Spinal Cord Injury

At what level does the spinal cord end?

L1 vertebrae

What is the function of the dorsal column-medial lemniscus tract? Ascending or descending?

“Poor Val Got GBS Twice, Keep Fighting”

• Proprioception - joint position

• Vibration - tuning fork

• Graphesthesia - to draw “A on palm”

• Barognosis - pressure “weight”

• Stereognosis - EC, identify object based on touch

• Two point discrimination - “1 vs. 2”

• Kinesthesia - do movement

• Fine touch - precise localization “point to…”

Ascending, sensory only

What is the function of the spinothalamic tract? Ascending or descending?

• Anterior STT - crude touch “yes I feel it no I don’t”

• Lateral STT - pain and temperature “Licensed PT”

Ascending, sensory only

What is the function of the corticospinal tract? Ascending or descending?

• Fine movement

Descending, motor only

What tract is affected in posterior cord syndrome? MOI?

• DCML only

• MOI: iatrogenic, medical error, rare

What tract is affected in anterior cord syndrome? MOI?

• Bilateral STT

  • Crude touch, pain, temperature

• Bilateral CST

  • Motor

• MOI: hyperflexion

• Worst prognosis for walking

What tract is affected in Brown Sequard syndrome? MOI?

• R DCML

  • Proprioception, vibration, etc.

• R CST

  • Motor

• R STT

  • OPPOSITE (L) pain and temperature “Brown PoT”

• MOI: gunshot/stab wound

What tract is affected in central cord syndrome? MOI?

• Small

  • Bilateral STT

    • Pain and temperature only

• Large

  • Bilateral DCML

  • Bilateral CST “MUD E”

    • UE > LE

    • Distal > proximal

  • Bilateral STT

• MOI: hyperextension

What is the SCI where only DCML is loss?

Posterior cord syndrome

What is the SCI where only DCML is spared?

Anterior cord syndrome

Why is the lumbar puncture done at L3-L4?

To protect the SC, if hurt → posterior cord syndrome, DCML lost

Describe the location, sensory, motor, and type differences between conus medullaris and cauda equina.

• Conus medullaris

  • Location: bilateral and symmetrical in perineum

  • Sensory: saddle distribution, bilateral, symmetric

  • Motor: symmetric

  • Type: UMN + LMN

• Cauda equina

  • Location: unilateral and asymmetrical in perineum, thighs, leg, back

  • Sensory: saddle distribution, unilateral, asymmetric

  • Motor: asymmetric

  • Type: LMN

  • Radicular pain common

What is the difference between complete and incomplete SCI?

• Complete - no sensory or motor fx in lowest sacral segments (S4 and S5)

• Incomplete - motor and/or sensory fx below the neurological including sensory and/or motor fx at S4 and S5

  • Anterior cord syndrome

  • Posterior cord syndrome

  • Brown sequard syndrome

  • Central cord syndrome

What are the key muscles associated with different levels of the SC?

• C5 - elbow flexors

• C6 - wrist extensors

• C7 - elbow extensors

• C8 - finger flexors

• T1 - fifth finger abductors

• L2 - hip flexors

• L3 - knee extensors

• L4 - ankle dorsiflexors

• L5 - long toe extensors

• S1 - ankle plantarflexors

Describe how to determine the sensory, motor, and neurological/functional level for SCI.

• Sensory level - the most caudal segment of the SC w/ normal sensory fx on BOTH sides of the body

  • Lowest level where sensation is 2/2

• Motor level - the most caudal segment of the SC w/ normal motor function on BOTH sides of the body

  • Lowest key muscle that has a grade of at least 3 (fair), providing the key muscles represented by segments above that level are judged to be 5 (normal)

• Neurological/functional level - the most caudal segment of the SC w/ normal sensory and motor fx on BOTH sides of the body

  • Pick the higher one

What are the levels of the ASIA Impariment Scale?

• ASIA A

  • Complete

  • No sensory or motor fx at S4-S5

• ASIA B

  • Incomplete

  • Sensory only, no motor fx present below NLI and S4-S5

• ASIA C

  • Incomplete

  • LESS THAN HALF of key muscle fxs below the single NLI have a muscle grade of 3 or more

• ASIA D

  • Incomplete

  • AT LEAST HALF OR MORE of key muscle fxs below the single NLI have a muscle grade of 3 or more

• ASIA E

  • Normal “E is me”

What are some complications with SCI?

• Cardiac: orthostatic hypotension, autonomic dysreflexia

• Pulmonary: respiratory dysfunction

• GU: urinary and bowel retention ± incontinence

• Integumentary: pressure ulcers

• MSK: contracture, weakness, tone

What is autonomic dysreflexia/hyperreflexia?

• At or above T6

• Noxious stimuli below level of lesion

• Rise in SBP of 20-30mmHg → diagnostic

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

• More common w/ complete SCI (ASIA A)

What are stimuli and sxs of autonomic dysreflexia?

• Stimuli

  • Bladder/bowel irritation i.e. clamped catheter

  • Painful stimulus BELOW level of lesion

  • GI irritation

  • Sexual activity

  • Labor

  • Fx below level of lesion

• Sxs

  • Increase BP (SBP 20-30mmHg)

  • Decrease HR

  • Severe headache, anxiety

  • Constricted pupils, blurred vision

  • Flushing, piloerection (goosebumps) above level of lesion

  • Dry, pale skin below lesion

  • Increased spasticity

What are interventions for autonomic dysreflexia?

• SIT UP AND LOWER LEGS → to drop BP

• Remove painful stimuli

  • Loosen clithing, abdominal binder

  • CHECK BLADDER DISTENTION → unclamp catheter, drain it

• Monitor vitals throughout - if still no change, medical/nursing assistance > meds to lower BP (nifedipine, nitrates, and captopril)

  • IP - call nurse

  • OP - call 911

Describe the SCI segmental level’s transfer and wheelchair skills.

• C1-C4

  • dependent, mech vent

  • Mechanical lift

  • Power wheelchair - head/chin/mouth control

• C5 mod-I

  • Dependent sliding board transfer

  • Manual WC - plastic coated hand rims

• C6 mod-I

  • Independent sliding board transfer

  • Manual WC - plastic coated hand rims

• C7/C8 independent

  • Transfers

    • C7 Even: independent w/o sliding board

    • C7 Uneven: dependent on sliding board

    • C8: may be able to do floor to WC

  • Wheelchair

    • Manual WC - plastic coated hand rims

    • C7 - independent on even surfaces; not independent on ramps, curbs

    • C8 - independent on ramps, curbs

• T1

  • Floor to wheelchair, wheelie

  • Independent

• T4

  • Sitting pivot

  • Independent

• L4

  • Standing pivot

  • Independent