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1

How common is post-traumatic syringomyelia in SCI?

"8%.
Ref: Review notes – Kathy Craven.

2% per SCIRE
22% at autopsy per SCIRE"

2

List 5 common symptoms of post-traumatic syringomyelia.

"1. Pain (segmental or radicular, aching/burning, worse with valsalva/cough/sneezing, usually in sitting position) - MOST COMMON
2. DTR loss (ascending) - EARLIEST SIGN
3. sensory loss - dissociated (loss of P/T at level of syrinx, sparing of V/P), aka 'suspended sensory loss' in cape distribution.

4. Increased or decreased spasticity
5. Hyperhidrosis
6. Autonomic dysreflexia
7. Loss of reflex bladder
8. Worsening orthostatic hypotension
9. New Horner's syndrome
10. Reduced respiratory drive
11. Diaphragmatic paralysis
12. Cranial nerve dysfunction

13. weakness.
14. fasciculations.
15. atrophy.
16. scoliosis.
17. sleep apnea (central or obstructive).
18. impaired CV reflexes.
19. sudden death.
20. brainstem symptoms: syringobulbia (diaphragm paralysis, dysphagia, dysphonia, nystagmus).

Ref: SC medicine principles practice textbook pg 502-503; SCIRE – syringomyelia document, Cuccurullo"

3

"Syrinx:
1. What is the most common resulting symptom?
2. What percent of SCI pt have syrinx?"

"1. radicular pain, gait ataxia, sensory disturbance, dysesthesias, motor weakness.if progressive sensory loss and increased spasticity
Ref: SCIRE – syringomyelia document pg 2.

2. two percent (2%); but 22% at autopsy
Ref: SCIRE – syringomyelia document pg 1.

0.3-3.2% incidence of syrinx in SCI, with mean of 1.3%.
Ref: SPINE Volume 30, Number 10, pp 1206 –1210."

4

"List 3 causes of neurologic decline after SCI.
"

"1. post-traumatic syringomyelia.
2. tethered spinal cord.
3. peripheral nerve entrapment.
4. myeloradiculopathy (late spinal cord/root compression from degenerative changes or instability).
Ref: SC medicine principles practice textbook pg 832-33.

5. any neuromuscular disease potentially (motor neuron disease, NMJ disorders, diabetic polyneuropathy, cervical radiculopathy, etc). GL thoughts.
6. Recurrence of spinal cord tumour. EK thoughts
7. inadequate spine decompression; review notes."

5

What must be ruled out in a SCI patient with fever and normal WBC?

"1. heterotopic ossification
2. DVT
Ref: D Hill."

6

Define HO, list 4 associated conditions and 4 complications.

"Heterotopic ossification is the formation of pathological (lamellar) bone in muscle or soft tissue where it does not usually occur (SCIRE – HO document; ERABI module 11; J Rehabil Med 2005; 37: 129–136).

CONDITIONS:
1. SCI.
2. TBI.
3. soft tissue/MSK trauma.
4. burns.
5. post arthroplasty.
6. post-radiation therapy (rare).

COMPLICATIONS:
1. pain.
2. decreased ROM./ankylosis ie joint fussion
3. pressure ulcers.
4. neurovascular compression.
5. increased spasticity.
6. phlebitis."

7

"What percentage of pts with SCI develop HO (heterotopic ossification)?
What percentage of HO is clinically significant?
When does HO usually occur after SCI?"

"20-30% develop HO.
10% of those with HO is clinically significant (affects ROM, ADL, mobility).
HO usually occurs within 4 months of SCI.
Ref: Braddom, pg 1335.

13-57% pts with SCI develop HO.
20% of HO is clinically significant, with 8% progressing to join ankylosis.
Within 6 months post SCI, with peak at 2 months.
Ref: Delisa pg 695."

scire: 3-12 weeks after spinal cord injury. Individuals with SCI typically present with joint and muscle pain, parasthesias and tissue swelling in the involved region, accompanied by a mild fever

8

name 4 psychiatric, social, or cognitive complications after SCI

"1. depression & suicide.
2. anxiety.
3. social isolation.
4. substance abuse issues.
5. physical/sexual abuse.
6. financial issues.
Ref: Spinal cord medicine principles and practice textbook chapter 65, 66."

9

What factors increase the likelihood of RTW (return to work) post-SCI?

"ENVIRONMENTAL BARRIERS:
1. able to drive.
2. job accommodation

NON-MODIFIABLE:
1. Younger age (declines after 50yo)
2. Male
3. Caucasian

PSYCHOSOCIAL FACTORS:
1. personality.
2. depression (lack of).
3. Greater formal pre-injury education

INJURY RELATED FACTORS:
1. less severe injury.
2. paraplegia (versus tetraplegia).
3. longer duration since injury.
4. AIS D injury
5. Calendar year after passage of Americans with Disabilities Act
6. Nonviolent SCI etiology

MODIFIABLE FACTORS:
1. Married
2. Employed at time of injury
3. Greater motivation to return to work
4. Lower level of social security disability benefits

Ref: Delisa p666; http://www.scireproject.com/case-studies/case-7-mrs-f-l/return-to-work."

10

What percentage of SCI individuals return to work?

"62% of Canadians with SCI remain unemployed.
Large variation in the world – 20-70%.
Ref: SCIRE http://www.scireproject.com/case-studies/case-7-mrs-f-l/return-to-work "

11

Name 6 predictors of independent living for pts with an SCI

"1. Marital status.
2. Transportation barriers.
3. Education level.
4. economic disincentives.
5. disability severity (berthed index).
Ref: Arch Phys Med Rehabil. 1984 Feb;65(2):66-73."

12

Name 4 predictors of discharge to nursing home.

"1. ventilator-dependent.
2. older age.
3. tetraplegic with non-useful motor recovery.
4. unmarried.
5. unemployed.
6. medicaid or health maintenance organization (HMO) insurance.
Ref: Delisa pg 666."

13

Name 5 changes in bowel function that occur after SCI?

"STOMACH:
1. Delayed gastric emptying
2. Post-prandial abdominal distension

INTESTINE:
1. Increased transit time
2. Decreased bowel/colonic motility (eg. GMCs).
3. Constipation

SPHINCTER:
1. Loss of sphincter control

GENERAL:
1. Autonomic dysreflexia with Bms

Ref: SCIRE, bowel management; Braddom pg 627.
Notes: UMN vs LMN injury?"

14

Is it possible to be motor incomplete but sensory complete in terms of ASIA assessment in SCI?

"Yes – less than 1% of traumatic SCI will be motor incomplete and sensory complete.
However, usually a transient finding.
Ref: review notes Christine Short."

15

Patient (incomplete paraplegia) has an ASIA LEMS (lower extremity motor score) of 10/50 at one week. What percent of patients would be expected to ambulate at one year, if the LEMS (lower extremity motor score) was the same at one month?

"LEMS is the total number summation of the grading of L/E muscles on ASIA exam.

LEMS at 1 month predicts community ambulation at 1 year:
a. 1-10: 45%/70%/21% (complete para/incomplete para/incomplete tetra).
b. 11-20: all paras/63% tetras
c. >20/50: ALL patients (para/tetra)

Ref: Spinal Cord Medicine pg 102.
Note: reference has a nice table to help predict ambulation."

16

Four control devices for a power wheelchair.

"Control devices can be activated by any reproducible movement of the body (arm, hand, wrist, fingertips or non upper arm movement (head, chin. Tongue, lips, mouth or lower limb).
Proportional control (responds to variable pressure) vs nonproportional control (binary, on/off).
1. Joy stick (t bar handle, knob, long extension handle, mouth stick).
2. Pneumatic controls (Sip and puff).
3. Chin or head pressure controls.
4. Voice activated switch.
5. Toggle switch.
6. myoelectric control switch.
7. Proximity sensing system.
8. Scanning system (eye).
9. Leaf switch .
10. Touch plate (foot).

Ref: Tan p329"

17

List 4 factors that lead to orthostatic hypotension in SCI.

"1. loss of tonic sympathetic control.
2. altered baroreceptor sensitivity.
3. lack of skeletal muscle pumps.
4. cardiovascular deconditioning.
5. altered salt and water balance.
Ref: http://www.scireproject.com/case-studies/case-9-mrs-m-m/orthostatic-hypotension

MS CBS has orthostatic hypotension"

18

List 5 cardiovascular concerns in pts with SCI.

"1. hypotension (low baseline and orthostatic).
2. bradycardia/cardiac arrest.
3. autonomic dysreflexia.
4. reduced CV fitness, altered exercise capacity.
5. CAD (atypical presentation, silent ischemia).
6. PVD (lack of claudication symptoms, delayed presentations).
7. DVT.
8. drug related effects (succinylcholine-induced cardiac arrest).
Ref: SCI medicine pg 180."

19

List 6 non-pharmacological treatments of Orthostatic Hypotension in a SCI pt

"LIFESTYLE:
1. small, frequent meals (less vagal tone).
2. increased salt (eg. Tablets)/water intake.
3. adjust activities/therapies to periods of higher BP.
4. avoid hot baths (vasodilation).
5. avoid valsalva.
6. avoid meds that drop BP (diuretics, antidepressants, alpha blockers, narcotics, caffeine).
7. exercise.

POSITIONS:
1. elevate head of bed during sleep (reduced nocturnal diuresis).
2. avoid rapid changes in positioning.
3. elevate wheelchair leg rests.

EQUIPMENT:
1. abdominal binders/compressive stockings.
2. tilt table, tilt in space wheelchair/recline.
3. FES (functional electrical stimulation) L2, SCIRE.
4. Biofeedback.
Ref: SCI medicine pg 181; Delisa pg 650, 689; http://www.scireproject.com/case-studies/case-9-mrs-m-m/orthostatic-hypotension/non-pharmacological-treatments."

20

List 6 pharmacological treatments of orthostatic hypotension in a SCI patient.

"1. Mineralocorticoids: fludrocortisone (increased salt/water retention).
2. sympathomimetics: alpha adrenergics (midodrine is selective, ephedrine is non-selective).
3. NSAIDS (indomethacin, ibuprofen).
4. clonidine.
5. ergot alkaloids (SCIRE – limited evidence for effectiveness).
6. erythropoietin.
7. vasopressin analogs (desmopressin).
8. somatostatin analogs (somatostatin, octreotide).
9. L-DOPS, L-NAME: precursor to noradrenalin; central acting (SCIRE).

Ref: SCI Medicine pg 181; http://www.scireproject.com/case-studies/case-9-mrs-m-m/orthostatic-hypotension/pharmacological-treatments

SCIRE:
1. Midodrine (Level 2 - effective)
2. Fludrocortisone (4 - not effective)
3. Ergotamine (5 - good with fludrocortisone)
4. Ephedrine (5 - may prevent)
5. L-DOPS (5 - with salt)
6. L-NAME (2 - effective)

""M FEEL"" good when my blood pressure is higher"

21

What is the mechanism of action of midodrine in orthostatic hypotension?

"1. A selective alpha 1 adrenergic agonist.
2. activates alpha-adrenergic receptors in arteriolar and venous vasculature, increasing vascular tone and blood pressure.

Ref: http://www.scireproject.com/case-studies/case-9-mrs-m-m/orthostatic-hypotension/pharmacological-treatments, SCIRE module"

22

What is the mechanism of action of fludrocortisone in management of orthostatic hypotension?

"1. mineralocorticoid.
2. causes kidneys to retain salt and hence increases water retention and plasma volume.

Ref: http://www.scireproject.com/case-studies/case-9-mrs-m-m/orthostatic-hypotension/pharmacological-treatments"

23

What is the mechanism of action for ephedrine in orthostatic hypotension?

"1. increases cardiac output.
2. induces peripheral vasoconstriction.
Ref: http://www.scireproject.com/case-studies/case-9-mrs-m-m/orthostatic-hypotension/pharmacological-treatments"

24

"Autonomic Dysreflexia:
4 cardinal symptoms.
List 4 signs."

"HEAD/NECK:
1. Headache
2. pupillary constriction (blurred vision) - ?dilated pupils with lesion above T1? (ref: Review notes).
3. sinus congestion.
4. seizures.
5. intracranial hemorrhage.

ABOVE LESION:
1. sweating.
2. flushing.

BELOW LESION:
1. pallor, cool extremities.
2. piloerection.
3. bladder/sphincter contraction.
4. stomach contraction.
5. erection or penile emission.

CARDIAC:
1. reflex bradycardia.
2. cardiac arrhythmias (eg atrial fibrillation).
3. myocardial infarction.
4. increased BP >20-40 mmHg above baseline (SCIRE: 20 mmHg above baseline).

OTHER:
1. pulmonary edema.
2. malaise.
3. nausea.
4. dry, cool pale skin (below lesion).
5. anxiety.

LIFE THREATENING:
1. spontaneous intracerebral hemorrhage.
2. seizure.
3. retinal hemorrhage.
4. arrhythmia.
5. myocardial infarction.
6. cardiac ischemia.
7. death.

Ref: Delisa pg 690-91.
Ref: 2003 -CMAJ article.
Ref: Review notes – Kathy Craven.
http://www.scireproject.com/case-studies/case-5-mr-c-m/autonomic-dysreflexia/clinical-features-of-ad

"

25

List 4 major steps in the pathophysiology of autonomic dysreflexia.

"1. strong noxious/non-noxious stimulus (eg. Bladder) travels proximally via spinothalamic and posterior columns below SCI.
2. massive reflex sympathetic activity from thoracolumbar sympathetics (SNS), causing massive vasoconstriction (splanchnic vasculature) and hypertension (HTN).
3. brain detects HTN via baroreceptors and CN 9/10.
4. Brain responds via massive Parasympathetic (PSNS) response:
a. descending inhibitory impulses to block sympathetic outflow (impaired from SCI).
b. slowing heart rate via vagus (compensatory bradycardia).

Ref: Review notes – Kathy Craven."

26

List 5 potential triggers of autonomic dysreflexia.

"1, BLADDER: Infection, Distension, Urinary tract , Urethral distension, Instrumentation, Calculus, outlet obstruction.

2. GI: Distension, Instrumentation, Infection or inflammation, Ulceration, Reflux, Anorectal Distension, Instrumentation, Hemorrhoids, Anal fissure

3. DERM: Pressure sore, Ingrown toenail

4. MSK: Heterotopic ossification, Fracture, Joint dislocation

5. REPRODUCTIVE: Labour and delivery, Menstruation, Testicular torsion, Ejaculation, Intercourse

6. HEME: Deep vein thrombosis, Pulmonary embolism

7. CNS: Syringomyelia

8. MEDS: Nasal decongestants, Sympathomimetics, Misoprostol
Ref: CMAJ • OCT. 28, 2003; 169 (9); review notes Kathy Craven."

27

List 5 pharmacological treatments for autonomic dysreflexia (HTN).

"CARDIAC:
1. nifedipine (Level 2 - may be useful during cystoscopy and other dx/tx procedures)

PROSTAGLANDIN E2 (Blood vessels):
1. nitrates (nitropaste 2%) (level 5 - no studies shown effectiveness)
2. captopril (level 4) [?blood vessels -> acts on kidneys]
3. prazosin alpha-1 selective (level 1 - reduce severity and duration of episodes)

SKIN:
1. phenoxybenzamine (Level 4 - not known)

BLADDER:
1. terazosin (Level 4 - may have positive effects on incontinence and AD)

SCROTUM
1. sildenafil (Level 2 - no effect during ejaculation)

Ref: http://www.scireproject.com/case-studies/case-5-mr-c-m/autonomic-dysreflexia/pharmacological-treatments-ad (this reference categorized meds as above)"

28

List 4 incomplete SCI syndromes

"1. Central cord Syndrome
2. Brown-Sequard syndrome
3. Anterior cord syndrome
4. Posterior cord syndrome
5. Conus Medullaris syndrome
6. Cauda Equina Syndrome
Ref: Cuccurullo pg 554.

Interestingly, posterior cord syndrome is not listed under the ASIA sheet"

29

Brown-Séquard syndrome. Name four key clinical features.

"C = contralateral, I = ipsilateral.

1. PAIN and TEMPERATURE impairment below level of lesion (C).
2. VIBRATION and PROPRIOCEPTION impairment below level of lesion (I).
3. loss of ALL SENSORY modalities at level of lesion (I).
4. MOTOR impairment (UMN) at and below level of lesion (I).
5. FLACCID motor weakness at level of lesion (I).
6. Can have UMN dysfunction of B/B, however favorable recovery.

Ref: Delisa pg 676."

30

2 causes of central cord syndrome

"1. Hyperextension injury with cervical spondylosis
Ref: Cuccurullo pg 554.

2. Syrinx/syringomyelia.
3. expanding intramedullary mass/tumour
Ref: 2008 – AAN – spinal cord anatomy, localization, and overview of spinal cord syndromes.

4. Fracture dislocation
5. Compression Fracture
Ref:?"