Clinical Management of Individuals with Traumatic Spinal Cord Injury - Part 1

- Disease of the respiratory system (pneumonia)

- Infectious disease (septicemia)

- Neoplasms (cancer)

- Hypertensive and ischemic heart disease

what are the top causes of mortality post SCI

- Unintentional injuries

- Diseases of the digestive system

- CVA

- Suicides

what are secondary causes of mortality post SCI

- MVA

- Falls

- violence

what are the 3 most significant causes of SCI

- Mechanical injury to tissue during accident

- Mechanical injury is usually irreversible at cellular level

- LMN symptoms at site of lesion if nerve roots as well as cord are injured

What are the Primary traumatic mechanisms of injury that lead to SCI

- Malignancies

- Vascular events

- Degenerative changes

What are non-traumatic injury mechanisms that lead to SCI

- Flexion injuries: severe whiplash, head tackling in football

- Extension injuries: fall forward with head strike on table, counter, object

- Compression injuries: diving accidents

What are the Primary Mechanisms of Injury to the cervical spine that result in SCI

hyperflexion

hyperextension

compression (axial loading)

• very mobile and vulnerable to injury

Most common mechanisms of cervical spine SCI

- Attaches to ribs to help contain and protect viscera

- Overlapping spinous processes further limit mobility

why is the thoracic spine more stable and harder to receive and SCI

- Vertebral canal narrower than in C-spine

- Blood supply poor and vasculature vulnerable

- Much greater force required to injure the T- spine (usually gunshot/stabbing, MVA, falls that cause significant orthopedic damage)

Key points about the thoracic spine and SCI

Thoracic

_______ SCI less common, but more likely to be a complete SCI when it does occur.

- Lacks the boney stability of T- spine, but vertebrae are large and sturdy and supported by strong paraspinal musculature

- Vertebral canal wider and cord better vascularized

- Includes transition of spinal cord (CNS) to cauda equina (PNS), which is less vulnerable to trauma

what are the aspects of the lumbar spine that make it more resistant or less like for a SCI to occur to it

Hyperflexion

flexion with distraction ("seat-belt injury")

compression

What are the Primary Mechanisms of Injury to the Lumbar spine that can lead to SCI

- Hemorrhage: usually associated with complete injury

- Edema: greater than 4 mm = poor prognosis

- Ischemia

- Inflammation: leads to vasoconstriction

- Ion derangement

What are Secondary Mechanisms of Injury that can result in SCI

- Excess Na and K+ outside of cells increases osmotic pressure (attracts water -> edema)

- Excess Ca2+ inside cells leads to demyelination and cytoskeleton destruction

what are Ion derangements that can lead to SCI

fluid

Primary mechanism of secondary injuries resulting in SCI is due to _____ buildup and pressure on the cord

- Injury to cervical segment(s) of cord (C1 - C8)

- UE involvement/impairment

what does the SCI classification of tetraplegia indicate

- Injury below the cervical segments (typically T1 and below)

- UE function preserved

what does the SCI classification of paraplegia indicate

No sensation in S4-S5 dermatome (Deep anal pressure, light touch, and/or pin prick)

what does the SCI classification of complete SCI indicate

- Preservation of sensation in S4 - S5 dermatome ("sacral sparing")

- Multiple classifications of incomplete SCI

what does the SCI classification of incomplete SCI indicate

- Tests sensation in a dermatomal pattern and bilaterally, to pin prick and light touch

- Tests motor function in a myotomal pattern in 10 key muscles, bilaterally

- Tests anal sensation and motor response to look for "sacral sparing "

How do we Determine the Neurologic Level of Injury using the American Spinal Injury Association (ASIA) Impairment Scale

- Deep anal pressure

- Voluntary anal contraction

What do the Tests for anal sensation and motor response to look for "sacral sparing " entail

Official neurological level of injury (NLI)

the lowest spinal segment where sensation and motor function are normal on both sides

- “Normal” sensory: lowest level with intact sensation (pin prick AND light touch)

- “Normal” motor: lowest level with at least 3/5, with every muscle above that graded 5/5

- Thoracic region: use sensation only (no “key” muscles)

what are the parts of determining the Official neurological level of injury (NLI)

- No S4-S5 motor or sensory function

- May include "Zone of Partial Preservation" - when there is preserved sensation or motor function below the NLI, but no sacral sparing

ASIA Impairment Categories: A - Complete SCI Criteria

- Sensory but no motor function preserved below the NLI

- Must have intact S4-S5 pinprick OR S4-S5 light touch OR deep anal pressure

- Must have no motor function preserved more than 3 levels below NLI on either side of the body

ASIA Impairment Categories: B - Sensory Incomplete SCI Criteria

- Must have intact voluntary anal contraction OR...

- Sparing of motor function > 3 levels below the ipsilateral motor level on either side of the body

- <1/2 of key muscles below NLI have grade of 3/5 or greater

ASIA Impairment Categories: C - Motor Incomplete SCI Criteria

Same as C AND... At least half of key muscles below NLI have a grade of 3/5 or greater

ASIA Impairment Categories: D - Motor Incomplete SCI Criteria

Sensory and motor normal in all segments (only used in tracking recovery)

ASIA Impairment Categories: E - Normal

S4-S5

ASIA A

Zone of Partial Preservation (ZPP)

- Only assessed in injuries with either absent motor OR sensory function in ___-___

- Most often seen in ASIA ___ injuries

- Most caudal level with ANY innervation

- Both motor and sensory documented

ASIA A

What ASIA level is the only injury that will have a sensory ZPP

S4-S5 sensation has to be intact in order to move from A to B (or C or D)

ASIA B/C/D injuries can only have a motor ZPP because …..

VAC

ASIA C and D will only have a motor ZPP if _____ is absent; many C and D injuries will have no ZPP at all

Proprioception, vibration, fine touch

what is the function of the DCML

caudal medulla

where does the DCML decussate

Pain, temperature, crude touch

What is the function of the spinothalamic tract?

in the spinal cord

where does the spinothalamic tact decussate

Lateral Corticospinal Tract

what is the primary descending spinal cord tract

- Lateral: motor to LE

- Middle: motor to trunk

- Medial: motor to UE

what are the parts and functions of the lateral corticospinal tract

Central Cord

What Syndrome is the most common incomplete SCI

Central Cord Syndrome

Vascular hemorrhage/trauma associated with cervical hyperextension injury

central cord syndrome

- Upper extremities more affected than lowers; good prognosis for return to ambulation (77%) and bowel/ bladder control (55%)

- Motor > sensory dysfunction

Brown-Sequard Syndrome

- Cord hemisection

- Associated with penetrating trauma (stabbing, GSW) at all levels

- Ipsilateral loss of motor function (LCST), proprioception, fine touch, and vibration (DCML)

- Contralateral loss of pain and temperature (STT)

what are the effects of Brown-Sequard Syndrome

Brown-Sequard

What Syndrome is associated with good functional recovery

- Hyperflexion injuries

- Vascular injury/occlusion (anterior spinal artery)

- Aortic surgery or trauma

what are causes of anterior cord syndrome

- lateral corticospinal tract

- lateral spinothalamic tract

Which tracts are impaired in anterior cord syndrome?

- Loss of motor function (LCST)

- Loss of pain and temperature (STT)

- Proprioception, vibration, and light touch intact (DCML)

what are the symptoms associated with anterior cord syndrome

- Loss of proprioception, vibration, light touch, and discrimination (DCML)

- Intact motor function (CST)

- Intact pain and temperature (STT)

what are the functional implications of Posterior Cord Syndrome

- Associated with non-traumatic etiology

- Vascular compromise (posterior spinal artery)

- Tumors

what are the causes of Posterior Cord Syndrome

Conus Medullaris Syndrome

- Most distal portion of the spinal cord is damaged

- L1-L2 vertebral level

- May include injury to sacral segments/lumbar nerve roots

- Mix of UMN and LMN symptoms with variable functional presentation

Mix of UMN and LMN symptoms with variable functional presentation

what is the functional presentation of Conus Medullaris Syndrome

Cauda Equina Syndrome

- GENERALLY, below vertebral level L1 (though there are individual differences)

- Affects peripheral nerve roots after they have exited the cord, but before they reach their target intervertebral foramina

- Areflexic bowel/bladder (flacid)

- Saddle anesthesia (butt/posterior thigh)

- Variable LE paralysis/paresis

what are the LMN symptoms associated with Cauda Equina Syndrome

Affects peripheral nerve roots after they have exited the cord

• BUT before they reach their target intervertebral foramina

why is Cauda Equina Syndrome classified as a LMN injury

- CAB (Circulation, Airway, Breathing)

- Spinal stabilization - collar, spineboard

What does Early Medical Management of SCI at the scene of the injury entail

- Medical stabilization: respiration and circulation

- Imaging: radiographs, CT, MRI

- Repeat neurologic exam

- Early immobilization + restore vertebral alignment

- Surgical vs. conservative stabilization

What does Early Medical Management of SCI at the emergency department entail

- Restricts unsafe ROM

- Typically used for 6 - 12 weeks post injury, dependent on physician protocol and radiologic evidence of bone healing

Key points about bracing for the Early Management of SCI

Spinal Shock

Temporary flaccid paralysis and loss of all reflex activity below the level of the lesion

24 hours

when might the stage of Areflexia or severe hyporeflexia spinal shock occur post injury

1-3 days post-injury

when might the stage of Gradual return of reflexes in spinal shock occur post injury

begins 1-4 weeks post-injury

when might the stage of Hyperreflexia in spinal shock occur post injury

continue to increase for up to 12 months post-injury, then stabilize

when might the stage of Hyperreflexia and spasticity in spinal shock occur post injury

DVT

What is the most common cardiovascular complication after SCI

- stasis

- diabetes

- PVD

- traumatic injury

- LE fracture

- tetraplegia

what risk factors of DVT associated with post SCI

- pain

- redness

- swelling

- increased spasticity

- discomfort with PROM

what are symptoms associated with DVT post SCI

ultrasound or Doppler

how do we diagnose a DVT

clots migration to IVC → coronary blockage or pulmonary embolism

what are complications with DVT that can occur post SCI

- anticoagulation meds (prophylactic)

- compression stockings

- pneumatic compression boots

- PROM/mobility

- placement of IVC filter (very common!)

what are prevention treatments for DVT post SCI

Orthostatic Hypotension

- More common with NLI above T6, but high likelihood with all cases of SCI

- Causes: vasodilation, hypovolemia, bedrest

- Road block: baroreceptors → sympathetic nervous system

- Symptoms: drop in BP, dizziness, pallor, loss of hearing or vision, nausea, fainting

T6

Orthostatic Hypotension is more common with NLI above ____, but high likelihood with all cases of SCI

- Hydration

- Supplemental salt

- Gradual acclimation to upright as tolerated

- Use of compression stockings on LEs

- Use of abdominal binder

- Vasopressors (medical intervention)

what are treatment options for orthostatic hypotension post SCI

areflexic

Neurogenic Bowel and Bladder post SCI

• Bowel/bladder usually ________ during spinal shock, then reflexes return in UMN presentation

- high-tone bowel/bladder

- Reflex incontinence (hyperactive emptying reflex)

- Difficulty with voluntary sphincter opening → retention + explosive reflex opening

what is the UMN presentation of Neurogenic Bowel and Bladder post SCI

- low-tone bowel/bladder

- Retention of urine/stool due to hypoactive/absent reflex

- Overflow incontinence...slow leak

what is the LMN presentation of Neurogenic Bowel and Bladder post SCI

- Upright mobility = emptying

- Transfer training to facilitate transfer to commode

- Positioning and mobility in wheelchair to facilitate self-catheterization

What is our role in therapy for Neurogenic Bowel and Bladder post SCI

- Respiratory insufficiency due to poor force production in respiratory muscles, pneumo/hemothorax, pain

- Aspiration of food/drink (due to muscle weakness or poor position)

- Pneumonia related to aspiration, immobility and decreased ability to clear secretions

what are Pulmonary Impairments that can appear post SCI

- Move!

- Upright tolerance

- Abdominal binder

- Secretion clearance (via suctioning, cough/ assisted cough, meds)

- Exercise (especially inspiratory muscles via incentive spirometer)

what are the treatments for Pulmonary Impairments that can appear post SCI

Pressure Ulcers

What is the #2 cause of mortality post SCI

- Lateral lean

- Anterior lean

- Tilt back (PWC)

- Wheelchair pushups*

what are the methods for weight shifting every 20-30 minutes for at least 2 minutes for SCI patients

Autonomic Dysreflexia

Uninhibited reflex sympathetic discharge triggered by noxious stimulus below NLI

- Very high BP

- Severe Headache

- Runny nose

- Flushing and sweating above the NLI

- Bradycardia

what are the symptoms associated with Autonomic Dysreflexia

- Very high BP

- Severe Headache

what are the most relevant symptoms of Autonomic Dysreflexia that are red flags

- Retinal hemorrhage

- MI

- CVA

- Seizure

- Death

what are the life-threatening complications associated with Autonomic Dysreflexia

- Get the patient UPRIGHT!

- Reassess BP frequently as it can change quickly

- Medication administration: Nitroglycerin paste

What does emergent medical attention for Autonomic Dysreflexia entail

- Distension of the bladder or bowel: Check the catheter bag, inquire about bladder/bowel schedule

- Tight or irritating garments: Untie shoes, loosen abdominal binder, check for wrinkles

- Skin breakdown: Relieve pressure from known wounds

Common causes of autonomic dysreflexia and what you can do:

Heterotopic Ossification

Formation of bone in soft tissue usually very close to joint capsule

A

spasticity

Heterotopic Ossification post SCI

- Risk increased in those with ASIA ___ injuries, _______, or pressure ulcers

- warmth, redness, pain at joint, sudden restriction in PROM (over 3 - 4 days)

- SCI population: reduced sensation

- Risk of AD

what are the symptoms associated with Heterotopic Ossification post SCI

hip

knee

elbow

what are the most common locations for Heterotopic Ossification post SCI

spasticity

- Overexaggerated stretch reflex

- Spinal cord damage prevents inhibitory signals from decreasing the reflex activity

T6

Thermoregulation and SCI

- Loss of autonomic control results in inability to regulate body temperature

- Worse for persons with injury above ___

- Core body temperature tends to match environment

nociceptive pain

- Musculoskeletal pain

- High reliance on UE's results in overuse injuries

neuropathic pain

- Nerve pain

- Burning, shotting, electric, hypersensitivity

- Difficult to treat

ADLs

Based on the typical presentation of a patient with central cord syndrome, which activity would be most challenging for the patient to complete?

Anterior Cord

You are evaluating a patient with a new SCI. You note that the patient can feel you touch their legs and proprioception is intact, however MMT reveals 0/5 in BLE. What SCI syndrome does this patient present with?

respiratory training and pressure relief education

Based on the top two causes of mortality following SCI, which of the following would be the most important interventions for a patient with tetraplegia?

Prioritize functional mobility, safety-related tasks, and initiation of patient education about the rehab process

What should you prioritize during an inpatient PT Examination for SCI

- Imaging reports

- Precautions: surgery, orthosis, hemodynamic instability, other movement precautions, nutrition status, skin integrity, respiratory status (trach? vent?)

- ASIA status

- Meds list

- Past medical history

- Social history and home setup

what should you look for during a chart review for Inpatient SCI

- Tolerance to upright

- BP stability

- basic bed mobility

- sitting balance

- transfers

- wheelchair mobility

- ability to weight shift

What functional/mobility related items should be examined during an inpatient PT examination for SCI

- Current functional status

- Assess seating system and wheelchair mobility

- Assess for secondary complications

what are the priorities during an outpatient PT examination for SCI