Quick Study Sess Flashcards
(201 cards)
1
Q
cause SCI
A
MVA 44%
Fall 18%
Violence 16%
Diving/sport 12%
2
Q
age SCI
A
16-30 years
median 26
average 41
3
Q
Gender SCI
A
male: female
4: 1
4
Q
SCI ethnicity
A
73.9 caucasian MVA
AA: violence
Hispanic: violence
Asian
NA
5
Q
What does first ten minutes emergent care SCI help
A
makes complete and incomplete more equal
6
Q
When SCI most common to occur
A
Daytime
July
Summer
Alcohol and substance plays role 17-49% in the accidents
7
Q
Leading cause by age of SCI
A
MVA below 45yrs
Falls above 45 yrs
8
Q
Common SCI type to least common
A
Incomplete tetraplegia 30%
Complete paraplegia 28%
Incomplete Paraplegia 21%
Complete tetraplegia 18.5%
most frequent level is C5
then C4–C6–T12
most vulnerable levels are:
C5-C7, T4-T7, T10-L2
9
Q
SCI employment
A
ASIA D full time same job young male white high IQ educated
10
Q
Rehab
A
increase independence, regain ability and mobility but also into the community, need special training to professionally be in rehab,
SCI able to live healthy and happy productive life
11
Q
Vertebrae
how many
A
8 cervical 12 Thoracic 5 lumbar *sacrum and coccyx not vertebrae 24 vertebrae 31 spinal nerves
12
Q
Intervertebral discs
the parts
vascularity
A
nucleus propolsus in the center
annulus fibrosis surrounding
avascular disc–blood supply from peripheral parts of adjacent blood vessels, nutrition from upper and lower surfaces of the vertebral body
13
Q
parts of a vertebrae
A
1 SP
2 TP
4 articular processes
14
Q
what do muscle attachments do for the spiner
A
needed for normal configuration of the spine (tightness or looseness of the muscles) prevent deformities, additional damage must be prevented
15
Q
ALL
A
anterior longitudinal ligament
–anterior vertebral body: atlas to sacrum
–limits extension
16
Q
PLL
A
posterior longitudinal ligament
–posterior to vertebral body in vertebral canal: from axis (C2) to sacrum
–limits flexion
17
Q
Ligamentum Flavum
A
in between laminae
upright head
18
Q
Ligamentum Nucha
A
ligament at the back of the neck that is continuous with the supraspinous ligament
19
Q
Supraspinous Ligament
A
posterior to SP
20
Q
Interspinous Ligament
A
btwn SP
21
Q
Dura Mater
function
A
outermost roots, ganglia, nerve
PROTECTS
LITTLE VASCULARITY
22
Q
Arachnoid mater
function
A
subarachnoid space
distributes CSF
23
Q
Pia Mater
function
A
adhere to cord
hold cord in place
24
Q
Where is spinal cord?
A
foramen magnum to L1/L2
25
How many spinal nerves?
31 spinal nerves
| one pair per spinal segment
26
Ventral Root
motor= somatic
anterior, efferent
anterior grey column:motor neurons for axial muscle
with sympathetic visceral part from ventral lateral grey--autonomic nervous system
27
Dorsal Roots
sensory =
posterior, afferent
posterior grey column
28
SAME and DAVE
sensory afferent, motor efferent
dorsal afferent, ventral efferent
dorsal horn and ventral horn come out of the central grey and join to form the spinal nerve (31 pairs on each side)
29
What level does cord end at?
L1
30
Vertebral Foramen
| Intervertebral foramen
both sites for exits for nerves
vertebral foramen is where the cord goes through
intervertebral foramen is where the spinal nerves exit
31
white matter
ascend, descend
myelin
ASCENDING
Posterior: dorsal column medial lemniscus (Cuneatus more lateral is UE until T6, medial is gracilis for LE T7 and below): fine touch, vibration, proprioception, 2 pt discrimination
Lateral: spinocerebeller: proprioception
Lateral/anterior: spinothalamic: pain, temp, crude touch
DESCENDING
lateral/anterior: corticalspinal: motor: most crossover in medulla
32
Grey matter
cell bodies, axon segments
anterior column: ventral horn--motor neurons affect axial muscles
lateral column: lateral horn--sympathetic of autonomic nervous system, visceral
posterior column: dorsal horn--sensory input: fine touch, proprioception, vibration (through receptors)
33
lesion to anterior cord
lose motor from ventral corticalspinal tracts as well as from spinothalamic tract
34
lesion to posterior cord
lose dorsal column sensation but spare corticospial and spinothalamic and anterior of spinocerebellar
35
anatomical relationship btw spinal cord and vertebral column
for C2 to T10
SP + 2 = # of SC segments
cord is shorter than vertebral column---nerve roots have to travel downwards before exiting vertebral canal
36
anterior spinal artery
give rise to sulcal artery to supply central cord
37
lateral spinal artery
lateral structures
38
segmental radicular artery
supply nerve root areas below T4
39
intertransverse ligament
btwn TP, limit lateral flexion of spine
40
meninges
The primary function of the meninges and of the cerebrospinal fluid is to protect the central nervous system.
41
vessel of adamkieicz
supply anterior spinal artery T8-L4:
supply thoracic, lumbar, sacral
42
posterior artery
posterior horn/structures
43
centrifugal system
supply central CORD
grey matter
44
centrapetal system
supply peripheral CORD
white matter
45
capillary network
more in grey matter than white
grey needs more vascular supply
46
development spinal paralysis
NTD
47
structural deformity spinal paralysis (4)
scoliosis
kyphosis
spondylolisthesis
ankylosing spondilitis--bamboo spine (lead to spinal compression, lose elasticity)
48
congenital malformation spinal paralysis (2)
kippel-feil syndrome: congenital cervical vertebrae fusion
sacralization of L5
49
familial paralysis spinal paralysis (2)
Friedreich's ataxia
Spinal cord agenisis
50
non traumatic spinal paralysis
develop
(4)
incomplete closure of spinal canal
structural deformities
congenital malformation
familial paralysis
51
acquired spinal paralysis
| 7
1. infective
2. degenerative
3. neoplastic
4. vascular
5. idiopathic
6. iatrogenic
7. psychological
52
infective spinal paralysis (4)
1. bacterial abscess
2. tubercular spine (Pott's Disease)
3. Viral: polio, herpes
4. Transverse Myelitis: inflammatory demyelination of cord segment
53
Pott's Disease
tuberculous spondylitis
54
Transverse Myelitis
inflammatory demyelination of cord segment
55
degenerative spinal paralysis (3)
1. disc herniation
2. ankylosing spondylitis (inflammatory arthritis affecting the spine)
3. multiple sclerosis (fatigue so diff than SCI)
56
neoplastic spinal paralysis
1. benign-meningioma, neurofibroma, osteosarcoma
| 2. malignant: glioma (connective tissue of CNS), metatstatics myeloma [can metstisize into spine]
57
vascular spinal paralysis (7)
1. AV malformation
2. angioma
3. dissecting aneurism
4. spontaneous anterior artery thrombosis
5. embolism
6. hemophelia
7. hemorrhage
58
iatrogenic spinal paralysis (5)
1. radiation
2. s/p surgery
3. s/p injection
4. vaccination
5. skull calipers
59
idiopathic spinal paralysis (2)
1. syringomyelia
| 2. multiple sclerosis
60
psychogenic spinal paralysis (3)
1. conversion reaction, hysterical paralysis
2. anxiety and neurosis "converts" into paralysis
3. secondary gain
61
traumatic spinal paralysis (5 forces)
1. retroflexion hyperextension
2. ventrohyperflexion or anteriorflexion
3. flexion with rotation
4. vertical stress
5. lateral flexion
or direct injury
62
Retrohyperflexion-hyperextension
who common
what happens
4 injuries
common: C4-C6
acceleration injury (rearended when stationary)--head jerks forward and back: big force on posterior aspect of vertebrae
1. SP pushed together: fx SP
2. tear ALL
3. avulsion fx where ALL attach to vert body
4. separation of anterior vertebral body and adjacent disc
63
Ventro-hyperflexion/anterior flexion
what happens
5 injuries
decceleration injury--anterior force and head whips forward
1. anterior compression and fractures
2. PLL tear
3. supraspinous ligament and infraspinous ligament tear
4. stability between vertebrae impaired and fx/dislocation
5. ***osteophyte or broken fragment can peirce the cord
64
flexion with rotation
what happens
3 injuries
highly unstable injury with loss of bony, ligamentous, and capsule integrity --rotate one facet joint over another
1. rotational force increase failure of facet joint capsule (compression, lateral translation)
2. predominant ANTERIOR bone disruption
3. subsequent disruption of both anterior and posterior columns
65
vertical stress
what happens
2 injuries
divers fx, land on their head or land hard on feet
1. "burst" fx (compression fracture): vertebral body can burst depending on amount of force
2. bony fragment and disc matter: can enter cord --tear and compress spinal cord
66
Lateral and rotational stress
what happens
3 injuries
MVA/trauma to side of head
lateral flexion of cervical spine + axial rotation
rotational force
1. stretch/rupture POSTERIOR ligaments
2. dislocate facets
3. may cause compression fx of bony structures
67
types of cord injury: 4 types of compression fx
type 1: wedge compression fx with teardrop chip--not cord damage
type 2: 1/2 vertebral body damaged--not cord damage
type 3: direct: compression and loss of vascular to SC
type 4: direct: can lead to compression and loss of vascular to SC
68
Direct injury to SC (8)
1. violence or blow
2. GSW
3. blast injury
4. stab wounds
5. violent muscle contraction
6. pathological fx
7. disc lesion
8. compression of SC
69
GSW (5 possible outcomes)
1. penetrate cord
2. intramedullary
3. extramedullary but intradurally
4. ricochet
5. indirect cord damage
70
missile penetrating the cord (4 things damaged)
1. severe cord or root damage-->total or partial paralysis
2 + 3. vascular and bony damage likely
4. injury to adjacent organs
71
missile lodged intramedullary
where is bullet
what injured
what do we do
bullet sitting in cord
probably COMPLETE LESION
leave bullet there---removal cause more damage
72
missile lodged extramedullary but intradurally
where is bullet
what injured
what do we do
btwn dura and cord, probably in arachnoid
CORD COMPRESSION
removal for pressure relief to improve function
73
missile lodged extradurally
where is bullet
what injured
what do we do
btwn bone and cord
VASCULAR DAMAGE may occur
easier to remove
74
richochet injury
indirect damage
where is bullet
what injured
ricochet injury projectile hits vertebral body and bullet or bone fragment injures cord
indirect cord damage: avulsed spinal nerve, tear dura, traction lesion (vertebrae pulled farther apart)
75
SCI blast injury
where happens
what injured
what do we do
explosives, grenades, land mines
result in HEMORRHAGE of brain and cord
can get inflamed meninges
TX: wound debridement, antibiotic
76
SCI: stab wound
```
where happens
what injured (3)
what do we do (3)
```
COMPLETE or INCOMPLETE LESIONS--discrepancy of level of external wound and cord injury
incomplete: Brown Sequard
Organs can be hurt
TX: debridement of wound, suture, antibiotics, treat CSF leakage
77
Violent muscle contraction SCI
what injured
violent stress/violent muscle spasms
combined effects of muscle contraction and deformity result in fracture at sites of bony attachment
78
pathological fractures SCI
may occur secondary to osteoporosis, tumors, metastasis
79
compression of spinal cord
rapid onset of sx (3)
slow onset of sx (4)
common
lesions are not confined to point of compression and may involve numerous segments above and below--destruction of neural elements and vascular supply due to stretching and pressing effects beyond bony or cartilage protrusion
rapid onset of symptoms: disc herniation into the cord, hemorrhage, vascular occlusion, pyogenic abscess
slow onset of symptoms: tumor, TB abscess, Potts disease, ostophyte
80
Pathological Change following injury of spinal cord
| 3
1. ischemia
2. inflammatory /ion derangement
3. apoptosis
81
SCI
ischemia
what is affected (3)
what causes it
1. reduction of BF rapidly affects grey matter (minutes), and white matter (2-3 hr)
2. primary cause of injury to anterior sulcal arteries--CENTRAL CORD
3. arteriole damage to ascending and descending tracts
blood supply disrupted by mechanical trauma and vasospasm
82
inflammation/ion derangement
SCI
(4)
inflammatory cells contribute to expansion of the area of tissue damage for 24-48 hrs after initial trauma
abnormal [k+] and [Na+] cause Ca2+ shift
[Ca2+] in neuron cause tissue destruction--disrupt neuron functioning and cause breakdown of protein and phospholipid
-->demyelination
83
apoptosis
SCI
cell death occurs as pathological process following CNS damage
begin 4-6 hrs post trauma for 24 hrs
up to 3 wks in areas of cord caudal and rostral to site of injury
(occur in oligodendrocytes needed to make myelin)
84
what we can use to classify spinal fx and dislocation
xray may show normal alignment while temporary subluxation may have occured at time of injury
AISA system --neurological manifestation to cords and roots
pathological and microscopic changes in cord--part of medical report
85
How are subluxations graded
they are graded 1-4
divide anterior to posterior diameter of lower vertebrae into 4 equal parts--the higher the grade the more the damage
86
most common cervical injuries
what level and type
75% flexion injuries in lower cervical spine because larger vertebral canal in upper cervical spine (something would need to move farther to damage cord)
C5/C6: 50%
C6/C7: 12%
C4/C5: 10%
87
jefferson fx
c1, often without neuro signs bc large spinal canal
88
odontoid fx
c2
| often without neuro signs bc large spinal canal
89
fx c2/c3 pedicle
extension fx
90
distinguishing feature between subluxation and dislocation
articular processes have not overridden
subluxation: cervical sprain, articular processes have not actually overridden, partial or temporary disruption of normal contact between articular surfaces --a sprain
dislocation: movement of one vertebrae over another
91
4 grades of compression fx / burst fx
type 1
what is broken
tear drop fx
rupture SUPERIOR cortical plate and breaks chip off anterior ligament
if neck flexed at impact anteriorsuperior 1/2 body is crushed with triangle wedging
92
4 grades of compression fx / burst fx
type 2
what is fx
entire UPPER 1/2 of vertebral body is fx
larger segment broken with flexion
93
4 grades of compression fx / burst fx
type 3
what is fx
fx of both SUPERIOR and INFERIOR plates
fx lines throughout body
fragmentation of anterior segment may occur
posterior cortex intact!
94
4 grades of compression fx / burst fx
type 4
what is fx
burst fx
most severe explosive type
crushes and destroys ENTIRE vertebral body --fragments can migrate into cord
95
Cervical, Thoracic, Lumbar
what most stable
what most fx
thoracic more protected because of rib cage and more force is needed to injury--so more likely to then get a complete lesion
lumbar intermediate stability (lesions incomplete)
cervical least stability
96
How do we know if a SCI is stable
all SCI are considered unstable unless proven otherwise
97
aim of tx post SCI
1. protect spinal cord from further injury
2. protect spinal already injured from further damage
3. control hemorrhage
4. reduce inflammation
5. maintain respiration
98
4 asessment SCI qs to ask
if conscious:
do you have any pain in your neck?
do you have any numbness anywhere?
if yes suspect cervical injury
can you flex and extend your arms and hands?
can you feel/move your legs/wiggle your toes?
99
medical first aid:
| what devices used on the scene SCI
5
1. cervical stabilization board
2. kendricks extrication device
3. insertion of NG tube
4. keep patient warm
5. IPPB
100
cervical stabilization board
what does it do
when is it used
imbobilize spine to prevent further damage
remian stabilized until xrays
if + for vertebral/cord damage must do ASAP surgery
101
Kendricks Extrication Device
what does it do
when is it used
alternative to cervical stabilization board
semi rigid brace immobilizes trink and cervical spine
102
Nasogastric tube insertion
why
NG tube to avoid aspiration of vomit secondary to paralytic illeus (intestinal paralysis)
103
Maintain Temperature SCI
why
POIKILOTHERMIA
bc disconnect from HYPOTHALAMUS loss of ability for pt to thermoregulate below level of the lesion and assumes temp of environments--cant sweat or shiver there
104
What are the acute cardiovascular complicaitons SCI (3)
Spinal Shock
Neurogenic Shock
Hypovolemic shock
105
Spinal Shock
FLACCID bc CNS SHUTDOWN: flaccid, hypotension, bradycardia, paralytic vasodilation
Phase 1: lose sensation/motor function and reflexes below the SCI (day)
Phase 2 return of some ie polysynaptic, but not all, reflexes below the SCI ie bulbocavernosus reflex.
Phases 3 and 4 are characterized by hyperreflexia, or abnormally strong reflexes usually produced with minimal stimulation. Interneurons/LMN below SCI begin. The first synapses to form are from shorter axons, usually from interneurons – this categorizes Phase 3. Phase 4 on the other hand, is soma-mediated, and will take longer for the soma to transport various growth factors, including proteins, to the end of the axon.[2]
106
Neurogenic shock
AUTONOMIC DYSFUNCTION: hypotension secondary to sudden disruption in neurological function (autonomic pathways) and blood pools in different areas
disruption of the autonomic pathways within the spinal cord.
Hypotension bc decreased systemic vascular resistance resulting in pooling of blood within the extremities lacking sympathetic tone. (also can get bradycardia)
107
Hypovolemic Shock
what is it
how do we treat
requires emergency attention--inadequate blood volume to the rest of the body
rapid thready pulse, nausea, increase BP, then BP will rapidly decrease
intubation or ventilation with air mask bag--incr O2 to tissues
ventilation, oxygenation, circulation
108
Emergency Room
xray: assess vertebral fx
skull traction: stabilize fx vertebrae
myelography: xray of sc with contrast medium
epidurography: xray of epidural space (meninge damage)
discography: film of disc with contrast
MRI/CT scan
109
myelography:
xray of sc with contrast medium
110
epidurography:
xray of epidural space (meninge damage)
111
skull traction:
stabilize fx vertebrae
112
discography:
film of disc with contrast
113
cervical skull traction
--what is it for
realign bony fragments in the cervical spine and reduce dislocation
HALO vest
skeletal traction
and/or internal fixation
114
Cervical skeletal traction
patient immobile vs patient mobile
patient immobile: crutchfield tongs, vinke tongs, gardner wells tongs
(fixators screwed into skull with some weight to distract spine and reduce fx)
patient mobile: HALO ring traction, minerva jacket, SOMI
115
Cervical Orthoses
non removable vs removable
non removable HALO-most restrictive
Removable: most to least restrictive
minerva brace-->4-post-->SOMI-->philadelphia
116
HALO
what is it
how stable
sheepskin vest, 4 posts drilled into skull, there is a distraction
most stabilization of damaged spine, allow patient to mobilize
essentially external fixation for cervical spine
117
minerva brace
what is it
how stable
jacket over thoracolumbar spine to stabilize and hold head and chin in place
less stable, more mobile
118
SOMI
sternal occipital mandibular immobilizer: push up under chin to stabilize head
cervical orthoses
119
philedelphia
what is it
how stable
least stable cervical orthoses
120
Skeletal traction
why (3)
stabilization
decompression
earlier patient immobilized the better the outcome
121
skeletal traction
6 issues
1. pin loosening
2. hygeine at pin sites
3. loss of motion at shoulder joints, TMJ
4. change in body schema: raises the COG
5. axial muscle atrophy
6. axial joint contracture
122
cervical collars
what is their purpose
ie philedelphia and miami
less restrictive, but less stabilizing
reminder, warmth
"transitional"
soft collars ineffective in limiting spinal motion
123
thoracolumbar bracing
is it effective
when is surgery done
not as effective in preventing motion as cervical spine bracing
surgical brace needed if: ie do laminectomy and fusion
1. if ligamentous injury
2. fx
3. neuro deficit
124
thoracolumbar braces
4 designs
1. body jacket-clamshell
2. jewett type 3 point brace
3. boston brace-scoliosis
4. semi-rigid support with shoulder straps
125
medical and surgical approach post SCI
what is done: 3 things
1. tx initial shock
2. reduction and stabilization offx, dislocation
3. care of associated injuries
126
what determines SCI tx (5)
1. is there cord damage
2. degree of displacement at injury
3. is injury stable
4. is there open wound
5. associated injury
127
conservative management post SCI
dr guttman
1. postural reduction with regular turning
2. pillow packs, stryker frame, roto rest
3. traction and manipulation
128
beds and frames: stabilization
4 beds
1. stryker frame: must be below 250lbs
cant use if marginal vital capacity
2. circoelectric bed: constant turns supine/prone
3. roto rest: arc 160 degrees every 3-4 min for 20 hrs /day
- -vinyl bolster: secure to decrease shearing, increase pulmonary secretions, may cause motion sickness
4. clinitron bed--air fluidized: hard to transfer
129
Cervical Cord Injury
Compression fracture
- what part is most common to have it
- mechanism
- what is involved
- what is not involved
C5 most common
- "wedge fx on xray": rupture of vertebral plates and shatter body
- can involve roots and/or cord
- fragments can PROJECT INTO CORD
LIGAMENTS CAN REMAIN INTACT-stability
130
Cervical Cord Injury
Flexion injury
- mechanism
- what is involved
- what is not involved
ANTERIOR DISLOCATION of cervical spine with cord compression and shearing--likely COMPLETE injury
UNSTABLE FRACTURE due to disruption of POSTERIOR LIGAMENTS
131
Cervical Cord Injury
Hyperextension injury
- what part is most common to have it
- who gets it
- mechanism
- what is involved
C4, C5
MVA: acceleration/deceleration
more common in elderly bc cervical DJD
occult soft tissue injuries
cord probably involved
CENTRAL CORD SYNDROME: upper > lower extremities involved
132
Cervical Cord Injury
Flexion + Rotation injury
- what part is most common to have it
- mechanism
- what is involved
- what is not involved
C5, C6
unilateral facet joint dislocation, vertebrae displaced on xray
spinal canal NARROWING
interruption of disc joints, and ligaments WITHOUT fx
often no neurological involvement due to insufficient canal narrowing!!!
if cord damage usually INCOMPLETE
133
What usually causes complete lesions of spinal cord?
1. bilateral facet joint dislocation
2. thoracolumbar flexion rotation
3. transcanal gunshot/projectile would
134
What usually causes incomplete lesions of spinal cord?
1. cervical spondylosis--vertebrae slide over another
2. unilateral facet joint dislocation
3. projectile injuries without canal penetration (swelling)
135
laminectomy and fusion
what are they
laminectomy allow for swelling
| fusion to regain vertebral stability
136
indication for laminaectomy
| 4
1. ascending neurological deficit
2. progressive paralysis
3. development of paralysis after free interval
4. pain due to irritation of a nerve root
137
surgical procedures in later stages
4 times its ok
1. persistent or recurring instability
2. restitution of neural function
3. treatment of spasticity and contractures
4. treatment of pain
138
What are the medications used post SCI
3 medications
methylprednisolone- need in first 8 hrs, to reduce inflammation-may improve sensory and motor outcome, may work and may have adverse effects
sygen (ganglioside): neural degeneration
diuretics (mannitol): prevention of inflammation
139
aims of medical management
1. prevent complications
2. prevent further damage to SC
3. aid in healing of damaged spine
4. relieve pressure on the cord
5. achieve healing of compound injuries after proper wound debridement
140
complete transection: what is lost (5)
1. bowel and bladder
2. normal sexual functioning
3. control of SNS
below level lose:
4. voluntary motor
5. sensation
141
incomplete lesion: what is lost and spared
spare of function below level of lesion
can spare motor, sensory, autonomic, bowel and bladder
142
SCI life expectancy
20% SCI dont reach acute hospitalization
--1,000 die annually
3% die in hospital
LIFE EXPECTED: 20 yr old
tetra: 33 yrs -->53
low tetra: 39 years-->59
para 44 yrs-->64
143
what happens once SCI pt stabilized
begin therapy-aggresive
be aware of complications that can occur
144
post acute medical complications
primary causes of death (4)
secondary (4)
primary
1. acute respiratory failure/pneumonia
2. heart disease
3. trauma
4. septicemia (infection complication)
secondary
1. chronic respiratory failure
2. bladder dysfunction
3. bowel dysfunction
4. cachexia (wasting)
145
spinal shock
1. what is it
2. how long
3. whats a good sign
4. what can prolong it
1. flaccid paralysis--paralysis, arrelfexia, sensory loss below lesion level
2. can last hrs to weeks to months
3. early resolution of spinal shock is + prognostic sign ---bulbocavernosus relfex is an early sign of spinal shock resolution
4. sepsis (complication of infection), malnutrition and other complications can prolong spinal shock
146
pressure sore
1. why a problem (2)
2. causes (2)
3. what makes prolonged healing (2)
1. SINGLE FACTOR INCREASE LENGTH OF STAY AND COST
MAJOR SOURCE OF DEATH BC INFECTION
2. pressure and shearing forces, spasticity also cause sheering
poor b&b can lead to skin maceration or infection
3. trauma ie adhesive tape burns and nutrition deficiency can make longer to heal
147
Heterotropic Ossification
what causes
what blood test done to assess risk
what problems does it cause
where does it happen
what to do to tx
1. form bone in skeletal soft tissue BELOW level of injury--connective tissue cells become osteoblasts and chondroblasts
2. blood test show high risk if: elevated alkaline phosphate
3. cause functional limitation in 20% of patients, interfere with safe and normal sitting posture, transfers, preserved AROM, exacerbates hygiene problems due to b&b issues
4. next to joints: hips, knees, elbows, shoulders, spines
5. can lead to joint ankylosis and need surgery to remove
early: PROM
late: DONT DO prom--fracture risk
148
osteopororis
cause
complication
prevention
1. due to changes in Ca2+ metabolism: change normal dynamic btwn osteoblast and osteoclast resporb--after SCI more resorb bone than form-->cause osteoporosis and increase risk of fx
secondary to immobility and lack muscle contraction
2. COMPLICATION: increase Ca2+ resorb, hypercalcuria, renal calculi-kidney stone cause autonomic dysreflexia
3. may prevent by spasticity, FES, standing, ambulation
149
Syringomyelia
1. what is it--how it presents
2. how to dx
3. how to tx
4. what causes and when
how common
1. cavitation of central gray matter of spinal cord-sensory loss of pain and temp in UE (spinothalamic, UE is more medial)***PAIN (local or radicular), associated with late deterioration of function after SCI
2. dx with HISTORY confirm with MRI
3. tx: lamimectomy and drainage/ surgical shunting
4. associated with spinal tumor, congenital abnormality (foramen magnum), arachnoiditis: can occur 2 mo to over 20 yrs post injury
3% of all SCI patients
8% in pts with complete tetraplegia
150
*autonomic dysreflexia
to who does it happen
what causes
sx
what to do
MEDICAL EMERGENCY: CAN BE LETHAL--hemorrhage CVA
T6 or higher
noxious stimuli below lesion level cause massive uncompensated autonomic outflow above level of lesion:
1. hypertension
2. tachycardia
3. sweating
4. flushing
5. shivering
6. headache
7. piloerection
* ******procedure:
1. sit pt up to lower BP
2. search for offending stimuli--usually kinked catheter (they may not feel it if lost sensation)
3. take BP: need to know baseline to see if HTN ie 140/80
4. if sx dont improve and even if they do notify nursing and doctor asap
151
Orthotstatic hypotension
what do we need to be aware of
what causes it
what to do to tx
resumption of upright position is difficult in early tx --need BP monitoring and be patient
3 causes of venostasis:
1, VASODILATION bc loss of LE SNS needed for vasoconstriction,
2. loss of muscle pump
3. prolonged bedrest
tx:
1. pressure garments: TEDs, abdominal binder
2. teach pt valsalva
152
thermoregulation
loss of connection btwn hypothalamus and cord: unable to control temperature below level of lesion
poikilothermia
will not sweat when hot or shiver when cold so need to address externally (precaution for extreme environmental temperatures)
153
Deep Vein thrombosis
PE
why high risk
how to tx
life threatening
high risk because decrease LE movement --lose LE muscle pump (hypercoaguble condition)
tx:
1. coumadin + heparin
2. wear TED/pressure garments
3. daily mobilization
154
C1-C3
ventilator?
what muscles?
ADL?
respirator dependent!!! phrenic nerve C3/4/5
may be able to come off respirator brief if train accessory muscles
facial muscles and some shoulder can be intact
voice but limited by poor breath support
GOALS
1. need trach + secretion management
2. dependent in ADL transfers
3. power chair with head
155
C4
ventilator?
what muscles?
ADL?
no ventilator but still respiratory risk
risk of overuse
have DIAPHRAGM, TRAPEZIUS, SCM
(deltoid, rhomboid, partial bicep, partial levator scap)
GOALS
1. can use head and neck for balance and mobility
2. dependent transfers
156
C5
what muscles?
ADL?
shoulder flexion and abduction (limited), shoulder ER,elbow flexion, forearm supination
have pec major, deltoid, biceps, brachialis, brachiradialis
GOALS
1. max assist (75% help) with transfer on sliding board
2. mobilize wc with lateral projections (high energy)
3. feeding (bicep) and hygiene (shoulder ER)
157
C6
what muscles?
ADL?
goals:
1. FIRST LEVEL OF INDEPENDENT TRANSFERS POSSIBLE -less common
2. tenodesis grasp
- full scapular muscle innervation
- pec (sternal),
- LATISSIMUS DORSI
- extension carpi radialis (tenodesis grasp with wrist extension)
serratus anterior
158
C7
what muscles?
ADL?
triceps
finger extensors
wrist flexors
(still risk of respiration complications without full accessory muscle innervation)
GOALS
1. can get independent transfers, bed mobility, wc mobilization
2. ADL with adaptive equipment
3. can ATTEMPT AMBULATION if lats have strong insertion on iliac crst
159
C8-T1
full hand intrinsics--wheelies to go over curbs
no LE or trunk but can be mobile
ambulation with KAFO more likely ( Knee-ankle-foot orthoses)
160
T1-T8
abdominals, intercostals, erector spinae
improved respiration
trunk control
head hip relationship!
161
T9-T12
full intercostals and abdominals
can use abdominals as hip flexor (high energy cost)
162
L1
partial innervation of hip flexors
illiopsoas
163
L2/L3
less energy for walking: still need KAFO and lofstrand crutches
quadratus: hip hikers
adductors,-gracillus
knee extension: rec femoris
(L3 is same with better innervation)
164
L4
possible ambulation with AFO
```
weak adductors
hamstrings!!!
peroneals
hip ERs
tibialis anterior
```
DF!!
165
L5
gastroc, soleus
| aisa and paper has as long toe extensors EHL, EDL
166
S1/S2
foot intrinsics
| aisa has as plantar flexors
167
S3,S5
cauda equina
ambulation
bowel and bladder symptoms?
LMN signs!!!!!!!!!!!!
168
Brown Sequard Syndrome
spinal cord hemisection
Lose
Same side
Corticospinal: MOTOR: ipsilateral weakness
Dosral column: proprioception, vibration, tactile sensation: ispilateral loss
opposite side
spinothalamic: pain, temperature, crude touch: contralateral loss
169
Anterior Cord Syndrome
incomplete lesion anterior two thirds of cord
poor prognosis if not early spontaneous recovery
DONT HAVE MOTOR CONTROL BUT KNOW WHERE THEY ARE IN SPACE
Lose:
- Corticospinal: MOTOR below level
- Spinothalamic: SENSORY:
Preserve
-Dorsal column: proprioception, vibration, fine touch
--vascular, traumatic, compression by bony fragments, demyelnation, infectious
170
Posterior Cord Syndrome
MOBILITY DIFFICULT UNLESS PATIENT USE VISUAL COMPENSATION
lose
dorsal column: proprioception, vibration, fine touch
preserve:
corticospinal: motor
spinothalmic: pain, temp
171
Central Cord Syndrome
ie cervical hyperextension leads to ligamentum flavum to bulge forward: fall
--more common in elderly
corticospinal: MOTOR (cervical most medial)
UE involve > LE involve
THE WALKING QUAD
**lose cervical an thoracic (cannot use AD/armswing, cannot catch themselves if they fall)
**spare lumbar and sacral
172
Right brown sequard
below level of lesion
Right loss of corticospinal motor and dorsal column
left loss of spinothalamic
173
Cauda Equina
cns vs pns
what cause lesion here
sx of cauda equina syndrome
nerve roots exiting at L1-L2 (below conus medularis)
JUNCTION OF CNS AND PNS
cauda equina = PNS
cauda equina lesions: tumor, trauma, spinal stenosis, inflammation, bleeds
sx:
1. gradual presentation/unilateral
2. absent LE reflex [knee/ankle jerk]
3. asymmetric flaccid paralysis (LMN)
4. more radicular pain (and minimal LBP)
5. asymmetrical saddle anesthesia (buttocks, perineum and inner surfaces of the thighs)
6. difficult erection/ejaculation
7. less frequent impotence than in conus meularis
7. urinary retention later in disease
174
conus medularris
L1/L2 vertebrae
distal bulbous end of the spinal cord = tapering end continues as the filum terminale
damage occur due to compression, stenosis, trauma, tumor
sx:
1. sudden and bilateral
2. KEEP KNEE JERK
3. distal LE flaccid paralysis
[Typically symmetric, hyperreflexic distal paresis of lower limbs that is less marked; fasciculations may be present]
4. more LBP [less radicular pain (radiating in dermatome)]
5. symmetrical perianal numbness
6. frequent impotence
7. early incontinence because lose bowel control --atonic anal sphincter
175
Bathing
MMT
ROM
LEVEL
side notes
contraindications
MMT: fair + deltoid, rhomboid, rotator cuff, bicep
ROM: 120 shoulder flexion
enough flexible be able to cross leg to wash it
Level:
C5/C6: UE bathing: after set up and transfer with AD
C6 can be independent with tenodesis
Tolerate: prolonged seating, sitting balance (trunk control--or use head/hips to maintain)
Contraindication: skin integrity, staples/sutures/woundcare, orthostatic hyotension,
176
Brush Hair
MMT
ROM
LEVEL
contraindications
MMT:
ROM:
shoulder flex/abduct: 110 degrees
IR 80 degrees
ER 30 degrees
Level: independent C6 with tenodesis
contraindication: shoulder pain and skin integrity
177
Shave Face
MMT
ROM
LEVEL
contraindications
MMT: fair+ rotator cuff, elbow flexors
```
ROM: wrist stability or splint
Shoulder flexion 60 degrees
Shoulder abduction 60 degrees
Shoulder ER 30 degrees
Elbow Flexion 120 degrees
Pronation/supination: 70 degrees
```
LEVEL:
C5 if already set up (two hand technique)
C6 can use tenodesis
contraindications
cut, bleed, facial skin integrity, cervical collar
178
Bowel
MMT
ROM
LEVEL
contraindications
MMT
needs endurance
ROM: be able to reach backside: shoulder adduction and extension
LEVEL
C6 / C7
179
Bladder
level
LEVEL
C5 can drain leg bag (loops, dont need digits)
C6 : don/doff external catheter/condom catheter
C6: male and female: intermittent catheterization (can be site for infection so intermittent)
-can use quad quip clamp, tenodesis splint, knee spreader
180
Dressing UE
MMT
ROM
LEVEL
contraindications
MMT: shoulder strength 4/5
also: sitting tolerance and balance
endurance
neck stability
ROM
shoulder flexion/abduction 90 degrees
Shoulder IR/ER: 30 degrees
Elbow flexion: 115-140 degrees
*prehension for fastening--finger intrinsics
LEVEL: C5/C6 (but not dexterity aspect)
contraindications
181
Dressing LE
MMT
ROM
LEVEL
contraindications (4)
MMT
f/g: pecs, rhomboids, supination, radial wrist extensors
**body control: min assist in transfer, balance in sidelie
(spasticity: can use it or it can get in the way)
ROM
knee flexion: 0-120 degrees
hip flexion: 110 degrees: stretch hamstrings
LEVEL: C7 (maybe C6 but time consuming)
contraindications
1. vital capacity <50%
2. skin breakdown
3. patient resistance to activity
4. pain in neck or trunk
182
Feeding
MMT
ROM
LEVEL
contraindications (3)
MMT
C5: fair+ deltoid, biceps with wrist equipment
C6/C7: fair+ wrist extensor strength for hand equipment with tenodesis
T1: finger flexion/extension
ROM
shoulder flexion/abduction: 45 degrees
shoulder IR: 60 degrees
elbow flexion: 120 degrees
LEVEL: see above
contraindications
1. respiratory restrictions: difficulty with swallowing, any loss of ability to swallow in dysphasia or weak/absent cough without abdominals not able to get foreign matter out of windpipe and choke
2. skin breakdown
3. pain: with swallowing or in repetitive UE motion
183
Drinking
level
all levels can suck in straw with cranial nerves
184
ECU: environmental control units
control the environment you are living in
communication ie call button, telephone, signal light, computer
management/manipulation: button, shoelace, don and doff
to help turn on and off a light, a door know opener
tenodesis splint
185
Beasy board
circular disc allows person to slide along board without friction and shearing force but circle may be too small
186
Notched Transfer Board
slide on board creates shear force on backside -- transferring independently more easy--notched help manipulate the board
187
REVIEW: ASIA SCALE LECTURE AND PHYSICAL THERAPY FOR ACUTE SCI INJURY LECTURE
!!!
188
ventilation
lesion involve C4
severe bleeding or edema yeilding sx above actual cord level
severe chest injury
PMH of chest disease
trach used if VC below 500-600ml
189
positioning
reposition every 2 hrs
| splinting as needed
190
passive ROM
maintain or increase ROM
assist circulation
start ASAP
2x/day
avoid extreme ROM
< 90 degrees if HALO
191
active ROM
maintain or increase muscle strength and functional ability
cervical--except for if cervical injury
gentle AROM and AAROM to innervated muscles
resistance:
need ortho clearance
if thoracic lesion-- bilateral exercise only to avoid asymmetrical pull on spine
192
HALO precautions
```
no pulling or holding rods or vest
neck movement
loosen or adjust pins or vest
perform activities that put pressure on neck
flex at waist
lift weight heavy (ie 5lbs)
```
diet: diminished neck motion, small bites, chew more, eat in upright position
sleep: sidelie or supine with towel roll behind neck, elevate head of bed. NOT PRONE
hyegeine: keep pins site clean, monitor for infection, clean daily with peroxide or saline . SPONGE BATH NOT SHOWER. clean under bath with rubbing alcohol
EMERGENCY WRENCH: attach direct to HALO at all times and easy accessible only to emergency remove HALO, not to adjust
193
ROM allowed
avoid hip flexion > 90 degrees
| avoid shoulder elevation > 90 degrees if wearing HALO
194
Muscle need for respiration
Diaphragm C4
Intercostals T1-T12
```
Abdominals T6-T12
----
accessory:
SCM: C2, C3
Trapezius: C2-C4, spinal accessory nerve
Scaleni (C2-C8)
```
195
Prophylactic Tx
breathing exercise to increase Vital Capacity
assisted cough: do not move C-spine or increase pain at fracture site
performed 3-4x/day for first 2 weeks
196
Tx infected chest
postural drainage unless contraindicated
--modify position as needed
--inspiration
--percussion and vibration (do not percuss if severe chest injury)
--assisted coughing--frequency of treatment depends on the severity of the conditions
197
when does patient need IPPB?
how much chest expansion
need if chest expansion
198
what Vital Capacity means need ventilation
500-600ml
199
what level of lesion need ventilator
may need if involves a C4
200
how often change positioning
every 2 hrs
201
what extreme ROM to avoid
<90 if HALO
