SCI

are SCI more common in men or women?

men

majority of SCI occur secondary to?

trauma

is complete SCI common?

rare, except in case of a penetrating injury

primary trauma damages ___ and disrupts ____ to the SC

neural tissue

blood supply

death of neural tissue is largely due to____

secondary damage (edema)

inflammatory processes are accompanied by edema, leading to ____

compression of SC tissue within confined dimensions of the vertebral canal

edema ___ (increase/decrease) the distance between ___ and ___ supplying vital O2 and nutrients

increases

cells

blood vessels

injury induced alterations in cellular metabolism result in ___ that further damages ___

excitotoxicity

vulnerable neural structures

primary cause of traumatic SCI

MVA

tetraplegia

impairment or loss of motor and/or sensory function in C segments due to damage of neural elements within the spinal canal (not peripheral or plexus)

tetraplegia involvement

trunk arms and legs and pelvic organs

paraplegia

impairment or loss of the motor and or sensory function in the T, L or sacral segments of the SC due to damage of the neural elements within the spinal canal

(not peripheral or lumbosacral plexus)

paraplegia involvement

legs, trunk, and pelvic organs

avg LOS for SCI in acute care

11 days

avg LOS for SCI in rehab

35 days

secondary conditions to SCI

-DVT

-pressure ulvers

-autonomic dysreflexia

-pneumonia

-orthostatic HTN

-spasticity

-depression

-UTI

-heterotropic ossification

-pain

what is the spinal canal (SC)?

column of neural tissue at base of brain stem and exits skull thru magnum foramen

SC protected by

vertebral canal

what are injuries that could happen to spinal canal?

-contusion

-laceration

-transection

-shear

-traction

how many "segmental" levels of SC?

31

C region, the SC segmental levels and spinal vertebra are at similar/same or different levels?

same/similar

more distal regions the SC segments and spinal vertebra are at same/similar or different levels?

large discrepancy between the vertebral level and SC segmental

lumbar enlargement

region of SC containing motor neurons that innervate the LE

lumbar enlargement

-comprised of

spinal segments L1-S3

lumbar enlargement

-located

anatomically at approx vertebral levels T9-12

SCI level determinantion

-motor level

-sensory level

-sacral sparring: S4-5/anorectal exam

SCI level determinantion

-motor level determined by

assessing strength of key muscles for each spinal level using MMT of grade 0-5

motor level defined by

the most caudal/ lowest muscle that has MMT of at least 3/5 as long as the immediate rostral/top muscle has a score of 5/5

sensory level

ability to feel either light touch or pin prick

what tract does light touch run?

dorsal columns

what tract does pin prick run?

lateral spinothalamic

sensory level determined by

most caudal/lowest level for both light touch and pin prick

sacral sparing determined by

presence of an anal sphincter voluntary contraction/ "wink" as present yes/no or sacral sensation to deep pressure yes/no

sensory: complete SCI

no VAC, deep pressure or PP/LT

sensory: incomplete SCI

yes to VAC or deep pressure or PP/LT

-AIS "C" at a min if voluntary contraction

incomplete SCI

-central cord syndrome

-brown -sequard synd

-ant cord synd

-conus medullaris synd

-cauda equina synd

posterior cord syndrome

-rare

-<1% of all

-very good outcomes bc generally affects dorsal column

-note for cause of things such as tumors or vit deficiency

-> majority of cases due to this

which incomplete SCI is least rehabable?

ant cord synd

ant cord synd

(flexion injury)

-damage to the ant cord or ant spinal artery

-flexion or teardrop or burst fx's

ant cord synd

-clinically

-loss of motor, pain and temp BL (loss of ventral column)

-relatively intact proprioception, light touch, and deep pressure

->preservation of dorsal columns

-difficult recovery

-sensory sparring below level of injury

flexion teardrop fx

vert burst fx

-occludes ant spinal artery

central cord synd

(hyperext injury)

-damage to the central aspect of spinal canal with sparring of peripheral portions of SC

-UE affected > LE

central cord synd

-recovery pattern

good

-intrinsic of hand last to come back if at all

central cord synd

-prognosis

ext injury often in adults

good

-age, education and spasticity correlated to better outcomes

central cord synd

-clinically

-should be able to walk, but lots of trouble with ADL's

-B/B and sexual function remain intact

-if sensory return is present then excellent prognosis

brown sequard syndrome

affects males and females equally

-damage to single side of SC (penetration, GSW, stab) or burst fx, tumor, or ischemia

brown sequard syndrome

-clinically: ipsilateral

(UMN)

-motor paralysis

-loss of proprioception, deep and light touch and vibration

-skin at level is anesthetic

-spastic

brown sequard syndrome

-clinically: contralateral

loss of pain and temp

(and pin prick, travel on same tract)

anatomy

-sensory fibers

in dorsal column

corticospinal tract fibers

cross in medulla and travel to SC on same side of body as muscles they innervate

lateral spinothalamic tract path

cross soon after in SC and travel to opp side of the body

conus medullaris

the terminal end of the SC located anatomically at ~T12-L2 in adults

conus medullaris synd

-injury of the sacral cord (conus) and the lumbar nerve roots

-peripheral damage

-trauma or compressive forces that result in narrowing of the vertebral canal can compress the nerves resulting in this

-can also occur due to infection

what innervates the bowel and bladder?

motor neurons of the S4and 5 spinal segments

conus medullaris synd

-clinically

B/L and symmetrical

-areflexic B/B and LE's, sexual dysfunction, decreased sensation (perianal area in particular), diminished achilles reflex

-mixed UMN and LMN presentation

cauda equina

bundle of nerve roots (consisting of the nerves from segmental levels L2-S5) that extend thru the vertebral canal below level of conus medullaris

cauda equina syndrome

-injury to the lumbosacral n roots within the neural canal

-peripheral n damage

cauda equina syndrome

-clinically

-areflexic BB and LE, sexual dysfunction, denervation atrophy to involved muscles

-typically asymmetrical and incomplete

Non-fx SCI

-spinal stroke

-transverse myelitis

-tumor on SC

spinal stroke

-sx's appear quickly

-occlusion has been reported and there is a disruption of the blood supply to the SC

spinal stroke

-sx's

-pain

-weakness

-BB issues

-spasticity

-sensory changes

spinal stroke

-causes

can include

-aortic disease and atherosclerotic embolization

-arteriovenous malformation

-clotting disorders

-vasculitis

-CABG

-can occur as complications after surgeries to chest cavity

spinal stroke

-prognosis

slightly < 1/2 show improvement but not recovery

transverse myelitis

-inflammation of both sides of 1 section of SC

-often damages insulating material covering N cell fibers (myelin)

-develops over few hours to days (can be several weeks)

transverse myelitis

-sx's

-pain (hallmark: usually in LE)

-weakness

-sensory problems

-B/B dysfunction

transverse myelitis

-causes

-infections

-immune system disorders

-MS

ASIA impairment scale

standardization of a single system to gather and analyze data

A

B

C

D

E

ASIA impairment scale

-A

complete

-no sensory or motor function preserved in the sacral segments (S4-5)

ASIA impairment scale

-B

sensory incomplete

-sensory NOT motor function preserved below neurologic level and extends thru S4-5

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

ASIA impairment scale

-C

motor incomplete

-motor function preserved below neurological level and the majority of muscles below level have a muscle grade of <3/5

-some sparring of motor function >3 levels below ipsilateral motor level on either side of body

ASIA impairment scale

-D

motor incomplete

-motor function preserved below level and majority of key muscles below level have grade >3/5

ASIA impairment scale

-E

normal

ISNCSC

International Standards for the Neurological Classification of SCI

-neurological level (NLI)

-sensory level

-motor level

-skeletal level

(key muscles chosen because they have single innervations and most muscle fibers)

ISNCSC: neurological level

most caudal level with intact sensation (PP and LT)

AND

3/5 in key muscles with normal motor (5/5) directly and sensory functions rostral on both sides of the body

ISNCSC: sensory level

most caudal segment of the SC with normal sensory functions (PP and LT) on both sides of the body

(2 all the way across)

ISNCSC: how to grade PPR and LT

0- absent

1- diminished

2- normal

ISNCSC: motor level

most caudal segment of SC with 3/5 AND normal motor function (5/5) at level above

ISNCSC: skeletal level

level by radiographic examination has most damage

ISNCSC: zone of partial preservation

ZPP

-selected incomplete injury and sensorimotor complete injuries

-segments partially innervated below/caudal to sensory and motor levels on either side of the body

ZPP: named by

-key muscle that is 3/5 MMT

-lowest dermatome or myotome on each side with some preservation

spinal shock

-temporary period of non function below level of lesion

-you might see someone with less spasticity than you would normally expect bc in time frame of spinal shock

spinal shock

-classified by

-absence of DTR and autonomic dysfunction-> usually hypotension and bradycardia

-C injuries demonstrate decreased sympathetic outflow and persistent parasympathetic output of vagus N

spinal shock

-cause

usually trauma

spinal shock

-how long does it last?

can last 12-16 wks but resolving slowly during that time

how to test spasticity vs movement?

-MMT

-DTR

-repeatable

-able to do in multiple positions

Key Muscle Groups

C1-4

sensory level and diaphragm

Key Muscle Groups

C4

trap

Key Muscle Groups

C5

elbow flexion

biceps

brachioradialis

Key Muscle Groups

C6

wrist ext

-ext carpi radialis longus and brevis

Key Muscle Groups

C7

elbow ext

-triceps

Key Muscle Groups

C8

finger flex

-flex dig prof (of middle finger)

Key Muscle Groups

T1

small finger abd (interossei)

Key Muscle Groups

T2-L1

sensory level (Beevor's sign)

Key Muscle Groups

L2

hip flex

-iliopsoas

Key Muscle Groups

L3

knee ext

-quads

Key Muscle Groups

L4

ankle DF

-tib ant

Key Muscle Groups

L5

great toe ext

-ext hallicus longus

Key Muscle Groups

S1

ankle PF

-gastroc

Key Muscle Groups

S2-5

sensory level and sphincter control

MMT

5/5

full strength and ROM