JROOZ REVIEW CENTER Skeletal level- level with greatest vertebral damage as
SPINAL CORD INJURY noted from radiographic exam
Neurologic level- refers to the most caudal segment of EPI: young pop. 16-30; m>f spinal cord with Normal motor and sensory level white>blacks>Hispanics>others Sensory level= refers to the most caudal segment of SC with 2/2 sensory fxn on Both Etio: May be due to physical impingement of the cord sides of the body (pin prick & light touch); 28 or interruption of blood supply, actual transaction of key sensory dermatomes on each side; max the cord is rare. score 224 Traumatic (70%): MVD; Falls; Violence 2-normal, 1-impaired, 0-absent NT for not Sports and rec: diving- non contact; football- testable, face is used as Normal control point contact MC indirect cause of SCI:alcohol C2-C8 CERVICAL 7 Non traumatic (30%) T1-T12 THORACIC 12 Vascular malformations L1-L5 LUMBAR 5 Vertebral subluxation 2 to RA or DJD SACRAL 4 Infection-syphilis; affects post column of SC Transverse myelitis; spinal neoplasms, syringomyelia, L R abscess of SC; Neurological do, spinals stenosis C5 2 2 C6 2 2 SC Blood supply C7 1 2 Ant 2/3- Ant. spinal artery C8 0 1 Post 1/3- Post. Spinal artery Level: c6 Reticular Artery- supplies rest of SC TEST:T1 and above N Artery of Adamkiewicz T2-L1 impaired Aka: Great Anterior Segmental Medullary Artery L2 absent Major Ant. Segmental Medullary Artery Score: 28 x2 sensationx2 sides= 112 Great Ant. Radiculomedullary Artery Artery of Lumbar Enlargement Motor level- most caudal segment with grade 3/5 fair or 4/5 good provided that the immediate rostral T8 to L1 unilateral; direct from aorta enters left side ms. Exhibits 5/5 since most muscles are innervated by of spinal cord more than 1 segmental n. root 5-N, 4-GOOD, 3 FAIR, 2 POOR, 1 TRACE, 0 ABSENT SCI classification: Testing for 10 myotomes ue- c5 –t1, LE L2to S1 Complete vs incomplete possible score of 100 50 left. 50 right Complete- no preserved motor or sensory fxn below C5 Sh.abd, elbow flex, FA sup. Sh. ER level of lesion and in the lowest sacral segment s4-s5 Zone of partial preservation- dermatome or C6 Wrist ext. FA pron, sh. Add,IR myotome below the level of lesion remains partially C7 Elbow ext. (triceps) wrist flex, Finger ext innervated but there is no fxn at S4-S5 C8 Finger flexors, ulnar dev Incomplete- partial preservation of sensory & motor T1 Finger abd/add- Interossei* fxn below level of lesion which includes lowest sacral segment S4-S5 L2 Hip flexors Sacral sparing- indicates possibility of SC L3 Knee extensors recovery with possible partial or complete return of L4 Dorsiflexors motor function; most centrally located tracts are L5 Gr. toe ext EHL spared; represents partial structure continuity Hallmark: Sensory- Perianal sensation, S1 Plantar flexors cutaneous innervations in the saddle area Test: C6 and above- N Motor- rectal sphincter contraction, and active C7to T1 fair contraction of toe flexors (sacrally innervated) L2toL3 poor L4 and below absent Paraplegia vs quadriplegia vs diplegia vs protoplegia Answer: 23 x 2(sides)= 46 Paraplegia- (pababa) bilat. LE and all or part of trunk lesion of thoracic, lumbar or cauda equine lesion; ASIA IMPAIRMENT SCALE Tetraplegia/quadriplegia-all 4 extremities total Diplegia-all fours are affected but LE (down) greater A -M -S COMPLETE than UE B -M +S INC Protoplegia- high tetraplegia lesion on c4 and above C +M<3 +S INC D +M>or=3 +S INC Designation of levels: E N N N (-)reflexes (-)motor, (-) sensory; (-) autonomic nervous SPINAL TRACTS: system (symp/parasympa) 1. DCML-ipsilateral dorsal column to medulla synapse (+)bulbocavernosus reflex- end of spinal shock; tag with dorsal column nuclei gracilis and cuneatus, cross catheter or pressure on glans penis/clitoris (+) at medial lemniscal to thalamus; contraction of anal sphincter discriminative(sensory modalities that require fine gradations of intensity and specific/ precise 2. Motor and sensory impairments localization on the body surface) rapidly conducting large diameter fibers; epicritic sensation 3. spasticity- increased voluntary contraction of ms, (proprioception, vibration, barognosis, stereognosis, increased stretch reflex (ms cntrxn from stretching ) 2pt discrimination, kinesthesia, graphesthesia, tactile excessive DTR localization, discriminative touch, texture recognition, Can be enhanced by internal and external sources simultaneous stimulation,) Med TX: baclofen, dantrium, lioresal Crosses at cervico medullary junction Aggressive: phenol blocks, rhizotomies (n.roots) 2 tracts: fasciculus gracilis: proprioception of LE myelotomies (SC), myotomy (ms.), neurectomy Fasciculus cuneatus- proprioception of UE (nerve), tenotomy (tendon)
2. sPinothalamic tract- contralateral decussates 2-3 4. pulmonary impairments- diaphragm (phrenic nerve segments above the SC (c3-C5) may not be active affecting pts breathing Ant- pressure and touch (APL) (stimulated by tens) (inhalation) Lat- pain and temp (LPT) enters Sc Affectation of Intercostals and abdominal ms- impair lamina 2 – substantia gelatinosa- where lat. And ant forced expiration and inhalation spinothalamic tract meets (gate control theory of pain) Tidal volume and vital capacity reduced MC cause of death p SCI- respiratory dysfunction 3. corticospinal –contralateral voluntary movt (inability to cough effectively-secretion build up, Drawing sc and tracts inadequate inhalation, exhalation- decr. Ventilation of lungs- atelectasis pneumonia respiratory insufficiency) Clinical syndrome: Above c4- ventilator or phrenic nerve stimulator 1. Brown sequard- spinal hemisection; penetrating C4- capable of respiration diaphragm trapz scapular injuries gswounds, stab elevation Ipsi: paralysis(corticospinal) , loss of vibration and Breathing: glossopharyngeal (frog) breathing 6-7 gulps proprioception, 2 pt discrimination (DCML) or air Contra: pain and temp “contra ni brown sequard and C5- needs assistance for manual cough technique pain and temp” C6 indep manual cough Coughing: T1-T3 non functional cough 2. Ant. Cord syndrome: worse prognosis T4-T8 weak(4) coughing(8) Damage to ant 2/3 of Sc; MC Cause: flexion (naiipit) T10 and above- functional (10) Only DCML intact all others affected loss of motor fx (corticospinal), loss of pain and temp (spinothalamic) Vital capacity: C4 30-50%; C5 40-60%; C6 60-80% 3. Central cord syndrome-Walking SCI Airshift maneuver- to ventilate lungs; maximal MOI: compression, Hyperextension inspiration, hold and feel air in lungs Damage to spinothalamic, corticospinal, DCML EU> LE; Motor> sensory 5. sexual dysfunction- Bladder dysfxn: urinary retention Erection UMNL>LMNL; incomplete>complete Female fertility is unchanged 4. Posterior cord syndrome Male- likely to become infertile Least frequent; loss of proprioception and epicritic Reflexogenic erection (from external physical sensation (DCML) stimulation of genitals or perineum) – UMNL, intact Seen with tabes dorsales (slow degeneration of all reflex arc s2-s4 parts of the body and progressive loss of DTR) from Psychogenic erection (cognitive activity, erotic syphillis fantasy)- LMNL
5. conus medullaris 6. Cauda equine 6. Bowel and bladder dysfunction- loss of voluntary of umnl Lmnl/ peripheral nerve control urination and defecation due to damage to L1 Injury below L1 sacral cords S2-S4 spastic flaccid Spastic bladder UMNL Flaccid bladder LMNL Regeneration possible Reflexive bladder nOn reflexive bladder automatic autonomous Primary impairments: Failure to store-unrinates Failure to empty- 1. Spinal shock-temporary phenomenon after trauma even if bladder is not full can’t urinate even where SC ceases to fxn below level of lesion; when full (+) incontinence Retentive bladder Above micturition reflex Damage to conus 2. DVT- formation of bld clot dislodged (embolus) center S2-S4 (above medularis or cauda serious medical condition since can obstruct artery conus medullaris) sacral equine, s2-s4 sacral sci- incr risk for dvt d/t decr. Or loss of active pumping reflex arc intact micturition reflex action of contracting ms Parasympathetic damage Homan’s sign- sp test innervation to detrusor ms Prevention: anti coagulant therapy (heparin warfarin), and bladder neck positioning schedule, ROM, proper positioning to sphincter (internal) intact prevent venous stasis, use of elastic stocking Reflex emptying- Valsalva maneuver SX: swelling of LE, pain and warmth in area triggered by manual incr. intra abdominal Test: Doppler US stimulation techniques pressure, crede TX: no PROM AROMS, bed rest anti coagulant therapy, stroking kneading, maneuver- manually surgery tapping suprapubic region compress lower or thigh and lower abdomen intermittent 3. Orthostatic hypotension- decr. bp during elevation abdominal stroking, catheterization, to upright position caused by loss of sympathetic pinching or hair pulling timed voiding control of vasoconstriction in combination with program severely reduced ms. Tone, (+) venous pooling Spastic bowel Flaccid bowel S/Sx: decr. Of BP greater than 20 mmhg, dizziness, Suppositories and digital Straining of available light headedness, nausea and blacking out stimulation techniques musculature and Prevention:monitor vital signs, elastic stockings, ace manual evacuation wraps to LE, abdmonial binder, gradual progression to technique vertical position (tilt table) Tx: Return to supine position, elevate legs, ankle 7. Cardiovascular fxn pumps SC Injury that blocks communication to brainstem sympathetic input to heart is lost and parasympathetic 4. Pressure ulcers/sores- prevention most impt. input remains- resulting in bradycardia, peripheral Proper positioning every 2 hrs, with pressure sore vasodilation, hypotension every 30 mins; in W/C pressure relief every 15 to mins, Significant in SCI above T6 resolves within a few sit on appropriate cushion, weeks of injury. *review pressure sites in different position
SC injury that blocks communication with Formation of new bone in ms or other connective hypothalamus can cause hypothermia 2 to peripheral tissue vasodilation (reflexive tone returns to peripheral (myositis ossificans- trauma to muscle tissue resulting vasculature resolves problem) to bony deposits in muscle) Hyperthermia occurs 2 to loss of sympathetic control TBI- shoulder; SCI-hips and knees of sweat glands- below level of lesion sweating does Sx: edema, Decr ROM,incr. temp in jt not occur, above lesion diaphoresis (compensation) TX: diphosphates
COMPLICATIONS: 6. contractures- from prolonged shortening of
1. autonomic dysreflexia (dysreflesix)- most dangerous structures around jt, from ms strength imbalance, complication of SCI pts with lesion above t6, MC in 1 st spasticity, gravity, habitual postures , immobilization) 3 yrs Selective stretching- do not stretch wrist extensors Noxious stimuli below level of lesion triggers and finger flexors- tenodesis effect- tenodesix c6 autonomic nervous system causing sudden elevation intact in bld pressure caused by: distended or full bladder, C7 can perform self ROM kink or blocked catheter, impacted bowel, bladder infection, pressure ulcers, extreme temperature 7. osteoporosis- loss of Ca from bones below level of changes, tight clothing, ingrown toe nails lesion – incr. risk of fractures Can lead to convulsions, hemorrhage and death Sx: high blood pressure, decrease HR severe pounding LEVELS head ache. Blurred vision, stuffy nose, profuse Wheelchair prescription sweating goose bumps below the level of lesion and C1-C3 electric (power) tilt in space, with mouth vasodilation or flushing above level of injury control- chin tuck, sip and puff, and seat belt Tx: treat as medical crisis- 1st check catheter, check C5- manual with projection aids (oblique) indoor; bowel for impaction, check other possible irritants power chair with hand controls for community Keep pt in sitting position. Lying pt will exacerbate C6-C7 manual with friction hand rims (vertical) incr. bp, if still unknown receive immediate medical C8-T1 manual with standard hand rims attention T1-T5 wheelchair sports T8 temperature dysregulation- temper8ture Functional C1-C3 capable of talking, mastication, sipping and T6-T8 (orthosix) swing to in parallel bars blowing KAFO with walker for short distances, wheelchair C4 mobile arm support powered for community C5 mobile arm support BFO T9-T12 indep floor to Wheelchair; indep tub transfers C6 tenodesix indep sliding board transfers modified KAFO with walker or forearm crutches using swing to indep bed mobility or Swing through on level surface C7 indep all transfers except W/C to floor ; LE ROM; W/C for outdoor and energy conservation indep dressing with button hook; able to get W/C in T12-L3 KAFO with crutches swing to, swing through or and out of car 4-pt; C8 indep at home except for heavy work indep home ambulators, can be community T1-T5 physiologic standing (standing table); can ambulators wheelie, W/C to floor; indep in all areas including self L4-L5 AFO, indep community ambulators care and car transfers,
