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Neuro Midterm > Spinal Cord Injury > Flashcards

Spinal Cord Injury Flashcards

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1
Q
  • 2500-3000BC:
A

First documented on the “Edwin Smith Surgical Papyrus,” described as “an ailment not to be treated”

Described a patient that we would now call a complete cervical spine injury

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2
Q
  • 400BC:
A

Hippocrates correlated visceral dysfunction with SCI

Constipation, bladder difficulty, bed sores, venous stasis

Poor outcomes associated with obstruction of visceral organs

Promoted special diets for SCI

Credited with first treating deformities with traction

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3
Q

SCI Epidemiology:

A

17,730 new cases per year

~291,000 persons living with SCI

> 50%: 16-30 year old at time of injury

Men to women: 4:1

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4
Q

SCI and MVC:

A

MVC is leading cause until age 45, when falls take over

In children, 2/3 of MVC SCI is due to children not wearing seat belt (properly or at all)
- MVC percentage is dropping due to improvements in car safety (was 40% in 2005)
- Violence is higher in minority groups

  • MVC data includes cars, motorcycles and bicycles with prevalence in that order
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5
Q

SCI and Sports:

A

diving is the primary injury, followed by snow skiing, surfing, wrestling and football

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6
Q

Where/when do most SCI occur?

A
  • More injuries occur in the South and Midwest
  • Most occur on weekends (especially Saturday night)
  • Peak amount of injuries in July
  • Most are single at the time of injury (larger divorce rate as well)
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7
Q

66% were employed at time of injury =

A

Less than half of that remain employed

Predictors of return to work:
> Higher education
> Young age
> White
> Married
> ASIA D
> Non-violent etiology
> Able to drive

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8
Q

Mortality – Risk Factors

A
  • older age
  • male
  • violent etiology of injury
  • higher level of injury
  • vent dependence
  • increase risk of suicide
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9
Q

Tetraplegia:

A

In the cervical region

UE, Trunk, and LE involved

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10
Q

Paraplegia:

A

In the thoracic, lumbar, or sacral region

Trunk and LEs involved

Can include Conus Medullaris and Cauda Equina*

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11
Q

Classification of Injury with percentages =

A

Incomplete Tetra: 47.6%
Incomplete Para: 19.9%
Complete Para: 19.6%
Complete Tetra: 12.3%

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12
Q

Common Fractures of the Spine =

A

C5 Burst Fracture
> C5 Burst: sagital CT scan, note narrowed spinal canal

“Chance” Fracture @ T12, L1, or L2
> Chance fx = seat belt fracture from hyperflexion injury. Decreased incidence with shoulder belt

Utilize stabilizing orthosis for 3-4 months typically, depending on surgical fixation

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13
Q

Dorsal Columns:

A

light touch, vibration, conscious proprioception – doccusate at pontomedullary junction

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14
Q

Lateral spinothalamic tract:

A

temperature, pain – doccusate within 2-3 levels of spinal cord

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15
Q

Spinocerebellar:

A

unconcious proprioception – do not doccusate, terminate in ispilateral cerebellum

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16
Q

Corticospinal tract:

A

motor control – doccusate at pontomedullary junction

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17
Q

Autonomic neurons:

A

are located laterally and exit by the ventral root, innervate smooth muscle

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18
Q

Blood Supply to Spinal Cord:

A

Artery of Adamkiewicz (arteria radicularis magna) clipped during AAA repair, most affecting T4-6 levels due to watershed zone

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19
Q

Defining SCI:ASIA Impairment Scale (AIS)

A

Level of Injury

Skeletal level
> Radiologically greatest vertebral damage

Neurologic level of injury
> Most caudal level where both motor & sensory modalities intact bilaterally

Motor and sensory levels are the same in less than 50% of complete injuries. Can be up to 4 “levels” – R/L sensory, R/L motor

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20
Q

AIS - Complete =

A

Absence of sensory & motor function in the lowest sacral segments

Motor complete (AIS A & B)

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21
Q

AIS - Incomplete =

A

Preservation of sensory OR motor in the lowest sacral segments (sacral sparing)

Sensory Incomplete (AIS B)

Motor & sensory incomplete (AIS C & D)

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22
Q

ASIA Scores =

A

A. Complete

B. Sensory Incomplete

C. Motor Incomplete (strength < 3/5)

D. Motor Incomplete (strength greater than or equal to 3/5)

E. Neurologically Intact

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23
Q

How to Score ASIA Exam

Q1.Is this injury complete vs incomplete?

A

Look for sensation at sacral levels

A (complete) vs B (sensory complete)

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24
Q

How to Score ASIA Exam

Q2. Is there motor preservation at the sphincter or >3 levels down from motor level of injury?

A

B vs C

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25
How to Score ASIA Exam Q3. Are the majority of muscles below NLI greather than or equal to 3/5?
C vs D
26
How to determine motor level:
At least 3/5 with ALL MOTOR ABOVE AT 5/5
27
Neurologic Level of Injury (NLI) =
Most caudal segment with intact sensory (both modalities) and motor without deficits above Translation: > Sensation 2/2 across, intact above > Motor level > Whichever is higher is the NLI
28
Zone of Partial Preservation (ZPP)
Dermatomes & myotomes caudal to NLI that remain partially innervated Used ONLY in complete (AIS A) injuries*
29
Complete SCI =
Tetraplegia (C1-T1) Paraplegia (T2 & below)
30
Incomplete SCI Syndromes =
Anterior Cord Central Cord Posterior Cord Brown-Sequard Conus Medullaris Cauda Equina
31
Anterior Cord Syndrome =
Etiology =Lesions of anterior spinal artery Presentation: > Loss of motor > Loss of pain & temperature > Relative preservation of position sense & vibration Prognosis: Generally poor (10-20%) for motor recovery
32
Central Cord Syndrome =
Etiology = Most common in older people following extension injuries > Damage to central aspect of cord, sparing peripheral aspects Presentation > Motor & sensory loss in UEs > Trunk & LEs may be affected dependent on severity Prognosis > 50 y.o. only 41% (I) community ambulators < 50 y.o., 97% (I) community amb
33
Central Cord Syndrome =
When process of central hemmorhage/necrosis due to tissue damage does not progress to full destruction of cord segment peripherally located fiber tracts intact Spatial orientation of tracts – cervical segments located closer to central gray matter T, L, S segments located progressively more peripherally in cord
34
Brown Sequard Syndrome =
Etiology = damage to ½ of the cord (hemi-section) Most common cause = stab/gunshot wound Presentation: Ipsilateral side > motor loss > sensory loss of proprioception, vibration Contralateral side > sensory loss of pain & temp Prognosis: Good for recovery – most will regain bladder/bowel function; most will become ambulatory
35
Conus Medularis =
Terminal segment of spinal cord at bony level of L1 Affects S2 to S4-5 UMN lesion (likely LMN component) Bowel and bladder dysfunction Sexual dysfunction LE strength may remain intact Saddle anesthesia
36
Cauda Equina =
Lesion below L1 LMN deficits LE motor weakness & atrophy (L2-S2) Areflexia/hypotonia Bowel & bladder involvement Pain May have spared perineum sensation - sometimes
37
UMN lesion presentation =
hyperreflexia hypertonia spasticity and/or clonus minimal atrophy (+) babinski absent fasciculations
38
LMN lesion presentation =
hyporeflexia hypotonia flaccidity severe atrophy (-) babinski present fasciculations
39
SCI evaluation =
skin integrity breathing and cough (respiratory) hemodynamic response ROM Muscle tone
40
SCI evaluation: skin integrity =
Skin: Surgical incision, abrasions from injury, protection 2/2 loss of sensory and motor function -Start thinking about seating systems, posture, ability to perform pressure relief, and equipment to assist with skin inspection
41
SCI evaluation: breathing and cough (respiratory) =
Respiratory: Level of injury and effect on diaphragm/abdominal function. A ny period of intubation? May experience with speech, swallowing, and limited activity tolerance secondary to impaired lung excursion. Any rib fractures?
42
SCI evaluation: hemodynamics =
Hemodynamics: Impaired HDR s/p injury, particularly presenting with symptomatic/asymptomatic hypotension and tachycardia initially at rehab. Managed with compression garments (abdominal binder, TEDS, Ace wraps, and medication) in addition to improving upright tolerance via tilt-in-space chair, tilt table, etc. Initial goal is to increase sitting and OOB tolerance to be able to trial appropriate equipment.
43
SCI evaluation: ROM =
GH/elbow/wrist extension, GH ER Hamstring >110*, IR/ER – bed mobility, advanced transfers & dressing ROM: Profound impact on functional ability – even mild restrictions can be detrimental (ex. Elbow ext in tetra) Shoulder, elbow wrist ext, forearm pronation and ER for C6 mobility Hamstring length for leg management and bed mobility hip flexion and rotation for floor transfers
44
SCI evaluation: muscle tone =
Time since injury (spinal shock = flaccid) UMN v LMN Effect on mobility + = ms bulk, bone/ms health, venous return, may assist function - = interfere with function, jt contractures, discomfort
45
Spinal Shock:
When this dissipates spasticity will begin to present, which needs to be closely assessed, monitored, and managed as it may begin to impede functional mobility Hypertonicity – some good for bone and muscle health, too much interferes with function and impacts ROM and skin
46
Modified Ashworth Scale = 0
No increase in muscle tone
47
Modified Ashworth Scale = 1
Slight increase in muscle tone, with catch and release or minimal resistance at end ROM
48
Modified Ashworth Scale = 1+
Slight increase in muscle tone, with catch followed by min resistance through < ½ ROM
49
Modified Ashworth Scale = 2
Marked increase in muscle tone throughout most ROM but affect part(s) easily moved
50
Modified Ashworth Scale = 3
Considerable increase in muscle tone, passive movement difficult
51
Modified Ashworth Scale = 4
Effected part(s) rigid in flexion or extension
52
Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)
clonus (ankle DF) flexor spasms (PinPrick) extensor spasms (hip/knee extension)
53
Clous (ankle DF) scale =
0 - no reaction 1 - mild, clonus maintained < 3 seconds 2 - moderate, clonus persisted 3-10 seconds 3 - severe, clonus persisted > 10 seconds
54
flexor spasms (PinPrick) scale =
0 - no reaction 1 - mild, <10 deg. excursion in flexion at knee and hip or extension of great toe 2 - moderate, 10-30 deg. of flexion at knee and hip 3 - severe, >30 deg. of knee and hip flexion
55
extensor spasms (hip/knee extension) scale =
0 - no reaction 1 - mild, clonus maintained < 3 seconds 2 - moderate, clonus persisted 3-10 seconds 3 - severe, clonus persisted > 10 seconds
56
Evaluation (Continued) =
sensation voluntary muscle function balance seating/position bracing
57
Voluntary Muscle Function =
“Key muscles” UE & LE Trunk - palpation and visual assessment substitution (Common substitutions - important for function but hurts eval - eliminate motions at other jts and palate) stabilization (Stabilizing ms can be weak or absent - making testing ms seen weaker - therefore provide stabilituty- honk about this functionally too. May have strong delta but if not in a stable seated position unable to use strength effectively) Muscle strength/function: LEMS, UEMS, still test other muscles than key muscles that are important for function
58
Trunk –
standard tests assume abs and back extensor function along entire spine Abs – use umbilicus + palpation – remains central = even pull all sides – absent or uniform along entire length above T5 or below T12 if moves up = > strength above (T5-T12) laterally = toward stronger side Back extensors – palpation
59
Bracing =
Halo > No pillow > No pulling on bars or vest Cervical Collar > Miami J, Aspen Cervical Thoracic Orthosis (CTO) TLSO > Don in supine via log rolling > HOB >30 and OOB
60
Typical Presentation by Level of Injury - Functional outcomes dependent on multiple factors =
Based on COMPLETE injury Age Body habitus ROM Arm : trunk length Comorbidities Motivation/psychological state
61
Typical Presentation: C1-3
Muscle Available > Facial muscles > Limited neck control Ventilator dependent > May be able to wean for very short periods using glossopharyngeal breathing
62
C3 with partial diaphragm innervation –
therefore longer weans (full focus on breathing) Able to talk with leak speech (cuff deflated some to allow air thru) mastication, sip/puff (I) power w/c mobility with specialty controls at household level (S in community) (I) pressure relief in power w/c via specialty controls (I) with ECU (environmental control unit) (I) directing all positioning, pressure relief, skin inspection (I) directing pulmonary management (I) directing management of all equipment
63
Typical Presentation: C4
Typical Presentation: C4 > Diaphragm > Trapezius > Levator scapulae, Rhomboids Available Movements > BREATH INDEPENDENT of VENT!!! > Scapular elevation Still limited respiratory function (may require permanaent trach, likely will need MIE for home for secretion management
64
Typical Presentation: C5
Muscles Available > Deltoid > Biceps brachii > Brachialis > Brachioradialis > Infraspinatus/teres minor > Supinator Operate power w/c with joystick Also beginning to get other muscles activating but very little due to multiple nerve root segments. Movements Available > Elbow Flexion & forearm supination > Shoulder ER, abd
65
Typical Presentation: C6
Muscles available > Pectoralis major – clavicular portion > Serratus anterior > Latissimus Dorsi > Extensor Carpi Radialis > Pronator Teres Significantly > functional potential than above levels Movements Available > Wrist Extension > Forearm Pronation > Shoulder/scap stability/strength
66
Typical Presentation: C7
Muscles Available > Pec major – sternal portion > TRICEPS > Flexor carpi radialis > Extensor pollicis longus/brevis > Extrinsic finger extensors Potential for independent function Movements Available > Elbow Extension > Wrist Flexion > Finger Extension
67
Typical Presentation: C8-T1
Muscles Available > Extrinsic finger flexors > Flexor Carpi Ulnaris > Flexor pollicis longus/brevis > Intrinsic finger flexors Movements Available > FINE MOTOR SKILLS
68

Neuro Midterm (7 decks)

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