Spinal Cord Injury PDF

SPINAL CORD INJURY I.​ INTRODUCTION A.​Anatomy: Spinal cord ⭐ -​ Continuation of medulla oblongata ⭐ -​ Carry signal from brain to body -​ Start: Medulla oblongata (MO) -​ En...

SPINAL CORD INJURY I.​ INTRODUCTION A.​Anatomy: Spinal cord ⭐ -​ Continuation of medulla oblongata ⭐ -​ Carry signal from brain to body -​ Start: Medulla oblongata (MO) -​ End: ⭐ ⭐ -​ Adult: L1 (below) ⭐ -​ Child: L3 (above) -​ Lumbar puncture/tap: between L3-L4 (d/t: widest space) ⭐ -​ Conus Medullaris - Tapered end of SC ; Upper motor neuron lesion (UMN) -​ Cauda Equina - “horse tail” -​ Collection of lumbosacral nerve roots descending to exit -​ Lower motor neuron (LMN) -​ Filum Terminale - Piamater prolongation ⭐ -​ Attachment: 1st coccygeal vertebral BELL MAGENDIE LAW ⭐ V - Ventral E - Efferent M - Motor D - Dorsal A - Afferent S - Sensory Central ​ Butterfly shape ​ Gray matter (d/t unmyelinated axon) Peripheral ​ White matter (d/t myelinated axon) Rexed Laminae I - Marginal / Lissaur’s tract (Fxn.: Pain, touch, & temp.) II - Substantia Gelatinosa (Fxn.: Pain, touch, & temp.) III & IV - Nucleus Proprius (Fxn.:PKV- Proprioception, tactile discrimination, & vibration) V - Noxious stimulus from viscera VI - Noxious stimulus from skin / Mechanoreceptor VII - Clarke’s Dorsal Nucleus (Fxn.: Balance) VIII & IX - Ant. Horn Cell (Fxn.: Motor) X - Central gray Commissure Aira C. Gonzales, PTRP ⭐ B.​Blood Supply Vertical Arteries (Main blood supply) 1.​ Anterior Spinal Artery (ASA) a.​ Composed of 1 b.​ Ant ⅔ of SC c.​ MC Infarction 2.​ Posterior Spinal Artery (PSA) a.​ Composed of 2 b.​ Post ⅓ of SC Ant. Spinal A. Infarction > Post. Spinal A. Infarction ⭐Segmental Arteries AKA: Radicular Artery -​ For enhancement of blood supply A.​Great Ant. Radicular Artery (GARA) -​ AKA: Artery of Adamkiewicz -​ Loc: Left and anterior -​ Level supply: T6-L3 or T12 -L2 -​ Lower half of SC (Supply) B.​ Watershed Zone -​ T4-T6 (above adamkiewicz) -​ Fewer segmental Arteries -​ Decrease blood supply C. NEURONS 1.​ Sensory Neuron (Ascending neuron) -​ 1st order : Dorsal root ganglion -​ 2nd order : Interneuron (post horn ➡ thalamus) -​ 3rd order : Thalamus ➡ Sensory cortex 2.​ Motor Neuron (Descending neuron) -​ 1st order : UMN (Cortex ➡ ant. horn) -​ 2nd order : Interneuron -​ 3rd order : LMN (Ant. horn ➡ Spinal nerves) 3.​ Interneuron “Intermediary” -​ Most numerous -​ Connects motor to motor -​ Connects Sensory to sensory -​ Connects motor to sensory Aira C. Gonzales, PTRP  4.​ Autonomic Neurons -​ Carry neurons to: -​ Cardiac mm -​ Smooth mm -​ Visceral organs -​ *Involuntary mm* -​ Pre ganglionic -​ Brain / SC to ganglion -​ Post ganglionic -​ Ganglion to glands / organ D. TRACTS ⭐Lateral spinothalamic tract Ascending tracts 1.​ a.​ Fxn: Pain, Temp. 2.​ ⭐Ant spinothalamic a.​ Fxn: Touch, Pressure 3.​ ⭐Dorsal column a.​ Fxn: Proprio-kinesthesia-vibration (PKB) 4.​ Ant spinocerebellar & Post spinocerebellar a.​ Fxn: Balance 5.​ ⭐Spinotectal a.​ Fxn: Visual reflex 6.​ SpinoReticular a.​ Fxn: Wakefulness, “arousal” ⭐ Descending tracts 1.​ Lateral corticospinal tract a.​Fxn: Fine & skilled movement 2.​ ⭐Ant corticospinal a.​Fxn: Fine & skilled movement 3.​Tectospinal tract a.​Fxn: Visual reflex (efferent) 4.​Reticulospinal tract Aira C. Gonzales, PTRP  5.​ ⭐ a.​Fxn: UE/LE - stimulate / inhibit flexor & extensor Rubrospinal tract a.​Fxn: UE - flexion , LE - Extension 6.​ ⭐Vestibulospinal tract a.​Fxn: UE & LE - Extension b.​“Vextibulo” II. SPINAL CORD INJURY -​ Any insult to SC resulting to motor, sensory, and/or autonomic Fxn alteration A.​EPIDEMIOLOGY ​ Age: 16 - 30 y/o (average: 26y/o) ​ Sex: M>F ​ Time: July or during summer ​ Type: Tetraplegia (C5) > Paraplegia (T12) B.​ETIOLOGY -​ Traumatic 70% (more common) 1.​ MVA - MC cause ⭐ 2.​ Falls - MC among elders 3.​ Assaults/violence - GSW, Stabwounds 4.​ Sports - MC is diving -​ Non traumatic 1.​ Tumor or neoplasm 2.​ Toxins 3.​ infection 4.​ Congenital abnormalities -​ * SCIWORA* - “spinal cord injury without radiographic abnormalities” -​ Common: Pediatric pxs -​ Common cause: Improper handling falls C. CLINICAL SYNDROMES “Incomplete SCI” 1.​ Anterior cord syndromes ⭐ ⭐ -​ Worst prognosis -​ MOI: hyperflexion -​ S/sx: LE >UE -​ (-) Motor Fxn -​ (-) Pain & temp 2.​ Posterior cord syndromes Aira C. Gonzales, PTRP  ⭐ ⭐ -​ Rarest ⭐ -​ MOI: hyperextension -​ S/sx: Abused joint “CHARCOT JOINT” -​ PKV: -​ (-) Proprioception -​ (-) Kinesthesia -​ (-) Vibration -​ Non traumatic cause a.​ Syphilis AKA: Tabes Dorsalis ⭐ -​ “sensory ataxia” -​ Cardinal signs: “RALI” -​ A. (+) Romberg sign -​ B. (+) Argyll robertson pupil -​ C. (+) Loss of reflexes -​ D. (+) Impaired sensation b.​ Subacute combined degeneration ⭐ ⭐ -​ Related to decrease or deficiency vit B12 (B12: produce myelin), also associated to “PERNICIOUS ANEMIA” (decrease B12) not direct will get SCI 3. Central Cord Syndromes ⭐ ⭐ -​ AKA: Walking SCI ⭐ -​ Most common incomplete SCI -​ Best prognosis ⭐ -​ MOI: Hyperextension or whiplash ⭐ (among drivers); ⭐ Cervical osteophyte (among Elders) -​ S/sx: UE > LE -​ (-) Motor Fxn -​ (-) Pain & temp. 4. Brown- Sequard cord -​ Half resection -​ MOI: Penetrating injuries, GSW, Stabwounds -​ S/sx: -​ Ipsi: (-) Motor, (-) PKV ⭐ -​ Contralateral: (-) Pain, (-) temp. Aira C. Gonzales, PTRP 5. Conus Medullaris Syndrome -​ UMNL -​ Spasticity -​ Hyperreflexive -​ Symmetrical 6. Cauda Equina Syndrome -​ LMNL -​ Flaccidity -​ Areflexive ⭐⭐⭐⭐ Conus Medullaris Cauda Equina Syndrome Paralysis Spastic Flaccid Bladder Spastic (reflexogenic Flaccid (areflexive bladder) bladder) Incontinence Urge incontinence Urinary retention Management 1.​ Pubic hair pulling 1.​ Crede maneuver 2.​ Abdominal stroking (pushing the abdomen 3.​ Suprapubic tapping inward & downward) 2.​ Valsalva maneuver Erection Reflexogenic Psychogenic “mental imagery” (common: S2-S4 lesions) Ejaculation (+) Needs more stimulation (+) D. CLINICAL MANIFESTATION -​ ⭐ 1.​ Spinal Shock Areflexia followed by SCI -​ Duration: 1 day to 3 days -​ (-) BULBOCAVERNOSUS REFLEX ⭐ -​ S: Pinch glands penis / clitoris or pull the Foley catheter -​ R: Anal sphincter contraction -​ ⭐ 2.​ Spasticity Probable to have: -​ Scoliosis -​ Hip dislocation Aira C. Gonzales, PTRP  -​ Management: -​ Pharmacologic: -​ Baclofen -​ Dianzopen -​ Dantrolene sodium -​ Intrathecal injections -​ Peripheral nerve blocks -​ Surgery: Resection: -​ Myelotomy SC -​ Myotomy Muscle -​ Neurectomy Nerve -​ Rhizotomy Nerve root -​ Tenotomy Tendon 3.​ Autonomic dysreflexia ⭐ -​ MC occurred in T6 or above T6 (cut of parasympathetic activity) -​ Stimulus: bladder distention “noxious stimulus” - activate sympathetic -​ Response: release of parasympathetic activity -​ S/sx: -​ Increase BP -​ Decrease HR -​ Vasoconstrict (Below) -​ Vasodilation (Above) -​ 4ps -​ Pounding headache -​ Profuse sweating -​ Piloerection -​ “peys” face flushing -​ ⭐ -​ Management: Elevate head / “upright sitting” (standard mx) -​ Check bladder -​ Check other irritantants -​ Call the emergency 4.​ Orthostatic Hypotension (OH) -​ Stimulate: Elevate head -​ Response: decrease BP -​ Management: “”TAE CO” -​ Tilt table -​ Ankle pumps -​ Elevate legs -​ Compression stockings Aira C. Gonzales, PTRP  5.​ Respiratory Impairments -​ C4 above -​ Management: “MPG” -​ Mechanical ventilator -​ Phrenic nerve (C4-C5) stimulator ⭐ -​ Glossopharyngeal breathing -​ Assisted coughing: SUPINE ⭐ E. COMPLICATIONS 1.​ Heterotopic ossification (HO) -​ MC: ⭐ -​ SCI: Hip > knee > shoulder > elbow -​ CVA/TBI: Shoulder -​ BURNS: Posterolateral elbow -​ Increased Risk to occur HO: FORCEFUL PROM EXERCISES w/ px’s SPASTICITY 2.​ Fractures and osteoporosis -​ MC: supracondylar (distal femur)⭐ -​ Management: weight bearing (WOLFF’S LAW) 3.​ Pressure Ulcers / Bedsores -​ MC sites: -​ Supine - Sacrum -​ Sitting - Ischial tuberosity -​ Side lying - lateral malleolus -​ Infant - occiput -​ Management -​ Turning every 2 hours -​ Pressure relief activities -​ Interval: 15-30 mins -​ Duration: 13 - 30 secs 4.​ Deep Vein Thrombosis (DVT) ⭐ ⭐ -​ MC cause: Immobility ⭐ -​ MC complication: Pulmonary infarction -​ Special test: Homan’s test -​ VIRCHOW’S TRIAD: “hiv” ⭐ ⭐ -​ Hypercoagulability ⭐ -​ Intimal wall damage ⭐ -​ Venous stasis -​ Pharmacological management -​ Heparin & Warfarin Aira C. Gonzales, PTRP  5.​ Cardiopulmonary complications -​ Heart: Arrhythmia -​ Lungs: Pneumonia (MC cause of death) ⭐⭐ -​ 2nd MC cause of death: heart dse -​ 3rd MC cause of death: septicemia -​ MC complication: pulmo -​ Pneumonia -​ Atelectasis -​ Obstructive sleep apnea (OSA) -​ Management: -​ Intubation -​ Tracheostomy III. SCI ASSESSMENT A.​ASIA SCALE (American Spinal Cord Injury Association) Classification: SENSORY MOTOR A - Complete (-) (-) B- Sensory (+) SSS (-) incomplete C - Motor (+) SSS (+) VAC incomplete MMT: >50% (0-2/5) D - Motor (+) SSS (+) VAC incomplete MMT: >50% (3-5/5) E - Normal ⭐ N N Criteria for Sacral Sparing Sensory 1.​ Deep Anal Pressure (DAP) (S4-S5) 2.​ Light touch & Pressure (S4-S5) Motor 1.​ Voluntary Anal Contraction (VAC) a.​ Put finger to px’s anus and ask to contract *Complete SCI = (-) Sacral Sparing* *Incomplete SCI = (+) Sacral Sparing* Aira C. Gonzales, PTRP Scoring: Sensory: 2 - Normal 1 - Impaired / Altered 0 - Absent -​ Modalities: -​ Light touch (brush , cotton) -​ Pinprick (pointy end, paper clip) Motor - MMT 5 - Normal (N) = Full ROM w/ max. Resistance 4 - Good (G) = Full ROM w/ moderate resistance 3 - Fair (F) = Full ROM w/ against gravity 2 - Poor (P) = Active motion w/ gravity eliminated 1 - Trace (T) = Visible cxn 0 - zero (Z) = Absent / no cxn B. LEVEL OF CLASSIFICATION: ​ Sensory level (SL) - most caudal segment w/ normal sensation ​ Motor level (ML) - most caudal segment w/ at least ⅗ MMT w/ 5/5 MMT above the level ○​ NOTE: If there’s no corresponding myotome applicable, ○​ Myotome = Dermatome ​ Neurologic level of injury (NLI) - most caudal segment w/ normal sensation & motor. Sample 1: -​ Sensory: (L) ® Motor: (L) ® -​ C5 2 2 C5 5 5 -​ C6 2 2 C6 5 5 -​ C7 2 0 C7 4 3 -​ C8 1 0 C8 2 3 -​ SL: L = C7 ML: L = C7 -​ R = C6 R = C7 -​ Final = C6 Final = C7 -​ NLI = C6 Sample 2: -​ Sensory: (L) ® Motor: (L) ® -​ T11 2 2 T11 (-) (-) -​ T12 1 2 T12 (-) (-) -​ L1 0 0 L1 0 0 -​ SL: L = T11 ML: L = T11 -​ R = T12 R = T12 -​ Final = T11 Final = T11 -​ NLI = T11 Aira C. Gonzales, PTRP Sample 3: -​ Sensory: (L) ® Motor: (L) ® -​ C6 2 2 C6 5 5 -​ C7 1 2 C7 5 5 -​ C8 1 1 C8 3 2 -​ T11 0 1 T11 0 4 -​ SL: L = C6 ML: L = C8 -​ R = C7 R = C7 -​ Final = C6 Final = C7 -​ NLI = C6 C. DERMATOMES ⭐ Computations: ​ Number of strips - x 28 ​ Maximum score - x 2 ​ Number of modalities (Light touch & pp) - x 2 ​ Laterality - x 2 ​ PERFECT SCORE (MAXIMUM): 224 ⭐ Sample 1: ​ nipple - N (T4) ​ Medial knee - impaired (L3) ​ S4 - S5 - 0 -​ Solution: -​ *Per segment -​ C2 - C8 = 7 x 2 x 2 x 2 = 56 -​ T1 - T4 = 4 x 2 x 2 x 2 = 32 -​ T5 - T12 = 8 x 1 x 2 x 2 = 32 -​ L1 - L3 = 3 x 1 x 2 x 2 = 12 -​ Total: 132 -​ Or -​ C2 - T4 = 11 x 2 x 2 x 2 = 88 -​ T5 - L3 = 11 x 1 x 2 x 2 = 44 -​ Total: 132 Sample 2: ​ 6th ICS to umbilicus - impaired by ​ Below T10 - Absent -​ Solution: -​ C2 - C8 = 7 x 2 x 2 x 2 = 56 -​ T1 - T5 = 5 x 2 x 2 x 2 = 40 -​ T6 - T10 = 5 x 1 x 2 x 2 = 20 -​ Total: 116 Aira C. Gonzales, PTRP Sample 3: ​ Inguinal - normal ​ Dorsum of the foot - impaired -​ Solution: -​ C2 - C8 = 7 x 2 x 2 x 2 = 56 -​ T1 - T12 = 12 x 2 x 2 x 2 = 96 -​ L1 - L5 = 5 x 1 x 2 x 2 = 20 -​ Total: 172 -​ / 2 unilateral = 86 *132 / 2 (unilateral) = 66 D. MYOTOMES ⭐ Computations: ​ Muscle group - x 10 ​ Maximum score - x 5 ​ Laterality - x 2 ​ Total = 100 Sample 1: ​ Wrist extension - Normal (C6) ​ Wrist flex & elb ext - fair (C7) ​ Finger flex - Fair (C8) ​ Finger abd - poor (t1) -​ Solution: -​ C5 - C6 = 2 X 5 X 2 = 20 -​ C7 - C8 = 2 X 3 X 2 = 12 -​ T1 = 1 X 2 X 2 = 4 -​ L2 = 0 -​ L3 = 0 -​ L4 = 0 -​ L5 = 0 -​ S1 = 0 -​ TOTAL: 36 Sample 2: ​ Elb ext - Normal (C7) ​ Knee ext below - absent (L3) ​ The rest - Fair (L4) -​ Solution: -​ C5, C6, C7 = 3 X 5 X 2 = 30 -​ C8 , T1= 3 X 3 X 2 = 18 -​ L2 = 0 -​ L3 = 0 -​ L4 = 0 -​ L5 = 0 -​ S1 = 0 -​ TOTAL: 48 Aira C. Gonzales, PTRP IV. SCI REHABILITATION A.​Crutch walking muscles ⭐ 1.​ Latissimus dorsi -​ Exercise: SEATED PUSH UP ⭐ 2.​ Lower trapezius -​ Action: Depression ⭐ 3.​ Deltoid -​ Most important muscle for wheelie 4.​ Pectoralis Minor ⭐ 5.​ Pectoralis Major -​ Most important muscle for using parallel bars and handrails ⭐ -​ FADER ⭐ 6.​ Triceps brachii -​ Shoulder extensors, ER, Ant deltoid = Locking of elbow ⭐ 7.​ Anconeus -​ Elbow extension Initiator 8.​ Wrist extensors 9.​ Finger flexors (FDS & FDP) 10.​ Thumb flexors B.​Orthosis & AD ​ Upper extremity ○​ C1 - C4 = AFO (Arm Forearm Orthosis) ○​ C1 - C5 = Long Opponents ○​ C1 - C6 = RHS (Resting Hand Splint) ○​ C5 = BFO (Balance Forearm Orthosis) - For feeding ⭐ ○​ C6 = Flexor Hinge ○​ C5 - C7 = Universal Cuff ○​ C6 - C7 = Short Opponents ○​ C8 - T1 = Lumbrical Bar ​ Lower extremity ○​ T1 - T12 = KAFO w/ walker ⭐ ○​ L1 L3 = KAFO w/ crutches (lofstrand) ○​ L4 - L5 = AFO w/ crutches (lofstrand) or quad cane C.​Functional goals ​ C1 - C3 = “MPG” ​ Mechanical vent ​ Phrenic nerve stimulator ​ Glossopharyngeal breathing ​ C4 = “HNP” ○​ Head, mouth, tongue, chin, ⭐ sip & puff wheelchair control Aira C. Gonzales, PTRP  ○​ No UE Fxn ⭐ ○​ Powered mobile arm support ​ C5 =“JOB” ○​ Joystick wheelchair control ○​ Oblique handrim wheelchair ⭐ ○​ Balance FA orthosis (BFO) - feeding ​ C6 “VAST” ○​ Vertical handrim wheelchair ⭐ ○​ ADL transfer w/ AD (sliding board , handrails, overhead trapeze) ⭐ ○​ Self care & driving w/ AD ○​ Tenodesix - ⭐ selective stretching ( Avoid: wrist & finger extension) ​ ⭐ ⭐ C7 - Friction handrim wheelchair ⭐ ○​ Self ROM (7) ○​ ADL independent w/o AD ​ Driving ​ Transfer ​ Feeding ​ Toileting ​ ⭐ C8 - Standard (8) wheelchair ○​ Self care (8) w/o AD ○​ Wheelies (8) *ADL Transfer* *Self care* *Driving* W/ - C6 W/ - C6 w/ - C6 W/o - C7 W/o - C8 w/o - C7 ​ T4 -T6 ○​ Physiologic standing ​ T6 - T9 ○​ Swing to gait ​ T9 - T12 ○​ Household ambulation ​ T12 - L2 ○​ Swing through gait ​ L2 - L3 ○​ Functional ambulation ​ L4 - L5 ○​ Community ambulation Conflicts: Book review!! 1.​ Drive(5) - C5 2.​ Hygiene (7) (dress & bathe) - C7 3.​ Community ambulation - L3 “communithree” Aira C. Gonzales, PTRP