1
Q
What is the annual incidence of spinal cord injury in the US?
A
54/million
2
Q
What is the prevalence of SCI in the US?
A
245,000 - 353,000 individuals
3
Q
What are the two most common causes of SCI?
A
- MVA (38.4%)
- Falls (30.5%)
4
Q
Nontraumatic Causes of SCI
A
- multiple sclerosis
- cervical/lumbar spondylosis
- amyotrophic lateral sclerosis
- primary/metastatic tumors
- infections/osteomyelitis
- vascular insufficiency/AVM
- herniated intervertebral disc
- SCIWORA
5
Q
What age range comprises the highest percentage of SCI?
A
16 - 30 (58.5%)
6
Q
How is the MOI of SCI different between individuals 0-45 YOA and those 46+?
A
MVA comprises the highest percentage of individuals age 0-45, while falls greatest cause in individuals over 46
7
Q
What is the mean age of SCI?
A
42 YOA
8
Q
What is the incidence of SCI in men vs. women?
A
82% men vs. 19% women
9
Q
What is the breakdown of SCI’s by level?
A
- paraplegia (41.3%); complete = 20% vs. incomplete = 21%
- tetraplegia (58.3%); complete = 14% vs. incomplete = 45%
- C5 = 15.7%
- C6 = 12.7%
- C6 = 12.6%
- T1/2 = 7.6%
- L1 = 4.8%
- Incomplete = 66% vs. complete = 34%
10
Q
What is the system used to classify patients with SCI?
A
International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)
11
Q
Spinal Cord Classification
A
- Sensory - dermatome testing
- Motor motor testing
- Neurological level is the most caudal segment with intact sensory and motor bilaterally
12
Q
How is a complete vs. incomplete SCI differentiated?
A
anal wink test
13
Q
What is required for maximal independent function?
A
- knowledge
- attitude
- ability
*Often will not be achieved until 18 months post injury or longer
14
Q
What are important treatment concepts for SCI?
A
- muscle substitution
- momentum
- head-hips relationship
15
Q
What are important options for muscle substitution?
A
- agonist muscle substitution
- substitution using gravity
- substitution using tension in passive structures
- substitution using fixation of the distal extremity
16
Q
T/F: Zone of partial preservation refers to both complete and incomplete SCI’s
A
False, only complete SCI’s
17
Q
What are the 10 muscle groups on the ASIA exam?
A
- elbow flexors (C5)
- wrist extensors (C6)
- elbow extensors (C7)
- finger flexors (C8)
- finger abductors (T1)
- hip flexors (L2)
- knee extensors (L3)
- ankle dorsiflexors (L4)
- big toe extensors (L5)
- plantarflexors (S1)
18
Q
What are the different ways to classify a SCI?
A
- skeletal level
- ISNCSCI Impairment Scale: complete vs. incomplete; types of incomplete
19
Q
Vascular Supply of the Spinal Cord
A
- the anterior aspect of the spinal cord is supplied by the anterior spinal artery and the posterior aspect is supplied by two posterior spinal arteries
- the Vessel of Adamkiewicz is a branch of the abdominal aorta and supplied the spinal cord from T8-L4
20
Q
Instability of the spinal column results when _ column(s) sustain injury
A
≥2
21
Q
Posterior Spinal Column
A
comprised of:
- vertebral arch (pedicles and facets)
- supraspinous ligament
- ligamentum flavum
22
Q
Middle Spinal Column
A
- posterior wall of the vertebral body
- the posterior longitudinal ligament
- posterior disc
23
Q
Anterior Spinal Column
A
- anterior vertebral body
- anterior longitudinal ligament
- anterior disc
24
Q
Injury to the conus medullaris results in which type of lesion?
A
upper motor neuron lesion, but may have mixed S/Sx d/t proximity to cauda equina
25
Injury to the cauda equina results in which type of lesion?
lower motor nerve lesion; nerve roots arising from the cauda equina innervate the detrussor muscles of the bladder and voluntary muscles of the external anal sphincter and urethral sphincter
26
Spinal shock after the initial SCI results in what transient effects?
temporary cessation of the following below the injury:
- spinal reflexes
- voluntary motor
- sensory functions
- autonomic control
27
What factors determine the extent of the SCI?
- boney impingement
- vertebral column displacement
- ligamentous injury
- vascular interruption
28
Flexion Injuries
Review in notes
29
Extension Injuries
Review in notes
30
What is meant by "quadruple threat" of injury?
- tissue destruction at the time of injury
- cellular disruption
- death by messenger - apoptosis
- functionless areas in the spine due to scar
31
Spinothalamic Tract
- pain, temperature, and crude touch
| - affects side contralateral to the lesion
32
Spinoreticular
- deep pain
| - affects side ipsilateral to the lesion
33
Dorsal Columns
- proprioception, vibration, discriminative touch
| - affect side ipsilateral to the lesion
34
Lateral Corticospinal/Rubrospinal Tract
- limb motor
| - affects side ipsilateral to the lesion
35
Ventral Corticospinal
- axial motor
| - affects side contralateral to the lesion
36
Vestibulospinal
- postural reflexes
| - affects sides bilaterally
37
Anterior Cord Syndrome
- dorsal columns intact
- loss of motor function - immediate
- loss of pain and temperature in the lateral spinothalamic tracts
- flexion injury (i.e. teardrop fx, burst fx, ASA damage)
38
Brown-Sequard Syndrome
- incomplete lesion of the spinal cord
- damage to only one side - ipsilateral UMNL
- proprioception, vibration, discriminative touch - lost ipsilaterally
- motor control lost - ipsilaterally
- pain, temperature - lost contralaterally
- penetrating traumatic injury (i.e. stabbing, gunshot, pen/screwdriver) or unilateral facet fx/dislocation
39
Central Cord Syndrome
- most common incomplete SCI
- the periphery of spinal cord spared, but lateral columns are affected
- usually the cervical cord
- pronounced UE weakness
- older adults w/ cervical spondylolysis and extension injury AND younger persons w/ trauma
- high amounts of spasticity usually present
40
What are the three potential causes of central cord syndrome?
1. hemorrhage and necrosis
2. damage to sulcal arteries (supply the central portion of the spinal cord)
3. common in extension injuries in older adults
41
Conus Medullaris Syndrome
- hyperreflexia
- hypertonicity
- preserved bulbocavernous reflex and anal sphincter tone (neurogenic bowel and bladder)
- bilateral symmetrical symptoms
42
Cauda Equina Syndrome
- flaccid paralysis
- absent reflexes (stretch, bulbocavernous)
- flaccid bowel and bladder
- usually asymmetrical
43
The extent of SCI depends upon the ________ and ________ of damage
severity and location
44
Which historical figure introduced the idea that the spinal cord is an extension of the brain?
Galen
45
Who developed the first dedicated spinal cord unit? Where?
Dr. Munro at Boston City Hospital
46
When did the VA begin developing units dedicated to SCI?
1943
47
When was the Model Spinal Cord Injury Systems (MSCIS) developed?
1970
48
How many new cases of SCI are there per year?
17,000
49
Where are patients discharged following SCI?
- 89.3%
- 6.6%
- others to group homes or hospitals
50
What is the LOS for tetraplegics at CHH? Paraplegics?
27.7 days vs. 19.8 days
51
The cervical spine innervates the:
neck, shoulders, arms, and diaphragm
52
The thoracic spine innervates the:
chest, back, and abdominals
53
The lumbar spine innervates the:
back and legs
54
The sacral spine innervates the:
posterior thighs, feet, genitals, and rectum
55
Injury from the cervical to thoracic vertebrae results in:
UMN lesion
56
Injury to lumbar vertebra results in:
LMN lesion (cauda equina)
57
Injury at T10-L2 vertebra level results in:
mixed lesion
58
Upper Motor Neuron
- hyperreflexia
- increased muscle tone
- spasticity
59
Lower Motor Neuron
- areflexia
- decreased muscle tone
- atrophy
60
What specific injuries accompanying SCI will determine the extent of neurological deficits?
- bony injuries
- nerve impingement
- presence of cord edema
- hemorrhage
61
What accounts for the 2˚ injury and swelling following SCI?
free radicals and glutamate release
62
Spine Injury Precautions after Spinal Cord Injury
- log roll only until spine surgery done and/or spinal orthotic fabricated
- orthotic on at all times
- head of bed < 30˚ degrees with orthotic off
- no hip flexion greater than 90˚
63
Halo vest
- restricts 90% of flexion/extension
- restricts all lateral flexion/rotation
- requires well-molded vest
- orthotic on at all times
64
SOMI
- restricts 80% flexion
- 85% extension/lateral flexion
- 60% rotation
- orthotic on at all times or change to c-collar in bed w/ HOB < 30˚ with orthotic off
- full orthotic on prior to OOB
65
Hard Cervical Collar
- restricts 75% flexion/extension and lateral flexion
- 50% rotation
- orthotic on at all times
66
Soft Cervical Collar
- restricts 5% flexion/extension
- 10% lateral flexion
- no rotation restriction
- orthotic on for comfort
67
TLSO
- restricts 60% flexion/extension
- 50% lateral flexion
- 30% rotation
- HOB < 30˚ w/ orthotic off
- no hip flexion greater than 90˚
68
LSO
- restricts 60% flexion/ext
- 40% lateral flexion
- 20% rotation
- HOB < 30˚ with orthotic off
- no hip flexion greater than 90˚
69
When does back strengthening begin?
not until the pt is completely weaned from the orthotic
70
Restrictions after SCI
- determine if presence of fractures and weight-bearing restrictions
- determine if there are any restrictions to ROM
- determine if any contraindications to particular therapies
71
T/F: You should grade up when performing the ASIA exam
False
72
Motor Grading Scale
```
0 = total paralysis
1 = palpable contraction
2 = active movement gravity eliminated
3 = active movement against gravity
4 = active movement against resistance
5 = active movement against full resistance
```
73
What determines complete versus incomplete?
presence of sensory or motor function at the S4/S5 level (rectum); volitional anal contraction, uni- or bi- LT/SDD that can be normal or impaired, OR the presence of any deep anal sensation on digital rectal exam
74
International Standards Exam - A
complete = no motor or sensory function is preserved in the sacral segments
75
International Standards Exam - B
incomplete = sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5
76
International Standards Exam - C
incomplete = motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle grade less than 3
77
International Standards Exam - D
incomplete = motor function is preserved below the neurological level and more than half of the key muscles below the neurological level have a muscle grade of 3 or more
78
International Standards Exam - E
normal = motor and sensory function is normal
79
When does most of the recovery occur in SCI patients?
6 mos up to 2 years
80
Central Cord Syndrome
- most common incomplete SCI
- seen in cervical cord injury
- characterized UE>LE weakness
- common in older individuals
- usually d/t hyperextension injury
- pts usually able to walk
- prognosis is good
81
What is the recovery progression of Central Cord Syndrome?
LE followed by bladder then proximal UE and sometimes hand
82
Brown-Sequard Syndrome
- 2-4%
- ipsilateral loss of sensation at the level of the lesion
- ipsilateral flaccid paralysis at the level of the lesion
- ipsilateral loss of position sense and vibration below the lesion
- contralateral loss of pain and temperature below the level of the lesion
83
Where does recovery start in Brown-Sequard Syndrome?
- ipsilateral proximal extensors, then distal flexor muscles
| - most regain B+B control
84
Anterior Cord Syndrome
- due to loss of blood flow to the anterior 2/3 of the spinal cord while preserving the posterior columns
85
T/F: motor and sensory occur at the same rate following SCI
True
86
T/F: Above T9 show no LE recovery
True
87
T/F: T9 to L2 show hip, knee, and foot recovery
False; these patients do not show foot recovery
88
Presence of lower abdominal motor function increases likelihood of _____ _____ recovery
hip flexion
89
T/F: Motor recovery takes longer than sensory
True; 12 months versus 3 months
90
Medical complications in SCI
- pneumonia
- blood clots
- AD
- irregular heartbeat and low BP
- spasticity
- HO
- pressure ulcers
- pain
- urinary and bowel retention incontinence
- sexual dysfunction
- contractures
- osteoporosis
91
At which level do individuals have impaired ability for inspiration and expiration
T8 and above
92
What's an important consideration in tetraplegic patients in terms of pulmonary embolism?
patients will not be able to feel chest pain from a PE
93
Orthostatic Hypotension
- an abnormal drop in BP wit upright position change
- due to interruption of the descending central axons that control the sympathetic outflow
- an absence of sympathetic response to positional changes with lack of vasoconstriction in the periphery
94
What are some of the causes of AD?
- distended bowel/bladder
- tight clothing
- pressure ulcers
- ingrown toenails
- UTI
95
Treatment for AD
- sit the patient up
- loosen clothing
- catheterize bladder
- check for fecal impaction
96
Spasticity results from a disturbance in the stretch reflex pathway with loss of __________ __________
descending inhibition
97
Spasticity is seen in individuals with a SCI above what level?
T10
98
How little time does it take for a pressure injury to develop? What tissue is most at risk?
30 mins; muscle
99
Heterotopic Ossification
- formation of bone in abnormal anatomic locations, usually periarticular
- hips > knees > shoulders > elbows
- onset typically 1 to 4 months post-injury
- presents with ST swelling, increased warmth, erythema with increasing duration, and loss or ROM
100
Treatment of HO
- active ROM
- Etidronate Disodium (Didronel)
- surgical resection
101
Osteoporosis after SCI
- 33% of bone loss at 25 weeks post-injury
102
Osteoporosis Treatment Options
- hormone replacement therapy
- Calcium and Vitamin D replacement
- Calcitonin
- Bisphonates
103
T/F: Early neuropathic pain is an indicator of long-term chronic pain
True
104
Post-Traumatic Syringomyelia
- cystic cavitation and gliosis of the spinal cord
- causes compression of the posterior and dorsolateral columns with early involvement of the spinothalamic tracts - pain/temperature
105
The bladder is innervated by what levels?
S2-S4
106
Flaccid Bladder
- LMN injury - below T12
- require intermittent catheterization q 3-6 hrs
- consider foley, suprapubic tube, condom catheter
- increased risk of UTI
107
Spastic Bladder
- UMN injury - above T12
- combination of bladder and sphincter dyssenergia
- require intermittent catheterization q 3-6 hrs
- foley, SPT, or continent stoma
- increased risk of UTI
- May use anti-cholinergic meds to decrease bladder spasms
108
Complications of Neurogenic Bladder
- UTI
- hydronephrosis
- renal stones
- bladder stones
- bladder cancer
- urethral damage/fistulas
109
Reflexive Bowel
- Above T12
- typically requires laxative
- bowel care is best when done 30 mins after a meal and upright
- require digital stimulation every other day at least
110
Areflexive Bowel
- below T12
- flaccid rectal sphincter
- high risk of incontinence
- require large amounts of fiber to bulk up stool
- require digital stimulation daily or after every meal
111
Neurogenic Bowel Complications
- impactions
- right sided nausea, vomiting, small formed stools, abdominal distension
- left-sided diarrhea abdominal distension
- hemorrhoids
- obstruction
112
Normal sexual function relies on the interaction of what two systems? What aspects of the cord?
- reflexogenic and psychogenic
| - higher cortical centers, thoracolumbar, and sacral cord
113
Pregnancy after SCI
- minimize use of meds that have teratogenic effects
- risk of pressure ulcer increased with added weight
- increased risk of UTI which may cause preterm labor
- increase fetal size increases respiratory compromise T5 and above
- Increased risk of thromboembolism
- difficult to detect labor with T10 and above - may have AD
- HTN for mom
- uteroplacental constriction/asphyxia for baby - C section
114
Pediatric SCI
- MVC most common cause
- may present with SCIWORA in children less than 10 yoa and most associated with complete injuries
- may have delayed neurological deficits from 30 mins to 4 days
115
Spinal Cord Independence Measure (SCIM)
- 17 items scored
- more sensitive to change than FIM
- valid and reliable
- 0-100 scale (higher = more functional independence)
116
Neuromuscular Recovery Scale
- helps predict outcome and prognosis
117
Quality of Life Index
- 7-point rating scale
- 5 statements
- reliable and valid in a variety of age groups
- important to reassess d/t change in perspective over time
118
Craig Handicap Assessment and Reporting Technique
- 6 categories
- cognitive independence
- physical independence
- mobility
- occupation
- social integration
- economic self-sufficiency
119
Physical Activity Recall Assessment for people with SCI( PARA-SCI)
- looks at energy expenditure for ADLs as well as more involved activities
120
Options for examining gait in SCI patient
- WISCI II
- 6-minute walk test
- timed up and go
- 10-meter walk test
- Rivermead Mobility Index
- Functional Ambulation Index
121
options for examining UE function in SCI patients
- CUE - Capabilities of Upper Extremity Function
- Grasp and Release Test
- Tetraplegic Hand Activity Questionnaire
- Wheelchair User's Shoulder Pain Index
122
What factors determine the outcome post-SCI
- type of injury
- canal to cord ratio
- speed/quality of emergent care
- pre-existing conditions
- age
- spasticity
- motor function recovery
- neurological level (most reliable for complete SCI)
- pain
- ROM
- body habitus
- mentation
123
C0-C4
- Innervates scalenes, SCM, levator scapulae, upper trap, and a portion of the diaphragm
- poor tolerance to vertical
- variable communication abilities
- dependent for care
- power w/c w/ specialty controls
- hoyer lift
- hospital bed
124
C5
- Innervates trapezius, rhomboids, deltoid, biceps (partial), brachialis, pecs (partial), serratus, rotator cuff, brachioradialis
125
What are the four domains for assessing pain using the International SPinal Cord Injury Pain Extended Data Set
- pain symptoms
- sensory signs
- treatments
- psychosocial domains and comorbidities
126
Nociceptive fibers
- A-delta: fast
| - C fibers: slow
127
Chemical nociception
pain arising from actual tissue damage
128
Mechanical nociception
pain arising from stretching of collagen fibers and this squeezing nerve endings between them
129
What is the most common type of pain following SCI?
neuropathic
130
What are the categories of neuropathic pain?
1. ectopic foci
2. ephaptic transmission
3. central sensitization
4. structural reorganization
5. altered top-down modulation
131
Ectopic foci
myelin damage leads to ion channel production and abnormal sensitivity to mechanical and chemical stimuli
132
Ephaptic transmission
crosstalk between nerves in demyelinated areas
133
Central sensitization
excessive responsiveness to peripheral input leads to alteration in central function
134
Structural reorganization
neuroplasticity in the CNS
135
Altered Top-Down Approach
decreased anti-nociceptive signals and increased nociceptive signals
136
What are the two main categories of nociceptive pain?
musculoskeletal and visceral
137
UE MS pain is persons with SCI 2x as likely if:
- female
- >40 YOA
- tetraplegic
- < 1 year with SCI
- completeness of injury also factored in
138
Neuropathic Pain
pain initiated or caused by a primary lesion or dysfunction of the nervous system
139
Above-level neuropathic pain
- CRPS
| - peripheral nerve compression
140
At-level neuropathic pain
- present in a segment or dermatomal pattern at or within 1-2 segments above or below the injury
- often associated with allodynia or hyperesthesia of the affected dermatome
- damage to the nerve roots, spinal cord, or development, of a syringomyelia
141
Below-level neuropathic pain
- also referred to as central pain, deafferentation pain, phantom pain
- spontaneously or evoked pain present diffusely below the level of the injury
142
Overactivity in which two tracts results in an UMN lesion?
vestibulospinal and reticulospinal
143
Characteristics of spinal cord spasticity
- disinhibition of the LMN below the spinal lesion results in increased excitability
- velocity-dependent increase in tonic stretch reflex
- brisk DTR
- exaggerated cutaneous reflexes
- involuntary flexor and extensor spasms
- clonus
144
Possible sites of circuitry alteration include:
1. increased neurotransmitter release between the Ia afferents and the MNs and the MNs and interneurons (increased glutamate)
2. changes in motor neuron excitability
3. sprouting of excitatory inputs
4. dendritic atrophy of the motor neurons
5. denervation hypersensitivity - post-synaptic changes in receptor number
6. changes in the serotoninergic system
145
Myoplasticity following SCI
- increased number of weak actin-myosin bonds
- disuse atrophy
- contracture
146
What are ways in which to measure spasticity?
- Modified Ashworth Scale
- DTR scale
- Penn Spasm Frequency Scale
- Spinal Cord Injury Spasticity Evaluation Tool
- Tardieu Scale
147
H/M ratio
reflects motor neuronal excitability; higher in spastic patients
148
Reason to treat spasticity
- painful
- interferes with mobility
- interferes with bowel and bladder function
- interferes with ADLs
- interferes with sleep
- causes other medical complications
- causes embarrassment for the patient
- pressure sore development
149
What are the four components of SCI injury?
- anatomical
- inflammation
- excitotoxicity
- neurochemical
Spinal Cord
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