Neuro SCI - Overview of SCI/Med Management/ASIA Exam

NLI

Neurological level of injury

What is the most common region of the spine for an SCI

Cervical

The (higher/lower) the injury, the (more/less) the impairments

Higher; more

What parts of the nervous system are affected by an SCI

Motor

Sensory

Autonomic

What are the 4 types of spinal cord syndromes

Brown-sequard

Anterior

Posterior

Central

Brown-sequard lesion

Hemisection of the spinal cord

-Ipsilateral proprioception and vibration

-Contralateral pain and temp

Common causes of SCI

-Trauma

-Back surgery

-Patients who wait a long time from sx onset until seeking medical help

What is the most common cause of SCI

MVA

What population commonly gets an SCI from a fall

Geriatric

Does the cervical spine have adequate or poor mechanical stability

Poor

An injury to the cervical spine is (more/less) likely to result in cord damage

More

Cervical injuries account for __% of SCI

60

If a patient has damage to C1 and C2, are neuro deficits common? Why or why not

Usually have no neuro deficit due the C1 and C2 having an increased canal space

What vertebrae of the c-spine are especially susceptible to SCI

C5-C7

What forces at the c-spine usually cause SCI

Flexion, axial loading, distraction, and extension

-Can also be caused by rotation, lateral flexion, or shear

Thoracic injuries are (more/less) likely than cervical injuries and are more likely to me (complete/incomplete)

Less; complete

(Low/high) forces are often required to cause an SCI at the thoracic spine

High

Why are injuries at the thoracic spine considered to have less chance of motor or sensory return

Small vertebral foramen

Poor vascular supply of the upper thoracic spine

What level of the t-spine are common for SCI injury

T12-L1

What forces often cause injury to the t-spine

Flexion, axial loading, or a combo of flexion and rotation

Common causes of SCI at the thoracic spine

GSW

MVA

Falls

The lumbar spine is considered to have (low/intermediate/increased) stability

Intermediate

The lumbar spine is (more/less) flexible than the thoracic, and (more/less) than the cervical

More; less

What level is the caudal equina

Around L1/2

How is the caudal equina often damaged

Compression, stretching, avulsion, or tearing

What forces often cause injury at the lumbar spine

Flexion, axial loading, or flexion combines with distraction or rotation

Associated injuries with a traumatic SCI

Fractures

Pneumo/hemothorax

Head injury

Brachial plexus injury

Peripheral nerve injury

The spinal cord can sustain damage due to _________ injury, ________, or ______ ______

Vertebral; traction; direct insult

In both penetrating and non-penetrating injuries, the (more/less) severe the disruption of the spinal canal leads to more serve neuro damage

More

T/F: The spinal cord does not need to be severed for irreversible damage to occur

True

Non-traumatic causes of SCI

Spinal hematoma

Infection

Transverse myelitis

Radiation

Aortic aneurysm

Neoplasm

MS plaque in the SC

Primary injury

Neuronal damage caused by blunt trauma to the spinal cord

Secondary injury

Causes most of the damage to the cord affecting both neuronal and glial cells

How long does secondary injury last in SCI

Days to weeks to months after the initial injury

Longer that they las, the less function the pt tends to get back

As the primary and secondary reactions start to subside, the necrotic region of the spinal cord is replaced by ____ ______ _____ or ________

Scar tissue; cysts; cavities

Sx of spinal shock

LMN sx: areflexia/hyporeflexia, flaccidity, hypotonia

Predictors of neurological return after SCI

Degree of impairment

Preserved motor function and pin prick

Pattern of injury

Early return

Age (younger the better)

Neurological deterioration

Associated with secondary injuries; patient gets worse as time goes on after their SCI

Ex: AS, sepsis, bed bound

Discomplete injury

When, in chronic SCI, testing reveals a complete injury but neurophysiological testing reveals some remaining connectivity

Most neuro return after an SCI occurs _ to _ months post-injury

6;9

Pre-hospital care for Sci occurs where

The site of the injury

-Want to stabilize the spine

Fracture management for SCI

Non-surgical

Surgical

Spinal orthoses

Benefits of head cervical orthoses (HCO)

Semi-rigid and rigid plastics

Provide more rigid stabilization of the c-spine

Include occiput and chi to decrease ROM

Used in stable spine conditions

Complications of HCOs

-Supported chin and clavicle area are common areas for skin breakdown

-Long-term use associated with decreased muscle function and dependency

Structure of a Philadelphia collar

-Semi-rigid HCO with a 2-piece system of Plastazote foam

-Plastic struts ant and post for support

-Upper portion supports the lower jaw and occiput, lower portion cover upper thoracic region

-Difficult to clean

-Thoracic / can be added to increase motion restriction and treat C6-T2 injuries

What orthosis is the gold standard for HCOs

Miami J collar

Structure of Miami J collar

Semi-rigid 2-piece system made of polyethylene, with a soft, washable lining

Thoracic / can be added to increase support and treat C6-T2 injuries

Indications for a Miami J collar

Same as the Philadelphia collar

Why is it important to educate patients and their families about donning and doffing the Miami J

Needs to be tight around the neck in order to stabilize the C-spine

Cervical thoracic orthoses (CTOs) have (less or greater) motion restriction in the middle to lower cervical spine

Greater

Is it common to use CTOs with unstable fractures

Used minimally

What orthoses has the greatest reduction in cervical mobilization (~90-95%)

Halo cervical orthosis

Structure of halo cervical orthosis

Cranial ring escude to the skill using 4 metal pins

The ring attached by four metal bars to a plastic vest and is worn continuously

Function of the halo cervical orthosis

Provides distraction forces that aid in the stabilization and reducing the load of the head on the c-spine

Structure of Minerva orthosis

Thermoplastic custom orthosis

Encases the chin, posterior skill and extends down to the lower ribs

May extend to the pelvis

Headband holds skull in place

The Minerva orthosis is reported to have (better/worse) cervical stabilization compared to the halo (except at C1 and 2)

Better

Positives of using the Minerva orthosis

Allows good shoulder ROM - early mobilization

Fewer complications than the halo

Structure of the sternal-occipital-mandibular immobilizer (SOMI)

CTO with anterior chest plate extending to the aphid process and metal or plastic bars curve over the shoulder

Straps from the bars over the shoulder and cross to the opposite side of the anterior plate for fixation

2 poster CTOs start from the best plate and attach to the occipital component

Comfortable and proper adjustment is crucial for motion restriction

What population is the SOMI ideally used for

Bed bound patients because the orthsiss has no posterior rods

Indications for the SOMI

Controls flexion in the C1-3 segments better than a cervicothoracic brace

AA instability

Neural arch fractures of C2 (flexion causes instability)

Molded plastic body jacket structure

Fabricated with high-temperature copolymer plastics and is well fitted in order to restrict motion in all planes

Downside to molded plastic body jacket

Hot for the patient

Purpose of a molded plastic body jacket

Anterior and lateral trunk containment increases intra-cavitary press ion in the stomach and abdomen

Jewett structure

Prefabricated metal frame with suprapubic, sternal, and thoracolumbar pads

What motions are restricted and encouraged with the Jewett

Restricts flexion and encouraged hyperextension of the lower thoracic and upper lumbar spine

Some control of rotation and lateral flexion

Is the Jewett appropriate for a unstable spine

No

Knight Taylor orthosis structure

Rigid posterior frame with axillary straps and abdominal support

Requires cervical extension for motion restriction above T8

What motions are allowed and restricted with the Knight-Taylor orthosis

Effective restriction: lumbar fix/ext, lat fix; lumbosacral lat flx

Intermediate Restriction: Lumbar and lumbosacral rotation

Unrestricted: Lumbosacral flexion and extension

What systems can be affected by an SCI besides the neuro system

Urinary

Gastrointestinal

Cardiovascular

MSK

Elements of the ASIA exam

Sensory level

Motor level

NLI

Complete vs incomplete

Sacral sparing

Zone of partial preservation

What element of the ASIA exam is only performed for complete SCIs

Zone of partial preservation

How many key dermatomes are there

28

What sensations are tested on the ASIA exam

Light touch and pinprick

What area of the body is used as the control for testing sensation

The face behind the ear

What is the scale used for sensory testing on the ASIA exam

0 = absent

1 = impaired

2 = normal

NT = not tested

When would sensation be documented as not tested

Usually done when wearing a wand or have a brace that cannot be removed

Light touch sensory scoring procedure

Use a cotton tip applicator

Stroke across skin moving over a distance that is not > 1 cm

For light touch sensory testing of C6-8, what are of the body should be used

Dorsum of the proximal phalanx

Chest and abdomen points for light touch should be test in the _____________ line

Midclavicular line

Pinprick sensory scoring procedure

-Clean safety pin

-Use consistent pressure in each dermatome

-Poke one time only

If a patient can feel the sensation but cannot differentiate between light touch and pinprick, what sensory score are they given for the pinprick section

Absent

What dermatome represents the most caudal aspect of the spinal cord

S4/5

Deep anal pressure

On digital rectal exam patient is asked to report sensory awareness

Recorded as "present" or "absent"

Sensory level

The level where sensory function is normal on both sides of the body

(Most caudal section were they score 2s on both sides and above)

How many key muscle groups are tested on the ASIA exam

10

Procedure for motor exam on ASIA

Examine rostral to caudal

Tested in supine

0-5 scale

ASIA motor exam: 1

Muscle twitch/partial ROM in gravity eliminated

ASIA motor exam: 2

Full active ROM in gravity eliminated position

ASIA motor exam: 3

Full active ROM against gravity

ASIA motor exam: 4

Able to generate some resistance

ASIA motor exam: 5

Normal strength

ASIA motor exam UE myotomes

C5: Elbow flexors

C6: Wrist extensors

C7: Elbow extensors

C8: Finger flexors

T1: Finger abductors

ASIA motor exam LE myotomes

L2: Hip flexors

L3: Knee extensors

L4: Ankle dorsiflexors

L5: Great toe extensor

S1: Ankle plantarflexors

Voluntary anal contraction

Contraction of EAS around examiners finger

Graded as absent/present

If you can't test a muscle, what do you document

Empty or not tested

If muscles have only the rostral root intact they will likely have a ___/5 strength

If both roots are intact, they will likely have ___/5 strength

3/5; 5/5

Motor score on ASIA exam

Level at which strength is at least a 3/5 with all level above being a 5/5

Scored for each side, overall score is last normal for both

For the thoracic spine, what grade is given for motor when you only have sensory information

if sensation is a 2 for that dermatome, you assume that they have 5/5 strength

Neurological level of injury

The most caudal level at which both motor and sensory are intact on both sides of the body

-Motor at least 3/5 with all level above being 5/5

-Sensory intact (B) for LT and PP with all sensation above intact

If there is no key muscle for a segment that has sensory intact, the _______ level defines the ______ level and the NLI

Sensory; motor