medical management of SCI

what is involved with immediate medical management of SCI with traumatic cases?

stabilization and decompression of the spine

steroid administration and hypothermia

what is involved with immediate medical management of SCI with non-traumatic cases?

essential to do a thorough differential diagnosis

bowel and bladder function is important

reflexes (UMN signs, LMN signs)

what is prognosis of stabilization and decompression of the spine?

20% within 14 hours regained 2 AIS grades or more within 6 months

compared to 9% with delayed surgery (2 days post-SCI)

what are common stabilization orthoses used for the cervical spine?

halo

minerva

cervical collar

what are common stabilization orthoses used for the thoracolumbosacral region?

TLSO

aspen

jewett

what are the areas of critical concern following SCI?

cardiovascular changes (HTN, autonomic dysreflexia)

bladder and bowel dysfunction

respiration

skin integrity

spasticity

what patient population commonly has cardiac and vasomotor changes?

T6 injury or above interrupts supraspinal sympathetic control

what are common cardiac and vasomotor changes?

bradycardia

hypotension (systolic 90-110) and orthostatic hypotension

DVT

impaired thermoregulation

reduced exercise tolerance

autonomic dysreflexia

autonomic dysreflexia develops if SCI is ______

above T6

why does bradycardia occur?

only parasympathetic function to control the heart (vagus nerve- CN X)

bradyarrhythmia

what causes hypotension and OH?

blood pools in vessels and organs

loss of sympathetic reflexes that control BP with position changes

what causes DVT?

venous stasis and changes in blood platelets/fibrinogen

what leads to impaired thermoregulation? what SCI level is this common in?

primarily cervical level

hyperthermia due to loss of sympathetic control of sweating

what is a sympathetic surge?

strong sensory stimulus (sometimes noxious) below the level of the injury that ascends and triggers a sympathetic response

what are body responses after a sympathetic surge?

pronounce HTN (20-40 mmHg above "normal" for person with SCI)

vasoconstriction

heart rate is slowed due to CN X

descending inhibitory responses are blocked by the injury

what are symptoms associated with vasoconstriction?

sweating, piloerection (goosebumps), facial flushing, headache, blurred vision, stuffy nose

autonomic dysreflexia is a ______ condition

life threatening

what happens if autonomic dysreflexia is not stopped?

seizures, stroke, MI, pulmonary edema, death

what are causes of autonomic dysreflexia?

bladder: full bladder or blocked catheter, kidney stones, UTI

GI tract: bowel impaction and distension

integ: tight clothing/shoes, pressure ulcers, blisters/burns or bug bites

reproductive system: intercourse; ejaculation, labor, menstruation

other: fracture, DVT, heterotopic ossification

describe general intervention for autonomic dysreflexia

take BP and continue to monitor frequently

sit the person up with lower extremities down (lower BP and improve cerebral circulation)

loosen clothing/belts and investigate for underlying stimulus and remove it/address it

call for medical support/911 if underlying cause not found or BP remains elevated

what will BP look like in a SCI patient with autonomic dysreflexia?

patients with SCI generally are hypotensive at baseline, so BP may be in "normal" range for non-SCI population

describe spastic bladder

UMN issue, leaks

lesion to spinal cord segments above conus medullaris and sacral segments (S2, S3, S4)

sacral reflex is overactive causing the bladder to react regardless of amount of urine in the bladder

failure to store urine

describe flaccid bladder

areflexic, LMN

urinary retention

sacral reflex is blunted or absent entirely

urine is not expelled from the bladder (sphnicter dyssynergia, reflux damages ureters and kidnets, renal caliculi)

_____ is very common following SCI

UTI

describe spastic bowel dysfunction

above S2 (UMN) spinal cord segment

reflex defecation can occur when the rectum fills with stool

use suppositories or digital stimulation to initiate peristalsis (valsalva or abdominal massage)

describe flaccid/areflexic bowel

S2-S4 spinal cord segments, conus medullaris or cauda equina (LMN)

bowel won't reflexively empty (constipation and bowel impaction)

manual evacuation and gentle valsalva

what muscle are involved with inspiration? what are their nerve root levels?

diaphragm: C3-C5

scalenes: C2-C7

what muscle are involved with expiration? what are their nerve root levels?

sternomastoid: accessory nerve and C2-C3

intercostals: T1-T11

abdominal muscles especially transversus abdominis: T7-L1

when does paralysis of the diaphragm occur? what is the associated patient presentation?

complete lesions C4 and above

paradoxical breathing pattern, dependent on ventilator, abset cough

when does paresis of the diaphragm occur? what is the associated patient presentation?

incomplete injury to C2-C4/5

may need ventilator

when does paralysis/paresis of intercostal and abdominal muscles occur? what is the associated patient presentation?

complete or incomplete SCI from C5 to T11

cough is extraordinarily weak with upper thoracic injuries above T5 due to lack of abdominal support (T6-T12)

ventilator not requires unless complications arise

teach assisted cough

what can compensate for abdominal laxity in sitting for people with tetraplegia?

abdominal binder

what happens with supine positions and respiration?

supine allows gravity to pull the abdominal contents back, allowing weak contractions of the diaphragm to expand the thorax for respiration

what is involved with skin integrity in the acute phase?

altered sensation

immobility due to paralysis/paresis

increased risk with tracheostomy, prolonged recovery following surgical decompression, low arterial BP in ED

sacrum/coccyx, ischium, greater trochanter, heels, also back of head, ears, scapula, elbows, and knees

what positioning can lead to pressure injury in sitting with SCI?

sitting with posterior pelvic tilt and shearing forces from sliding forward in wheelchair

what positioning can lead to pressure injury in bed with SCI?

sliding down in bed

sitting reclined in bed increased shear at sacrum, do not elevate HOB past 30 degrees for more than 20 minutes

what is involved with pressure injury prevention?

change position every 2 hours

HOB no greater than 30 degrees

float the heels

avoid dragging/scooting --> shearing forces

use overhead lift system

regular skin checks

nutrition

monitor sweating and incontinence

describe spasticity after SCI injury

after spinal shock has resolved, spasticity and hypertonia in muscles that have loss descending motor drive (UMN lesion)

disruption to CST

reflexes below injury level will be hyperreflexic, clonus and upgoing Babinski, medications

describe flaccidity after SCI injury

flaccidity occurs when alpha motor neurons, the peripheral nerve, or ventral nerve root is damaged (LMN lesion)

conus medullaris/cauda equina

what happens with most injuries below the T11 vertebral body?

will have a LMN injury in addition to injury to the spinal cord proper due to the presence of nerve roots traveling distally to exist the lumbosacral region

what is heterotopic ossification? what is it associated ith?

develops within first 2 months

associated with spasticity, smoking, UTI, pneumonia

nonspecific signs of inflammation --> joint and muscle pain and swelling in region and a low fever

PT focus on improving ROM once acute phase resolves

describe osteoporosis and its relation to SCI

after SCI, get bone resorption and calcium in the urine

bone mineral loss up to 50% in hip and knee

weight bearing and muscle contraction activities can help (standing frame or tilt table)

who is at high risk for fracture?

under 16 years old

high alcohol use

low BMI

SCI >10 years, motor complete SCI, paraplegia

female

prior fx (or family history of fx)

use of anticonvulsants, opioids, or heparin