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Flashcards in Spinal cord injuries Deck (29):
1

What is the incidence of spinal cord injuries ?

  • 11,000 new cases /pa in us
  • 34% incomplete tetraplegia
    • central cord syndrome most common
  • 25% complete paraplegia
  • 22% complete tetraplegia
  • 17% incomplete parpaplegia

2

What are the demographics of the injury?

  • Bimodial distribution
  • young individuals with significant trauma
  • older individuals by degenerative spinal cord narrowing

3

Where is the most likely anatomical location?

  • Cervical spine 50%

4

Describe the mechanism of injury?

  • RTA 50%
  • Falls
  • Gun shot wounds
  • Iatrogenic- 3-25% occur after initial traumatic episode due to improper immobilisation and transport

5

Describe the pathopysiology?

  • primary injury due to damage to neural tissue due to direct trauma
  • irrversible
  • secondary injury- injury to adjacent tissue due to
    • decreased perfusion
    • lipid perioxidation
    • free radicals/cytokines
    • cell apoptosis

6

what are the associated conditions?

  • spinal shock
  • neurogenic shock
  • closed head injury
  • noncontiguous spinal fractures
  • vertebral artery injury
    • atlas fractures
    • facet dislocation

7

Name the different types of spinal cord injury?

1)COMPLETE

  • an injury with NO SPARED MOTOR or SENSORY FUNCTION BELOW THE AFFECTED LEVEL
  • Pt MUST HAVE RECOVERED FROM SPINAL SHOCK ( bulbocavernosus reflex is intact) before an injury is determined as complete

2) INCOMPLETE

  • an injury with SOME PRESERVED MOTOR or SENSORY function BELOW the injury level
    • ​anterior/posterior/central cord syndrome
    • cauda equina syndrome
    • Brown sequard syndrome

a) PARAPLEGIA

  • injury to thoracic/lumbar /sacrum-> impairment function pelvis/LL. Arm function preserved

b) QUADRAPLEGIA

  • injury to cervical spine->impairment of function arms, trunk,legs 

8

Can you name some incomplete injuries?

  • Central cord syndrome
  • brown-sequard syndrome
  • anterior cord syndrome
  • posterior cord syndrome
  • cauda equina syndrome
  • conus medullaris syndrome

9

What are at the asia classification for spinal cord injuries

1) Determine if pt is in spinal shock

  • check bulbocavernous reflex

2) Determine Neurological level

  • Lowest level where Sensory and motor function are NORMAL BILATERALLY

3) injury Complete or Incomplete?

  • complete
    • no voluntary ANAL contraction
    • 0/5 distal motor
    • 0/2 distal sensory- no perinanal senation
    • Bulbocavernosus reflex present
  • incomplete
    • voluntary anal contraction
    • sacral sparing
    • or palpable/ visible muscle contraction below injury or
    • perianal sensation 

10

What is the ASIA score?

  • American Spinal Injury Associtation score
  • A COMPLETE
    • no motor or sensory function preserved in sacral segements S4-5
  • INCOMPLETE-
    • Sensory function preserved but not MOTOR function below neurological level includes S4-5
  • C INCOMPLETE
    • Motor function preserved below neurological level
    • > half of muscle power grade<3
  • D INCOMPLETE

    • Motor function preserved below neurological level
       


    • at least half of muscle power grade >3


       





  • E NORMAL



     





    • Motor and sensory NORMAL



       

11

What are the acute phase conditions?

  • NEUROGENIC SHOCK
  • SPINAL SHOCK

12

What is neurogenic shock characterised by?

  • HYPOTENSION and RELATIVE BRADYCARDIA in a patient with an ACUTE SPINAL CORD INJURY
  • potentially fatal

13

What is the mechanism?

  • CIRCULATORY collapse from LOSS of SYMPATHETIC TONE
  •  Disruption of autonomic pathway within the spinal cord->
    • lack of sympathetic tone
    • decreased systemic vascular resistance
    • pooling of blood in extremities
    • hypotension

14

How is neurogenic shock treated ?

  • vasopressors to tx hypotension- noradrenaline
  • central lines to monitor fluid management

15

What is SPINAL shock?

Defined as a

  • TEMPORARY LOSS OF SPINAL CORD FUNCTION and REFLEX ACTIVITY BELOW LEVEL OF SPINAL CORD INJURY

16

What is spinal shock characterised by?

  • FLACCID AREFLEXIC PARALYSIS
  • BRADYCARDIA - loss sympathetic tone
  • HYPOTENSION  - loss sympathetic tone
  • ABSENT BULBOCAVERNOSUS REFLEX

 

  • usually resolves in 48 hrs
  • at conclusion spasticity, hyperreflexia, & clonus slowly progress over days- wks

17

What is the end of spinal shock defined by?

  • The return of the BULBOCAVERNOSUS reflex
  • Cannot evaulate the neurological deficit until spinal shock phase has resolved

18

What is the mechanism in spinal shock?

  • Neurons become HYPERPOLARIZED and UNRESPONSIVE to brain stimuli

19

What does evaluation involve ?

  • proper spinal immobilisation
  • primary survery
    • airway
    • breathing- above c5 intubation
    • circulation
    • inital survey- head/spine 
    • secondary survey
      • -c spine remove collar observe any defects/head injury
      • palapte post cervical spine
      • absence of post midline spine tenderness in awake,alert pt predicts low probability of significant cervical injury
      • log roll
      • neuro exam

20

what is the acute tx of spinal cord injury?

  • Braken review of cochrane 2012 -improve neurological outcome up to 1 year post injury
  • High dose methylprednisolone for non penetrating Spinal cord injuries within 8 hours of injury load 30mg/kg over 1st hour, then 5.4mg/kg/hr for 23 hours if <3 hours post injury
  • can lead to improve root function at injury level
  • may or may not lead to spinal cord function improvement
  • dvt prophylaxis cardiopulmonary management- avoid hypotension
  • Acute closed reduction with axial traction 
    • alert/orientated pts with neurological deficits and compression due to fracture/dislocation

21

What is the definitive tx of SCI?

NON OP

  • bracing and observation
    • most GSW
    • Mets CA pts with <6 mo life expectancy
      • multiple spinal mets
      • multiple extrapsinal mets
      • critically ill,
      • aggressive ca - lung

Surgery

  • SURGICAL DECOMPRESSION AND STABILISATION
    • most incomplete SCI
      • when neurology plateau/ worsening
      • may faciliate nerve root function return
    • most complete SCI
      • stabilise spine to faciliate rehab & minimise halo/orthosis
      • consider tendon transfer
    • Mets ca with >6 mo survival
    • GSW 
      • progressive neurology w retained bullet
      • bullet in thecal sac

22

What are the surgical indications for surgical decompression and stabilisation?

  • MOST INCOMPLETE SCI
    • decompress when neurology plateau or worsening decompression may facilitate nerve root function return
  • MOST COMPLETE SCI
  • Stabilise spine to faciliate rehab minimise need for halo/orhtosis
  • METASTATIC CA PATIENTS with >6 mo to life
  • GSW with retained bullet and deterioration in neurological status.

23

what are the complications of SCI?

  • Skin problems
  • venous thromboembolism
  • urosepsis
    • common cause of death
  • sinus brachycardia
  • orthostatic hypotension
    • lack of sympathetic tone
  • autonomic dysreflexia
    • potentially fatal
    • increase in systolic BP by 20% associated with 1 ( piloerection, facial flushing, sweating) 
    • headache, agitation, hypertension
    • check foley ( distended bladder), bowel
    • pt in sitting position, chck foley/ disimpact patient
    • bp monitored may need nitrates
  • major depressive disorder

24

What are the goals of rehab in a pt with spinal cord injury?

  • Assess & identify mechanism for reintegration into the community based on functional level and daily needs
  • pt learns transfers, self care and mobility skills
  • hand function is limiting facotr for most pts
  • tendon transfers resotre function to paralysed arms/hands
  • functional electrical stimulation is a technique that uses electrical currents to stimulate & activate muscles affected by paralysis

25

hat is the functional outcome level for SCI C1, C2, C3?

  • Ventilatory dependent with limited talking
  • Electric wheelchair with head/chin control

26

What is the functional outcome level for SCI C4?

  • initally Ventilator dependent but can become independent
  • Electric wheelchair with head or chin control

27

What is the functional outcome level for C5?

  • Ventilator independent
  • electric chair with hand control, unable to live independently
  • biceps and elbow function intact unable to extend wrist c6, supinate c7

28

What is the functional outcome level for c6?

  • Much more independence than C5- can bring hand to mouth as wrist extension & supination intact
  • Manual wheelchair w slide board transfers
  •  live independently

29

What is the functional outcome level for c7?

  • improved trcieps strenfth
  • improved use of manual wheelchair with independent transfers