Overview of SCI and Medical Management

How any new cases of SCI per year in the US?

17,810

approximate prevalence of SCI

294,000

average age at injury for SCI

43

Males account for approx _____ of new SCI cases

78%

most common causes of SCI

vehicular, falls, violence, sports, medical/surgical

average acute care length of stay

11 days

average rehab care length of stay

31 days

what percent of patients with SCI are rehospitalized within the 1st year?

30%

length of stay for patients with SCI has ______ on average since the 1970s

declined

when is mortality for SCI the highest

during the 1st year and with higher level injuries (ventilator)

primary causes of mortality for patients with SCI

infection (pneumonia, septicemia)

what causes of mortality are increasing in rate in the SCI population?

endocrine/metabolic/nutritional diseases, accidents, nervous system diseases, accidents, MSK disorders

now more people with SCIs have ______ injuries

incomplete

what % of people with an SCI also have a TBI?

26-74%

main categories of SCI

traumatic or nontraumatic

what is defined as a traumatic SCI

any blunt force or penetrating injury to the cord

complete anatomical separation of the cord (transection) is _______

very rare

example types of injury to the SC

concussion, contusion, compression, shearing/tearing, transected

what is the primary pathophysiology of traumatic SCI

the direct trauma to the cord, penetrating or blunt

what is the secondary pathophysiology of traumatic SCI

cascade of physiologic intra and extra cellular biochemical events that cause disruption to normal cord function, causes further damage after initial trauma

when do spasticity and hyperreflexia set in?

1-12 months post injury

how is the cardiorespirtory system compromised due to SCI?

neurogenic shock→ bradycardia and hypertension, disrupted innervations to diaphragm, intercostals and hypercarbia

used for the standardized assessment of SCI severity

ISNCSCI and AIS

classification for complete loss of motor and sensory function

AIS A

classification for complete loss of motor function w/ some sensory spared

AIS B

classification for incomplete loss of motor and sensory function

AIS C-D

hemisection of the cord w/ asymmetrical sequelae; often from a GSW or stab

Brown-Sequard Syndrome

what parts of the SC are damaged due to Brown-Sequard syndrome?

all sensory and motor tracts on the side of injury

how is the prognosis of Brown-Sequard syndrome

good prognosis for walking recovery

what impairments present due to Brown-Sequard syndrome

ipsilateral loss of motor function, light touch, deep pressure, proprioceptive sensation, vibration, and 2 point discrimination; contralateral loss of pain and temperature

damage to the anterior portion of the cord and/or vascular supply (anterior spinal artery)’ often caused b y flexion injur, fracture,disc compression, or anterior artery vascular compromise

Anterior cord syndrome

what tracts are affected by anterior cord syndrome?

CST and spinothalamic tract (ALS)

what is preserved with anterior cord syndrome?

vibration/ light touch/ 2 point discrimination (DCML)

what functions are impaired due to anterior cord syndrome?

motor function, pain and temperature sensation

prognosis for anterior cord syndrome

poor for return of bowel/bladder function, ambulation, and hand function

what is the least conmon sC syndrome

posterior cord syndrome

damage to the posterior columns of the SC (DCML); caused by cervical hyperextension, posterior spinal artery compromise, tumors, and vitamin B12 insufficiency

posterior cord syndrome

what functions are lost with posterior cord syndrome?

proprioception and vibration

damage to sacral SC segments and nerve roots; caused by trauma or tumoprs

conus medullaris syndrome

symptoms of conus medullaris syndrome

saddle anesthesia, bowel/bladder dysfunction, mild/bilateral LE weakness, hypertonicity, severe LBP, UMN and LMN signs

damage to lumbosacral nerve roots L2-sacrum; caused by trauma, tumors, spinal stenosis, infection, disc herniation/compression

cauda equina injuries

Symptoms of cauda equina injuries

saddle anesthesia, bowel/bladder dysfunction, LE weakness/flaccid paralysis that is more assymmetric, hyporeflexia, severe LBP, LMN signs

what can help to improve outcomes with SCI?

early surgical decompression and stabilization

hat medical management is given to patients after an SCI?

blood pressure augmentation (MAP>85 for 7 days), some get methylprednisone in high dose but is controversial due to many side effects

why is blood pressure augmentation used after an SCI?

reduces risk of ischemia and increases perfusion to neural tissue

what type of SCI is autonomic dysreflexia most common in?

T6 of above (sympathetic chain location)

common signs and symptoms of AD

increased BP, bradycardia, pounding headache, flushing, profuse sweating, nasal congestion, anxiety, visual changes

emergency complication where stimuli below the level of lesion trigger sympathetic discharge→ causes vasoconstriction and parasympathetic response above level of injury

autonomic dysreflexia (AD)

possible underlying causes of AD

bowel/bladder distention, bladder infection, bowel impaction, skin breakdown, ingrown toenail, ROM/aggressive stretching, muscle spasms, labor/delivery

1st step to take if you notice a patient developing signs of AD

sit them up and lower legs (to drop BP)

steps to treat AD

sit up and lower legs to drop BP→ remove noxious stimulus, check vitals→ get help if needed→ early patient education

common problem with early mobilization to upright

BP drop from orthostatic hypotension

likely causes of OH in SCI population

imbalance of sympathetic and parasympathetic nervosus system and decreased mobility

medical complications that commonly develop in SCI population

AD, OH, DVT/PE, respiratory complications, urologic complications, heterotrophic ossification, osteoporosis/fractures, contractures, pressure sores, pain, syringomyelia

inflammatory rxn in periarticular tissues w/ bone matrix formation and calcification

heterotrophic ossification (HO)

factors that increase risk for fracture

female, lower BMI, complete SCI, paraplegia, longer time post-SCI

prolonged shortening of tissues around the joints that limits motion

contractures

causes of pressure sores

prolonged pressure or shearing forces

development of a tapered, fluid filled cavity usually in the upper levels of the cord; initial loss of pain/temp in UEs and chest which may spread in “cape like” distribution

syringomyelia

what percent of patients with sCI are under 15 years old?

3-5%

common causes of pediatric SCI

MVA, violence, birth injuries

SCI types unique to pediatrics because of the immaturity of the spinal column

lap belt injuries, SCI w/o radiographic abnormality

what type of SCI are infants and adolescents most prone to?

cervical

what type of SCI are children between 5 and 10 most prone to?

paraplegia and complete injuries (lap belt)

medical issues unique to children w/ SCI

hip subluxation, scoliosis, neglect/self harm to extremities, bowel/bladder if untrained, more skin issues, unable to verbalize AD symptoms

ISNCSCI coonsiderations in pediatrics

exam not reliable <4 y/o and too complex for <8 y/o, children< 10 distressed by pinprick exam, inconsistency w/ anorectal exam

what is hip subluxation defined as?

> 20% migration index

how common is hip subluxation in children w/ SCI?

94% injured at 10 or younger, 9% in those injured older than 10

what can PTs due to help kids w/ hip subluxation due to SCI?

educate patients/caregivers and teach protective positions for sleeping/sitting, avoid flex/IR/ADD

how common is neuromuscular scoliosis in children w/ SCI

>90%, prevalence increases w/ younger age of injury

mainstay treatment for scoliosis

TLSO

effects of scoliosis treatment (bracing/surgery) on function in children w/ SCI

trunk motion is needed for ADLs/transfers

metabolic impact of SCI in children

risk for obesity, 11/20 w/ metabolic syndrome, decreased oxygen uptake

impact of SCI in children on bone

not fully known, have low bone mineral density

intervention concepts for pediatric SCI

work on function specific to child/family needs, same principles as adult but make age-appropriate, ambulation