Week 3- SCI Intro and Pathophysiology Flashcards
PART 0: SPINAL CORD ANATOMY REVIEW
PART 0: SPINAL CORD ANATOMY REVIEW
How many vertebrae are there?
- 7 Cervical
- 12 Thoracic
- 5 Lumbar
- 5 Sacral (fused)
- 4 Coccyx (fused)
How many spinal nerves are there?
- 8 Cervical (C1-C8)
- 12 Thoracic (T1-T12)
- 5 Lumbar (L1-L5)
- 5 Sacral (S1-S2)
- 1 Coccygeal
- Our spinal cord is a continuous structure starting at the base of the medulla and running all the way down to the __-__ intervertebral space in adults.
- At this point, the spinal cord tapers into the _______ __________. And then you’ll see this bundle of spinal nerves extending inferiorly from the lumbosacral region and conus medullaris that forms the ______ _______.
- L1-L2
- conus medullaris, cauda equina
- The spinalnerves exitthecervicalspine_____their corresponding vertebral body level. (ex: C7 nerverootexits aboveC7 through the C6-C7 neural foramen. C8exitsin between T1 and C7, since there is no C8 vertebral body level.)
- After the cervical region, this layout transitions with the spinal nerves exiting ________ their respective vertebrae.
- ABOVE
- BELOW
What are the 3 parts of the central gray matter?
- Dorsal Horn
- Intermediate Zone
- Ventral Horn
What is the white matter made of?
-Ascending and Descending columns
- White matter increase _______ to _______.
- Volume of gray matter is highest in ______ and ________ regions.
- caudal to cranial
- cervical and lumbosacral
What are the 2 main blood supplies to the spinal cord?
- Anterior and Posterior Spinal Artery
- **Several radicular arteries found throughout the cord supplying segmental vasculature to the SC.
What are the (3) Ascending Sensory Tracts?
- Dorsal Column Medial Lemniscus Pathway
- Anterolateral Pathways
- Spinocerebellar Pathway
Dorsal Column Medial Lemniscus Pathway:
- (Conscious) __________, vibration, ______ and _________ touch.
- Second order neurons cross in _______ _______ in internal arcuate fibers.
- proprioception, vibration, light and discriminative touch
- caudal medulla
Anterolateral Pathway:
- _____, _________, ______ touch
- Second order neurons cross at level of ______ ______ through anterior commissure.
- pain, temp, crude touch
- spinal cord
Spinocerebellar Pathway:
- Unconscious proprioception from ____________.
- Terminates in __________.
- trunk and limbs
- cerebellum
What are the (6) Descending Motor Tracts?
- Lateral Corticospinal Tract
- Anterior Corticospinal Tract
- Rubrospinal Tract
- Vestibulospinal Tract
- Reticulospinal Tract
- Tectospinal Tract
Lateral Corticospinal Tract:
- Function: Volitional movement of _________ ______.
- Cross at the _____________ and descend contralaterally.
- contralateral limbs
- pyramidal decussation
Anterior Corticospinal Tract:
- Function: Control of bilateral _______ and _______ muscles.
- Descend ipsilaterally until level of _________, at which point splits into bilateral innervation.
- axial and girdle
- spinal cord
Rubrospinal Tract:
- Function: Assists LCST with descending drive for movement of _________ limbs.
- Originates in _________, crosses in _________, and descends contralaterally.
- contralateral limbs
- red nucleus, midbrain
Vestibulospinal Tract:
- Medial VST: Originates in ______ medulla, descending bilaterally to cervical region to control positioning of _____/______.
- Lateral VST: Originates in ______, descends ipsilaterally down spinal cord to aide in _______ _______ and _______.
- rostral medulla, neck/head
- pons, truncal control and balance
Reticulospinal Tract:
- Function: Aids in ________ and ____-related movements.
- Originates in both _______ and _______ RF and descends __________.
- posture and gait-related movements
- pontine and medullar RF and descend ipsilaterally
Tectospinal Tract:
- Function: Assists with coordination of _____ and ____ movements.
- Originates in __________, crosses in _________, and descends contralaterally to upper cervical cord.
- head and eye movements
- superior colliculus, crosses in midbrain
Autonomic Nervous System:
- What are the 2 parts of the ANS?
- Which is located at the thoracic/lumbar region?
- Sympathetic/Parasympathetic Nervous System
- Sympathetic
__________ Nervous System:
- Fight or Flight
- Pupil dilation
- Bronchodilation
- Cardiac acceleration
- Digestive Inhibition
- Piloerection
- Systemic vasoconstriction
Sympathetic
_____________ Nervous System:
- Rest and Digest
- Pupil constriction
- Bronchoconstriction
- Cardiac deceleration
- Digestion stimulation
Parasympathetic
PART 1: INTRO AND ACUTE MANAGEMENT
PART 1: INTRO AND ACUTE MANAGEMENT
- What are the (2) ways a spinal cord injury can occur?
- Which is more common and makes up around 90% of cases seen?
- Traumatic
- Non-Traumatic
-Traumatic
Why does the MOI (force direction) matter in spinal cord injuries?
Depending where/direction of force often dictates where in spinal cord we will see the damage.
- ________ injury is most common in lumbar injuries.
- _______-_______ injury is most common in cervical injuries.
- ___________ injuries are almost exclusive to cervical injuries.
- flexion
- flexion-rotation
- hyperextension
What are the (4) spinal areas of greatest frequency of injury?
-C5, C7, T12, L1
What are a few (3) non-traumatic causes of SCI?
- disc prolapse
- vascular insult
- infections
Traumatic Cervical Injury:
- ___ and ___ most frequently involved areas of injury.
- Flexion, vertical loading, and extension accompanied by ________ or __________.
- C5 and C7
- rotation or lateral flexion
Traumatic Thoracic Injury:
- Less likely to be injured from traumatic causes due to rib cage and higher _______ as compared to cervical region.
- ___-____ _______ is most common site of injury.
- Common MOI: _______ motion or vertical compression.
- stability
- T12-L1 junction
- Flexion
Traumatic Lumbar Injury:
- Neurological damage from trauma is usually incomplete due to large vertebral canal and relatively good ________ supply.
- Most injuries occur at ___
- Most common MOI: ______ injuries
- vascular
- L1
- flexion
Do we typically have to worry about the sacrovertebral column injuries? Why or why not?
-No, because by the time we get down there we are talking about the conus medullaris and cauda equina.
- What is the average age of injury?
- Are males or females more at risk?
- What percentage of injuries are cervical, thoracic, lumbar?
- What is the most frequent SCI?
- The frequency of complete vs incomplete paraplegia is about _______.
- 43 years old
- Male (78%)
- Cervical (>50%), Thoracic (33%), Lumbar (the rest)
- Incomplete Tetraplegia
- equal
What are the (2) main ways to classify SCIs?
- Tetraplegia
- Paraplegia
- Tetraplegia involves injury to the _______ spinal cord. It involves ____ extremities and the trunk.
- Paraplegia involves injury to the _______/________ spinal cord. It involves ______ and _____.
- cervical (C1-C8), all 4
- thoracic/lumbar (T1-L5), BLEs and trunk
What is another way that we classify SCIs? (2)
- Complete
- Incomplete
Complete SCI:
-Absence of ______ and ______ function below lesion level.
-More _______ presentation of SCI.
Can have Zones of Partial Presentation (ZPP), what is this?
- sensory and motor function
- severe
- Dermatomes and myotomes caudal to the sensory and motor levels that remain partially innervated.
Incomplete SCI:
- Involves partial preservation of _______ and ______ functions below the lesion level.
- _______ prognosis than complete SCI due to preserved axon function.
- Incomplete SCIs occur _____ frequently than complete.
- sensory and motor
- Better
- more frequently
The degree of SCI (Complete vs Incomplete, level of neurological injury) is determined by what?
-ASIA Exam
SCI Acute Medical Management:
- What is the primary goal of management?
- What 2 things may be done to help stabilize the spine?
- What drug has a small window of opportunity and helps to stabilize cell membranes, decreases inflammation, increases nerve impulse generation, and improving blood flow to damaged areas? What is the timeframe?
- Stabilize spine, smallest movements can worsen.
- Surgery (closed or open decompression), External support devices (HALO, CTLSO, TLSO, ISO)
- Methylprednisone (3-8 hours)
How does methylprednisone help incomplete vs complete SCIs?
- INCOMPLETE: Enhances return of some function below spinal level
- COMPLETE: increases chances for return of function of the last preserved spinal level post-SCI
What are (3) pathophysiological secondary sequelae of SCIs?
- Ischemia
- Edema
- Demyelination and necrosis of axons progressing to scar tissue formation
PART 2: COMPLICATIONS OF SCI PT.1
PART 2: COMPLICATIONS OF SCI PT.1
List some complications of SCI.
- Spinal Shock
- Autonomic Dysreflexia
- Pressure Ulcers
- Postural Hypotension
- Pain
- Spasticity
- Contractures
- Heterotopic Ossification (HO)
- Edema
- DVT
- Osteoporosis & renal calculi
- Respiratory compromise
- Bladder & bowel dysfunction
- Sexual dysfunction
What are the (3) main autonomic dysfunctions related to SCIs (T6 and above)?
- Spinal Shock
- Autonomic Dysreflexia
- Impaired Thermoregulation
Spinal Shock:
- Temporary phenomenon with injuries ___ and above.
- Cord in its entirety ceases to function below the lesion and is thought to be due to loss of ________ tone.
- Spinal reflexes, voluntary motor control, sensory function, and autonomic control are absent below the level of the lesion
- Initially: ↑ ↑ BP → ↓ BP, HR, hypothermia, venous stasis
- Usually resolves within ___-____ days of the injury. What is the 1st thing to typically return?
- T6
- sympathetic tone
- 1-3 days, sacral/anal reflexes
Autonomic Dysreflexia:
- Over-activity of the ANS, only seen with injuries ____ and above.
- Caused by irritating stimulus introduced to body ______ level of SCI.
- What is the most common cause?
- What are some other causes?
- T6
- below
- Most common = FULL BLADDER
- full bowel, wounds/pressure sores, burns, ingrown toenails, kinked clothing, foreign object pressing against skin
What are the symptoms of autonomic dysreflexia? (5)
- Pounding HA**
- goose bumps
- sweating above level of injury
- bradycardia
- skin blotching
Why are we on high alert for the symptoms of autonomic dysreflexia?
-It is the bodies way of saying that something is wrong.
What are the (6) steps of intervention if we see autonomic dysreflexia symptoms come on?
- ) If patient lying down, sit them up immediately.
- ) If already in sitting, remain in sitting (DO NOT LIE DOWN), perform pressure relief
- ) Check catheter
- ) Check clothing
- ) Check skin
- ) Initiate emergency response if not resolved within 10 minutes
Why is patient education so important with autonomic dysreflexia patients?
-They could be at home one day and have if happen and they need to react or instruct someone on how to react.
Impaired Thermoregulation:
- Only seen with injuries ___ and above.
- Due to loss of ________ output.
- Body’s ability to control blood vessel response that conserve or dissipate heat is lost. (sweat/shiver lost, hypo/hyperthermia risk)
- ______ level injuries result in greater disturbances in temperature control.
- T6
- sympathetic output
- Higher level
What are the S/Sx of impaired thermoregulation? (2)
- Hyperthermia: skin feels hot and appears flushed, feeling weak, dizziness, HA, visual disturbances, nausea, tachycardia, weak or irregular HR
- Hypothermia: shivering, exhaustion/drowsiness, confusion, slurred speech,
What patient education is important with patients who have impaired thermoregulation?
Appropriate clothing to match the weather outside and not what they are feeling.
PART 3: COMPLICATIONS OF SCI PT.2
PART 3: COMPLICATIONS OF SCI PT.2
Spasticity:
- ___% of SCI patients will experience spasticity (__% identify it as problematic).
- More common with _______ lesions.
- Why is skin breakdown with spasticity of concern specifically with these patients?
- Will often elect to get what to help with spasticity?
- ~65% (50%)
- cervical lesions
- These are WC bound patients and are at increased risk for breakdown as opposed to ambulatory patient.
- Baclofen pump
Pulmonary Dysfunction:
- “__, __, ___ keeps the patient alive” (without these, patients will need supportive devices or techniques to breath)
- Below ____= normal ventilatory and respiratory function.
- “C3, C4, C5 keeps the patient alive”
- T10
Neurological Level of SCI and Muscles of Respiration:
- C1-C2 = What respiratory muscles are functional?
- C3-C4 = ?
- C5-C8 = ?
- T1-T5 = ?
- T6-T10 = ?
- T11 and below = ?
- C1-C2 = SCM, Upper Trap, Cervical extensors
- C3-C4 = Partial diaphragm, Scalenes, LS
- C5-C8 = Diaphragm, Pecs, SA, Rhomboids, Lats
- T1-T5 = Some intercostals, Erector Spinae
- T6-T10 = Intercostals and abdominals
- T11 and below = Respiratory muscles intact
Bladder Dysfunction:
- What level of spinal cord injury can we see this?
- Alteration of reflexive and voluntary control of micturation.
- ______ of SCI determines type of dysfunction.
- Lesion _______ conus medullaris/sacral segments = spastic/hyperreflexic bladder. (involuntary voiding)
- Lesion ______ CM/sacral segments segments = flaccid/areflexic bladder. (overflow and stress incontinence)
- Any level
- Level
- Above = spastic/hyperreflexic
- To = flaccid/areflexic
What are some ways to manage bladder dysfunction? (4)
- External collection devices (catheter)
- Intermittent catheterizations
- Medication
- Surgery (Suprapubic catheter, bladder augmentation)
What is the biggest drawback to catheters?
-Indwelling catheters are a breeding ground for infection. (UTIs often seen if used chronically)
Bowel Dysfunction:
- ___% of patients with SCI report bowel dysfunction, and 34% require assistance to manage.
- _____ of SCI determines type of dysfunction
- Above ___: spastic/reflex bowel (Excrement is involuntary and incomplete).
- ___-____: flaccid/areflexive bowel (Bowel overfills and over-distends)
- Bowel dysfunction is the 2nd most common cause of ________ ____________.
- 40% of individuals with SCI will report significant health problems related to bowel management. What are (3) examples?
- 98%
- Level
- S2 = spastic/reflex bowel
- S2-S4 = flaccid/areflexive bowel
- autonomic dysreflexia
- rectal prolapse, hemorrhoids, abdominal pain and bloating
What are some ways to manage bowel dysfunction?
-Reflex Bowel Programs (trigger bulbocavernosus reflex through Digital Stim Programs or Bowel Suppositories)
What are the symptoms of bladder and bowel dysfunction? (6)
- Fever/chills
- Nausea
- HA
- Increased spasticity
- Autonomic dysreflexia
- Dark or bloody urine
Sexual Dysfunction:
- Males: Directly related to level and completeness of injury. Erectile capacity spared with _____ lesions, but fertility can be impacted.
- Females: Menstruation and fertility more likely to be ________.
- UMN
- spared
Blood Pressure Instability:
- What is the most common issue? Why?
- ____ dysfunction common
- ___ and up: bradycardia, excessive peripheral vascular dilation
- Orthostatic hypotension, due to lack of an efficient muscle tone AND loss of sympathetic vasoconstriction response in the LE’s causes Venous Pooling.
- Cardiovascular (CV)
- T6 and up
What are some ways to manage blood pressure instability?
-TED stockings, abdominal binder**, ace wraps, monitoring fluid intake
Are abdominal binders or LE compression garments more helpful in preventing orthostasis in SCI.
-abdominal binders
Pain:
- _________ and __________!
- What are some common causes of pain in this population? (4)
- Neuropathic and Orthopedic!
- Irritation and damage to neural elements, mechanical trauma, surgical interventions, poor handling and positioning
- Neuropathic Pain is poorly localized c/o numbness, tingling, burning, shooting, and aching pain and visceral discomfort ______ level of injury.
- This can be exaggerated by what things? (5)
- below level of injury
- noxious stimuli, UTI, spasticity, bowel impaction, cigarette smoking
Orthopedic Pain common sites of pain include ______ _______ injuries and __________.
- shoulder overuse injuries
- low back
a lot of these are preventative
Osteoporosis and Renal Calculi:
- Due to changes in calcium metabolism. (bone mineral density found to decrease for up to ___ years after injury.)
- Decreased ______ may lead to demineralization of bones which can lead to vertebral compression frx and other frx.
- Calcium from bones absorbed into blood and deposited into the kidneys which can result in what?
- 3 years
- WB
- kidney stones
What are some ways to manage Osteoporosis and Renal Calculi?
- Early mobilization
- Therapeutic standing
- Administration of calcium supplements
- Good dietary management
PART 4: THE ASIA EXAM
PART 4: THE ASIA EXAM
What is the gold standard for how we pull together diagnostic, clinical and prognostic information about a person’s SCI.
-The ASIA Exam
- Do all SCIs have an ASIA exam completed?
- How long does the ASIA Exam take?
- Yes
- 60-90 minutes (no time to do often)
What are the (4) main parts to the ASIA Exam?
- Determine Motor Level
- Determine Sensory Level
- Determine Neurological Level
- Determine ASIA Level
Motor Level:
- Refers to the most _______ segment with normal motor function on each side of the body.
- Performed by examining ________ in UE and LE, as well as voluntary _____ contraction.
- caudal
- myotomes, anal contraction
Sensory Level:
- Refers to the most _______ segment of the spinal cord with normal sensory function on each side of the body.
- Evaluated via a key sensory point within each of the ____ dermatomes on the R and L (light touch, sharp/dull) and deep ______ sensation.
- caudal
- 28, anal sensation
Neurological Level:
- Refers to the most caudal segment of the spinal cord with normal _______ and _________________ function on both sides, provided there is normal function rostrally.
- Helpful in predicting which parts of the body may be affected by paralysis and loss of function.
- Used for prognostic indicators and expected ___________ capabilities.
- Determined by evaluating integrity of what (3) things?
- sensory and antigravity muscle function
- functional capabilities
- motor function, sensory function, sacral reflex activity
ASIA Level:
- Determine whether lesion is _______ or _________.
- ASIA level involves looking at _______/_______ exam, but also considers any preservation of ________ segments.
- S4-S5 innervates what?
- Complete or incomplete
- sensory/motor, sacral segments (S4-S5)
- anus
What are the 5 ASIA Levels?
- A = Complete
- B = Sensory Incomplete
- C = Motor Incomplete
- D = Motor Incomplete
- E = Normal
ASIA A: Complete
- No ________ or _______ function is preserved in the _________ segments.
- ______ may be present.
- sensory or motor, sacral (S4-S5)
- ZPP
ASIA B: Sensory Incomplete
- ________ but not _______ function is preserved below the neurological level and includes the _________ segments (light touch/pin prick at S4-5 or deep anal pressure).
- AND no motor function is preserved more than ____ levels below the motor level on either side of the body.
- Sensory but not motor, sacral (S4-S5)
- 3 levels
ASIA C: Motor Incomplete
- _____ function is preserved at the most caudal sacral segments for voluntary anal contraction.
- OR patient meets criteria for _______ ________ status (sensory function preserved at most caudal sacral segments (S4-S5) by LT, PP, or DAP), and has some sparing of motor function more than ___ levels below ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.)
- For ASIA C - less than half of key muscle functions below the single NLI have a muscle grade ≥ ___.
- Motor function
- sensory incomplete status, 3 levels
- ≥3
ASIA D: Motor Incomplete
-Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ ___.
- ≥3
ASIA E = _________
-Normal
SCI Prognosis:
- ___% of people with SCI who survive the first 24 hours are still alive 10 years later.
- Mortality rates are significantly higher in _______ post injury (__-__ more likely to die prematurely than people without SCI).
- Life expectancy = ___% of normal and varies based on level of injury. (Higher injury and older age = more negative effects on life expectancy)
- What are the 2 leading causes of death in SCI patients?
- About ___% of persons with SCI are re-hospitalized one or more times during any given year following injury.
- 85%
- first year (2-5x more likely)
- 90%
- Pneumonoia and Septicemia
- 30%
SCI Prognosis:
- What are some prognostic indicators for walking? (5)
- Which is the #1 prognostic indicator for walking?
- ASIA Level***
- Early exam of reflexes
- SCI syndromes
- Acquired SCI < Traumatic SCI
- Age
