SCI vs Stroke Notes PDF

# SCI vs Stroke - Longer time in rehab with stroke. - Younger age demographic for SCI. ## Etiology - **Traumatic Injury** - MVA - Falls - Homicide/suicide - **Traumatic Injury** - Tumors - Birth defects - Infections - ALS/MS - **High Impact** - SC compression O/T...

# SCI vs Stroke - Longer time in rehab with stroke. - Younger age demographic for SCI. ## Etiology - **Traumatic Injury** - MVA - Falls - Homicide/suicide - **Traumatic Injury** - Tumors - Birth defects - Infections - ALS/MS - **High Impact** - SC compression O/T - Rheumatoid arthritis affects the spine. ## SCF Classification - **Depends on level of SC impact.** - Lower = Less damage - Higher = More, less intact SC ## Paraplegic - Partial/complete paralysis of trunk/LE ## Tetraplegic - Partial/complete of all 4 extremities & trunk ## What is the most distal neurological level where we move normal function? "No" indicates for complete # Testing Motor Function - Test both sides - Test muscles & myotomes next to suspected level of impairment. # Myotomes - Muscles/set of muscles innervated by a specific spinal nerve. - 8 Cervical - 12 Thoracic - 5 Lumbar - 5 Sacral - 1 Coccygeal Nerve - 16/31 control voluntary muscle movement # C7 SCI = C7 last myotome prop function ### Upper Extremity Motor Function: Upper Extremity Myotomes * **C5:** Shoulder Abduction * **C6:** Elbow flexion/Wrist Extension * **C7:** Elbow Extension/Wrist Flexion * **C8 T1:** Finger Abduction ### Lower Extremity Motor Function: Lower Extremity Myotomes * **L1 & L2:** Hip flexion * **L3 & L4:** Knee Extension * **L4:** Ankle dorsiflexion * **L5:** Great toe extension * **L5 to S2:** Knee flexion * **S1 & S2:** Plantar flexion * **S2 & S3:** Adduction toes # Sensory Function - Dermatome innervation - Skin - Upper Extremity: C5-T2 - Hand: Below C5, one spinal single - Upper thigh/groin: L1/2 - Lower thigh/medial knee: L3/4 ## Complete vs Incomplete - **No sensory or motor below level of lesion** - **Some sensory or motor below lesion** - Anterior cord syndrome - Central cord syndrome # Anterior Cord Syndrome - Related to cervical flexion injuries - Involves anterior spinal cord - **Head is flexed forcibly** = corticospinal & spinothalamic damage - Loss of motor function/pain/temp sensation below lesion - Dorsal columns intact - Proprioception/body position intact ## Comparison of Key Features | Feature | Anterior Cord Syndrome (ACS) | Central Cord Syndrome (CCS) | |-----------------|--------------------------------------------|-----------------------------| | Cause | Flexion injury, ischemia, trauma | Hyperextension injury, trauma, edema | | Motor Function | Loss below the injury | Greater weakness in arms than legs | | Pain & Temp | Loss below the injury | Variable, often diminished | | Touch, Vibration, | Preserved | Generally preserved | | Proprioception | Preserved | Better, especially for leg recovery | | Prognosis | Poor for motor recovery | | # Central Cord Syndrome - Common in cervical hyperextension injuries - **Head and neck flung backwards** - UE more severely involved - Central (cervical tract/central) - Usually less severe sensory deficit # Respiration - Diaphragm (Phrenic nerve): C3-C5 - Intercostals: T1-T11 - **Primary Muscles of Respiration** - Diaphragm (Phrenic nerve) (C3-C5) - Intercostals (T1-T11) - **Accessory Muscles** - Sternocleidomastoid (accessory nerve) - Trapezius (accessory nerve) - Scaleni (C3-C8) - Pectoralis minor (C6-C8) - Serratus anterior (C5-C7) **Incomplete if we say something below injury level is still working** - Higher the injury, greater impact on breathing <br> ***Progressive loss of respiratory function with higher neurological level*** | Neuro Level | | | |-------------|-------------------------------------------|--------------------------------------------------------------| | at C3 | Sternocleidomastoid (accessory nerve) | | | | Trapezius (accessory nerve) | | | | Diaphragm - phrenic nerve (C3-C5) | | | | Scaleni (C3-C8) | | | at C7 | Serratus anterior (C5-C7) | | | | Pectoralis minor (C6-C8) | 2 primary inspiratory muscles | | | External intercostals (T1-T11) | | | | Internal intercostals (T1-T11) | | | at T11 | Internal obliques (T7-T12) | | | | External obliques (T7-T12) | | | | Rectus abdominis (T7-T12) | | | | Transversus abdominis (T7-T12) | 5 primary expiratory muscles | # Accessory assist inspiration | | | | |---------|------------------------------------|---------------------------------| | **Spinal Level** | **Inspiratory** | **Primary Expiratory** | | Cervical 1 | | | | 2 | | | | 3 | Diaphragm | | | 4 | Diaphragm | | | 5 | Diaphragm | | | 6 | | | | 7 | | | | 8 | | | | Thoracic 12 | Ext Intercostals | Int Intercostals | | 2 | Ext Intercostals | Int Intercostals | | 3 | Ext Intercostals | Int Intercostals | | 4 | Ext Intercostals | Int Intercostals | | 5 | | | | 6 | | | | 7 | | | | 8 | | | | 9 | | | | 10 | | | ## What is Henry (SCI case #3) at risk of developing? Why? # Respiratory Impairment - **High C spine lesions:** Spontaneous respiration significantly impaired/lost. - Requires breathing assist - **Lumbar spine lesions:** Fully innate respiratory muscles - **Loss of primary muscles:** - Abdominals & internal intercostals - ↓ in expiratory efficiency - ↓ ability to cough/remove secretions - ↑ susceptibility to pulmonary issues # Bladder Function - **Primary spinal reflex involved in control @ levels S2, S3, S4** <br> ***Bladder Function*** | | | |-------|-------------------------------------------------------------------------------------------------| | 1a. | Increase in urine stretches bladder wall. | | 4. | Pontine Micturition Center inhibits sympathetic pathway to allow detrusor to contract. | | 2-3. | Release urine. | | 4. | Holding fluid in. | <br> <start_of_image> Schematic figure of the micturition reflex pathway. The bladder is shown and the relevant neuronal pathways. The micturition center is housed in the pontine micturition center located in the pons. The pudendal nerve is responsible for voluntary control of the external sphincter. Activation of the pontine micturition center will signal to the motor neurons of the pelvic nerve to signal the detrusor muscle to contract via parasympathetic efferents. Thereby, the bladder will evacuate. The bladder wall is also innervated by somatic and autonomic nerves. The sacral spinal cord houses the spinal micturition reflex that will stimulate the detrusor muscle if sensory receptors in the bladder wall are stretched. (Image Source: [https://www.researchgate.net/figure/Figure-5-Spinal-micturition-reflex-pathway-and-the-role-of-the-pons-micturition-center_fig1_338622835](https://www.researchgate.net/figure/Figure-5-Spinal-micturition-reflex-pathway-and-the-role-of-the-pons-micturition-center_fig1_338622835)) - **Reliant on parasympathetic arc @ S2, S3 (sacral SC)** - Stimulate detrusor contraction of the internal urethral sphincter - Reflex allows for contraction at bladder for urination. - Cueing relaxation so pathway used. - Lower motor neuron cortex - **If injury below L1:** - LMN presentation - **If injury above L1:** - UMN presentation # Bladder Dysfunction & Anatomy - Spinal cord ends @ L1. - Anything below L1 is spinal cord ## Spastic / Reflex Bladder - Related to UMN injury/incontinence ## Flaccid / Non Reflex Bladder - Related to LMN injury - Urinary leaks ## UMN Dysfunction - **Spastic / Reflex** - Occurs when injury is ↑ S2-S4 level. - Spinal reflex intact ## LMN Dysfunction -**Flaccid/reflex bladder** - @ or below conus (S2-S4). - Affected spinal reflexes # Level of Spinal Cord Lesion & Naming Bladder Dysfunction | | Spastic (reflexive) Bladder (UMN) | Flaccid (nonreflexive) Bladder (LMN) | |-------------------------------------------|----------------------------------|----------------------------------| | Spinal micturition reflex intact? | Cord injury ABOVE S2 | Cord injury AT or BELOW S2-4 | | Communication with pons? | Vertebral level T11-12 or higher | Vertebral level T12 or lower | | Bladder is spastic or flaccid? | | | | Bladder training approach | | | - **Loss UMN control but try to learn to use spinal micturition reflex and a "trigger" stimulus for planned reflex voiding.** - **NO UMN AND NO LMN control, must establish a planned "timed" voiding pattern initially attending to patient's pattern of incontinence then train for regular predictable intervals.** # Level of Spinal Cord Lesion and Male Sexual Arousal | | Same divisions as with bladder dysfunction | |-------------------------------------------|---------------------------------------------| | Spinal level "reflexive" sexual arousal? | | | Psychogenic arousal via thoracolumbar or | | | sacral cord centers? | | | | Spastic (reflexive) Bladder (UMN) | Flaccid (nonreflexive) Bladder (LMN) | | | Cord injury ABOVE S2 | Cord injury AT or BELOW S2-4 | | | Vertebral level T11-12 or higher | Vertebral level T12 or lower | - **Erectile capacity greater in UMN lesions because of presence of spinal reflexogenic erections.** - **Erectile capacity "possible" in LMN lesions "if an incomplete LMN lesion because of mediation from cortex via T-L or sacral cord centres.** # Female Response ## UMN Lesions - **Reflexogenic stimulation unlikely (reflex exists)** - **Psychogenic response lost (cannot connect to cortical centres)** ## LMN Lesions - **Reflex response** - **Psychogenic response likely there if thoracolumbar connections are there (incomplete lesion)** ## Noxious Stimulus Pathway - Signals discomfort/need for response. 1. Bladder fills, activates sensory receptors 2. Sensory signals travel through spinothalamic tracts --> brain 3. Brain recognizes bladder full and action to release descending tract 4. Motor response of bladder contraction # Autonomic Dysreflexia - Occurs in patients with SCI ↑ T6 level - Dysregulation of ANS = uncoordinated autonomic response - Could result in life threatening hypertensive episode when there is noxious stimuli - ANS compromised bc of SCI & vasodilate (counteract hypertension by vasodilation) # Normal / Abnormal Responses **Normal** 1. Stimulus activates sympathetic NS. 2. Vasoconstriction ↑ BP 3. Body activates baroreceptors which detect ↑ BP 4. Send signals to VN to slow down HR and to vasomotor sensor to dilate blood vessels. **Abnormal** 1. SCI @ T6 or above 2. Vasoconstriction exaggerated ↑ BP 3. & regulate this & send signals to regulate response # Pressure Sores - Skin ulcer due to unrelieved pressure 1. Impaired sensation 2. Inability to move body # Contractures - Adaptive shortening of muscle tendon (spastic shortening of muscle tissue) and body just adapts.