Neuro Rehab - SCI and interventions

A high-dose corticosteroid medication administered intravenously (IV) right in the initial hours of SCI

Methylprednisolone

What are the 3 major spinal arteries?

1 anterior spinal artery + 2 posterior spinal arteries

What does the dorsal column/medial lemniscus tract carry?

Discriminative touch, vibration, and conscious proprioception

A lesion of the dorsal column below the medulla causes what type of loss?

Ipsilateral loss

What does the spinothalamic tract carry?

Pain, temperature, and crude touch

A spinothalamic lesion causes loss on which side?

Contralateral, beginning approximately 1-2 segments below the lesion

What is the major descending motor pathway from the cerebral cortex?

Corticospinal tract

A lesion of the corticospinal tract causes what type of loss?

Ipsilateral loss

What does the rubrospinal tract primarily control?

Distal UE limb movements

Complete spinal cord injury in which all sensation and motor function are lost below the injury; rare

Transection

Sudden traumatic force exerted on the vertebral column from the vertical axis

Longitudinal compression

Sudden, extreme bending of the spinal column

Hinging

Vertebral column pushed beyond its normal range of rotation

Shearing

Significant bleeding that causes pressure buildup on the spinal cord

Contusion

An incomplete SCI where the cord is cut or torn, often by vertebral fragments

Laceration

When is an SCI/fracture considered unstable?

When normal movement could cause further cord displacement and damage

What are examples of external stabilization?

Halo, hard cervical collar, soft cervical collar, TLSO

Tetraplegia?

Involvement of all 4 extremities and trunk

Paraplegia?

Involvement of all or part of the trunk and lower extremities

Absence of sensory and motor function below the neurological level, including the lowest sacral segment

Complete SCI

Presence of sacral sparing

Incomplete SCI

Partial sensory and/or motor innervation in the sacral region below the neurological level

Sacral sparing

What are zones of partial preservation?

Dermatomes/myotomes below the neurological level that remain partially innervated

What are the major incomplete SCI syndromes?

Anterior cord, central cord, posterior cord, Brown-Séquard, and cauda equina/conus medullaris

Anterior cord syndrome is typically associated with what injury?

Flexion injury

What artery is disrupted in anterior cord syndrome?

Anterior spinal artery

What functions are lost in anterior cord syndrome?

Motor

Pain

Temperature

What is preserved in anterior cord syndrome?

Dorsal column functions: discriminative touch, vibration, conscious proprioception

Central cord syndrome is typically caused by what?

Hyperextension injury

In central cord syndrome, which extremities are more affected?

UE > LE for both motor and sensory loss

Posterior cord syndrome involves damage to what artery?

Posterior spinal artery

What tract is primarily lost in posterior cord syndrome?

Dorsal column

What remains intact in posterior cord syndrome?

Motor function, pain, and temperature

Brown-Séquard syndrome results from what type of injury?

Hemisection of the spinal cord, usually from penetrating trauma

What is lost ipsilaterally in Brown-Séquard syndrome?

Motor function

Light touch

Vibration

Proprioception

What is lost contralaterally in Brown-Séquard syndrome?

Pain and temperature, beginning 1-2 segments below the lesion

Where does the spinal cord end?

L1-L2

What is the conus medullaris level?

S3-S5

What are classic conus medullaris findings?

Saddle anesthesia, sphincter loss, generally bilateral and symmetrical findings

What is cauda equina injury?

LMN injury involving lumbosacral roots

What pattern is typical of cauda equina injury?

Variable sensorimotor and bowel/bladder deficits; generally asymmetrical and incomplete

What is the purpose of ASIA (American Spinal Injury Association) standards?

To perform standardized neurological testing, assess functional disability, and help determine prognosis

What is the neurological level of injury?

The most caudal spinal cord segment with normal motor and sensory function bilaterally

What is the skeletal level?

The radiographic level of greatest vertebral damage

How is the sensory level determined?

Most caudal dermatome with a 2/2 score for both pinprick and light touch bilaterally.

What position is strength testing tested in?

Supine

Key Sensory Points: At the midclavicular line and the fourth intercostal space, located at the level of the nipples

T4

Key Sensory Points: At the midclavicular line, located at the level of the xiphisternum

T6

Key Sensory Points: At the midclavicular line, located at the level of the umbilicus.

T10

What is the motor level?

The most caudal key muscle with strength ≥3/5, provided the key muscle above is 5/5

What is AISA A?

Complete — no motor or sensory function in the sacral region

What is AISA B?

Incomplete — sensory but no motor function below neurological level, extending through sacral segments

What is AISA C?

Incomplete — motor function below neurological level, but the majority of key muscles below the level are

What is AISA D?

Incomplete — motor function below the neurological level with ≥3/5 strength in the majority of key muscles below the level

What is AISA E?

Normal

Memory Trick for ASIA Classifications

A = Absent

B = Both? → sensory only

C = Can move, but weak

D = Does better (≥3)

E = Everything normal

Motor Exam (Myotome Testing)

C5

Elbow Flexors (Biceps Brachii, Brachialis)

C6

Wrist Extensors (Extensor Carpi Radialis Longus, Extensor Carpi Radialis Brevis)

C7

Elbow Extensors (Triceps)

C8

Long Finger Flexors (Flexor Digitorum Profundus)

T1

Small Finger Abductor (Abductor Digiti Minimi)

L2

Hip Flexors (Iliopsoas)

L3

Knee Extensors (Quadriceps)

L4

Ankle Dorsiflexors (Tibialis Anterior)

L5

Long Toe Extensors (Extensor Hallucis Longus)

S1

Ankle Plantarflexors (Gastrocnemius, Soleus)

Why is shoulder ROM important after SCI?

Shoulder flexion, abduction, and ER are important for transfers

What is tenodesis grip?

Functional grasp produced through the relationship between wrist position and finger flexion/extension; important with wrist extensor function

Why is long finger flexor tightness important in SCI?

It can affect the tenodesis grip

Why is wrist extension (C6) functionally important?

Tenodesis, hooking during ADLs, and assisting with wheelchair propulsion

Why is triceps (C7) especially important?

Major increase in function; helps with wheelchair push-ups and transfers

What does C5/biceps contribute to?

Bed mobility and transfers

What does L4/ankle DF contribute to?

Ambulation without an assistive device

Stage 1 pressure injury

Reddened skin

Stage 2

Blistering/open sore

Stage 3

Crater with damage below the skin

Stage 4

Damage to muscle and bone

How often should pressure reliefs be performed?

Every 15-30 minutes for 60 seconds

What is the primary inspiratory muscle?

Diaphragm — C3-C5

What happens after SCI above T1?

Loss of intercostal function → paradoxical breathing

Why may a person with SCI breathe better in supine?

Abdominal contents push the diaphragm upward, increasing its resting level and allowing greater excursion with contraction

What level of injury may require ventilator support?

C4 or higher

Modified Ashworth Scale

Measures spasticity/tone

Modified Ashworth 0

No increase in tone

Modified Ashworth 1

Slight increase with catch/release or minimal resistance at end ROM

Modified Ashworth 1+

Catch followed by minimal resistance through the remainder of ROM

Modified Ashworth 2

More marked increase through most ROM, but limb easily moved

Modified Ashworth 3

Considerable increase; passive movement difficult

Modified Ashworth 4

Limb rigid in flexion or extension.

What happens to tone during spinal shock?

Initially decreased

Medication to manage increased tone

Baclofen (oral or pump), valium, botox

Why does orthostatic hypotension occur after SCI?

Loss of sympathetic vasoconstriction

Loss of muscle pumping

Prolonged bed rest

Who is at risk for autonomic dysreflexia?

Individuals with SCI at T6 and above

Is autonomic dysreflexia an emergency?

Yes

What commonly triggers autonomic dysreflexia?

Full bladder, bladder infection, catheter blockage, severe constipation, and pressure sores

What are signs of autonomic dysreflexia?

Headache, hypertension, increased spasticity, sweating above lesion, goosebumps, and flushed face

What is the first treatment for autonomic dysreflexia?

Remove the noxious stimulus

If the stimulus cannot be found quickly, what should you do?

Assist the patient to an upright position to help decrease BP

Nociceptive vs Neuropathic Pain

Nociceptive- pain in which NORMAL NERVES transmit information to CNS about trauma to tissues

Neuropathic- pain in which a DAMAGED NS (peripheral or central) adapts secondary to injury, there is an abnormal processing of afferent input