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Year 2 PBL > U11W4: spinal cord injury > Flashcards

U11W4: spinal cord injury Flashcards

1
Q

How many spinal nerves are there?

A

Consists of 31 spinal nerves.

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2
Q

What are the four main functions of the vertebral column?

A

Protection - the spinal cord within the spinal canal
Support - the weight of the body
Axis - central axis of the body
Movement - posture and movement, origin and insertion point of muscles

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3
Q

What makes up the vertebral column?

A

Bony vertebrae that are linked by atricular synovial joints and the fibrouscartilogenous intervertebral disks
There are 7 cervical vertebrae
there are 12 thoracic vertebrae
There are 5 lumbar vertebrae
There are 5 fused sacral vertebrae
There are 4 fused coccyx

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4
Q

What are the key features of the vertebrae?
Can you lable them in this image?

A

The vertebral body (weight bearing)
The vertebral arch:
- spinous process
- transverse process
- pedicles (green)
- lamina (purple)
- articular processes (sup in yellow)

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5
Q

What are the unique features of the cervical vertebrae?

A

Triangular foramen
Bifid spinous process (except C7 and C1)
Transverse formaine for vertebral arteries
Triangluar vertebrael foramen

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6
Q

What are some unique features of thoracid vertebrae?

A

Demi facets for head of rib
Costal facests on transverse process for shaft of rib
Spinous process if obliquely inferiorly.
Circular vertebral foramen

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7
Q

What are the key features of the lumbar vertebrae?

A

Largest vertebrae
Kidney bean shaped vertebral body
Triangluar shapes vertebral foramen
Position of spinous process allows needle access between the vertebrae as do not extend inferioly past the level of the vertebral body.

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8
Q

What are the different ligaments supporting the vertebral column?

A

Left to right
Anterior longitufinal ligament
Posterior longitudinal ligament
Ligamentum flavum
Interspinal ligament
Supraspinous ligament

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9
Q

What are the key features of the spinal cord?

A

Spinal cord is surrounded by three layers the innermost pia mater, archnoid mater and the dura mater.
L1 - conus medullaris - end of spinal cord
Continues are the cauda equina - lower motor neurons
The filum terminale is a fibrous continuation of the spinal cord that fuses with the coccyx - contains the remnants of the meningeal layers and helps fixate the spinal cord.

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10
Q

What is a burst fracture?

A

When a vertebra is crushed in all directions due to a significant trauma that crushes the bone such as motor vehicle accident or severe fall. - high energy axial loading spinal trauma.
Includes the vertebral body endplate and cortex.
Frequently includes retropulsion of fragments into the spinal canal
More severe than compression fracture
Incomplete - one endplate or complete both endplates

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11
Q

How do vertebral burst fractures normally present?

A

Often after a high energy axial trauma
Back pain or lower limb neurological deficit.

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12
Q

What vertebral level of burst fractures most likely?

A

T9-L5

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13
Q

What are the key radiographic features of a burst fracture?

A

Loss of vertebral height on lateral views.
Interpedicular widening
Bone fragment retropulsion into the spinal canal.
Burst vertebral body

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14
Q

How is a burst fracture different to a wedge fracture?

A

Burst - bursting of whole vertebral body cortex and one or both endplats
Wedge fracture - posterior body cortex often remains intact, often hyperflexion injuries, anterior section often collapses - one fragment may disconnect or front just remains squished.

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15
Q

How is a burst fracture different to a compression fracture?

A

Burst is often thought of as a severe compression fracture
Compression tends not to have a retropulsion of fragments into the spinal canal.
Compression tends to mainly affect the anterior vertebral body and has little risk of affecting the spinal nerves or cord, considered stable

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16
Q

What are the key features of a complete spinal lesion?

A

Loss of bilateral motor function
Complete loss of sensation below the level of the lesions
May be quadriplegic (all four limbs typically cervical in origin) or paraplegic (lower body only - thoracic, lumbar or sacral in origin)

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17
Q

What are the key features of an incomplete spinal lesion?
What are the different types?

A

Partial damage to the spinal cord means some function is retained and others are lost
Can be classified as:
Anterior cord syndrome (damage to CS and ST)
Central cord syndrome - often in cervical region and damages ST and CS
Posterior cord syndrome - damage to DCML

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18
Q

What are the different dermatomes of the body?

A

Use images from google to check your understanding of this - no goot one image.

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19
Q

What are the different features of E.coli that can be tested for?

A

Normally a stool test
Gram stain - gram negative rods.
Catalse positive - foams when hydrogen peroxide added as catalses conversion to water and oxygen
Coagulase negative - will not coagulated rabbit plasma
Oxidase negative - absence of colouration or light pink when DMPD is added.

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20
Q

What clinical assessments may be used for a spinal cord injury?

A

Upper/lower limb neurological examination - includes testing for motor, range of motion, sensation and reflexes
Spine examination
GAIT examination
Romberg test (balance)
Imaging techniques - such as an X-ray or CT
Respiratory function - to identify paralysis of the respiratory muscles
Assessment of Pain - visual analogue scale
Assessment of activity - often the spinal cord independence measure

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21
Q

How can myelograms be used to diagnose spinal cord injuries?

A

Contrast material is injected into the space around the spinal cord and nerve routes (often the subarachnoid space)
Use real time x-ray often fluroscopy
Allows to view the anatomy of the structures.

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22
Q

How is Transcranial magentic stimulation used to diagnose spinal cord injuries?

A

Neurophysiological examination
Aims to detect parts of the corticospinal tract that remain functional
Uses magnetic fields to stimulate neurons in the brain - then looking for muscle twitches or electrical activity in the eriphery to decide of the tract is functional and if information has been passed down the corticospinal tract.

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23
Q

Regulation od blood pressure**

A
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24
Q

What is an ionotrope?
What are the different types?

A

Substances that affect the contractility of the heart
Positivie inotropes - increase contractility
Negative ionotropes - decrease contractility.

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25
Q

What are the different types of adrenergic receptors?

A

Alpha 1
Alpha 2
Beta 1
Beta 2
There is also a beta 3 but this is less important

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26
Q

What type of receptors are adrenergic receptors?

A

GCPRs.

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27
Q

What are the different adrenergic agonists that may be used in neurogenic shock?

A

Dopamine
Norepinephrine
Phenylephrine
Epinephrine
Dobutamine

28
Q

What are the features of alpha 1 receptors?

A

Adrenergic receptor
Found in all smooth muscle in glands and organs
Are activatory
Cause smooth muscle contraction - hypertension

29
Q

What are the features of beta 1 receptors?

A

Are adrenergic receptors
Found in the heart - increases HR (when found in SAN) and contractility (when found in the ventricular muscle) and juxtaglomerular cells - stimulate renin release.
This helps to increase cardiac ouput

30
Q

What are the features of alpha 2 receptors?

A

Are adrenergic receptors
Found at pre-synpatic terminals
Provide negative feedback to prevent the release of neurotransmitter.

31
Q

What is the role fo beta 2 receptors?

A

Are adrenergic receptors
Found in all smooth muscle in glands and organs
Causes inhibition of contraction - causes vasodilation of blood vessels.

32
Q

What is the use of norepinephrine as inotropic support?

A

Receptor: selective for alpha 1 > alpha 2 > beta 1
Effects: vasoconstriction and ionotropy
Therefore is the first line treatment for hypotension in septic shock, is also used in most types of shock.

33
Q

What is the mechanism of action at beta 1 and beta 2 receptors receptors?

A

Is a heterotrimeric GPCR
Is inacitve when GDP bound to alpha subunit
Binding of ligand causes conformational change and GDP is released and GTP binds to alpha subunit - becomes active and detaches
Migrates within the cell membrane and binds to and activates adenylyl cyclase
This catalyses the conversion of ATP to cAMP
cAMP acts as a second messenger to increase the intracellular calcium ions conc
Intrinsic GTPase of GPCR hydrolyses GTP to GDP and deactivates the receptor

34
Q

What is the mechanism of action at alpha 2 receptors?

A

Are GPCRs - heterorecptors
Is an autoreceptor
Ligand binds and activates GPCR - GDP exchanged for GTP
Alpha subunit is released and inhibits adenylyl cyclase - decreases conversion of ATP to cAMP - decreases cAMP mediated increase in intracellular Ca2+ - therefore Ca2+ in the presynpatic terminal is lower - this inhibits NT release

35
Q

What is the mechanism of action at alpha 1 receptors?

A

Is GPCR
Binding of ligand causes exchange of GDP to GTP - the alpha sununit is now active and able to bind to phospholipase C, this leads to the conversion of PIP2 to IP3 and Diacylglycerol.
IP3 increases Ca2+ release from ER or SR
Both increase protein kinase C activativy which brings about physiological effects.

36
Q

What is the use of noradrenaline for ionotropic support?

A

Is classified as a sympathomimetic or a vasoconstrictor.
Is often given intravenously
Acts at beta 1 receptors (GPCRs) in the heart - in the SAN this will increase heart rate - in the ventricular muscle this will increase contractility.
(via adenylyl cyclase - cAMP- Calcium ions)
Ca2+ depolarisation of pacemakers and binds to troponin C in contractile cells.
This has an overall positive chronotropic, dromotropic and inotropic effect.

Also acts on alpha 1 receptors to stimulate vasoconstriction of blood vessels (not in coronary arteries)
This increases systemic vascular resistance and increase venous return leading to an increase in BP.

37
Q

What physiological response limits the usefulness of noradrenaline as an inotropic modifier?

A

HR will only increase to an extent due to baroreceptor reflex
Will be activated when mean arterial BP is too high
Vagal response - lead to reflex bradycardia.

37
Q

What is thoracic decompression procedure?

A

A procedure to relieve pressure on the spinal nerves in the thoracic region
Is indicated in spinal stenosis or trauma causing compression of the spinal cord.
Uses general anaesthetic to remove the bone or disc.
Is often followed by spinal fusion surgery and physiotherapy to stabilise the spine.

38
Q

What are the different techniques for thoracic decompression procedure?

A

Laminectomy - the entire lamina and thickened ligaments are removed
Laminotomy: just a section of the lamina and ligament is removed
Foraminotomy ; increase the space where the spinal nerve roots leave the spinal canal
Laminoplasy: create and hinge on one side of the vertebrae and cutting a portion of the vertebrae on another side. This swining portion of vertebrae is held in place by small wedges and plates/screws. This widens the spinal canal.

39
Q

What is a spinal fusion procedure?

A

When 2 or more vertebrae are joined together by placing an additional section of bone in the space between them
This helps prevent excessive movement between 2 adjacent vertebrae, decreasing he risk of further irritation or compression of nearby nerves
This bone can be taken from a donor, elsewhere in your body or a synthetic material.
This may be fixated by screws and rods to secure the bone.
This is normally done under general anaesthetic

40
Q

What is the function of graduated compression stockings?

A

Apply greatest degree of compression at the ankle and compression decreases up the garment.
Reduces the diameter of major veins which increases velocity and volume of blood flow
This can improve venous return and improve venous return
Gradient ensures blood flows back upwards towards the heart.
This can improve cardiac output.

41
Q

What are the key issues of adminstering health care in rural areas?

A

Limited access to healthcare facilities - greater distance to secondary care centres
Healthcare workforce shortages
Financial constraints - people struggle to afford prescriptions or private treatment.
Transportation barriers
Aging population
Emergency response challenges - longer waiting time

42
Q

What are some key rural health issues?

A

Farm accidents - injury by cattle is the biggest killer in agriculture
Rural road accidents have higher fatality rates
Zoonoses - lyme disease, ringworm.

43
Q

What help is available for people who live alone and require health care?

A

Charities - Age UK, British Red Cross (support up to 12 week after leaving hospital)
Social care - careres for help with personal care and activities of daily living, disability equipment and home adaptations, personal alarms and home security systems.
Companionship care service.

44
Q

What is the self-regulatory model?

A

Links our ocgnitive and emotional responses to how we cope with an injury.
Stage 1: perception of injury influences our cognitive representation and emotional response
Stage 2: we then cope with these thoughts and emotions (approach or avoidant)
Stage 3: we then apprais how well we have coped which can influence out continued ability to cope. THis regulates our own behaviour

45
Q

What is spinal shock?

A

The altered transient physiologic state immediately after a spinal cord injury.
Causes suppressed spinal reflexes and loss of muscle tone below the point of injury.
Due to loss of tonic excitation from higher cerebral centres.

45
Q

What is virchows triad?

A

Three factors that predispose a person to develop vascular thrombosis
- hypercoagulability of blood
- alteration in blood flow in the vessels
- vessel wall injury/endothelial damage

46
Q

What are the different stages of spinal shock?

A

1: lasting up to 24 hours - loss of descending tracts, hypo or areflexia
2: lasting up to 3 days: denervation supersensitivity - initial re-emergence of reflexes
3: lasts up to 1m - axon support synpase growth - initial hyperreflexia
4: Up to 12 months - flaccidness is replaced by spasticity.
Can also cause autonomic dysregulation particularly if damage is above T6.

47
Q

What is neurogenic shock?

A

Systolic BP less than 100mmHg with a heart rate less than 80bpm, consequent to spinal cord injury.
Lasts 1 to 6 weeks after the initial injury.
Occurs due to spinal shock, where sympathetic neuronal activity has been lost so little control over vascular tone.
Most common with lesions at or above L6.

48
Q

What is hypothermia and what are its affects?

A

Core body temperature below 35 degrees. Causes by excessive cold stress and inadequate ability to generate heat.
Mild Present with shivering, tachypnoea, tachycardia and hypertension
Moderate: bradycardia, bradypoea, altered mental status

49
Q

What are the different methods of warming a patient up after hypothermia?

A

Passive ; dry blanekts or clohtes
Active external: heated blankets with warm air
Active core: peritoneal or colonic lavage with warm saline.
Active warming can cause hypotension.

50
Q

How does hypothermia affect the nervous system?

A

Can cause hypothermia-induced reversible polyneuropathy.
This may be due to changes in metabolism in order to preserve energy(reduced HR and BP), vasoconstriction of the periphery to preserve energy and oxygen supplies, reduced oxygen consumption or build-up of toxins

51
Q

Suggest why a patient with a lesion at T9 to the spinal cord, may also experience temporary loss of sensation in the arms after lying of the floor all night waiting for help.

A

1) hypothermia induced reversible polyneuropathy - due to vasoconstriction and metabolis changes to preserve energy, cause injury to nerve cells

2) Secondary neurological effects - may have inflammation or odema after a spinal cord injury, this may cause damage to the other nerves at different levels of the spinal cord - result in temporary loss of function until the inflammation/swelling resolves.

3) Spinal cord concussion - reversible, no physical damage to the spinal cord - inflammation, changes in blood flow, disruption of ion channels.

52
Q

Why after falling down the stairs might a patient feel electric shock passing through her legs?

A
  1. Mechanism: dysesthesia
    When abnormal or unpleasant sensations occur due to stimuli that would not normally cause discomfort.
    Abnormal pressure/damage on a nerve causes it to misfire, transmission of signals may be disrupted due to damage in the spinal cord so impulse travels abnormally.
    These anomalous signals are interpreted as pain.
  2. Neuropathic pain - SCI leads to formation of abnormal neural circuits that generate spontaneous pain signals, inflammation from injury may sensitise nerve fibres to pain signals. Central sensitisation - CNS becomes hyperexcitable leding to more frequent and intense pain signals.
53
Q

What are some common reasons why an elderly patient might be lightheaded?

A

Hypoglycemia
Postural hyper tensions
Dehydration
Anemia.

54
Q

How do you calculate mean arterial pressure?

A

DP + 1/3(PP)
or
DP + 1/3( SP-DP)

55
Q

How are spinal cord injuries commonly assessed?

A

American Spinal Injury Association Impairment Scale
Assesses 28 specific dermatomes bilaterally for light touch and pinprick sensation, each dermatomes is scored between 0-2(norm) for each sensation.
Motor strength is recorded for five specific muscle groups bilaterally and scored from 0-5 (norm).
May also complete a digital rectal exam.
Injuries are then graded between A to E(normal)

56
Q

What do the differents grades of spinal cord injuries mean in the ASISIS?

A

A; complete lesion - no motor or sensory function
B: incompete - sensory preserved but no motor
C and D: incomplete: motor function presered in some areas to varying degrees
E: normal sensory and motor.

57
Q

What is the mechanism of action of LMW heparin?

A

Chemistry: Anti-coagulant activity, naturally release from mast cells
Pharmacology: Binds reversibily to and Activate antithrombin which accelerates the inactivation of coagulation enzymes factor Xa.
Physiology: does not lysis existing clots, prevents the progression of existing or new clots.
Clinical: prevent DVT, pulmonary embolism.

58
Q

List and describe why different tests may indicate the patient has a UTI.

A

Temperature - elevated 38 - sign of infection due to eoxgenous and endogenous pyrogenes
Blocked catheter flow - due to biofilm accumulation
Blood tests:
Decreased creatinine clearance - due to dehydration, or upper UTI damage to kidney (decrease GFR)
Elevates ESR or CRP - sign of inflammation.
Urine tests:
White blood cells and casts
bacteria

59
Q

Why does a patient with a UTI on gentamicin need to be monitored every 6 hours?

A

Monitoring for signs of toxicity or side effects
Monitoring to ensure signs of UTI are not worsening - risk of sepsis
Gentamicin has a narrow therapeutic window meaning there is only a small difference in the concentration of a therapeutic and a toxic dose.
Monitor for signs of kidney damage - neprhotoxicity - caused by accumulation of genatmicin in tubules causing oxidative stress and impaired mitochondrial function

60
Q

What is a rehabilitation unit after spinal cord injury?

A

Specialist focus on recovering from debilitating injuries
Outpatient service - includes occupational therapy, physiotherapy and rehabilitation nurses
Develop personalised treatment plans.
Aims to increase independence - both functional ability and self confidence.
For spinal cord injuries may focus on muscle strength, coordination and mobility.
May or may not be attached to a hospital.

61
Q

What is the mechanism of action of gentamicin?

A

Clinical: is useful against gram-positive and gram negative organisms, commonly used against E.coli and Pseudomonas aeruginosa.
Chemistry: aminoglycoside
Pharmacology: crosses the cell membrane of the bacteria, binds to 16sRNA of 30 subunit of bacterial ribosome, prevents translocation, hence inhibits protein synthesis resulting in truncated, non-functional or lack of proteins.
This lack of proteins is thought to have a knock-on effect by reducing proteins involved in oxidation-reduction reactions leads to the accumulation of reactive oxygen species which can lead to bacteria death.
Is bactericidal

62
Q

What is the mechanism of action of ampicillin?

A

Clinical: susceptible infections: h.pylori, community acquire pnuemonia, endocarditis, Lower UTI, useful against a wide range of gram-positive and some gram-negative organisms.
Chemistry: contains a beta-lactam ring
Pharmacology: mimics D-ala-D-ala, binds to PBP transverse peptidase enzyme by a covalent bond, irreversibly prevents the cross linking of peptoglycan in cell wall, - bacteria cell death by osmotic lysis

63
Q

What does a rapid urine analysis test measure and how might this diagnose a condition?

A

Protein - infection, pre-eclampsia, kidney disease
Glucose - DM
ketones- Diabetic, alcoholic or starvation ketoacidosis
Birlirubin/urobilinogen - liver problems or hemolytic anemia
Leukocyte estrase - infection (enzyme produced by active neutrophils)
Nitrite - produced by anaerobic respiration of bacteria
Blood - infection, cancer

Year 2 PBL (27 decks)

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