NPTE: SCI

Anterior cord syndrome

hyperflexion injury

-loss of pain and temperture bilaterally

-loss of motor bilaterally

Central cord syndrome

aka walking SCI

hyperextension injury

if small lesion: bilateral pain and temp

if large lesion:

-loss of motor and sensory function

-affects motor > sensory

-affects UE > LE and proximal > distal

SAFETY RISKS BUT USUALLY CAN AMBULATE

affected tracts: spinothalamic, corticospinal, dorsal column

Brown-Sequard Syndrome

stab gunshot wound

-ipsilateral motor loss (corticospinal)

-ipsilateral proprioception, light touch, vibration loss (dorsal column)

-contralateral loss of pain and temperature sensation (spinothalamic)

nemonic: brown pott

Cauda equina syndrome

injury below L1

-lower extremity motor and sensory loss

-areflexic bowel and bladder and saddle anesthesia

Posterior Cord Syndrome

causes: RARE iatrogenic aka medical error; compression of posterior spinal artery or (NPTE focuses on medical error) hyperextension injury

-DCML affected ... loss of vibration, proprioception, 2 point discrimination, sterognosis

-motor function is preserved

-sensory ataxia due to DCML involvement

Dorsal vs ventral horns vs intermediate

dorsal (posterior): sensory

ventral (anterior): motor

Spinal shock

transient period of reflex depression and flaccidity; can last several hours to 6. months or more

S/S: flaccid paralysis, areflexia, vasodilation, decreased cardiac output and venous pooling

-abscence of reflex activity impairs autonomic regulation, which results in hypotension and loss of ability to sweat

What reflex indicates the body is out of spinal shock?

bulbocavernosus S2-4

What level do you start to see respiratory function issues?

above C4

-above C3-C5 need ventilator because supplies phrenic nerve and assist diaphragm control

Below ___ patient can normally be weaned from ventilator

C4 (must teach assistive coughing to help; glossopharngeal breathing is used when diaphragm is denervated)

At ___ and below patient can learn self assisted coughing techniques

C5

Below ___ patient is likely to have near normal ventilatory respiratory functions

T10

Respiratory muscles C1-T11

Autonomic dysreflexia

occurs with injuries at or above T6 --> disruption of sympathetic response

-MEDICAL EMERGENCY

-vasoconstriction occurs leading to hypertension and decreased HR

-increased BP, decreased HR, headache, flushing, profuse sweating, anxiety, constricted pupils, blurred vision, piloerection

-systolic increases by 20-30

-vasoconstriction below level of injury and vasodilation above

Factors that cause autonomic dysreflexia

-bowel and bladder distension, infection, impaction, catheterization blocked, abdominal binder

-skin breakdown, pressure sores, ingrown toenail, and similar stimuli

neurogenic shock

occurs with SCI above T6

-S/S: decreased BP, decreased HR, cyanosis, warm and dry extremities, decreased CO, peripheral vasodilation and venous pooling

Orthostatic hypotension seen with SCI above

T6

Spastic bladder

seen in injury above S2 sacral segment

-bladder contracts and reflexively empties in response to certain level of filling pressure

-reflex action present

-treat with intermittent cauterization every 3-6 hours

-bladder can be emptied by: manual stimulation or timed voiding schedule

Flaccid bladder

seen in injury below S2

-no reflex present

-can be emptied by: crede maneuver (manual compression of lower abdomen; valsalva; timed voiding schedule

Independence level for each spinal cord injury

Heterotopic ossifications

- Common

- Generally near large joints

- No aggressive stretching!

Fasciculus cuneatus

ascending tract; sensory tract for trunk, neck, and UE proprioception, vibration, two-point discrimination, and graphesthesia

Fasciculus gracilis

ascending tract; sensory tract for trunk and LE proprioception, vibration, two-point discrimination, and graphesthesia

Spinocerebellar tract (dorsal)

ascending tract; sensory tract that ascends to the cerebellum for ipsilateral (I/L) subconscious proprioception, tension in muscles, joint sense, posture of the trunk and LEs

Spinocerebellar tract (ventral)

ascending Tract; sensory tract that ascends to the cerebellum, with some fibers crossing and subsequently recrossing at the level of the pons for I/L subconscious proprioception; tension in muscles; joint sense; and posture of trunk, UEs, and LEs

Spinothalamic tract anterior

ascending tract; sensory tract for light touch and pressure

Spinothalamic tract (lateral)

ascending tract; sensory tract for pain and temperature sensation

Corticospinal tract anterior

descending tract; pyramidal motor tract responsible for I/L voluntary, discrete, and skilled movements

Note: Damage to corticospinal (pyramidal) tracts results in a positive Babinski sign, absent superficial abdominal and cremasteric reflexes, and the loss of fine motor or skilled voluntary movement

Corticospinal tract lateral

descending tract; pyramidal motor tract responsible for C/L voluntary fine movement

Note: Damage to corticospinal (pyramidal) tracts results in a positive Babinski sign, absent superficial abdominal and cremasteric reflexes, and the loss of fine motor or skilled voluntary movement

Where does the spinal cord end?

L1 and then goes into conus medullaris then to cauda equina (we do lumbar punctures at L3-4 to avoid spinal cord injury)

Dorsal column medial leminscus (DCML)

-Proprioception

-vibration

-graphesthesia

-barognosis

-stereognosis

-2-pt discrimination

-kinesthesia

-fine touch

(poor val got GBS 2x, keep fighting)

Anterolateral system

Anterior STT: Crude touch ("did you feel it")

Lateral STT: Pain and temperature

Corticospinal tract

movements

Which tracts are ascending vs descending tracts

ascending: sensory tracts (DCML and anterolateral system)

descending: corticospinal

Conus medullaris vs cauda equina

conus medullariS = symmetrical

cauda equinA = asymmetrical

Complete vs incomplete SCI

complete: No sensory or motor function in the lowest sacral segments (S4 and S5)

Incomplete: Motor and/or sensory function below the neurological level including sensory and/or motor function at S4 and S5

ASIA SCI assessment segmental level muscle groups C5-S1

Motor level steps

1. Lowest Level at which strength is at least

3/5

2. All levels above being 5/5

Scored for each side, overall score is last

normal for both

Sensory level steps

Defined as the level where sensory

function is normal on both sides of the

body.

Easy Steps:

1. Lowest level where you have "2's"

2. All above levels being "2's"

(0 is no sensation; 1 is present/impaired, 2 is normal)

Neurological level

CAUDAL most level with NORMAL

sensory and motor function on

BOTH sides of the body.

Easy Steps:

1. Find Motor and Sensory level

2. Pick the higher one

ASIA A-E scale

ASIA C: more than half have a grade less than 3/5

Autonomic dysreflexia/hyperreflexia causes and signs/symptoms

• At or above T6

• Noxious stimuli below level of lesion

• Rise in systolic blood pressure of 20 to 30 mmHg is diagnostic of an episode of autonomic dysreflexia

• More common in chronic stage (3-6 months after injury); can be seen in acute too

• More common with complete SCI

What to do with autonomic dysreflexia

• SIT UP and LOWER LEGS

• Remove painful stimuli:

̶Loosen clothing, abdominal binder

̶CHECK BLADDER distension: Unclamp catheter, drain it

• Monitor vitals throughout: If still no change, medical/nursing

assistance > meds to lower BP (Nifedipine, nitrates, and captopril)

Functional level C1-L3 transfers vs WC/ambulation ability

look at chart with spinal cord injury functions

Diaphragm innervation

C3,4,5 keep the diaphragm alive

C4 can be off ventilator if they do

glossopharyngeal breathing