spinal cord injury: epidemiology, diagnosis and management Flashcards
what is a SCI?
a spinal cord injury is a complete or partial interruption of the sensory and motor tracts of the spinal cord
-this can lead to the loss of ability to feel or move below the level of the lesion
what are examples of non traumatic causes of an SCI?
-vascular
-tumour
-infection
-degenerative cervical myelopathy
what are traumatic causes of a SCI?
-falls
-RTC
-sports
-assault / violence
raer causes:
-natural disaster
-self harm
-occupational injury
what are 2 places in the spine that are most vulnerable to SCI?
low cervical
low thoracic
what is the financial cost of SCI influenced by?
-nature of initial injury
-timeliness of initial Rx
-length of stay in hospital
-different medical costs
how is the level of injury SCI classified?
-neurological level- ie the lowest segment of the spinal cord with normal sensory and motor function
-skeletal level - level of damage on radiological examination
what is the main clinical assessment system of SCI?
-the American spinal cord injury association
the ASIA scale
-measures motor and sensory function and assess the degree of completeness
what does the clinical assessment of SCI involve?
-motor assessment - 10 muscle groups - graded 0-5 on the Oxford scale
-sensory assessment - pinprick and light touch, graded 0 (absent) to 2 (normal sensation)
-anorectal examination - assesses S4/S5 dermatomes and voluntary anal contraction, determines if injury is complete or incomplete
what is a complete SCI?
A complete spinal cord injury results in total loss of motor and sensory function below the level of injury, including the sacral segments (S4-S5).
-NB anal rectal assessment
what is an incomplete SCI?
An incomplete spinal cord injury means some motor or sensory function remains below the level of injury, including sacral sparing (S4-S5).
-must have anal sensation or contraction
describe the ASIA impairment scale scores
-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 the 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 the level have a grade 3 or more
-E= normal - motor and sensory function is normal
what are the prognostic value of the ASIA scores?
-AIS score A have a 91.7% negative predictive probability for independent ambulation at one year
-AIS D patients have a 97.3% positive predictive probability for independent ambulation at one year
Describe central cord syndrome
incomplete SCI causing weakness in ULs> trunk > LL’s
-hyperextension injuries
-cervical spondylosis or stenosis in older people can predispose
-compression of the cord anteriorly by osteophytes and posteriorly by ligaments flavour
-associated with fracture dislocation and compression fractures
describe brown sequard syndrome
incomplete spinal cord injury caused by damage to one side (hemisection) of the spinal cord, leading to a unique pattern of motor and sensory deficits on both sides of the body
-on the same side of injury - muscle weakness / paralysis and loss of touch, proprioception etc
-on opposite side of injury - loss of pain and temperature sensation
describe anterior spinal cord syndrome
-a lesion that produces variable loss of motor function and sensitivity to pain and temperature while preserving proprioception
-caused by high velocity accidents eg forced flexion or a diving injury
-non traumatic causes eg vascular - anterior spinal artery thrombosis, aortic aneurysm
describe the clinical presentation of anterior spinal cord syndrome
-severe motor loss due to anterior horn cell damage and damage to the motor tracts at rental aspect of cord
-loss of temperature and pain sensation
-preservation of proprioception
-preservation of tactile, joint position sense and vibration
what are the 4 pillars of trauma management for SCI
-resp
-cardio
-vertebral stability
-neuro-protection
describe vertebral stability management
-SCI may or may not be caused by structural damage ad instability of the vertebral column
-if no vertebral instability: generally mobilised within a few days if medically stable
-if vertebral instability: conservative or surgical management
-surgery: spinal fusion or halo traction and brace
what are early physiotherapy precautions for sci?
-any rotation of spine
-rolling
-unilateral arm movement
-long sitting in the initial phases of rehab
-sitting out
-standing
what are examples of conservative management for high cervical SCI?
what is spinal shock?
acute reaction immediately post injury involving flaccid paralysis of all levels
and loss of reflex activity
-associated with hypotension
-gradually resolves, takes days to months
-duration of spinal shock is a potential indicator of outcome
what are examples of CVS complications of SCI in the early days?
neurogenic shock
orthostatic hypotension
autonomic dysreflexia
describe neurogenic shock
hypotension + bradycardia + hypothermia
-more commonly in injuries above T6 due to the disruption of sympathetic outflow
-loss of sympathetic tone
what are the signs and rx of orthostatic HYPOTENSION
-signs: feel faint and LOC
-Rx: lie down and raise the legs or tilt the wheelchair backwards
what is autonomic dysreflexia
a potential life threatening complication of SCI
-caused by dysregulation of the ANS in people with a SCI above T6
- un-co-ordinated reflex sympathetic discharge in response to a noxious stimulus below the level of SCI and leads to dangerously high BP
-can occur anytime throughout a patients lifetime with a SCI above T6
what are the triggers of autonomic dysreflexia
-bladder eg urinary retention, UTI, bladder spasms
-bowel - constipation, feral distention
-boils - skin, sores, pressure etc
-bones - fractures etc
-babies - SCI patients who are pregnant
-haemorrhoids and fissure - back passage
what is the treatment for autonomic dysreflexia?
-position the patient upright
-remove tight clothing
-systematically check for 6 Bs and remove obvious triggers- check catheter, skin etc
-monitor BP
-escalate to medical support- management of 6Bs and vasodilation
-If BP docent drop after 10 mins or SBP> 150mmHg, medical team will administer vasodilators
how can pressure sores be prevented?
-positioning
-changes of position
-care of skin
-posture correction
-correct seating
-pressure relief
