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PHTH 551- Neurological Rehabilitation > SCI > Flashcards

SCI Flashcards

1
Q

What is a SCI?

A

Direct or indirect involvement of the spinal cord resulting in alteration or complete cessation of all CNS functions including: motor, sensory and autonomic system.

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2
Q
  1. What bones make up the SC?
  2. What is the role of the spinal cord?
  3. Where do the majority of cervical lesions occur?
  4. Where do the majority of thoracic lesions occur?
  5. Is it important to education pt about the SC?
A
  1. Cervical (7), Thoracic (12), lumbar (5), sacral (5 fused), coccyx (4 fused) vertebrale.
  2. Flexibility, support and protection.
  3. C4-C6 because this is where there is maximal flexion of the cervical level.
  4. T12-L1 because this is the least flexible region of thoracolumbar level.
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3
Q
  1. How many peripheral nerves are there?
  2. What is the relationship b/w nerves and vertebral segments.
  3. What is the difference b/w a central and peripheral lesion?
A
  1. 31
  2. The nerve may not always be at the same level as the corresponding vertebrae level.
  3. An upper motor neuron lesion does not give the same symptoms as a peripheral lesion.
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4
Q
  1. The spinal cord goes b/w what levels?
  2. What are the divisions of the SC?
  3. What is below the sacral division?
  4. What is below 3?
A
  1. C1 to L1/L2
  2. Cervical=UE, Thoracic=Trunk. Lumbo-sacral= bowel, bladder, sexual function and LE
  3. Conus medullaris (sacral segment for innervations of blow, bladder, sexual and LE)
  4. Conus Equina
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5
Q

What are the SCI classifications?

A

TVA: C1-C3, ventilator dependent. Complete lesion above C4.

High tetra: C4-C5. Can be taken off ventilator

Tetra without triceps; C6

Tetra with triceps, C7

Tetra «Deluxe»: C8-T1- Fingers can pick up things.

Para without abdominals
T2-T5

Para with abdominals
T6-T12- better sitting balance

Conus Medullaris

Cauda Equina- peripheral lesion. How come in SCI? Bc it is in the vertebral canal so it is considered a SCI

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6
Q

What is the relationship between vertebral and neurological segments:

  • Low Cervical
  • High Thoracic
  • Low Thoracic and Lumbar
A
  • Cervical Level: Same Level
  • High Thoracic: 1 to 2 levels difference
  • Low thoracic and lumbar: 3 to 4 levels difference.

Vertebral level does not necessarily correspond to neurological level.

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7
Q

What are the 2 internal components of the spinal cord?

A 
1. Gray matter: Non-myelinated
Horizontal pathways: 
-Ventral Horn
-Posterior Horn 
-Lateral Horn (Thoracodorsal, ANS) Thoracic and lumbar regions have lateral horn.

Gray matter has a topographic and somato-topic arrangement.

Ventral: alpha motor neurons
Lateral: Sympathetic.

  1. White matter: Myelinated
    Topographic organization: Ascending and descending tracts
    -Anterior
    -Posterior and lateral column

Somatotopic organization: central vs peripheral area.

Different syndromes.

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8
Q

What arteries supply blood to the SC?

A

Anterior spinal artery: anterior 2/3 SC
-Protrusion of disk can hit this artery

Posterior spinal artery: posterior 1/3
-Rarely involved. If so, proprioceptive deficits.

Segmental arteries: Adamkiewicz arteries

  • Penetrate vertebral canal T12-L1
  • Supplies thoracic, lumbar and sacral SC

lesions at T12-L1 may rupture artery, may cause ischemia and necrosis.

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9
Q

What is the ASIA

A

American Spinal Injury Association

  • International standards for the neurological classification of the SC
  • Determines the lesion at the spinal cord level and its severity
  • Evaluation&prognostic (what is going to happen in future) tool
  • Motor and sensory examination in supine
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10
Q

What is Tetraplegia?

A

Impairment or loss of motor and/or sensory function(s) at the cervical segments of the spinal cord (SC) due to damage of neural elements within the spinal canal.

Results: impairments of arms, trunk, legs , pelvic organs.

  • Does not include brachial plexus lesions or injuries at peripheral nerves outside the neural canal.
  • Stops at the level T1
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11
Q

What is paraplegia?

A

Impairment or loss of motor and/or sensory function(s) at the thoracic, lumbar or sacral segments (but not cervical) of the SC, secondary to damage of the neural elements within the spinal canal.

Results: arm function is spared, but impairment at the trunk and/or legs (depending of the level of the lesion), bowel/bladder, sexual function…

Excludes: lesions to lombosacral plexus or injuries to peripheral nerves outside the neural canal.

Starts at the level: T2

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12
Q

How do you determine the severity of the lesion?

A

-Done by the doctor

Complete:
-Absence of sensory and motor function in the lowest sacral segment (S4-5)

Incomplete:
-Partial preservation of sensory and/or motor function in the lowest sacral segments (S4-5)

Test:

  • Sacral sensation at the anal mucocutaenous junction and deep anal sensation.
  • Motor function: presences of voluntary contraction of the external anal sphincter upon digital exam.
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13
Q

What are the levels of the ASIA impairment scale?

A 
A=Complete: No sensory or motor function in sacral segment (SS). 
Clinical picture (CP: depends on level of the lesion)

B=Incomplete: Presence of sensory. No motor SS, and not motor function preserved more than 3 levels below motor level.
CP: Same as A

C=Incomplete: Sensory and motor preserved at SS. Sparing motor function > 3 levels below neurological level. < half of the key muscle functions below the neurological level have a muscle grade >3/5.
CP: Not able to walk (w/ no orthosis)

D=Incomplete: Criteria C, but half or more of the key muscle functions below neurological level have a muscle grade of >3/5.
CP: Usually able to stand and walk.

E=Normal

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14
Q

What is the sensory level? How is it examined?

A

Most caudal dermatome w/ normal sensation to light touch and pin prick on each dermatome on each side (2 Sensory Levels)

LT: Cotton ball, at precise points according to ASIA chart.

PP: Discrimination between pin prick and blunt touch at ASIA sites.

0=Absent
1=Impaired
2=Normal

8/10 is good. If pt feels determine if it is normal by comparing to the face.

Go from top to bottom.

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15
Q

What is the neurological level?

A

Last segment normal on sensation and motor on both sides. Highest of the 4 values.

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16
Q

What is the motor level?

A

The most caudal myotome having at least 3/5 and all myotomes above are 5/5.

  • Pt supine
  • Evaluate R and L
  • Muscle grade 0 to 5, no +/-
  • There are no myotomes at the trunk level and above C5, so motor level=sensory for these segments.
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17
Q

What is the vertebral level?

A

Level according to X-ray that has the greatest damage.

Nor really useful from clinical perspective.

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18
Q

What are the steps to an ASIA classification?

A
  1. Sensory Level L and R
  2. Motor Level L and R
  3. Single neurological level (lowest segment where motor and sensory function is normal on both sides)
  4. Complete or incomplete lesion.
  5. Determine ASIA Impairment Scale. (Asia A, B, C, D)
    Complete=A
    Is the injury motor incomplete No=AIS B
    Are at least 1/2 of the myotomes below the neurological level graded 3 or better? Yes=D No=C
19
Q

What is central cord syndrome?

A

-Exclusively in cervical
-Central part of SC involved
-Falls, MVA causes
-Motor: UE more involved.
-Sensory: UE more involved.
-CP: can walk, difficulty eating.
Prognosis: good for LE, less for UE.

20
Q

What is Brown-Sequard Syndrome?

A

-Hemisection of SC (stabbing or gun shot wound common causes)
-Ipsilateral: Loss of voluntary motor control on the same side as the SC damage
-Contralateral: Loss of pain and temp on the opposite side.
CP: Can walk w/ 1 long leg brace and one short one.
Prognosis: 75-90% independent ambulation w/ 1 leg brace.

21
Q

What is anterior cord syndrome?

A
  • Lesion to anterior SC or anterior spinal artery.
  • Loss of motor function and sensitivity to pain and temp.
  • Proprioception is preserved (posterior column)
22
Q

Conus Medullaris

A

Injury of the sacral cord or lumbar nerve roots w/ in the spinal canal.
-Result: areflexic bowel and bladder, flaccidity of lower limbs.
CP: Similar to peripheral lesions (lack reflexes).

23
Q

Cauda Equina Syndrome

A

5% of all SCI
-Injury to lumbosacral nerve roots w/in the neural canal.
1-6% of all disc herniations
-Peripheral lesions
P: Flaccid paralysis, no reflexes, no clonus.

24
Q

Posterior Cord Syndrome

A
  • Lesion to posterior SC or posterior artery
  • Bilat loss of proprioception, vibration and 2 point discrimination
  • Least common SCI <1%
  • Most difficult to treat (pt strong, but they do not know where their limbs are in space)
25
Q

What are the causes of SCI?

A
  1. Congenital lesion
  2. Traumatic Lesion 35/million, 50%,
    - Direct lesions (fracture or bilocation of vertebrae) or
    - Indirect lesion (fragment of vertebrae does not hit the SC) (more frequent)

For both Complete lesion 40% and Incomplete 60%.

  1. Non-Traumatic Lesions (50%
    - Intra medullary lesion OR
    - Extra Medullary lesion

For both complete or incomplete.

26
Q

What are some of the differences b/w traumatic and non-traumatic lesions?

A

Non-traumatic:
-Progressive
-50% of all SCI
-Mean Age: 61 yrs
-Sex distribution: 50:50
-Causes (most common): spinal stenosis, tumors, disc herniation
-Severity: most frequent neurological deficit is incomplete paraplegia (64%)
Prognosis: Good functional and neurological

Traumatic:

  • Sudden onset
  • Mean Age at time of injury: 38 yrs
  • Sex Distribution: 20 W: 80 M
  • Causes: fall, transport, sports, fire arms
  • Severity:Complete (30%) Incomplete (70)
  • Prognosis: According to severity
27
Q

What conditions are associated w/ SCI?

What are some trends in SCI 2016?

A

Head trauma (TBI)-impacts rehab

  • More incomplete lesions
  • Elderly people falling from their own heigh
  • More people w/ mental health problems associated w/ sci.
28
Q

Medical Management of SCI?

A

Conservative: Stable lesions such as gunshot or stabbing.

Surgical:

  • Posterior (Cervical, thoracic or lumbar lesions)
  • Anterior (cervical lesions): problems w/ trachea, esophagus and dysphagia)
  • Lateral (thoracotomy, thoracic, lumbar): more extensive, associated w/ more pain
  • Lamiectomy for decompression.
29
Q

Immobilization of SC?

A

Internal Fixation:

  • Bone graft from iliac crest
  • Wires, rods, plates, screws
  • May cover a few or several segments. More segments= less mobile.

External:
Type will depend on severity and site of lesion
-3 months, then a weaning period of 1-2 wks or days.
-Cervical Lesions: HAL vest, SOMI, Miami, Foam (may types of braces).
-Thoracic: TLSO, SHIELD, Sternal pad kit, pendulous.

30
Q

What 2 factors determine the clinical manifestation of an SCI?

A
  1. Level of the lesion
    Tetra or para plegia
    If certain clinical manifestations will be present or not ( respiratory, autonomic dysreflexia, intact UE)
  2. Severity of the Lesion:
    Extent of certain manifestations (muscle strength…)
31
Q

What clinical manifestations should be addressed w/ SCI?

A
  • Spinal shock (traumatic lesions)
  • Motor function
  • Sensory function
  • Muscle Tone (spasticity, clonus, babinski, reflexes during acute phase)
  • CV function: postural hypotension, AD
  • Respiratory function
  • Bowel, bladder
  • Thermoregulation
  • Sexual Function
32
Q

Voluntary Motor Function in SCI

Evaluation?

A

Alteration/absence of motor function below level of lesions (varies according to severity, level, symmetry)

Eval: ASIA motor, MMT, Scan (UE), myometer, muscle atrophy

33
Q

Sensory Function in SCI
Evaluation?
Treatment?
Consequences?

A

Alteration/absence of sensory function below level of lesions (varies according to severity, level, symmetry)

Eval: ASIA (LT and PP), proprioception (sense of movement large/small amplitude), hot/cold for modalities

Treat: Education, pressure relief in WC, skin inspection

Consequences: pressure sores, risk of infection.

34
Q

Muscle tone:
A. What are the 4 cardinals signs?
B. Flaccidity, what level?
C. Spasticity?

D. Evaluation?

A

A. 1.Clonus 2.Hyperreflexia 3.Babinski 4.Hypertonus

B. Absence of muscle tone, T12

C. Increase muscle tone above T12

D. Passive mobilisations (Ashworth scale)
Clonus, reflexes, babinski.

35
Q
  1. Respiratory function involvement?

2. Evaluation?

A
  1. Tetraplegia C1-C3 AIS A, B ventilator dependant.
    Tetraplegia: Weak ineffective cough, ↓ VC
    High paraplegia; effective but weak cough, ↓ VC
    Low paraplegia; strong effective cough (near or normal), normal VC.
  2. Auscultation, O2 sat, VC, peak cough flow, breathing pattern and rhythm, accessory muscle use and strength, rib cage mobility, secretions.
36
Q

What are the two types of pain?

How is pain evaluated?

A
  1. Nociceptive pain: Secondary to trauma, surgery. Dull aching pain, met related, eased by rest, NSAIDs effective.

Neuropathic pain: Zone of partial preservation and/or below lesion. Hard to treat, NSAIDs not effective. Burning, stabbing, pressing. Not related to positioning or activity.

  1. Nature, site, intermittent vs constant, intensity, what increases or decreases.
37
Q

What other things should be evaluated?

A
  • ROM, posture
  • Balance (sitting or standing, Collot)
  • Function: mat mobility, transfers, ASIA D (Gait)
38
Q

What are the most common complications from an SCI?

A 
Pressure sores
Autonomic Dysreflexia
Contractures 
Postural Hypotension 
Thrombophlebitis
39
Q
  1. What are the most common pressure points?
  2. Risk factors for pressure sores?
  3. Evaluation
  4. Prevention
  5. Treatment
A
  1. Lying down: sacrum, heels, occiput
    Sitting: coccyx, ischial tuberosity
    Sidelying: malleoli, trochanters.
  2. Humidity, friction, pressure, heat
  3. Observation of the skin
  4. Change position every 2 hrs (90/30 rule)
  5. Pt education, proper equipment and positioning, air mat during treatment of pressure sore, diet, precautions w/ ex.
40
Q
  1. What is postural hypotension?
  2. Causes?
  3. Evaluation
  4. Treatment
A
  1. Sudden drop in systolic bp more than 20 mmHg assuming standing position
  2. Prolonged immobilisation, decreased muscle tone, lack of sympathetic facilitation.
  3. Arterial pressure, pulse, observation.
  4. Education, move pt slowly or treat supine, medication, tilt table, compressive stockings.
41
Q

What is autonomic dysreflexia?

Causes?
Clinical Manifestation?

Treatment?

A

Excessive reaction of the sympathetic system caused by a noxious stimulus below the level of the lesion. Lesions above T6

Causes: bladder distension, constipation, stretching.

Clinical manifestations: headache, flushing, high BP.

  1. Sit pt up (decrease PB).
  2. Loosen clothing.
  3. Take BP
  4. Find cause, verify bladder condition
  5. Medical attention if necessary (can be life threatening)
42
Q

Thrombophlebitis:

  • Incidence
  • Cause
  • Clinical manifestation
  • Eval
  • Treatment
A

Blood clot in a major blood vessel.

  • 2-12 weeks post injury
  • Cause: Immobilisation, venous stasis, Sx
  • Manifestation: pain, swelling, redness or fever
  • Eval: recognize clinical manifestation, anthropometric measure of legs.
  • Medical attention ASAP, Passive mvmt contraindicated 48 hrs following diagnosis, Antiembolic stockings 3 months, anticoagulotherapy 3 months.
  • Pulmonary embolus complication.
43
Q

What are the most common contractors by condition?

Causes?
Eval?

A

Tetraplegia C5-6: UE and biceps

Tetra and paraplegia: LE 1. Hamstrings 2. Psoas 3. Gastroc

Causes: span 2 articulations, positioning

Eval: ROM

44
Q

What is the prognosis following an SCI?

A

Complete lesion in acute phase, very few ppl improve.

Incomplete lesion more then 70% will increase to better ASIA.

Better prognosis if LT and PP then LT alone.

PHTH 551- Neurological Rehabilitation (12 decks)

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