Chapter 21 Spinal Cord Injury (Direct Text) Flashcards Preview

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Flashcards in Chapter 21 Spinal Cord Injury (Direct Text) Deck (35):
1

EPIDEMIOLOGY OF TRAUMATIC SCI
There are ≈12,000 new patients who survive SCI in the United States each year.1 Since 2005, the mean age at time of injury is _______ years. ♂:♀ = 4:1. _______ _______ is the most common category, followed by _______ _______ (22.9%), _______ paraplegia (21.5%), and complete tetraplegia (16.9%). Since 2005, the most common etiologies are vehicular crashes (41.3%), followed by falls (27.3%), acts of violence (15.0), unknown (8.5%), and sports (7.9%). The proportion of injuries from _______ has increased and that from _______ has decreased.

EPIDEMIOLOGY OF TRAUMATIC SCI
There are ≈12,000 new patients who survive SCI in the United States each year.1 Since 2005, the mean age at time of injury is 40.2 years.1 ♂:♀ = 4:1. Incomplete tetraplegia is the most common category, followed by complete paraplegia (22.9%), incomplete paraplegia (21.5%), and complete tetraplegia (16.9%). Since 2005, the most common etiologies are vehicular crashes (41.3%), followed by falls (27.3%), acts of violence (15.0), unknown (8.5%), and sports (7.9%).1 The proportion of injuries from falls has increased and that from sports has decreased.

2

SELECTED TRACTS
The majority of descending corticospinal motor fibers cross at the medulla to become the _______ _______ tract (_______). A small number of CST fibers do not decussate at the medulla and descend via the anterior CST before crossing at the level of the anterior white commissure. Although often depicted in many representations of the spinal cord (see Fig. 21-1, right), the existence of a somatotopic organization of the _______ CST has been challenged.

SELECTED TRACTS
The majority of descending corticospinal motor fibers cross at the medulla to become the lateral corticospinal tract (CST). A small number of CST fibers do not decussate at the medulla and descend via the anterior CST before crossing at the level of the anterior white commissure. Although often depicted in many representations of the spinal cord (see Fig. 21-1, right), the existence of a somatotopic organization of the lateral CST has been challenged.

3

SELECTED TRACTS
The ascending dorsal white columns cross in the medulla, via the medial _______, then go on to the _______. These fibers carry joint _______, _______, and light touch (LT) sensation.

SELECTED TRACTS
The ascending dorsal white columns cross in the medulla, via the medial lemniscus, then go on to the thalamus. These fibers carry joint position, vibration, and light touch (LT) sensation.

4

SELECTED TRACTS
The spinothalamic tracts, which carry _______, _______, and nondiscriminative _______ sensations, cross to the _______ side shortly after entry to the cord in the ventral white commissure of the spinal cord.

SELECTED TRACTS
The spinothalamic tracts, which carry pain, temperature, and nondiscriminative tactile sensations, cross to the contralateral side shortly after entry to the cord in the ventral white commissure of the spinal cord.

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CLASSIFICATION OF SCI: INTERNATIONAL STANDARDS FOR THE NEUROLOGIC CLASSIFICATION OF SCI
Perform a supine sensory examination of the 28 dermatomes at the key sensory points for pin prick (PP) and LT, including _______ sensation. The sensory level is the most caudal level with intact (grade _______) sensation for both PP and LT.

CLASSIFICATION OF SCI: INTERNATIONAL STANDARDS FOR THE NEUROLOGIC CLASSIFICATION OF SCI
Perform a supine sensory examination of the 28 dermatomes at the key sensory points for pin prick (PP) and LT, including rectal sensation. The sensory level is the most caudal level with intact (grade 2) sensation for both PP and LT.

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CLASSIFICATION OF SCI: INTERNATIONAL STANDARDS FOR THE NEUROLOGIC CLASSIFICATION OF SCI
Rectal sensory examination includes evaluation of _______ rectal _______ as determined by the patient's ability to feel the examiner's finger during digital rectal examination.

CLASSIFICATION OF SCI: INTERNATIONAL STANDARDS FOR THE NEUROLOGIC CLASSIFICATION OF SCI
Rectal sensory examination includes evaluation of deep rectal sensation as determined by the patient's ability to feel the examiner's finger during digital rectal examination.

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CLASSIFICATION OF SCI: INTERNATIONAL STANDARDS FOR THE NEUROLOGIC CLASSIFICATION OF SCI
Perform a supine motor examination of 10 key muscle groups and voluntary anal contraction. The motor level for each side is the most caudal level with grade ≥_______, where all muscles rostral to it are grade _______.

CLASSIFICATION OF SCI: INTERNATIONAL STANDARDS FOR THE NEUROLOGIC CLASSIFICATION OF SCI
Perform a supine motor examination of 10 key muscle groups and voluntary anal contraction. The motor level for each side is the most caudal level with grade ≥3, where all muscles rostral to it are grade 5.

8

Determine the single neurologic level, which is the most caudal level at which both sensory and motor modalities are _______ intact, as defined earlier. Classify injury as complete or incomplete. Complete injuries have no _______ or _______ function, including deep _______ sensation (preserved in sacral segments S4-5). Somatosensory evoked potentials (SSEPs) may be useful in differentiating complete versus incomplete SCI in patients who are uncooperative or unconscious.

Determine the single neurologic level, which is the most caudal level at which both sensory and motor modalities are bilaterally intact, as defined earlier. Classify injury as complete or incomplete. Complete injuries have no motor or sensory function, including deep anal sensation, preserved in sacral segments S4-5. Somatosensory evoked potentials (SSEPs) may be useful in differentiating complete versus incomplete SCI in patients who are uncooperative or unconscious.

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Sensory levels are scored as 0 (_______), 1 (_______, including _______-esthesia), 2 (_______), or not testable (NT). When scoring PP, inability to distinguish PP from LT is scored 0/2. Muscles are graded from 0 (total paralysis) to 5 (normal active movement with full ROM against full resistance), or NT.

Sensory levels are scored as 0 (absent), 1 (impaired, including hyper-esthesia), 2 (normal), or not testable (NT). When scoring PP, inability to distinguish PP from LT is scored 0/2. Muscles are graded from 0 (total paralysis) to 5 (normal active movement with full ROM against full resistance), or NT.

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Categorize by American Spinal Injury Association (ASIA) Impairment Scale (AIS) A to E.
A Complete – No sensory or motor function is preserved in the lowest sacral segments S _______-_______. The ZPP (only used in ASIA A) refers to the most caudal segment below the level of injury with partial sensory or motor function. Determine the zone of partial preservation (ZPP) if ASIA _______. ZPP is defined as preserved segments below the neurologic level of injury (NLOI) and used in _______ injuries.
B Incomplete – _______ but no _______ function is preserved below the neurologic level and must include sacral segments S4-5.
C Incomplete – _______ function is preserved more than three levels below the neurologic level, and more than half of the key muscles below the neurologic level have a muscle grade 3. (?)
D Incomplete – Motor function is preserved more than three levels below the neurologic level, and at least half of the key muscles below the neurologic level have a muscle grade ≥3. (?)
E Normal – LT, PP, and motor function of the key muscles are normal.
Note: For an individual to receive a grade of ASIA C or D, there must be _______ or _______ S _______-_______ sparing. In addition, the individual must have either (1) voluntary _______ _______ contraction or (2) sparing of motor function more than three levels below the motor level.

Categorize by American Spinal Injury Association (ASIA) Impairment Scale (AIS) A to E.
A Complete – No sensory or motor function is preserved in the lowest sacral segments S4-5. The ZPP (only used in ASIA A) refers to the most caudal segment below the level of injury with partial sensory or motor function. Determine the zone of partial preservation (ZPP) if ASIA A. ZPP is defined as preserved segments below the neurologic level of injury (NLOI) and used in complete injuries.
B Incomplete – Sensory but no motor function is preserved below the neurologic level and must include sacral segments S4-5.
C Incomplete – Motor function is preserved more than three levels below the neurologic level, and more than half of the key muscles below the neurologic level have a muscle grade 3.
D Incomplete – Motor function is preserved more than three levels below the neurologic level, and at least half of the key muscles below the neurologic level have a muscle grade ≥3.
E Normal – LT, PP, and motor function of the key muscles are normal.
Note: For an individual to receive a grade of ASIA C or D, there must be sensory or motor S4-5 sparing. In addition, the individual must have either (1) voluntary anal sphincter contraction or (2) sparing of motor function more than three levels below the motor level.

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SCI CLINICAL SYNDROMES
Central Cord – This incomplete syndrome is typically seen in older persons with cervical spondylosis who experience neck _______ injury, resulting in greater upper limb rather than lower limb impairment. Bowel, bladder, and sexual dysfunction are _______. The postulated mechanism of injury involves cord compression both anteriorly and posteriorly, with inward bulging of the _______ _______ during _______ in a stenotic spinal canal. Penrod retrospectively studied 51 patients with central cord syndrome and noted better overall recovery of ambulation, self-care, and bowel/bladder function in patients 50 years of age than their older counterparts at time of discharge from rehabilitation.

SCI CLINICAL SYNDROMES
Central Cord – This incomplete syndrome is typically seen in older persons with cervical spondylosis who experience neck hyperextension injury, resulting in greater upper limb rather than lower limb impairment. Bowel, bladder, and sexual dysfunction are variable. The postulated mechanism of injury involves cord compression both anteriorly and posteriorly, with inward bulging of the ligamentum flavum during hyperextension in a stenotic spinal canal. Penrod retrospectively studied 51 patients with central cord syndrome and noted better overall recovery of ambulation, self-care, and bowel/bladder function in patients 50 years of age than their older counterparts at time of discharge from rehabilitation.

12

SCI CLINICAL SYNDROMES
Brown-Séquard – _______ the cord produces _______ weakness and proprioceptive loss and _______ loss of PP and temperature sense. The prognosis for ambulation is _______ among the incomplete SCI syndromes.

SCI CLINICAL SYNDROMES
Brown-Séquard – Hemisection of the cord produces ipsilateral weakness and proprioceptive loss and contralateral loss of PP and temperature sense. The prognosis for ambulation is best among the incomplete SCI syndromes.

13

SCI CLINICAL SYNDROMES
Anterior Cord – There is variable loss of motor and PP sensation, with relative preservation of _______ and LT. Prognosis for motor recovery is generally considered _______. Typically, the anterior cord syndrome results from a vascular lesion in the territory of the anterior spinal artery, but it may also be seen resulting from retropulsed disks/ vertebral fragments. Intraoperative SSEPs, which primarily monitor the posterior column pathways, may miss the development of an anterior cord syndrome.

SCI CLINICAL SYNDROMES
Anterior Cord – There is variable loss of motor and PP sensation, with relative preservation of proprioception and LT. Prognosis for motor recovery is generally considered poor. Typically, the anterior cord syndrome results from a vascular lesion in the territory of the anterior spinal artery, but it may also be seen resulting from retropulsed disks/ vertebral fragments. Intraoperative SSEPs, which primarily monitor the posterior column pathways, may miss the development of an anterior cord syndrome.

14

SCI CLINICAL SYNDROMES
Cauda Equina – Cauda equina injuries may be due to neural canal compression or fractures of the sacrum or spine at _______ or below. While the damage occurs within the spinal cord, the syndrome can be described as “multiple lumbosacral radiculopathies,” since the cauda is comprised of lumbosacral nerve roots. Sequelae depend on the roots involved but usually involve impairment of bowel, bladder, and sexual function. _______, _______ anesthesia, and lower limb _______ are also characteristic. Radicular neuropathic pain is common and can be severe. Recovery is possible because the nerve roots can recover. Consultation for possible early surgery is indicated.

SCI CLINICAL SYNDROMES
Cauda Equina – Cauda equina injuries may be due to neural canal compression or fractures of the sacrum or spine at L2 or below. While the damage occurs within the spinal cord, the syndrome can be described as “multiple lumbosacral radiculopathies,” since the cauda is comprised of lumbosacral nerve roots. Sequelae depend on the roots involved but usually involve impairment of bowel, bladder, and sexual function. Areflexia, saddle anesthesia, and lower limb weakness are also characteristic. Radicular neuropathic pain is common and can be severe. Recovery is possible because the nerve roots can recover. Consultation for possible early surgery is indicated.

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SCI CLINICAL SYNDROMES
Conus Medullaris – A pure conus medullaris lesion (e.g., intramedullary tumor) results in _______ anesthesia and _______, _______, and _______ dysfunction due to cord injury at the S _______-_______ segments. Anal cutaneous and _______ (S2-4) and ankle deep tendon reflexes (S1,S2) may be either absent or preserved depending upon whether the lesion is “high” in the conus. Prognosis for recovery is poor. Conus lesions due to trauma (e.g., L1 vertebral body fracture) are typically accompanied by injury of some of the lumbosacral nerve roots, resulting in a variable degree of lower limb dysfunction.

SCI CLINICAL SYNDROMES
Conus Medullaris – A pure conus medullaris lesion (e.g., intramedullary tumor) results in saddle anesthesia and bladder, sphincter, and sexual dysfunction due to cord injury at the S2-4 segments. Anal cutaneous and bulbocavernosus (S2-4) and ankle deep tendon reflexes (S1,S2) may be either absent or preserved depending upon whether the lesion is “high” in the conus. Prognosis for recovery is poor. Conus lesions due to trauma (e.g., L1 vertebral body fracture) are typically accompanied by injury of some of the lumbosacral nerve roots, resulting in a variable degree of lower limb dysfunction.

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BASIS FOR ACUTE INTERVENTIONS
High-dose steroids have been reported to be _______ in acute SCI by inhibiting lipid peroxidation and scavenging free radicals. The use of IV methylprednisolone (MP) in acute nonpenetrating traumatic SCI is supported by the National Acute Spinal Cord Injury Studies (NASCIS).7,8 The results of the NASCIS trials, however, have been challenged by some authors and organizations.

BASIS FOR ACUTE INTERVENTIONS
High-dose steroids have been reported to be neuroprotective in acute SCI by inhibiting lipid peroxidation and scavenging free radicals. The use of IV methylprednisolone (MP) in acute nonpenetrating traumatic SCI is supported by the National Acute Spinal Cord Injury Studies (NASCIS).7,8 The results of the NASCIS trials, however, have been challenged by some authors and organizations.

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In the NASCIS 2 trial, segmental and long-tract neurologic function modestly improved at 6 weeks, 6 months, and 1 year post-SCI in patients receiving MP within 8 hours of SCI as compared with placebo or naloxone. MP was given as a 30 mg/kg bolus over 1 hour, then as a 5.4 mg/kg/h drip for an additional 23 hours. The NASCIS 3 trial further refined the MP protocol such that when steroid treatment is initiated within _______ hours of SCI, MP is administered for _______ hours; if initiated at 3 to 8 hours post-SCI, MP is administered for an additional 24 hours, for a total of 48 hours.

In the NASCIS 2 trial, segmental and long-tract neurologic function modestly improved at 6 weeks, 6 months, and 1 year post-SCI in patients receiving MP within 8 hours of SCI as compared with placebo or naloxone. MP was given as a 30 mg/kg bolus over 1 hour, then as a 5.4 mg/kg/h drip for an additional 23 hours. The NASCIS 3 trial further refined the MP protocol such that when steroid treatment is initiated within 3 hours of SCI, MP is administered for 24 hours; if initiated at 3 to 8 hours post-SCI, MP is administered for an additional 24 hours, for a total of 48 hours.

18

GM-1 ganglioside (Sygen) has never been approved for the treatment of SCI. A study demonstrated neuroprotective and neuroregenerative effects in vitro. The Sygen Multicenter Acute SCI Study11 showed a more rapid time course of neurologic recovery in the Sygen + IV MP versus the IV MP group. However, the outcomes in both groups were found to be _______ at 26 weeks.

GM-1 ganglioside (Sygen) has never been approved for the treatment of SCI. A study demonstrated neuroprotective and neuroregenerative effects in vitro. The Sygen Multicenter Acute SCI Study11 showed a more rapid time course of neurologic recovery in the Sygen + IV MP versus the IV MP group. However, the outcomes in both groups were found to be similar at 26 weeks.

19

The optimal timing for surgery after SCI is unknown. Retrospective data suggest a role for urgent _______ in the setting of bilateral facet dislocation or incomplete SCI with progressive neurologic deterioration.

The optimal timing for surgery after SCI is unknown. Retrospective data suggest a role for urgent decompression in the setting of bilateral facet dislocation or incomplete SCI with progressive neurologic deterioration.

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PROGNOSIS AND RECOVERY IN TRAUMATIC SCI
Complete SCI – Only 2% to 3% of patients who are AIS A at 1 week post-SCI improve to AIS D by 1 year. In persons with complete tetraplegia, >95% of key muscles in the ZPP with grade 1 or 2 at 1 month post-SCI will reach grade 3 at _______ year; ≈25% of the most cephalad grade 0 muscles at 1 month recover to grade 3 at 1 year,13 those having pin sensation being the most likely to recover motor function. Most upper limb recovery occurs during the first _______ months, with the greatest rate of change during the first _______ months. Motor level is superior to the neurologic or sensory level in correlating with function. In patients who are complete paraplegics at 1 week post-SCI, NLOI has been found to remain unchanged at 1 year in 73%, improve 1 level in 18%, and improve ≥2 levels in 9%. Waters reported that only 5% of complete paraplegics eventually achieve community ambulation.

PROGNOSIS AND RECOVERY IN TRAUMATIC SCI
Complete SCI – Only 2% to 3% of patients who are AIS A at 1 week post-SCI improve to AIS D by 1 year. In persons with complete tetraplegia, >95% of key muscles in the ZPP with grade 1 or 2 at 1 month post-SCI will reach grade 3 at 1 year; ≈25% of the most cephalad grade 0 muscles at 1 month recover to grade 3 at 1 year,13 those having pin sensation being the most likely to recover motor function. Most upper limb recovery occurs during the first 6 months, with the greatest rate of change during the first 3 months. Motor level is superior to the neurologic or sensory level in correlating with function. In patients who are complete paraplegics at 1 week post-SCI, NLOI has been found to remain unchanged at 1 year in 73%, improve 1 level in 18%, and improve ≥2 levels in 9%. Waters reported that only 5% of complete paraplegics eventually achieve community ambulation.

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Incomplete SCI – Incomplete tetraplegics often recover multiple levels below the initial level. Waters15 reported that 46% of incomplete tetraplegics recover sufficient motor function to ambulate at _______ year; 80% of incomplete paraplegics regain hip flexors and knee extensors (KEs; grade ≥3) by _______ year. In a review of 27 patients who were initially sensory incomplete, Crozier reported that partial (or greater) preservation of _______ sensation below the zone of injury was predictive of eventual functional ambulation.

Incomplete SCI – Incomplete tetraplegics often recover multiple levels below the initial level. Waters15 reported that 46% of incomplete tetraplegics recover sufficient motor function to ambulate at 1 year; 80% of incomplete paraplegics regain hip flexors and knee extensors (KEs; grade ≥3) by 1 year. In a review of 27 patients who were initially sensory incomplete, Crozier reported that partial (or greater) preservation of PP sensation below the zone of injury was predictive of eventual functional ambulation.

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Miscellaneous – The _______-hour post-SCI neurologic examination may predict recovery more reliably than an examination performed on the day of injury. Absence of the bulbocavernosus reflex beyond the first few days can signify a lower motor neuron lesion and have implications on bowel, bladder, and sexual function. On MRI, presence of hemorrhage and length of edema are independent negative predictors of motor function at 1 year. Strength ≥ _______/5 in the b/l _______ _______ and one _______ _______ correlates with community ambulation.

Miscellaneous – The 72-hour post-SCI neurologic examination may predict recovery more reliably than an examination performed on the day of injury. Absence of the bulbocavernosus reflex beyond the first few days can signify a lower motor neuron lesion and have implications on bowel, bladder, and sexual function. On MRI, presence of hemorrhage and length of edema are independent negative predictors of motor function at 1 year. Strength ≥3/5 in the b/l hip flexors and one knee extensor correlates with community ambulation.

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EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C1-3 – _______ dependent (or may have _______ nerve pacing); D for secretion management. I with power WC mobility and pressure relief with equipment; otherwise essentially D for all care (but I for directing care).

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C1-3 – ventilator dependent (or may have phrenic nerve pacing); D for secretion management. I with power WC mobility and pressure relief with equipment; otherwise essentially D for all care (but I for directing care).

24

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C4 – may be able to breathe w/o a ventilator. May use a _______ _______ support for limited ADLs if there is some elbow flexion and deltoid strength. May be able to use a sip–puff or head-control WC.

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C4 – may be able to breathe w/o a ventilator. May use a mobile arm support for limited ADLs if there is some elbow flexion and deltoid strength. May be able to use a sip–puff or head-control WC.

25

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C5 – may require A to clear secretions. May be I for feeding after setup and with adaptive equipment, e.g., a _______ _______ orthosis with utensil slots and mobile arm support. Requires A for most upper body ADLs. Most patients will be unable to do self–clean intermittent catheterization. I with power WC; some users may be I with manual WC on noncarpeted, level, indoor surfaces. Some may drive specially adapted vans.

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C5 – may require A to clear secretions. May be I for feeding after setup and with adaptive equipment, e.g., a long opponens orthosis with utensil slots and mobile arm support. Requires A for most upper body ADLs. Most patients will be unable to do self–clean intermittent catheterization. I with power WC; some users may be I with manual WC on noncarpeted, level, indoor surfaces. Some may drive specially adapted vans.

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EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C6 – May use a _______ _______ and short opponens orthosis with utensil slots. I with feeding except for cutting food. I for most upper body ADLs after setup and with modifications (e.g., Velcro straps on clothing); A to D for most lower body ADLs, including bowel care. Some males may be I with self–intermittent catheterization (IC) after setup; females are usually D. Some patients may be I for transfers using a sliding board and heel loops, but many will require A. May be I with manual WC, but power WCs are often used, especially for longer distances and outdoors. May drive an adapted van.

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C6 – May use a tenodesis orthosis and short opponens orthosis with utensil slots. I with feeding except for cutting food. I for most upper body ADLs after setup and with modifications (e.g., Velcro straps on clothing); A to D for most lower body ADLs, including bowel care. Some males may be I with self–intermittent catheterization (IC) after setup; females are usually D. Some patients may be I for transfers using a sliding board and heel loops, but many will require A. May be I with manual WC, but power WCs are often used, especially for longer distances and outdoors. May drive an adapted van.

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EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C7 – Essentially I for most ADLs, often using a _______ _______ splint and _______ cuff. May require A for some lower body ADLs. Women may have difficulty with IC. Bowel care may be I with adaptive equipment, but suppository insertion may still be difficult. I for mobility at a manual WC level, except for uneven transfers. Patients may be I with a nonvan automobile with hand controls if the patient can transfer and load/ unload the WC.

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C7 – Essentially I for most ADLs, often using a short opponens splint and universal cuff. May require A for some lower body ADLs. Women may have difficulty with IC. Bowel care may be I with adaptive equipment, but suppository insertion may still be difficult. I for mobility at a manual WC level, except for uneven transfers. Patients may be I with a nonvan automobile with hand controls if the patient can transfer and load/ unload the WC.

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EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C8 – Completely I with ADLs and mobility using _______ WC and adapted car.

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
C8 – Completely I with ADLs and mobility using manual WC and adapted car.

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EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
Paraplegia – Trunk stability improves with lower lesions. Upper and midthoracics may stand and ambulate with b/l KAFOs and _______ crutches (i.e., swing-through or swing-to gait), but the intent is usually exercise, not functional mobility. Using orthoses and gait-assistive devices, lower thoracics and L1 SCI patients can do household ambulation and may be I community ambulators. L2-S5 SCI patients may be community ambulators with or w/o orthoses (i.e., KAFOs or AFOs) and/or gait-assistive devices. (AFOs generally compensate for the ankle weakness, while canes and crutches primarily compensate for hip abduction and extension weakness.)

EXPECTED FUNCTIONAL LEVELS
(I, independent; A, assist; D, dependent; predicted outcomes are based on patients of typical age for traumatic SCI – older patients have overall poorer expected outcome)
Paraplegia – Trunk stability improves with lower lesions. Upper and midthoracics may stand and ambulate with b/l KAFOs and Lofstrand crutches (i.e., swing-through or swing-to gait), but the intent is usually exercise, not functional mobility. Using orthoses and gait-assistive devices, lower thoracics and L1 SCI patients can do household ambulation and may be I community ambulators. L2-S5 SCI patients may be community ambulators with or w/o orthoses (i.e., KAFOs or AFOs) and/or gait-assistive devices. (AFOs generally compensate for the ankle weakness, while canes and crutches primarily compensate for hip abduction and extension weakness.)

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SELECTED ISSUES IN SCI
Autonomic Dysreflexia (AD) – can occur in 48% to 85% of patients with SCI at _______ or above.18 Since resting SBPs can be 90 to 110 mm Hg in this population, SBPs of 20 to 40 mm Hg > baseline may signify AD.18 A noxious stimulus below the level of injury causes reflex sympathetic vasoconstriction (BP ↑). Due to the SCI, higher CNS centers cannot directly modulate the sympathetic response. The body attempts to lower BP by carotid and aortic baroreceptor/vagal-mediated bradycardia, but this is usually ineffective (Fig. 21-2).
The primary treatment of AD entails removing the source of noxious stimulus. This is most commonly bladder dysfunction, and the second most common cause is bowel distention. Other causes include pressure ulcers, undiagnosed fractures, abdominal emergencies, ingrown toenails, and body positioning. Table 21-1 gives a complete chart of the causes of AD.

SELECTED ISSUES IN SCI
Autonomic Dysreflexia (AD) – can occur in 48% to 85% of patients with SCI at T6 or above.18 Since resting SBPs can be 90 to 110 mm Hg in this population, SBPs of 20 to 40 mm Hg > baseline may signify AD.18 A noxious stimulus below the level of injury causes reflex sympathetic vasoconstriction (BP ↑). Due to the SCI, higher CNS centers cannot directly modulate the sympathetic response. The body attempts to lower BP by carotid and aortic baroreceptor/vagal-mediated bradycardia, but this is usually ineffective (Fig. 21-2).
The primary treatment of AD entails removing the source of noxious stimulus. This is most commonly bladder dysfunction, and the second most common cause is bowel distention. Other causes include pressure ulcers, undiagnosed fractures, abdominal emergencies, ingrown toenails, and body positioning. Table 21-1 gives a complete chart of the causes of AD.

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SELECTED ISSUES IN SCI
Long-Term Routine Urinary Tract Surveillance after SCI – Upper tract follow-up can include renal scan with GFR or renal scan with 24-hour Cr clearance yearly to follow renal function. Renal and bladder ultrasound can be done annually to detect _______ and _______. Lower tract evaluation can include urodynamics once the bladder starts exhibiting uninhibited contractions (or at around 3 to 6 months postinjury) and then as determined by the clinician (often done annually). Routine cystoscopy to potentially diagnose neoplasm at an earlier rather than a later stage should be performed annually as patients approach 10 years of chronic indwelling (urethral or suprapubic) catheter use or sooner (after 5 years) if there are additional risk factors (heavy smoker, age > 40 years, and history of many UTIs).

SELECTED ISSUES IN SCI
Long-Term Routine Urinary Tract Surveillance after SCI – Upper tract follow-up can include renal scan with GFR or renal scan with 24-hour Cr clearance yearly to follow renal function. Renal and bladder ultrasound can be done annually to detect hydronephrosis and stones. Lower tract evaluation can include urodynamics once the bladder starts exhibiting uninhibited contractions (or at around 3 to 6 months postinjury) and then as determined by the clinician (often done annually). Routine cystoscopy to potentially diagnose neoplasm at an earlier rather than a later stage should be performed annually as patients approach 10 years of chronic indwelling (urethral or suprapubic) catheter use or sooner (after 5 years) if there are additional risk factors (heavy smoker, age > 40 years, and history of many UTIs).

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SELECTED ISSUES IN SCI
Posttraumatic Syringomyelia – seen in ≈3% to 8% of posttraumatic SCI patients as manifested by neurologic decline or up to 20% on autopsy. It can develop as early as 2 months post-SCI. Pain is often worsened by _______ or _______, but not by _______ supine. Ascending sensory loss, progressive weakness (including bulbar muscles), ↑ sweating, orthostasis, and Horner's syndrome may also be seen. Diagnosis is by MRI. Treatment is usually observational and symptomatic. Surgical interventions are available for large, progressive lesions

SELECTED ISSUES IN SCI
Posttraumatic Syringomyelia – seen in ≈3% to 8% of posttraumatic SCI patients as manifested by neurologic decline or up to 20% on autopsy. It can develop as early as 2 months post-SCI. Pain is often worsened by coughing or straining, but not by lying supine. Ascending sensory loss, progressive weakness (including bulbar muscles), ↑ sweating, orthostasis, and Horner's syndrome may also be seen. Diagnosis is by MRI. Treatment is usually observational and symptomatic. Surgical interventions are available for large, progressive lesions.

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SELECTED ISSUES IN SCI
Sexual Function and Fertility – Females: 44% to 55% of women with SCI can achieve orgasm. Menses typically returns within _______ months post-SCI, and reproductive function is preserved. Incidence of prematurity and small-for-date infants is high, but there is no increase in spontaneous abortions. Spinal anesthesia is recommended during delivery for patients with SCI at T6 or above to avoid AD.

SELECTED ISSUES IN SCI
Sexual Function and Fertility – Females: 44% to 55% of women with SCI can achieve orgasm. Menses typically returns within 6 months post-SCI, and reproductive function is preserved. Incidence of prematurity and small-for-date infants is high, but there is no increase in spontaneous abortions. Spinal anesthesia is recommended during delivery for patients with SCI at T6 or above to avoid AD.

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SELECTED ISSUES IN SCI
Sexual Function and Fertility – Males: With complete upper motor neuron SCI, _______ erections can usually be achieved, although _______ is rare. With incomplete SCI, reflexogenic erections are usually attainable; ejaculation is less rare than for those with complete SCI; and some patients can achieve psychogenic erections. Complete or incomplete injuries below T11 may result in erections of poor quality and duration. Infertility is common after SCI, due to factors including retrograde ejaculation and poor sperm quantity and motility. Vibratory ejaculation in which the ventral penile shaft is stimulated requires that the postinjury period is > _______ months and L2-S1 is intact. Electroejaculation (seminal vesicle and prostatic stimulation through the rectum) is another option.

SELECTED ISSUES IN SCI
Sexual Function and Fertility – Males: With complete upper motor neuron SCI, reflexogenic erections can usually be achieved, although ejaculation is rare. With incomplete SCI, reflexogenic erections are usually attainable; ejaculation is less rare than for those with complete SCI; and some patients can achieve psychogenic erections. Complete or incomplete injuries below T11 may result in erections of poor quality and duration. Infertility is common after SCI, due to factors including retrograde ejaculation and poor sperm quantity and motility. Vibratory ejaculation in which the ventral penile shaft is stimulated requires that the postinjury period is >6 months and L2-S1 is intact. Electroejaculation (seminal vesicle and prostatic stimulation through the rectum) is another option.

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SELECTED ISSUES IN SCI
Tendon Transfer Surgery in Tetraplegia – Triceps function can be restored in the C _______, _______ SCI patient with a posterior _______-to-_______ or a _______-to-_______ transfer. Lateral key grip can be restored in a C6 SCI patient via the modified Moberg procedure, which involves attachment of the brachioradialis (C5,6) to the flexor pollicis longus (C8,T1) and stabilization of the thumb carpometacarpal and IP joints.

SELECTED ISSUES IN SCI
Tendon Transfer Surgery in Tetraplegia – Triceps function can be restored in the C5,6 SCI patient with a posterior deltoid-to-triceps or a biceps-to-triceps transfer. Lateral key grip can be restored in a C6 SCI patient via the modified Moberg procedure, which involves attachment of the brachioradialis (C5,6) to the flexor pollicis longus (C8,T1) and stabilization of the thumb carpometacarpal and IP joints.