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Clin Med Fall 2015 > Spinal Cord Injury Test 3 > Flashcards

Spinal Cord Injury Test 3 Flashcards

1
Q

Spinal Cord Injury

A

cord be a zone of injury where nerves/spinal cord of different levels are affected

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2
Q

Pathophysiology of SCI

A
  • physical alteration of cord /cutting of cord fibers
  • cord intact w/ auto-destructive process (result of a force of injury
  • cord intact with vascular compromise
  • Traumatic or Non-Traumatic
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3
Q

Non traumatic Etiology

A
  • vascular malformations
    • aneurism, thrombus, embolus, arterial venous malformation (no capillaries)
  • vertebral degeneration and subluxation
    • osteoporosis, severe kyphosis, RA, kyphoscoliosis, stenosis, Paget’s disease, AA dislocations
  • Primary or secondary neoplasms(cancer)
    • multiple myleoma , myeloma, metastases from breast or lung
  • infections
    • myelitis, syphillis, Gulian -Barre
  • abscess(collection of pus)
    • necrosis of tissue
  • congenital defect
    • spinia bifida
  • other
    • myelopathy secondary to radiation therapy, MS, ALS, syringomyelia
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4
Q

Traumatic etiology

A
  • sports (12%)
  • violence(16%)
  • falls(22%)
  • MVA (46%)
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5
Q

Incidence of SCI

A
  • 20-60 new cases /million persons (average 40/ million)
  • 11,000 new cases/yr
  • *6-8 cases/million ppl die before they get to the hospital each yr
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6
Q

Prevalence of SCI

A
  • over 200,000 individuals in US
  • 225,000-296,000
  • 80% of all traumatic cases are male (77.8% of SCI since 2000 occurred in males)
  • over half of all SCI cases are between ages 15-30 y/o
  • since 2000 11.5% of SCI have occurred in those 60+y/o
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7
Q

MOI

A

Factors which affect vertebral injury

  • direction of force applied to system
  • position of the person’s head at time of injury
  • magnitude, rate of application and duration of injuring forces
  • point of application
  • infer forces from history of accident and pattern of vertebral and lig. injury
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8
Q

MOI of C spine

A
  • poor stability, designed for mobility (increased risk of injury)
  • 40% incidence in spinal cord injury w/ damage to Cervical vertebrae
  • 52% of SCI occur in cervical region
  • three most common damaging forces are; flexion, vertical loading, and extension
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9
Q

Hyperflexion MOI in C-spine

A
  • head collision in which head strikes steering wheel or windshield
  • blow to the back of the head, fall on the back of the head
  • compression anteriorly, distraction posteriorly
  • C5-C7
  • wedge fx of vertebral body , tearing of posterior lig.,anterior dislocation of vertebral body, disruption of disc, fx of posterior structures(SP, laminae,pedicles)
  • *note in spine generally 50% of SCI are due to excessive flexion as MOI
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10
Q

flexion with rotation MOI in C spine

A
  • often seen with lateral flexion
  • often results in dislocation and locking of a single facet joint
  • may also present with fx of lamina or pedicle
  • often stable situation
  • neurologic damage; Brown sequard (hemisection of cord), nerve roots
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11
Q

vertical compression /axial loading MOI in Cspine

A

-high velocity blow to the top of the head
-often have burst fx (comminuted)
-fx fragments may migrate posteriorly and enter spinal canal and lodge in cord
-rupture of disc
-occurs most frequently at C4-C5 resulting in complete quadriplegia
(may occur with near drowning)

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12
Q

hyperextension MOI in cervical spine

A
  • strong posterior force-rear end collision, fall and hit chin or forehead
  • distraction anteriorly, compression posteriorly
  • fractures of posterior structures; SP, laminae, facets
  • avulsion fx of anterior aspect of vertebrae
  • anterior structures torn
  • rupture or disruption of disc
  • C4-C5 most common location
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13
Q

MOI for SCI in thoracic

A

-t-spine is much more stable than C-spine
(rib cage T1-T10)
-T spine injuries most commonly caused by GSW(gunshot wound), MVA, falls
-T12-L1 most commonly injured

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14
Q

MOI in thoracic spine

A

Flexion:
-wedge fx:most common
-posterior lig complex may be damaged due to distractive forces (severe)
Vertical Compression
- burst fx bone fragments into spinal cord

*thoracic spine not usually injured by isolated extension or lateral flexion forces

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15
Q

Flexion-rotation MOI for Lumbar SCI

A
  • posterior to anterior force directed at rotated vertebral column
  • typically causes fx-dislocation
  • posterior lig complex is ruptured accompanied by vertebral body fx(s)
  • result: highly unstable injury
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16
Q

Flexion -Distraction MOI for Lumbar SCI

A

(chance fx)

  • often result from use of lap belt without shldr restraint
  • lap belt( back seat) becomes a pivot point (fulcrum)
  • have flexion -distraction forces from that point
  • bony fxs and lig tears are horizontally oriented
  • injury in thoracolumbar area
  • may also have severe internal injuries
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17
Q

Penetrating wound MOI SCI

A

low velocity;
-knife, ice pick, low velocity bullets-spinal cord physically cut
high velocity;
- high powered rifles, explosion( does not have to penetrate spine or spinal cord to cause damage to neural structures-concussive forces)

18
Q

Diagnosis

A

Radiographs

  • C-spine:lateral radiograph
    • rapid and effective at dx w/ 85% accuracy
    • add open mouth and AP radiograph - almost100% accuracy
  • CT:
    • gives valuable information on impingement on neuronal canal as well as bony limits of spinal canal
  • Myelography
    • rarely used alone, may be in conjunction with CT or MRI (may be contraindicated early on bc increases fluid in system which could cause more damage)
  • MRI
    • appropriate imaging tech for visualizing the necessary tissues however in acute SCI other equipment in the surrounding area my limit its use ( doesn’t expose pt to repeated radiation)
19
Q

Pathophysiology

A
  • concussion:
    • forces applied near cord
  • contusion:
    • brusied, contact w/ vertebral column, hyperflexion/ext causing brusing
  • laceration:
    • by object or bony object or tissue
  • ascending sensory tracts
  • descending motor tracts
    • anterior horn cells, spinal nerves, descending tract damage
    • initially flaccid-> spasticity increasing over time
  • involevment of other systems
    • ANS
    • Integument
    • CV
    • respiratory; innervation of diaphragm/ unable to clear secretions
    • Bowel/Bladder function
    • sexual function
    • MS
20
Q

Classification of SCI

A
  • functional
  • extent of injury
  • level of injury
21
Q

Functional classification

A 
Quadriplegia:
-all four extremities and trunk are involved
-visceral mm also involved
-cervical cord
-paresis=incomplete
-plegia= complete
Paraplegia:
 -lower extremity and trunk involvement
-thoracic , lumbar and sacral cord injury
- visceral involvement
22
Q

Extent of injury

A

Complete:
- all motor and sensory function are lost below the level of the injury
Incomplete:
- an injury is classified as incomplete if there is any function below the level of injury
-preservation of some sensory/motor function below the level of injury

23
Q

Classification of incomplete injuries

A
  • anterior cord syndrome
  • posterior cord syndrome
  • central cord syndrome
  • brown-sequard syndrome( hemisection)
  • sacral sparing
  • cauda equina injury (LMN vs UMN)
24
Q

Extent of injuries

A

consider:

  • UMN/LMN lesion:
    • conus medularis, cauda equina
  • zone of injury
    • includes cord structures, tracts, bony structures, nerve roots
25
Q

level of injury defintion

A

lowest level in which functional motor power and sensation remain intact
-functional motor power; abiity to accomplish full ROM against gravity without resistance (MMT: fair or 3/5)
(not necessarily level of skeletal damage)

26
Q

Level of injury examples

A

-C5 complete quadriplegia
* C5 fair strength of biceps /deltoid
*C5 dermatome intact
-C5 incomplete (motor) quadriplegia
*C5 fair strength of biceps and deltoid
* C5 dermatone intact
**may have some strength /sensation below level
( may have dermatome or mytome below level but unlikey both

27
Q

Level of injury by american spinal injury assocation (ASIA)

A

A: complete:
- no motor or sensory function is preserved in sacral segments S4-S5
B: sensory incomplete:
-sensory but no motor function is preserved below the neurological level; sensory function extends through segments S4-S5 and No motor function is preserved below more than 3 levels below the motor level on either side of the body
C: Motor Incomplete:
- motor function is preserved below the neurological level and more than half of the key mm below the neurological level of injury have a mm grade below 3
D:Motor Incomplete:
-motor function is preserved below the neurologic level and at least half the key mm below the neurologic level of injury have a mm grade 3 or more
E: normal:
- motor and sensory function is normal when tested in all segments

28
Q

emergency care of the pt with SCI

A
  • assessment
  • immobilization
  • extrication
  • transport
29
Q

assessment

A
  • observe for possible MOI
  • complete medical assessment -ABC (airway, breathing, circulation
  • if need CPR-no hyperextension
  • neuro status-mm movement/sensation
  • when in doubt suspect SCI
30
Q

immobilization

A
  • immobilize pt in potions found or in neutral , if such alignment can be easily achieved (no neuro change)
  • back board( long or short) cervical immobilizer (Philadelphia collar, Stifneck collar)
31
Q

extrication

A

-implies the use of force or ingenuity in freeing from a difficult position or situation (out of a vehicle, out of water, off field)

32
Q

transport

A

minimal mvmt/jarring during transport

-dont want to further injuries on ride to hospital

33
Q

Acute care of pt w/ SCI

A
  • Assesment
  • Stabilization
    • medical
    • neurological
      • frequent assesmet-hourly,
      • methlyprednisolone,lazaroid, GM-I, decadron~steroids to decrease 2ndary damage
      • minmize IV fluids
    • orthopedic
  • transport
34
Q

orthopedic stabiliztion

A
  • reduction w/ traction
  • reduction w/ orthosis
  • reduction w/ surgery
35
Q

reduction w/ traction

A

-person in spinal traction
-cruthfield or Garner well tongs attached to skull
-stryker frame, kinetic bed, rotorest, circoeletric bed, specialized mattress
( not often used; possible for nonsurgical candiate
~person can be rotated 180 degrees to change position, traction maintains pt ion good alignment)

36
Q

reduction w/ orthosis

A

-halo
-SOMI (sternal occipital mandibular)
-Philadelphia collar
-custom body jacket
-LS flexion, extension, lateral flexion control orthosis
-TLSO flexion control orthosis
(named for the motions they control)

37
Q

reduction w/ surgery

A

indications

  • fx will not reduce
  • gross spinal mal-alignment
  • cont. cord compression
  • deteriorating neurological status
  • unstable fx
  • cont.instability after conservative care (nonunion)
38
Q

reduction w/ surgery options

A
  • bone graft-vertebral body support/stabilization
  • wiring spinous processes or transverse processes
  • rods or springs-distraction or compression
39
Q

other medical possibilities

A
  • hyopthermia (cool internal body temp to 92 degrees)
  • receptor blackers
  • growth factors
  • fetal cell transplants
  • regeneration associated genes (RAGs)~may be driving force in axonal regneration
40
Q

Prognosis

A
  • prognosis for survival is good if pt makes it alive to the hospital
  • 90% pts w/ SCI admitted to acute care are eventually d/c to home (10% LT facility)
  • mortality rates are greatest in first 4 weeks
  • decreased lifespan compared to typical population
    • respiratory complications, infections, cardiac problems
41
Q

cost of SCI

A 
First yr
-high tetraplegia (C1-C4): $741,425
-low tetraplegia(C5-C8):$478,782
-paraplegia: $270,913
-low tetraplegia(C5-C8):$218,504
Every yr after
-high tetraplegia:$132,807
-low tetraplegia (C5-C8):$-54,400
-paraplegia: $27,568
-incomplete motor function at any level: $15,313
42
Q

Prognosis

-estimated lifetime costs

A 
by 25 y/o
-high tetraplegia:$2,924,513
-low tetraplegia (C5-C8):$1,653,607
-paraplegia: $977,142
-incomplete motor function at any level: $ 651,827
by 50 y/o
-high tetraplegia:$1,721,677
-low tetraplegia (C5-C8):$1,047,189
-paraplegia: $666,473
-incomplete motor function at any level: $472,392

Clin Med Fall 2015 (10 decks)

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