Untitled Quiz

Spinal Cord Injury Overview

• 18,000 new cases per year in the U.S.
• Approximately 300,000-2 million individuals with SCI in the U.S.
• Average age of injury: 43
• Most common between 16-30 years old and 65+.
• 80% Male, 20% Female

Etiology

• Two categories:
  • Traumatic injury (62%):
    • Motor vehicle accident (MVA) - 38%
    • Falls - 32%
    • Violence - 14%
    • Sport-related
  • Nontraumatic damage (38%):
    • Disease or pathological influence (e.g., MS, ALS)
    • Vascular dysfunction (thrombosis, embolism, hemorrhage)
    • Spinal stenosis and other degenerative processes
    • Spinal neoplasms
    • Infection

Spinal Level and Impact of Injury

• 56% cervical
• 44% thoracic, lumbar, or sacral lesion
• 18% incomplete paraplegia
• 33% incomplete tetraplegia
• 24% complete paraplegia
• 18% complete tetraplegia

Other Statistics

• Hospital stay average is much shorter than in the past.
  • Acute care - ~11 days
  • Rehab unit - ~32 days
• Life expectancy has improved since the 1980s but remains lower than for individuals without SCI.
  • Age of onset
  • Level and extent of neurological injury significantly affect life expectancy.
• Financial impact is extremely high.
  • ~$1,000,000 (C1-C4)
  • ~$500,000 (Paraplegia)
  • Average lifetime costs (injured at 25): ~$3.5 million (C1-C4), ~$2.5 million (C5-C8), and ~$1.6 million (Paraplegia)

Classification of Spinal Cord Injuries

• Two categories:
  • Tetraplegia (quadriplegia): Motor and/or sensory impairments of all four extremities and trunk. Includes respiratory muscles. Lesion at the cervical cord.
  • Paraplegia: Motor and/or sensory impairments of all or part of the trunk and both lower extremities. Lesion at the thoracic, lumbar spinal cord, or cauda equina.

Spinal Cord Review

• Extends from the medulla at the foramen magnum to the L1 vertebral level.
• Cauda equina: Nerve roots running down from the spinal cord beyond L2 (L2 through S5 nerve roots).
• Filum terminale: Threadlike, non-neural filament running from the conus medullaris.

Central Nervous System Cross-section View of the Spinal Cord

• Central grey matter: Neuronal cell bodies in an "H" or butterfly shape.
• Posterior horn: Transmits sensory impulses.
• Anterior horn: Transmits motor impulses.
• Peripheral white matter: Myelinated axons and fiber tracts (ascending - sensory and descending - motor)

Spinal Nerves

• 31 pairs of spinal nerves
• C1-C7 exit above corresponding vertebrae
• C8 exits below C7 vertebrae
• Nerves named based on vertebral level.

Cross Section of Spinal Cord Showing Tracts

• Key tracts and their functions are diagrammed.

The Spinal Cord

• Detailed diagram showing innervation levels for muscles, sympathetic/parasympathetic systems and nerves associated with the different regions of the body.

Designation of Lesion Level

• Essential to accurately identify the lesion.
• Determine extent of neurological impairment.
• Used to set functional goals (e.g., American Spinal Injury Association (ASIA) International Standards of Neurological Classification of SCI)
• Find figure 20.3, p. 762 for detailed standardized assessment tool.

Neurological/Motor/Sensory Levels

• Neurological level: Most caudal level of spinal cord with normal bilateral motor and sensory function.
• Motor level: Most caudal segment of spinal cord with normal bilateral motor function.
• Sensory level: Most caudal segment of spinal cord with normal bilateral sensory function (pin prick and light touch).

Complete vs. Incomplete Spinal Cord Injury

• Complete spinal cord injury: No sensory or motor function in lowest sacral segments (S4 and S5).
• Incomplete spinal cord injury: Motor or sensory function present below neurologic level.

ASIA Impairment Scale

• Standardized way to communicate degree of impairment.
• Find Figure 20.1, p. 763.

Clinical Syndromes

• Brown-Sequard syndrome: Lesion involving one side of the spinal cord (hemisection). Key characteristics noted.
• Anterior cord syndrome: Lesion involving the anterior two-thirds of the spinal cord. Key characteristics noted.
• Central cord syndrome: Lesion involving the center of the spinal cord. Key characteristics noted.
• Cauda equina: Lesion in lower spinal cord affecting various nerves responsible.

Body Structure/Functional Impairments

• Spinal shock: Initial period after injury characterized by areflexia, flaccidity, and loss of sensation/motor function below lesion level. Duration typically several days to weeks.
• Autonomic dysreflexia (hyperreflexia): Pathological reflex potentially life-threatening. Typically occurs in lesions above T6. Several initiating stimuli causing rapid onset blood pressure increases.
• Spastic Hypertonia: Spasticity occurs in about 65% of people with spasticity. Spasticity occurs below lesion after spinal shock.
• Cardiovascular impairment (Postural Hypotension): Decrease in blood pressure when assuming upright/vertical posture. Caused by loss of sympathetic vasoconstriction control. More common with SCI above T6.
• Impaired Thermoregulation: Hypothalamus can't control blood flow. Inability to shiver/vasodilate with heat and/or vasoconstrict with cold.
• Pulmonary Impairment: Affected by level of the injury. Progressive loss of respiratory function as level of injury increases/uses of accessory muscles.
• Bowel and Bladder Impairment: Requires long term management/UTIs - major cause of morbidity and mortality.
• Pain: Nociceptive and neuropathic.
• Secondary and other impairments: Pressure injuries, UTI, pulmonary infections, DVT, musculoskeletal injuries (contractures, osteoporosis, fractures), heterotopic ossification (osteogenesis in soft tissues).

Early Medical Management

• Emergency Care: Begin treatment and rehab at time of injury, maintain breathing and prevent shock, fracture stabilization, immobilization.

Immobilization

• Halo vest: Provides traction and virtually eliminates movement.
• Thoracolumbosacral orthosis (TLSO): Custom-made, hard plastic device to contain trunk, minimize movement.
• Harrington rods: Pair of rods to provide support in spinal traction or compression.

Physical Therapy Outcomes and Goals

• Functional expectations for patients with SCI.
• Table 20.5, pp. 784-787; Handouts; lecture.

Physical Therapy Interventions

• Respiratory management (Respiratory Muscle Training, Glossopharyngeal Breathing, Abdominal Binder).
• Skin care (prevention).
• Mobility skills and Strength.
• Cardiovascular and Endurance Training.
• Sitting Balance.
• Transfers.
• Locomotor Rehabilitation.
• Activity-Based Upper Extremity Training
• Wheelchair skills.
• Gait/Walking Skills.
• Neurotechnologies.
• Health and Wellness.
• Patient-related education.

Secondary Complications of SCI

• Psychological Considerations: independence, isolation, body image, cognitive impairments, depression, pain, medication side effects.