral Paring
What type of SCI usually has Psychogenic Erection?
Cauda Equina Syndrome
Painful erection
Priapism
Vaginal Spasm
Vaginismus
Painful intercourse for female
Dyspareunia
Female oral sex
Cunnilingus
Male oral sex
Fellatio
Cross-section injury with the worst prognosis
Anterior Cord Syndrome
Cross-section injury with the best prognosis
Central Cord Syndrome
MOI of Anterior Cord Syndrome
Hyperflexion or Flexion
S/sx of ACS
Bilateral motor, pain and temperature loss; Spared DCML
MOI of Posterior Cord Syndrome
Hyperextension or extension injury
S/sx of PCS
Bilateral proprioception and vibratory loss; Spared CST and LSTT
Two non-traumatic causes of PCS
Syphilis and Vitamin B12 Deficiency
What specific cause of PCS in syphilis?
(+) Tabes dorsalis: problem in dorsal SC
What stage of syphilis does PCS come out?
Tertiary stage
What DCML s/sx seen in syphilis?
(+) Sensory ataxia
Sensory ataxia
No relay of somatosensation as input for balance
Vitamin B12 deficiency causes what condition can lead to PCS?
(+) Posterolateral sclerosis problem with DCML
What DCML s/sx seen in Vitamin B12 deficiency?
Sensory Ataxia
MOI of central cord syndrome
Hyperextention
MOI of central cord syndrome in older adults
Cervical Osteophytes
Location of UE in the SC
Near in the center
Another name of Central Cord Syndrome
Walking SCI
MOI of Brown-Sequard Syndrome
Gunshot, Stab wounds
S/sx of Brown-Sequard Syndrome
Ipsilateral: motor, proprioception, vibratory loss; Contralateral: pain and temperature loss
What level does the C/L pain and temp loss manifest?
2 segment below the level of the lesion
The spinal level that causes quadriplegia
Cervical
The spinal level that causes paraplegia
Thoracolumbar
The spinal level that causes tetraplegia
Cervical
Most common spinal level affected in paraplegia
T12-L1
Most common spinal level affected in SCI
C5 incomplete paraplegia
A brief period of areflexia that occurs from 24 hours to 3 days
Spinal Shock
How to test for Spinal Shock?
Bulbocavernosus reflex
Bulbocavernosus reflex procedure
Pinch the glans penis/clitoris or pull the indwelling foley catheter
(+) Bulbocavernosus reflex
Anal sphincter contraction
Pharmacological management for spasticity
Baclofen intake
4 PT management for spasticity
Slow Icing, NMES, Daily Stretching program, slow PROMS
What is autogenic inhibition?
You will fatigue the muscle to induce relaxation
What is reciprocal inhibition?
You will activate the antagonists and relax the agonist
Surgical management for muscle
Myotomy
Surgical management for spinal cord
Myelotonomy
Surgical management for spinal nerve
Neuroctomy
Surgical management for tendon
Tenotomy
Surgical management for ventral root
Rhizotomy
Surgical management for dorsal root intractable pain
Dorsal Rhizotomy
Surgical management for scissoring gait
Myotomy of adductor longus
Surgical management for crutch gait
Myotomy of hamstrings
Hypersensitivity to external stimuli that were commonly seen in injuries above T6
Autonomic Dysreflexia or Hyperreflexia
Five causes of autonomic dysreflexia
BILPA: Bladder distention, Ingrown toenail, Labor pain, Pressure sores, Aggressive stretching
Cause of OH
Immediate Transition from STS
AD or OH: Tachycardia
Orthostatic Hypotension
AD or OH: Pounding headache
Autonomic Dysreflexia
AD or OH: Fainting
Orthostatic Hypotension
AD or OH: Piloerection
Autonomic Dysreflexia
AD or OH: Bradycardia
Autonomic Dysreflexia
AD or OH: Dizziness
Orthostatic Hypotension
AD or OH: Facial Flushing
Autonomic Dysreflexia
AD or OH: Lightheadedness
Orthostatic Hypotension
AD or OH: Decrease BP
Orthostatic Hypotension
AD or OH: Increase BP
Autonomic Dysreflexia
AD or OH: Diaphoresis
Autonomic Dysreflexia
Diaphoresis
Excessive sweating
Management for Orthostatic Hypotension
Elevate the legs and give ankle pumps
Management for Autonomic Dysreflexia
Sit the patient up and give sublingual calcibloc
Process of bone growth at an abnormal site
Heterotrophic ossification
Diagnosis where there is HO on the muscle
Myositis Ossification
4 common sites of HO
Hips, Knees, Shoulder, Elbow
What causes the presence of neurogenic HO?
Traumatic SCI
Site of HO in TBI and CVA
Shoulder
Site of HO in Burns
Posterior elbow
Site of HO in UE
Brachialis
Site of HO in LE
Quadriceps
Pharmacological management for HO/MO
Etidronate Disodium (didronel)
Laboratory hallmark seen in (+) HO or MO
Increase alkaline phosphatase
Slowing down of blood flow
Virchow’s triad
Virchow’s triad
Hypercoagulability, Intimal wall damage, Venous stasis
Preventive PT management for DVT
AROMS and Ankle Pumps
Pharmacological management for DVT
Blood thinners
3 blood thinners used for DVT
Heparin, Coumadin, Warfarin
Immobilization causes ____?
Decrease bone desposition
What law states that increase pressure = increase bone deposition?
Wolff’s law
PT management for osteoporosis
WB and muscle contraction
Two commons sites of fracture in SCI patients
The distal femur and proximal tibia
PT management for fractures
WB activity on tilt table
Most common site of pressure sores in supine
Sacrum
Most common site of pressure sores in infants
Occiput
Most common site of pressure sores in sitting
Ischial tuberosity
Bed positioning to prevent pressure sore
Turning every 2 hours
Wheelchair positioning to prevent pressure sore
Chair pushups or WB relief activities every 15-20 mins
Common cardiac problem in SCI
Arythmia
The most common cause of death in SCI
Pneumonia
The second common cause of death in SCI
Atelectasis
“ASIA” scale
American Spinal Injury Association
Sensory scoring of ASIA
O= absent, 1 = impaired, 2 = normal, NT = not testable
Two sensations tested in ASIA
Light touch and Pinprick
Patient’s position in assessing ASIA scale
Frog-legged position
What is the grade if the patient cannot identify the stimulus as a pinprick or light touch?
Grade 0
Motor scoring: 5
Normal full active ROM against gravity with full resistance
Motor scoring: 1
Palpable contraction
Motor scoring: 3
Full active ROM against gravity
Motor scoring: 2
Full AROM, gravity eliminated
Motor scoring: 4
Full AROM against gravity with moderate resistance
What is the sensory level?
Most caudal segment with intact sensation (2/2 score) both pinprick and light touch
What is the motor level?
Most caudal segment with at least 3/5 and the segment immediately above should be 5/5
What is the neurological level of injury (NLI)
Caudal part where motor and sensory level coincide
What is a complete injury?
There is no sacral sparing
What is an incomplete injury?
There is sacral sparing
Motor criteria for sacral sparing
Voluntary anal contraction (VAC)
Procedure for VAC
Contraction of anal sphincter upon command
Sensory criteria for sacral sparing
Deep anal pressure, light touch sensation, and pinprick sensation at S4-5
Procedure of DAP
Patient can feel the pressure put by the PT at the internal anal wall
Location of touch sensation and pinprick
S4-5
(+) Sensory sacral sparing
1/3 criteria
ASIA classification A prognosis
Worst
ASIA classification E prognosis
Best
ASIA classification A name
Complete
ASIA classification B name
Sensory Incomplete
ASIA classification C name
Motor Incomplete
ASIA classification D name
Motor Incomplete
ASIA classification E name
Normal
ASIA classification A sacral sparing
(-) sensory or motor sacral sparing
ASIA classification B sacral sparing
(+) sensory; (-) Motor
ASIA classification C sacral sparing
(+) sensory; (+) Motor = >50 muscles below NLI is 0-2/5
ASIA classification D sacral sparing
(+) sensory; (+) Motor = >50 muscles below NLI is 3-5/5
ASIA classification E sacral sparing
Normal
Total number of dermatomes assessed in ASIA scale
28 dermatomes
Total points in sensory assessment in ASIA scale
112 points LT/PP
Total number of myotomes assessed in ASIA scale
10; 5 = UE + 5 = LE
Total points in motor assessment in ASIA scale
100; 50 = UE + 50 = LE
C1-C3 respiratory outcomes
Glossopharyngeal breathing
C5 respiratory outcome
Manually assisted coughing and quad coughing
C6 respiratory outcome
Self-assisted coughing
C4 wheelchair
Power wheelchair
4 controls of power wheelchair
Tongue control, Chin control, Voice control, Sip & Puff
C5 wheelchair
Joystick
C5 wheelchair projections
Oblique handrim projections
C5 orthosis
Balanced forearm orthosis
C6 wheelchair projections
Vertical handrim projections
C6 orthosis
Tenodesis splint and wrist driven flexor hinge orthosis
C7 wheelchair handrims
Friction handrims
C8 wheelchair handrims
Standard Handrims
What wheelchair activity can C8 patient can do?
Wheelie
T1-T8 foot orthosis
KAFO
L4-L5 Assistive device
Loftstrand
T9-T12 gait pattern
Swing to
L1-L3 foot orthosis
KAFO
T1-T8 Assistive device
Walker
L4-L5 gait pattern
2 point
T9-T12 foot orthosis
KAFO
T1-T8 Gait Pattern
Swing to
L1-L3 Gait pattern
4 point
T9-T12 Assistive device
Walker
L4-L5 foot orthosis
AFO
L1-L3 Assistive device
Loftstrand
C6 2 ADL
Indep bed mobility with equipment and indep sliding board transfers
C7 3 basic ADL
Prop up (elbow extension), LE ROM, Dress upper and lower garments
C7 4 independent ADLS
Indep driving, bed mobility, transfers in all surface, toileting
T1 ADL
Wheelchair to floor transfers
T4 ADL
Squat-pivot transfers
