626- Everything Spinal Cord Injury

In _______, all 4 limbs AND the trunk are impacted

tetraplegia

In _______, BLEs are impacted and there may or may not be trunk involvement

paraplegia

At what level of the spine does the conus medullaris transition to the cauda equina?

L1

SCI above L1 causes ______ symptoms

UMN

SCI below L1 causes ______ symptoms since this is a PNS injury

LMN

Which spinal tract:

controls ipsilateral voluntary, discrete, and skilled movement of the trunk. Contains a mix of crossed and uncrossed fibers

anterior corticospinal

Which spinal tract:

controls contralateral voluntary fine movement of the limbs?

lateral corticospinal

Which spinal tract:

crosses at the pyramids in the medulla?

lateral corticospinal

Damage to which spinal tract causes:

spasticity, UMN signs, ipsilateral loss of fine motor or skilled voluntary movement?

Corticospinal

Stroke impacting the corticospinal tracts causes _______ motor damage

contralateral

Which spinal tract:

Contains ipsilateral somatosensory fibers that convey...

Sensory

Proprioception

Vibration

2 point discrimination

Graphesthesia

PCML

Where does the PCML cross?

cuneate and gracile nuclei in the medulla

Damage to the PCML in the spinal cord causes ________ deficits

ipsilateral

Which spinal tract:

controls conscious pain and temperature sensation?

Lateral spinothalamic

Which spinal tract:

controls conscious touch and pressure sensation?

anterior spinothalamic

Where do the spinothalamic tracts cross?

anterior horn

SCI damaging the spinothalamic tracts causes ________ deficits

contralateral

SCI to the corticospinal tracts causes ________ deficits; PCML causes _______ deficits; spinothalamic tracts causes ______ deficits

ipsilateral; ipsilateral; contralateral

Which area of the cervical spine is most commonly damaged in hyperflexion SCIs?

C5/6

What is the most common mechanism for compression SCis to the cervical spine?

diving accidents or a fall to the top of the head

Hyperextension SCIs are common in which patient population?

elderly

What is the most common mechanism for hyperextension SCIs?

fall forward with neck hyperext as the chin hits the ground

True or False:

Thoracic SCIs are rarely traumatic thanks to protection from the ribcage

True

Thoracic SCIs usually result from-

Transverse myelitis, tumors, abscesses

What is the most common site of SCI in the lumbar spine?

T12-L1

The following MOIs describe causes of which spinal cord syndrome?

-hyperflexion injuries in the cervical spine

-aneurysm or ischemia in the anterior spinal artery

Anterior cord syndrome

Anterior Cord Syndrome: Impairments

-ipsilateral loss of motor function below lesion

-contralateral loss of pain and temp below lesion

Anterior Cord Syndrome: Preservations

PCML- deep touch, vibration, proprioception

Which spinal cord syndrome requires much longer hospital and IPR stays?

anterior cord

The following MOIs describe causes of which spinal cord syndrome?

-stroke in posterior spinal artery

-tumor

-abscess

-rarely traumatic

Posterior cord

Posterior Cord Syndrome: Impairments

-ipsilateral loss of deep touch, proprioception, vibration

-sensory ataxia/stomping/steppage gait

Posterior Cord Syndrome: Preservations

Motor function, pain, light touch

The following MOIs describe causes of which spinal cord syndrome?

-hyperextension to cervical spine

-severe stenosis in the cervical spine

Central cord syndrome

Central cord syndrome: impairments

-cervical tracts

-severe loss of function in BUEs

-varying degrees of sensory involvement

-poor fine motor

Which cord syndrome has severe difficulty with ADLs d/t severe loss of function in the arms?

central cord

Central cord syndrome: preservations

-lumbar and sacral tracts

-leg and motor function, usually recover ability to amb

-Normal b/b and sexual function

The following MOIs describe causes of which spinal cord syndrome?

-gunshot or stab wound to spinal cord

-hemisection of cord

Brown Sequard

Brown Sequard Syndrome: Impairments

-contralateral pain and temp loss

-ipsilateral paralysis and sensory loss

True or False:

Patients with Brown Sequard Syndrome typically achieve good functional gains during IPR

True

_____ cord syndrome results from a SEVERE traumatic injury or massive tumor/stroke

Transverse

________ syndrome is very rare and occurs when the distal spinal cord is damaged, usually occurring from tumor or abscess

Conus Medullaris

Which spinal cord syndrome causes a mixture of UMN and LMN symptoms?

Conus Medullaris Syndrome

The following MOIs describe causes of which spinal cord syndrome?

Herniated disk

Tumor

Infection

Fracture

Tumor

Narrowing of the spinal canal

Cauda Equina Syndrome

Cauda Equina Syndrome: Impairments

-saddle paresthesia

-flaccid paralysis of LEs

-areflexic b/b

-impaired sexual function

Cauda Equina Syndrome causes ______ signs

LMN

True or False:

In cauda equina syndrome, there is potential for damaged nerves to regenerate since this is a peripheral nerve injury

True

Appropriateness of corticosteroid administration s/p SCI depends on how well the patient is ______

breathing

When should the ASIA exam be administered?

When the patient is out of spinal shock, typically >72 hours post injury

What range can the ASIA be administered in post-SCI?

3-15 days

______ is the immediate loss of sensory, motor, and automatic control below the level of SCI

Spinal shock

Describe the symptoms of spinal shock

-flaccidity

-areflexia

-autonomic deficits

-hypotension

The ASIA exam cannot be administered while a patient is still in spinal shock because we are unable to-

accurately assess the NLI

A patient with SCI will initially present with ______ signs

LMN

You are evaluating a patient 2 days s/p hyperextension injury to the cervical spine. The patient is demonstrating a mix of UMN and LMN signs. They have a positive Babinski sign, and all deep tendon reflexes are hyperreflexive with clonus. Is it ok to administer the ASIA exam at this time?

yes

What 3 domains are assessed on the ASIA?

Sensory, motor, anorectal

In the sensory portion of the ASIA, there are _____ dermatomes on each side for both LT and PP

28

What should be used to assess LT sensation on the ASIA?

cotton ball or a q-tip

What should be used to assess PP sensation on the ASIA?

a safety pin

Before administering the sensory portion of the ASIA exam, PTs must establish a frame of reference by-

lightly stroking the end of a q-tip across 1cm of the patient's cheek and asking the patient to say yes when they feel it

Each dermatome should be assessed a MINIMUM of _____ times for both LT and PP sensation

5

After the patient reports they can feel the LT or PP sensation, what should you ask them next?

If the q-tip or safety pin feels the same or different as the sensation on the cheek

LT or PP is scored as ______ if an alternate site is unavailable OR if sensation is altered on the face

NT

You should add a _____ to your sensory score if a non-SCI condition is present resulting in the impairment in sensory function

*

LT sensation score: 0

patient can feel LT < 80% of the time

LT sensation score: 1

able to feel LT ≥80% of the time BUT sensation feels different than the cheek

LT sensation score: 2

accurate 80% of the time AND feels the same as the cheek

In completing the assessment of light touch appreciation at C5 on the left, the patient accurately detects the cotton 8 of 8 attempts but reports the sensation feels duller on his outer elbow than his face. What is the score for LT at C5 on the left?

1

In completing the assessment of light touch appreciation at T1 on the right, the patient accurately detects the cotton 7 of 10 attempts on his inner elbow and reports the cotton feels much sharper on his arm than his face. What is the score for LT for T1 on the right?

0

In completing the assessment of light touch appreciation at L3 on the right, the patient accurately detects the cotton 8 of 10 attempts and reports the cotton feels the same around his knee as it does on his face. What is the score for LT at L3 on the right?

2

When establishing a frame of reference for PP sensation, PTs should-

alternate randomly between sharp and dull ends, asking the patient to indicate whether the sensation was sharp or dull

PP Sensation score: 0

patient correctly discriminates between sharp/dull <80% of the time

PP Sensation score: 1

able to discriminate from sharp/dull ≥80% of the time, but sensation feels different than the cheek

PP Sensation score: 2

accurate 80% of the time AND feels the same as the cheek

In completing the assessment of pin prick at C5 on the left, the patient can feel the safety pin 10 of 10 attempts but incorrectly states "sharp" or "dull" 4/10 times. What is the score for PP at C5 on the left?

0 (only 60% success)

In completing the assessment of pin prick at T1 on the right, the patient accurately detects the safety pin 8 of 10 attempts and reports the safety pin feels much sharper on his arm than his face. What is the score for PP for T1 on the right?

1

In completing the assessment of pin prick at L3 on the right, the patient accurately detects the safety pin 8 of 10 attempts and reports that it feels the same it does on his face. What is the score for PP at L3 on the right?

2

Before administering the ASIA, PTs should educate the patient on what it entails _____ day beforehand

1

What equipment is needed to complete the ASIA sensory portion?

2 safety pins, q-tip, ASIA paper

What sensory levels are assessed in the ASIA?

C2-S5

How many myotomes are assessed in the ASIA motor exam?

5 myotomes in BUE/LEs for 20 total

True or False:

When scoring the ASIA motor exam, it is okay to deviate from the standardized testing position

false

What muscle group is assessed in the ASIA for the following dermatome?

C5

elbow flexors

What muscle group is assessed in the ASIA for the following dermatome?

C6

wrist extensors

What muscle group is assessed in the ASIA for the following dermatome?

C7

elbow extensors

What muscle group is assessed in the ASIA for the following dermatome?

C8

finger flexors

What muscle group is assessed in the ASIA for the following dermatome?

L2

hip flexors

What muscle group is assessed in the ASIA for the following dermatome?

L3

knee extensors

What muscle group is assessed in the ASIA for the following dermatome?

L4

ankle dorsiflexors

What muscle group is assessed in the ASIA for the following dermatome?

L5

great toe extensors

What muscle group is assessed in the ASIA for the following dermatome?

S1

ankle plantar flexors

The patient is ALWAYS ______ during the ASIA motor exam

supine

If a patient cannot accurately be tested in one of the standardized positions for the ASIA motor exam, how should that myotome be scored?

NT

ASIA Motor Grade: 0

No visible or palpable contraction; gravity eliminated position

ASIA Motor Grade: 1

Less than full ROM, at least trace voluntary contraction; gravity eliminated position

ASIA Motor Grade: 2

Full ROM, no resistance in gravity eliminated position

ASIA Motor Grade: 3

Full ROM, no resistance in anti-gravity position

ASIA Motor Grade: 4

Full ROM, some resistance in anti-gravity position

ASIA Motor Grade: 5

Full ROM, full resistance in anti-gravity position

If a non-SCI condition is present and resulting in the impairment in muscle function, what should be added to the motor score on the ASIA?

*

We should always start ASIA motor testing in the grade ____ antigravity position

3