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Brad 4th Ed Part 2 > Ch. 55 SCI > Flashcards

Ch. 55 SCI Flashcards

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1
Q

Incidence of SCI by age

A

Lowest for < 15 yo
Highest for 16-30 yo
Average age of onset 40.2

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2
Q

Incidence of SCI by sex

A

80% male

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3
Q

Divorce rate in SCI

A

Increased in SCI in 1st 3 years post-injury compared to general pop

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4
Q

MCC of SCI in order

A

MVA
Falls
Violence
Sports

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5
Q

MCC of SCI in elderly

A

Falls

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6
Q

MCC of SCI in African Americans

A

Violence

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7
Q

MC time fore SCI

A

Weekends and Summer

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8
Q

MC level of plegia in order

A

Incomplete tetra
complete tetra
complete para
incomplete para

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9
Q

Predictors of mortality

A 
1st post-injury year
older
male
injured by violence
neuro complete
ventilator dependent
high neuro level
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10
Q

MCC of death

A 
Resp dz, esp PNA 
"other" heart disease
Infection/parasites
HTN/ischemic heart disease
Neoplasm
PE
GU dz
Suicide
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11
Q

SC terminates at level

A

L1-2

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12
Q

What does the posterior horns contain?

A

Cell bodies of sensory neurons

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13
Q

What does the anterior horn contain?

A

cell bodies of interneurons and motor neurons

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14
Q

Where is the gracilis located?

A

posterior medial column

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15
Q

What does the gracilis contain?

A

Fibers from T7-L5 dermatomes that real touch, vibration and position sense

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16
Q

Where is the cuneatus tract?

A

lateral posterior column rostral to T6

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17
Q

What does the cuneatus tract contain?

A

Dermatomes above T7 that relay touch, vibration, position sense

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18
Q

Where do the gracilis and cuneatus ascend?

A

Ipsilaterally to the medulla

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19
Q

What does the lateral spinothalamic tract contain?

A

Fibers that relay pain and temp sensation

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20
Q

Where does the spinothalamic tract ascend?

A

Contralaterally to the thalamus

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21
Q

Where is the lateral corticospinal tract?

A

Centrally and posterior in the lateral column

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22
Q

What does the corticospinal tract contain?

A

Fibers from motor cortex that are responsible for voluntary and reflex movement

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23
Q

Where does the corticospinal tract ascend?

A

90% ascend ipsilaterally and cross midline in the caudal medulla forming pyramidal decussations. 10% do not cross in medulla

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24
Q

What is Brown-Sequard synd?

A

Damage to one side of SC resulting in > ipsi weakness & position sense loss w/ contralateral pain & temp loss

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25
What is an upper motor neuron?
corticospinal neuron
26
What is a lower motor neuron?
motor neuron that synapses in the SC & exits SC to innervate muscle
27
What is UMN synd?
``` loss of voluntary movement spasticity hyperreflexia clonus Babinski's sign ```
28
What is conus medullaris synd?
Injury to sacral SC and lumbar nerve roots l/t areflexic bladder, bowel and lower limbs
29
What is Cauda Equina synd?
Injury to lumbosacral roots w/in spinal canal l/t arflexic bladder, bowel and lower limbs
30
What is spinal shock?
Transient suppression and gradual return of reflex activity below level of injury
31
Describe phase 1 of spinal shock
0-24 hrs post injury | Motor neuron hyperpolarization manifesting as hyporeflexia
32
Describe phase 2 of spinal shock
Days 1-3 Denervation super sensitivity and receptor upregulation reflex return
33
Describe phase 3 of spinal shock
1-4 weeks post injury | interneuron synapse growth early hyperreflexia
34
Describe phase 4 of spinal shock
1-12 mo post injury long axon synapse growth late hyperreflexia
35
Where does the posterior spinal artery begin and supply?
Branch from vertebral a | suppl posterior 1/3 of SC
36
Where do the anterior spinal arteries begin and supply?
Branch from vertebral a form single artery supply anterior 2/3's of SC
37
Where do the segmental radicular arteries travel?
from the aorta through intervertebral foramina divide into ant & post anastomose w/ respective arteries
38
What is the artery of Adamkiewicz?
anterior radicular artery usually on left side that supplies T12-L2
39
Where does the artery of Adamkiewicz travel?
Divides into small ascending & large descending branches on anterior surface of SC. Descending branches anastomosic circule w/ terminal branches of posterior spinal arteries around the conus medullaris
40
What area of the SC is most prone to ischemia?
Anterior portion of T1-4 and T12-L2 as they are dependent on individual radicular arteries
41
What is the anterior cord syndrome?
Paraplegia w/ loss of pain & temp sensation w/ sparing of touch & position sense
42
MC location of fx or dislocation in the spine
T12 and L1 vertebrae
43
What is a Jefrerson fx?
Burst fx of atlas (C1) | caused by axial compression
44
What is a hangman's fx?
Traumatic spondylolisthesis of the axis (C2) | caused by hyperextension & axial compression
45
What causes an odontoid fx?
Hyperflexion, hyperextensions or excessive lateral bending
46
What is a Chance fx?
Anterior wedge fracture of the vertebral body with horizontal fracture through posterior elements or distraction of facet joints and spinous processes
47
What causes a Chance fx?
Anterior force with hyperflexion | ex) passenger with lap belt but no cross body belt in a car accident
48
What is a clay shoveler's fx?
avulusion fx of the SP of C6, C7 or T1 due to flexion w/ rotation
49
What is a flexion tear drop fx?
retropulsion of vertebral body into the spinal canal, detached from anterior fragment (teardrop)
50
What are flexion tear drop fx associated with?
incomplete anterior cord syndrome
51
What is central cord synd?
Cervical SCI d/t hyperext sacral sparing Weakness in UE>LE
52
Which is a more common cause of non-traumatic SCI, extradural or intradural tumors?
Extradural tumor (MC metastatic lesions)
53
What is an extradural tumor?
Arise from structures outside the dura, MC vertebral body
54
What the MC types of metastatic tumors to the spine?
Lung Breast Prostate Kidney
55
What are the mech of metastasis to the spine?
Direct extension Hemotogenous through Batson's vertebral venous plexus Valveless venous system draining through the thoracic, abdominal and pelvic viscera
56
What are primary spine tumors?
``` Multiple myeloma Ostoegenic sarcoma Vertebral hemangioma Chondrosarcoma Chondroma ```
57
What are intradural space tumors?
``` Ependmomas Astrocytomas Meningiomas Schwannomas Neurofibromas ```
58
Described the presentation of spinal tumors
``` Pain worse in supine Night sweats Fevers Unexplained weight loss Anorexia ```
59
Treatment of acute SC compression by tumor
Steroids (dexamethasone) to dec inflam changes and prostaglandin production Radiation Surgery
60
Who is at risk for bacterial vertebral osteomyelitis?
IVDA Immunocompromised DM Renal disease on HD
61
MC bacteria and location of vertebral osteomyelitis
Staph aureus | Lumbar spine
62
Clinic presentation of vertebral osteomyelitis
Spine pain Fever Neuro deficit Elevated CRP, ESR
63
What is Pott's disease?
Mycobacterium tuberculosis to the spine
64
What should be in the DDx of rapidly evolving myelopathy without history of trauma
``` SLE MS Neuromyelitis optica Paraneoplastic syndrome Nutritional deficiency Vascular insufficiency Infection Transverse myelitis ```
65
What is transverse myelitis?
myelopathic process of unknown cause resulting in inflam of the SC
66
How many tetraplegic ASIA A patients convert to ASIA D in 1 year
2-3%
67
How man motor complete tetraplegic patients recover one motor level w/in 1 year of injur
30-80%
68
What is the most important prognostic factor for single level motor recovery in complete tetraplegics?
Initial presence of nonfunctional strength grade 1 or 2 at that level
69
What is a better sensory predictor of ambulation in an incomplete tetraplegic pt?
Presence of pinprick sensation near anus have >70% change of walking compared to light touch sensation
70
What is recovery of lower limb function with paraplegia dependent on?
Level and completeness of injury
71
What patient group has the best prognosis for ambulation in traumatic SCI?
Incomplete paraplegia
72
What is the goal mean arterial pressure for acute SCI?
85 mmHg for 7 days
73
What is neurogenic shock?
Hypotension and bradycardia due to sympathetic denervation
74
How is neurogenic shock treated?
Intravascular volume repletion and vasopressors
75
What is an ideal WC propulsive stroke?
Occurs at steady speed that maximizes handrim contact or push angle while keeping stroke frequency and force to a minimum
76
What neurologic level of injuries cannot operate a car?
C1-4
77
What are the leading causes of death in SCI?
``` Pulmonary complications Atelectasis Pneumonia Respirator failure PE ```
78
What is a Passy-Muir valve?
One-way airflow valve put in line with ventilator tubing to vocalize with exhalation. Used only with a deflated cuff
79
When is the risk greatest for DVT in SCI?
Between 7-10 days after injury
80
How long should motor incomplete SCI patients be on DVT ppx?
Until time of discharge
81
How long should uncomplicated SCI patients be on DVT ppx?
8 weeks
82
How long should motor complete SCI patients with additional risk factors be on DVT ppx?
12 weeks
83
Which patients are affected by Autonomic dysreflexia?
T6 or above which is above major splanchinc outflow
84
What are the symptoms of AD?
``` Pounding headache Systolic and diastolic HTN Profuse flushing of face, beck and shoudlers Nasal congestion Pupillary dilation Bradycardia ```
85
Causes of AD
``` Distended bladder Fecal impaction Ingrown toe nails Labor & delivery Orgasm Surgery ```
86
Tx of AD
``` Sit patient up Remove restrictive clothing or garments BP monitored ~2-5 minutes Evacuation of bladder Remove fecal impaction Nitro paste or nifedipeine Monitor BP for 2 hr after resolution ```
87
What SCI level can have impaired thermal regulation?
T6 and above due to loss of supraspinal control
88
What is poikilothermia?
Inability to regulate core body temperature. Have higher body temp in hot environments and lower temp in cold
89
When is primary bone resorption most prominent in SCI?
First 7 months after SCI
90
What are markers of bone resorption and when should they be monitored?
Urinary calcium and N-telopeptide elevated 8-12 weeks after SCI
91
What are markers of bone turnover?
Parathyroid hormone & 25-hydroxyvitamin D low after SCI despite normal Ca
92
What is a marker of bone formation?
Serum ostocalcin | Low after injury and inc after 6 mo
93
What are risk factors for hypercalcemia in SCI?
``` Children/adolescents Recent injury Male complete injury Tetraplegia Dehydration Prolonged immobilization ```
94
What is treatment of hypercalcemia?
IVF Diuretics Bisphosphonates Calcitonin
95
How is secondary hyperparathyroidism treated?
Ca & vitamin D supplmentation
96
Where is the greatest risk of loss of bone mineral density?
Lower limbs below level of lesion great from proximal to distal
97
What should be spared in loss of bone mineral density?
weight bearing vertebral column. look for secondary causes of osteoporosis
98
What can help protect against bone loss in SCI?
Passive weight-bearing in standing frame FES cycle ergometry Oral bisphosphonate Ca & vitamin D supplementation
99
What are factors that contribute to dysphagia in cervical SCI?
Immobilization of c-spine ST swelling nerve trauma after anterior spine surgery Limited laryngeal elevation by trach tubing
100
How long and what medications should be given in SCI for GI ppx?
histamine-2 receptor antagonist or PPI for 3 mo post-injury
101
What is a GI complication associated with high paraplegia?
Gallblladder dz and pancreatitis d/t dec SNS stimulation
102
When does adynamic ileus typically occur in SCI?
1-2 days post injury d/t loss of SNS and PNS tone during spinal shock Resolves 2-3 days with bowel rest
103
What does the vagus nerve innervate?
PNS innervation to Esophagus to splenic flexture of colon | modulates peristalsis
104
What does pelvic nerve innervate?
S2-4 PNS innervation to descending colon to rectum
105
What does the somatic pudenal nerve innervate?
External anal sphincter and pelvic floor mucles
106
What is a reflexic or UMN bowel?
SCI above sacral segement defecation cannot be initiated by voluntary relaxation of external sphincter Reflex mediated colonic peristalsis
107
What is an areflexic or LMN bowel?
Destruction of anterior horn cells of S2-4 no reflex-mediated colonic peristalsis slow stool propulsion by myenteric plexus Atonic anal sphincter prone to stool leakage
108
What does PNS innervation of the bladder control?
modulates contraction of the urinary bladder with opening of bladder neck to allow voiding Pelvic splanchnic nerve S2-4
109
What does SNS innervation of the bladder control?
Relaxation of bladder body and narrowing of neck to inhibit voiding Hypogastric nerves T11-L2
110
What does the pudendal nerve control in bladder?
External urinary sphincter | S2-4
111
What is a UMN bladder?
Unable to voluntary contract Reflex voiding possible Damage above sacral segments
112
What is a LMN bladder?
Damage at S2-4 No reflex voiding Bladder atonic and prone to leakage
113
What is detrusor-sphincter dyssynergia?
simultaneous reflex contractile activity of bladder and external urinary sphincter
114
What is the targeted cath volumes for I/O cathing?
500 ml for total fluid intake of 2,000 ml/day
115
What medication can help to inhibit voiding between I/O cath?
Anticholinergics | Botox
116
What is an augmentation cystoplasty?
Adding portion of small intestine to bladder to create high capacity low pressure reservoid
117
What is reflex voiding?
Bladder tapping in males to stimulate urination
118
What are risks of reflex voiding?
``` high PVR Vesicoureteral reflux Hydronephrosis Renal failure UTI Bladder stone formation ```
119
What are risks associated with indwelling catheter?
``` UTI Bladder stone formation Epidiymitis Prostatitis Hypospadias Bladder cancer ```
120
What can indicated at UTI in a SCI patient?
``` Fever Spontaneous voids between caths Hematuria AD Increased spasticity Foul smelling urine Malaise ```
121
What is needed to generate erection and lubrication psychogenically in SCI?
Some degree of LT and PP sensation in T11-L2 dermatomes | Bulbocavernous reflex
122
In what patients are orgasms unlikely to occur?
Absent bulbocavernous reflex Absent anocutaneous reflex No sensation S4-5
123
What is first line therapy for erectile dysfunction?
Type phosphodiesterase inhibitors
124
What has been shown to decrease sperm quality?
Deteriorates 2 weeks post SCI Ejaculatory frequency >1/week Reflex bladder emptying compared to I/O cath
125
When can women with SCI experience amenorrhea?
Post injury up to 4 months
126
What functional complications are associated with pregnancy in SCI?
``` Difficult transfers WC propulsion Respiratory compromise Self cathing Labor increasing spasticity Not recognizing labor in Patients with T10 and above injury ```
127
What is the distribution of pressure ulcers in acute hospitalization for SCI?
``` Sacrum 39% Calcaneus 13% Ischium 8% Occiput 6% Scapula 5% ```
128
What is the distribution of pressure ulcers 2 year after SCI?
``` Ischium 31% Trochanter 26% Sacrum 18% Calcaneus 5% Malleolus 4% ```
129
What is autolysis?
Moisture retentive barrier applied to superficial ulcer causing endogenous enzyme degradation of nectrotic tissue
130
What is Chemical debridement?
Application of commercially available enzymes to selectively degrade necrotic tissue
131
What is sharp debridement?
Excision o f necrotic tissue with sharp instrument
132
What is mechanical debridement?
Hydrotherapy or application of wet to dry dressings
133
What are the nutritional requirements in SCI with pressure ulcers?
25 kcal/kg/day | 1.5-2g protein/kg/day
134
What is nociceptive pain?
Pain arising from activation of peripheral nerve endings or sensory receptors encoding noxious stimuli
135
What is neuropathic pain?
Pain arising due to lesion or disease affecting somatosensory system
136
What is At-level SCI pain?
neuropathic pain in segmental pattern in dermatomes at NLI and 3 levels below but not lower
137
What is Below-level SCI pain?
Neuropathic pain >3 dermatome levels below NLI d/t lesion of SC Typically pain in region rather than dermatomal
138
Tx of At-level and Below-level SCI pain
``` Gabapentin Pregabalin Tramadol Amitriptyline SSRI or SNRI Oipids Itnrathecal ziconotide (neurotoxin) Desensitization CBT ```
139
What is the 1st line tx of spinal spasticity?
Oral baclofen | GABA analog that binds to GABA B receptors, main inhibitory of the SC
140
What is the maximum recommended dose of baclofen and side effects?
80 mg/day Fatigue Dizziness Seizures
141
What medications bind to GABA A receptors?
Benzodiasepines
142
What is the MOA of tizanidine and its SE?
Central alpha2-adrenergic agonist Sedation Liver function ABN
143
What is the MOA and SE of dantrolene?
Inhibits release of calcium from muscle sarcoplasmic reticulum inhibiting excitation-contraction coupling in muscle SE: Hepatoxicity
144
What is the MOA of botox?
Binds to receptor sites on presynaptic nerve terminal at NMJ inhibiting release of Ach
145
When is intrathecal baclofen used?
Severe generalized spasticity
146
What is Heterotopic ossification?
True bone in extraskeletal etopic sites | localized warm swelling with reduced ROM
147
When does HO develop in SCI and what there the MC locations?
``` W/in 4 mo of injury Hips (90%0 Knees Shoulders Elbows ```
148
How is HO diagnosed?
Elevated alkaline phosphatase Bone scan Xray positive when HO matures
149
Tx of HO
IV etidronate 300 mg/day for 3 days Oral etidronate 20 mg/kg/day for 6 months Surgical removal once HO mature
150
What are causes of SCI in children?
Lap belt injuries Birth injury Child abuse Carnioverebral junction injury (RA, Down syndrome, skeletal dysplasia)
151
What is the management of bladder and bowel emptying in children with SCI?
Infant: diaper 3-4 yo: I/O cath 5-7 yo: self caths 2-4 yo: bowel program
152
What are common ortho problems in children with SCI?
Hip instablity | Scoliosis
153
What are some characteristics of SCI in elderly?
Incomplete injury MC Cervical stenosis Women >men Inc comorbidities & complications

Brad 4th Ed Part 2 (28 decks)

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