SCI

Spinal cord Injuries 

Overview of CNS

• Afferent (away) & efferent (towards) tracts 

• 33 vertebrae 

  • 7 cervical 

  • 12 thoracic 

  • 5 lumbar 

  • 5 sacral 

  • 4 coccygeal (coccyx) 

Reflex arc 

• Takes out the brain, spinal cord reacts 

• Sensory receptors fire, brain won't get the message until after the body already acts 

• **Important concept on why some movements occur with spinal cord injuries and why some don't

Etiology 

• 1973, database recording how many spinal cord injuries occur

  • CDC contained that information 

  • Most common reasons:

    • Motor vehicle accidents (MVA)

    • Falls

    • Acts of Violence 

    • Sports related accidents 

Incidence/ Prevalence 

• 54 cases per 1 million (18,000 new cases/year)

• Demographics:

  • 78% more common in males (AMAB)

  • Mean age: 43 y/o

  • 60% white 

  • 22% black 

  • 13% hispanic 

  • 2.7% asian 

Classification 

• Complete 

  • Effects ascending & descending tract

  • Cord is completely transected 

  • No function or feeling below the injury 

    • Upper motor neurons 

      • Reflex arc intact below LOI but no longer mediated by brain 

      • Characteristics:

        • Loss of voluntary control & function

        • Spastic paralysis 

        • No muscle atrophy 

        • Hyperactive reflexes  

    • Lower motor neurons 

• Incomplete

  • Partial transected cord 

  • Some motor and/or sensory function below LOI

  • Some function and/or feeling below the injury 

    • Anterior cord syndrome

      • Direct or indirect damage to anterior spinal artery 

      • Clinical signs 

        • Loss of motor function below LOI 

        • Loss of thermal, pain, and tactile sensation below LOI 

        • Light touch & proprioceptive awareness = unaffected 

    • Brown-sequard Syndrome 

      • 1 side of spinal cord is damaged 

      • Clinical signs:

        • Ipsilateral loss of motor function below LOI 

        • Ipsilateral decrease in deep pressure & proprioceptive awareness 

        • Contralateral loss of pain, temperature & touch 

    • Central Cervical Cord Syndrome

      • UEs neural fibers are more impaired than LEs 

      • Central structures are damaged & structural changes to vertebrae

      • Most common = neck hyperextension + spinal cord narrowing 

      • Age related 

        • Clinical signs:

          • Motor & sensory functions in LEs less affected than UEs 

          • Could have flaccid paralysis in UEs

    • Cauda Equina 

      • Damage to spinal nerves exiting spinal cord 

      • Some change of regeneration/ recover of function if roots are not severely damaged 

      • Direct trauma from fracture dislocation of lower thoracic/upper lumbar vertebra 

        • Clinical signs:

          • Loss of motor function & sensation below LOI 

          • Absence of reflex arc 

          • Motor paralysis - flaccid & muscle atrophy below LOI 

          • B/B function are areflexic 

    • Conus Medullaris

      • Similar to cauda equina injuries 

        • Clinical signs:

          • Loss of motor & sensory function below LOI

          • No reflex arc

          • Motor paralysis with flaccidity & muscle atrophy 

          • B/B incontinence & sexual dysfunction more severe than cauda equina injuries 

Impact of injury

• Quadriplegia/ Tetraplegia 

• Paraplegia  

American Spinal Injury Association Impairment Scale 

• Level A Complete 

• Level B Sensory Impairment 

• Level C Motor Incomplete 

• Level D Motor Incomplete 

• Level E Normal 

Manual Muscle Testing (MMT)

Post traumatic Complications 

• Spinal shock 

  • Altered reflex activity immediately following traumatic SCI

  • Result = segments below LOI are deprived of signals; resulting in flaccid paralysis of muscles below LOI & absence of reflexes 

  • Flaccid paralysis of muscles below LOI 

  • No reflex arc 

  • Bladder is catheterized 

  • May require ventilator depending on the LOI (affecting diaphragm and muscles) 

  • Lasts 1 week - 3 months following injury 

  • Areas above LOI will return to normal when spinal shock subsides & areas below LOI will function as if reflex arc is intact 

  • When spinal shock stops = areas of spinal cord above LOI operate as they should & below structure will act like they have a reflex arc 

    • Increased flexor muscle spasticity 

    • Following this phase - increased spasticity in extensor muscles for 6-12 months is common 

    • 1 year post injury = things should start to settle 

      • Think of a plant-> spinal cord still has function above & below LOI = it has communication problems with the brain 

• Autonomic dysreflexia/ Hyperreflexia 

  • Exaggerated response of ANS 

  • ANS responsible for sympathetic & parasympathetic NS responses 

  • Usually occur with individuals with SCIs above T6 

  • Caused by nerves below LOI being irritated 

  • Common sources of irritation 

    • Overfull bladder/bowels 

    • UTIs 

    • Decubitus ulcers (pressure ulcers) 

    • Ingrown toenails 

  • Signs to look out for:

    • Sudden pounding headache 

    • Diaphoresis (excessive sweating) 

    • Flushed skin 

    • Goosebumps 

    • Tachycardia or bradycardia (HR)

  • Body's way of warning person that something is wrong below LOI (intact SCs will feel like it is bothersome or irritating) 

  • Managing = FIND THE CAUSE & ALLEVIATE IT

  • Appear suddenly & must be taking care of promptly 

  • If not dealt with can cause stroke or death 

  • Most prevalent during early stages of SCI but can appear at any time 

• Postural Hypotension 

  • BP decrease 

  • Seen more in cervical or thoracic SCIs 

  • Blood pools in LEs d/t reduced muscle tone in trunk & legs

  • Attempts to sit up following prolonged period of bed rest 

    • Symptoms:

      • Lightheadedness 

      • Dizziness 

      • Pallor 

      • Sudden weakness 

      • Unresponsiveness 

    • Preventative measures 

      • Use of anti embolism hosiery and ab binders (external assist circulation) 

      • Getting into upright position slowly 

• Deep Vein Thrombosis (DVT)

  • Reduces circulation caused by decreased muscle tone

  • Frequency of direct trauma to legs causing vascular damage (trauma during transfers or bed mobility)

  • Prolonged bed rest

    • Signs:

      • Swelling of LEs

      • Localized redness 

      • Low grade fever 

  • Undetected or unmanaged DVT = embolism or death 

  • Greatest risk for DVT = initial 2 weeks post injury  

• Thermal regulation 

  • Maintaining body temp = problem for T6 and above SCIs

  • Poikilothermia = body will assume the same temp as the external environment 

  • Hot weather = body has difficulty regulating (hyperthermia)

  • Cold weather = body  has difficulty regulating and restricting blood vessels (hypothermia) 

  • Extreme temps should be avoided 

• Respiratory complications 

  • At or below T12 = normal respiratory functions 

  • Complete injuries above C4 = will need respiratory 

  • Phrenic nerve stimulator 

  • C4 & below do not usually use respirators but could still have respiratory complications 

  • Deep breathing & assisted coughing techniques & devices used for full breaths 

  • Productive cough techniques to keep lungs clear 

  • Most common cause of death in SCIs****

• Increased spasticity 

  • Increased muscle tone in areas below LOI

  • Amount of spasms = decreases as LOI descends down SC

  • Can be triggered by heightened emotional state/stress, UTIs and infections, positioning and pressure injuries 

    • Upside = Can help with B/B management, transfers, participation in ADLs 

    • Downside = can result in contractures, pain or reduced ability to participate in ADLs

• Dermal Concerns 

  • **refer to book 

• Heterotopic Ossification/ Ectopic Bone 

  • Abnormal formation of bone deposits in soft tissue muscle/joints/tendons 

  • More common in hips & knees & less common in shoulder and elbow 

  • Secondary to injury; most common inTBIs and SCIs 

    • Signs:

      •  Heat, pain, swelling, and decreased AROM/PROM

• Genitourinary Concerns 

  • UTIs = most common and dangerous complication leading to kidney failure 

  • Bladder = sensory & motor functions involved and affected 

  • UMN

    • reflex/spasitic bladder = bladder can contract & void reflexively 

      • Involuntary movement but can be stimulated by reflex arc involvement 

    • Can not rely on sensation 

    • Uses catheters and other methods of emptying bladder 

    • Voiding schedules are used 

    • S2-5 affected

  • LMN 

    • Nonrelfex or flaccid bladder 

    • Seen during spinal shock phase 

    • Reflexive emptying of bladder cannot occur (reflex arc destroyed)

    • Must use catheter schedule and other tactical methods to ensure bladder emptying 

    • Crede maneuver = using pressure of fist on bladder to help empty bladder 

    • Valsalva maneuver = closing glottis and contracting ab muscles 

    • Repeated use can cause hemorrhoids, inguinal hernias, and vesicoureteral (backwards urine flow) 

    • Chronic overstretching of bladder will cause complications with being able to full empty adequately 

    • Residual urine can breed infections including kidney stone, UTIs, kidney failure and potential death 

      • Signs of UTIs:

        • Dark urine, foul smell, fever, chilis, increased spasticity 

      • Best treatment for UTIs = prevention 

        • Voiding schedule 

        • Sterile utensils and methods

        • Maintain proper diet

        • Adequate fluid intake 

        • Prompt attention to warning signs 

• Bowel function 

  • What is peristalsis 

  • Can become of flaccid 

  • Stool can be eliminated reflexively if nerves in rectum are stimulated 

  • ** rest in book 

• MH complications

  • **in book 

Medical/ Surgical Management 

• Should be organized immediately following onset injury 

• Laminectomies 

• Spinal fusion 

• External alignment devices 

  • TLSO

• Devices for cervical stabilization of “halo” devices 

• Pharmacological management 

• Therapeutic hypothermia 

• Fetal stem cell research 

  • ** more located in textbook

Impact on Occupational Performance 

• Grooming 

• Oral hygiene 

• feeding/ eating 

• Bathing 

• Dressing 

• Toileting 

• Personal device care 

• Functional mobility 

• Sexual expression

• Home maintenance

• Care for others 

• Health management 

• rest/sleep 

• Education 

• Work 

• play/leisure 

• Social participation, functional communication, & emergency response 

• Cannot do basic ADLs independently for themselves which puts them in a position where they cannot care for others 

• Basic life events are a challenge due to being unable to take action themselves, they rely on others

  • Ie. finding a ride for their child to go to soccer practice because the tempalegia individual is unable to drive 

  • Cooking 

  • dressing, etc 

• Providing for themselves and their family (if insurance or disability isn't fully covered OR if it isn't enough)