Intro to Spinal Cord Injury PDF

**Intro to Spinal Cord Injury** **What is a SCI?** - **Damage** to the **spinal cord** resulting in **symptoms below the level of injury** **Review of Spinal Tracts** - **DCML: sensory (ascends)** - functions: proprioception, vibration, fine touch, and pressure - crosses at the med...

**Intro to Spinal Cord Injury** **What is a SCI?** - **Damage** to the **spinal cord** resulting in **symptoms below the level of injury** **Review of Spinal Tracts** - **DCML: sensory (ascends)** - functions: proprioception, vibration, fine touch, and pressure - crosses at the medulla - located at the dorsal column of the spinal cord - **Spinal-Thalamic Tract: sensory (ascends)** - Functions: pain, temperature, crude touch - crosses immediately - located at the anterolateral portion of the spinal cord - **Corticospinal Tract: motor (descends)** - Functions: controls voluntary movement from the neck to the feet - Base of the pyramids (medulla) - located at the anterior and lateral (largest) portions of the spinal cord **Spinal Cord Cross Section** - **Cervical**: involves brachial plexus (arms affected\> legs) and located medially - **Sacral**: more lateral and affects legs\> arms A diagram of the spinal cord **Etiology** - 18,000 new cases annually in the USA - Currently between 300,000-2 million people with SCI in the US - Most common **between ages 16-30, 19 the most, why?** - Involves frontal lobe development and myelination - Can be traumatic or non-traumatic - Most traumatic incidents occur with accidents and risk-taking behavior - 80% male and 20% female **Mechanisms of Injury: Traumatic** - MVA- 38% - Falls (elderly)- 32% - Violence- 14% - Sports-related injuries- 9% **Mechanisms of Injury (Non-traumatic)** - Arterial venous malformation (AVM) - Thrombus, embolus, or hemorrhage to arterial supply of the spinal cord (stroke of a vessel) - Infection of the cord (common setting of IV drug abuse) - Tumor - MS with lesions to the spinal cord - ALS - Spinal stenosis: less space + fall will squish the space **Life Expectancy** - **Incomplete** (sensory and motor intact) longer than **complete** (no sensory or motor) - **Paraplegia** (2 limbs/trunk, legs, and pelvic organs) longer than **tetraplegia** (4 limb paralysis) - **Lower cervical tetraplegia** longer than **higher cervical tetraplegia,** why? - Diaphragm C3-C5 - **Mortality rate** is highest in the 1^st^ year after injury **Spinal Shock** - Happens immediately after SCI: **flaccid-full body** - A period of **areflexia** that last **24hrs** - Reflexes return **gradually over 1-3 days** - Can have **hyperreflexia for 1-4 weeks** after that - Should perform ASIA **within 72 hrs** after injury - **NO ASIA the first 24 hrs**, could show up as a complete SCI, but if too late could be hyperreflexia **Naming System** 1. Spinal level of injury 2. Anatomical location of injury in cord 3. Completeness of injury  Sensory LOI: DCML and STT A medical chart with a human body Description automatically generated\ **Sensory Scale** 2= intact 1= diminished 0= absent NT = Not Testable **Motor Scale** 0= total paralysis 1= palpable or visible contraction 2= active movement, gravity eliminated 3= active movement, against gravity 4= active movement, against some resistance 5= active movement, against full resistance 5\*= normal corrected for pain/disuse NT= Not Testable **Main Levels** **UE** C5: elbow flexors C6: wrist extensors: **\*\*\*Clinical importance**- \"tenodesis grip\" is where the fingers naturally flex and close when the wrist is extended, allowing individuals with limited hand function, to grasp objects by simply moving their wrist; essentially using the passive tension of the flexor tendons to achieve a grip without active finger flexion C7: elbow extensors C8: finger flexors T1: finger abductors (little finger) **LE** L2: hip flexors L3: knee extensors L4: Ankle DFs L5: Big Toe extensors S1: Ankle PFs - If there is no DAP or anal contraction = complete SCI ASIA A **ASIA Impairment Scale** A= **Complete**, Complete: **no motor or sensory** function is preserved in the sacral segments **S4-S5** B= **Incomplete**: **sensory but no motor** function is preserved **below** the **neurological level** and includes the sacral segments **S4-S5** C= **Incomplete**: **motor function** is preserved **below the neurological level**, and **more than ½** of key mm. below the neurological level have a **mm. grade less than 3 (2's & 1's)** - Maybe walker! D= **Incomplete**, **motor function** is preserved below the neurological level, and **at least ½** of key mm. below the neurological level have a **mm. grade of 3 or more (3's-5's)** - For sure walker! E= **Normal**: motor and sensory function is normal **Motor Level of Injury** - Determined by test 10 key mm. groups on L and R sides of body - "The lowest myotome that has a grade of at least a 3 if the one above it is a 5" - Example: **L2 Myotome (Hip Flexion)**: 5 (Normal strength) - **L3 Myotome (Knee Extension)**: 4 (Weak, but still able to move against gravity and some resistance) - **L4 Myotome (Ankle DF)**: 3 (Able to move against gravity, but not full resistance) In this example, the **L4 myotome** (Ankle DF) is the lowest myotome with a grade of **at least a 3**, and the myotome above it (L3) has a grade of **4**. This aligns with your criteria of wanting the lowest myotome with at least a 3, assuming the myotome above it is a 5. **Possible injury level: L3 or L4** - The injury is likely at or just above **L3**, because that\'s where strength starts to decrease below normal levels. - If the injury is at L3, the person would still have functional strength at L2, but L3 and below would be affected. - If the injury is at L4, it could be due to a loss of strength below that level, particularly affecting muscle groups below the L4 myotome. **Summary:** The injury level could be at **L3**, **L4**, or slightly above L3 (but below L2) based on the strength pattern. In practice, the injury would likely be classified as a **L3 spinal cord injury**, with some muscle groups (L2-L3) still functional, and others (L4 and below) weakened or paralyzed. - Graded on 1-5 scale (not +/- grades) - May differ from L to R - May differ from sensory level of injury **Sensory Level of Injury (less important for function)** - Determined by **light touch** and **pin prick** on both the R and L side of the body - Graded on a 3 pt. scale: 0=absent, 1=impaired, 2=normal - "The most caudal level with normal light tough and pinprick sensation" - May differ L to R - May differ from motor level of injury **Neurologic Level of Injury-** "the most caudal level of the spinal cord with normal motor and sensory function both the R and L sides of the body **Zone of Partial Preservation** - Used to apply only to complete injuries (ASIA) and defined as: "dermatomes and myotomes caudal to the sensory or motor level that remain **partially innervated**" - Revised in 2019 to included incomplete - **Motor ZPP's** can be included in incomplete with absent Voluntary Anal Contraction **(VAC)** - **Sensory ZPP's** can be included in incomplete with absent Deep Anal Pressure **(DAP)** **Types**  - **Posterior Cord Syndrome**: "slapping feet" presentation and B DCML sensory loss, trauma most likely - **Anterior Cord Syndrome**: B corticospinal (motor) and sensory (STT), blood flow issue or stroke occurs here usually - **Central Cord Syndrome**: most likely caused by trauma (ex.whiplash), have arm deficits (UEs), varying degrees of sensory impairment, sacral sparing - **Cauda Equina Syndrome**: LMN, flaccid paresis, saddle anesthesia, usually incomplete due to spinal n. - **Brown-Sequard Syndrome**: Ipsilateral loss of DCML, and CST, CL loss of STT - **Conus Medullaris**: Mixed LMN and UMN **LMN** **vs. UMN Injuries** - UMN: Above Conus Medullaris - LMN: Below Conus Medullaris - Can have a mixed presentation - Generally, T12 and below is most likely LMN or mixed A table with numbers and percentages Description automatically generated **LMN** - Generally below T12 - Hyporeflexia- cannot control sphincters - Flaccidity - Decreased tone/spasticity - Negative UMN signs - Flaccid bladder and bowel - Psychogenic responses for sexual function **UMN** - Generally above T12 - Hyperreflexia - Increased tone/spasticity - Positive UMN signs - Spastic or hyperreflexive bladder and bowel - Reflexogenic arcs for sexual function **Types of Settings**  Acute care: beginning stages Acute Rehab: these patients have to learn how to everything over again LTACH: for people with chronic wounds or vented **Secondary Complications: Cardiovascular Pulmonary** - Pneumonia (PNA) - Aspiration - Diaphragmatic/respiratory muscle impairment - PE/DVT - BP Management **\*\*Orthostatic Hypotension**: in T6 and above injures (autonomics that control BP are affected) **Secondary Complications: Autonomic** - **Autonomic Dysreflexia**- can be fatal (T6 and above) why?- BP keeps increasing, pts. can stroke out with this condition bc of no parasympathetic response - BP Management- you want to get this patient up not lying down to help decrease - Sweating response - Loss of descending control of ascending sympathetic reflexes - Lack of inhibition from higher centers **Symptoms of Autonomic Dysreflexia** - HTN (raise of 20-30 mmHg systolic) - Bradycardia - Headache (severe and pounding) - Profuse sweating - Increased spasticity - Vasodilation above level of injury (leading to flushing) - Constricted Pupils - Nasal congestion - Piloerection - Blurred vision - Dry pale skin due to vasoconstriction (below level of injury) **Secondary Complications: Neurologic** - Tone/spasticity changes: UMN or LMN - Neuropathic pain - Sensory loss **Secondary Complications: MSK** - Motor Loss - Osteoporosis - Secondary Overuse Injuries - Heterotopic Ossification- abnormal bone grows into soft tissue - Osteomyelitis (in setting of pressure injury): inflammation of bone **Secondary Complications: Psychological (grief and loss)** - Adjustment to trauma and or loss - Higher depression rates - Higher psychiatric illness diagnoses post-injury - Higher health care utilization for psychiatric diagnosis **Secondary Complications: GI/GU** - **UTI:** leading type of infection following SCI - **Reflexive** bladder/bowel (UMN): tone is too much so they void - **Flaccid** bladder/bowel (LMN): happens with gravity **\*Maturation reflex:** bladder **\*** **Bulbocavernosus reflex:** bowel **Secondary Complications: Integumentary** - High risk for **pressure injuries** due to: - Decreased sensation - Decreased mobility - Decreased blood flow - Increased potential for incontinence - Staging: **Stage 1**: intact skin, **non-blanchable** **Stage 2**: **partial thickness** looks like a blister or scrape **Stage 3**: full thickness into the **subcutaneous** fat layer **Stage 4**: full thickness involving **muscle or bone** **Deep Tissue Pressure Injury**: persistent **non-blanchable** discoloration with a **dark wound bed** due to **prolonged pressure or shear**. **May evolve rapidly** to a stage 3 or 4 level (within minutes to hours) A close-up of a skin condition Description automatically generated A close-up of a wound Description automatically generated**LTACH** A close-up of a tissue injury Description automatically generated **PT Management: Acute Care** - ICU main ?: Can they sit up? - Early mobility once medically stable - Focus exam: sensory/motor function/respiratory function, skin integrity, PROM, BP fluctuations **Intervention:** - PROM/contracture prevention - Skin prevention - BP management w/change in position (Reverse Trendelenburg to prevent shear) - Respiratory function - Education - Upright positioning: Tilt every 15 mins - Basic Mobility **PT Management: Acute Rehab (avg. 32 days for SCI)** **PT Exam:** - ROM, strength, outcome measures, functional mobility level **Interventions:** - Aerobic Capacity - Skin integrity/management: prevent secondary injury - **ADL's/functional mobility** - Pain/spasticity management - Education - Strengthening - **DME, w/c, and bracing needs** **LTACH** - Mobility as able - Focus exam on: sensory/motor function, respiratory function, skin integrity, PROM, BP fluctuations - PROM/contracture prevention - Skin prevention or treatment - BP management with change in position - Respiratory function - Education - Upright positioning - Basic Mobility **PT Management: Out-patient** **PT Exam:** - MSK/Neuro/CV/Pulm/Integument integrity - Knowledge of SCI and level of independence - Community reintegration/navigation - Goal directed activities: return to sport, childcare, work, etc. - Prevent MSK repetitive use injuries - Overall strengthening - CV endurance - Pain management  A medical equipment instructions for wheelchairs Description automatically generated with medium confidence