- Our spinal cord is a continuous structure starting at the base of the medulla and running all the way down to the __-__ intervertebral space in adults. - At this point, the spinal cord tapers into the _______ __________. And then you’ll see this bundle of spinal nerves extending inferiorly from the lumbosacral region and conus medullaris that forms the ______ _______.

- L1-L2 - conus medullaris, cauda equina

- White matter increase _______ to _______. - Volume of gray matter is highest in ______ and ________ regions.

- caudal to cranial - cervical and lumbosacral

Dorsal Column Medial Lemniscus Pathway: - (Conscious) __________, vibration, ______ and _________ touch. - Second order neurons cross in _______ _______ in internal arcuate fibers.

- proprioception, vibration, light and discriminative touch - caudal medulla

Anterolateral Pathway: - _____, _________, ______ touch - Second order neurons cross at level of ______ ______ through anterior commissure.

- pain, temp, crude touch - spinal cord

Lateral Corticospinal Tract: - Function: Volitional movement of _________ ______. - Cross at the _____________ and descend contralaterally.

- contralateral limbs - pyramidal decussation

Anterior Corticospinal Tract: - Function: Control of bilateral _______ and _______ muscles. - Descend ipsilaterally until level of _________, at which point splits into bilateral innervation.

- axial and girdle - spinal cord

Rubrospinal Tract: - Function: Assists LCST with descending drive for movement of _________ limbs. - Originates in _________, crosses in _________, and descends contralaterally.

- contralateral limbs - red nucleus, midbrain

Vestibulospinal Tract: - Medial VST: Originates in ______ medulla, descending bilaterally to cervical region to control positioning of _____/______. - Lateral VST: Originates in ______, descends ipsilaterally down spinal cord to aide in _______ _______ and _______.

- rostral medulla, neck/head - pons, truncal control and balance

Reticulospinal Tract: - Function: Aids in ________ and ____-related movements. - Originates in both _______ and _______ RF and descends __________.

- posture and gait-related movements - pontine and medullar RF and descend ipsilaterally

Tectospinal Tract: - Function: Assists with coordination of _____ and ____ movements. - Originates in __________, crosses in _________, and descends contralaterally to upper cervical cord.

- head and eye movements - superior colliculus, crosses in midbrain

Autonomic Nervous System: - What are the 2 parts of the ANS? - Which is located at the thoracic/lumbar region?

- Sympathetic/Parasympathetic Nervous System - Sympathetic

Week 3- SCI Intro and Pathophysiology Flashcards by Chance Lee Cauble

PART 0: SPINAL CORD ANATOMY REVIEW

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How many vertebrae are there?

7 Cervical
12 Thoracic
5 Lumbar
5 Sacral (fused)
4 Coccyx (fused)

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How many spinal nerves are there?

8 Cervical (C1-C8)
12 Thoracic (T1-T12)
5 Lumbar (L1-L5)
5 Sacral (S1-S2)
1 Coccygeal

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Our spinal cord is a continuous structure starting at the base of the medulla and running all the way down to the __-__ intervertebral space in adults.
At this point, the spinal cord tapers into the _______ __________. And then you’ll see this bundle of spinal nerves extending inferiorly from the lumbosacral region and conus medullaris that forms the ______ _______.

L1-L2

- conus medullaris, cauda equina

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The spinalnerves exitthecervicalspine_____their corresponding vertebral body level. (ex: C7 nerverootexits aboveC7 through the C6-C7 neural foramen. C8exitsin between T1 and C7, since there is no C8 vertebral body level.)
After the cervical region, this layout transitions with the spinal nerves exiting ________ their respective vertebrae.

ABOVE

- BELOW

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What are the 3 parts of the central gray matter?

Dorsal Horn
Intermediate Zone
Ventral Horn

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What is the white matter made of?

-Ascending and Descending columns

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White matter increase _______ to _______.

- Volume of gray matter is highest in ______ and ________ regions.

caudal to cranial

- cervical and lumbosacral

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What are the 2 main blood supplies to the spinal cord?

Anterior and Posterior Spinal Artery

- **Several radicular arteries found throughout the cord supplying segmental vasculature to the SC.

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What are the (3) Ascending Sensory Tracts?

Dorsal Column Medial Lemniscus Pathway
Anterolateral Pathways
Spinocerebellar Pathway

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Dorsal Column Medial Lemniscus Pathway:

(Conscious) __________, vibration, ______ and _________ touch.
Second order neurons cross in _______ _______ in internal arcuate fibers.

proprioception, vibration, light and discriminative touch

- caudal medulla

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Anterolateral Pathway:

_____, _________, ______ touch
Second order neurons cross at level of ______ ______ through anterior commissure.

pain, temp, crude touch

- spinal cord

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Spinocerebellar Pathway:

Unconscious proprioception from ____________.
Terminates in __________.

trunk and limbs

- cerebellum

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What are the (6) Descending Motor Tracts?

Lateral Corticospinal Tract
Anterior Corticospinal Tract
Rubrospinal Tract
Vestibulospinal Tract
Reticulospinal Tract
Tectospinal Tract

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Lateral Corticospinal Tract:

Function: Volitional movement of _________ ______.
Cross at the _____________ and descend contralaterally.

contralateral limbs

- pyramidal decussation

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Anterior Corticospinal Tract:

Function: Control of bilateral _______ and _______ muscles.
Descend ipsilaterally until level of _________, at which point splits into bilateral innervation.

axial and girdle

- spinal cord

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Rubrospinal Tract:

Function: Assists LCST with descending drive for movement of _________ limbs.
Originates in _________, crosses in _________, and descends contralaterally.

contralateral limbs

- red nucleus, midbrain

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Vestibulospinal Tract:

Medial VST: Originates in ______ medulla, descending bilaterally to cervical region to control positioning of _____/______.
Lateral VST: Originates in ______, descends ipsilaterally down spinal cord to aide in _______ _______ and _______.

rostral medulla, neck/head

- pons, truncal control and balance

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Reticulospinal Tract:

Function: Aids in ________ and ____-related movements.
Originates in both _______ and _______ RF and descends __________.

posture and gait-related movements

- pontine and medullar RF and descend ipsilaterally

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Tectospinal Tract:

Function: Assists with coordination of _____ and ____ movements.
Originates in __________, crosses in _________, and descends contralaterally to upper cervical cord.

head and eye movements

- superior colliculus, crosses in midbrain

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Autonomic Nervous System:

What are the 2 parts of the ANS?
Which is located at the thoracic/lumbar region?

Sympathetic/Parasympathetic Nervous System

- Sympathetic

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__________ Nervous System:

Fight or Flight
Pupil dilation
Bronchodilation
Cardiac acceleration
Digestive Inhibition
Piloerection
Systemic vasoconstriction

Sympathetic

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_____________ Nervous System:

Rest and Digest
Pupil constriction
Bronchoconstriction
Cardiac deceleration
Digestion stimulation

Parasympathetic

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PART 1: INTRO AND ACUTE MANAGEMENT

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- What are the (2) ways a spinal cord injury can occur? | - Which is more common and makes up around 90% of cases seen?

- Traumatic - Non-Traumatic -Traumatic

Why does the MOI (force direction) matter in spinal cord injuries?

Depending where/direction of force often dictates where in spinal cord we will see the damage.

- ________ injury is most common in lumbar injuries. - _______-_______ injury is most common in cervical injuries. - ___________ injuries are almost exclusive to cervical injuries.

- flexion - flexion-rotation - hyperextension

What are the (4) spinal areas of greatest frequency of injury?

-C5, C7, T12, L1

What are a few (3) non-traumatic causes of SCI?

- disc prolapse - vascular insult - infections

Traumatic Cervical Injury: - ___ and ___ most frequently involved areas of injury. - Flexion, vertical loading, and extension accompanied by ________ or __________.

- C5 and C7 | - rotation or lateral flexion

Traumatic Thoracic Injury: - Less likely to be injured from traumatic causes due to rib cage and higher _______ as compared to cervical region. - ___-____ _______ is most common site of injury. - Common MOI: _______ motion or vertical compression.

- stability - T12-L1 junction - Flexion

Traumatic Lumbar Injury: - Neurological damage from trauma is usually incomplete due to large vertebral canal and relatively good ________ supply. - Most injuries occur at ___ - Most common MOI: ______ injuries

- vascular - L1 - flexion

Do we typically have to worry about the sacrovertebral column injuries? Why or why not?

-No, because by the time we get down there we are talking about the conus medullaris and cauda equina.

- What is the average age of injury? - Are males or females more at risk? - What percentage of injuries are cervical, thoracic, lumbar? - What is the most frequent SCI? - The frequency of complete vs incomplete paraplegia is about _______.

- 43 years old - Male (78%) - Cervical (>50%), Thoracic (33%), Lumbar (the rest) - Incomplete Tetraplegia - equal

What are the (2) main ways to classify SCIs?

- Tetraplegia | - Paraplegia

- Tetraplegia involves injury to the _______ spinal cord. It involves ____ extremities and the trunk. - Paraplegia involves injury to the _______/________ spinal cord. It involves ______ and _____.

- cervical (C1-C8), all 4 | - thoracic/lumbar (T1-L5), BLEs and trunk

What is another way that we classify SCIs? (2)

- Complete | - Incomplete

Complete SCI: -Absence of ______ and ______ function below lesion level. -More _______ presentation of SCI. Can have Zones of Partial Presentation (ZPP), what is this?

- sensory and motor function - severe - Dermatomes and myotomes caudal to the sensory and motor levels that remain partially innervated.

Incomplete SCI: - Involves partial preservation of _______ and ______ functions below the lesion level. - _______ prognosis than complete SCI due to preserved axon function. - Incomplete SCIs occur _____ frequently than complete.

- sensory and motor - Better - more frequently

The degree of SCI (Complete vs Incomplete, level of neurological injury) is determined by what?

-ASIA Exam

SCI Acute Medical Management: - What is the primary goal of management? - What 2 things may be done to help stabilize the spine? - What drug has a small window of opportunity and helps to stabilize cell membranes, decreases inflammation, increases nerve impulse generation, and improving blood flow to damaged areas? What is the timeframe?

- Stabilize spine, smallest movements can worsen. - Surgery (closed or open decompression), External support devices (HALO, CTLSO, TLSO, ISO) - Methylprednisone (3-8 hours)

How does methylprednisone help incomplete vs complete SCIs?

- INCOMPLETE: Enhances return of some function below spinal level - COMPLETE: increases chances for return of function of the last preserved spinal level post-SCI

What are (3) pathophysiological secondary sequelae of SCIs?

- Ischemia - Edema - Demyelination and necrosis of axons progressing to scar tissue formation

PART 2: COMPLICATIONS OF SCI PT.1

List some complications of SCI.

- Spinal Shock - Autonomic Dysreflexia - Pressure Ulcers - Postural Hypotension - Pain - Spasticity - Contractures - Heterotopic Ossification (HO) - Edema - DVT - Osteoporosis & renal calculi - Respiratory compromise - Bladder & bowel dysfunction - Sexual dysfunction

What are the (3) main autonomic dysfunctions related to SCIs (T6 and above)?

- Spinal Shock - Autonomic Dysreflexia - Impaired Thermoregulation

Spinal Shock: - Temporary phenomenon with injuries ___ and above. - Cord in its entirety ceases to function below the lesion and is thought to be due to loss of ________ tone. - Spinal reflexes, voluntary motor control, sensory function, and autonomic control are absent below the level of the lesion - Initially: ↑ ↑ BP → ↓ BP, HR, hypothermia, venous stasis - Usually resolves within ___-____ days of the injury. What is the 1st thing to typically return?

- T6 - sympathetic tone - 1-3 days, sacral/anal reflexes

Autonomic Dysreflexia: - Over-activity of the ANS, only seen with injuries ____ and above. - Caused by irritating stimulus introduced to body ______ level of SCI. - What is the most common cause? - What are some other causes?

- T6 - below - Most common = FULL BLADDER - full bowel, wounds/pressure sores, burns, ingrown toenails, kinked clothing, foreign object pressing against skin

What are the symptoms of autonomic dysreflexia? (5)

- Pounding HA** - goose bumps - sweating above level of injury - bradycardia - skin blotching

Why are we on high alert for the symptoms of autonomic dysreflexia?

-It is the bodies way of saying that something is wrong.

What are the (6) steps of intervention if we see autonomic dysreflexia symptoms come on?

1. ) If patient lying down, sit them up immediately. 2. ) If already in sitting, remain in sitting (DO NOT LIE DOWN), perform pressure relief 3. ) Check catheter 4. ) Check clothing 5. ) Check skin 6. ) ***Initiate emergency response if not resolved within 10 minutes***

Why is patient education so important with autonomic dysreflexia patients?

-They could be at home one day and have if happen and they need to react or instruct someone on how to react.

Impaired Thermoregulation: - Only seen with injuries ___ and above. - Due to loss of ________ output. - Body's ability to control blood vessel response that conserve or dissipate heat is lost. (sweat/shiver lost, hypo/hyperthermia risk) - ______ level injuries result in greater disturbances in temperature control.

- T6 - sympathetic output - Higher level

What are the S/Sx of impaired thermoregulation? (2)

- Hyperthermia: skin feels hot and appears flushed, feeling weak, dizziness, HA, visual disturbances, nausea, tachycardia, weak or irregular HR - Hypothermia: shivering, exhaustion/drowsiness, confusion, slurred speech,

What patient education is important with patients who have impaired thermoregulation?

Appropriate clothing to match the weather outside and not what they are feeling.

PART 3: COMPLICATIONS OF SCI PT.2

Spasticity: - ___% of SCI patients will experience spasticity (__% identify it as problematic). - More common with _______ lesions. - Why is skin breakdown with spasticity of concern specifically with these patients? - Will often elect to get what to help with spasticity?

- ~65% (50%) - cervical lesions - These are WC bound patients and are at increased risk for breakdown as opposed to ambulatory patient. - Baclofen pump

Pulmonary Dysfunction: - "__, __, ___ keeps the patient alive" (without these, patients will need supportive devices or techniques to breath) - Below ____= normal ventilatory and respiratory function.

- "C3, C4, C5 keeps the patient alive" | - T10

Neurological Level of SCI and Muscles of Respiration: - C1-C2 = What respiratory muscles are functional? - C3-C4 = ? - C5-C8 = ? - T1-T5 = ? - T6-T10 = ? - T11 and below = ?

- C1-C2 = SCM, Upper Trap, Cervical extensors - C3-C4 = Partial diaphragm, Scalenes, LS - C5-C8 = Diaphragm, Pecs, SA, Rhomboids, Lats - T1-T5 = Some intercostals, Erector Spinae - T6-T10 = Intercostals and abdominals - T11 and below = Respiratory muscles intact

Bladder Dysfunction: - What level of spinal cord injury can we see this? - Alteration of reflexive and voluntary control of micturation. - ______ of SCI determines type of dysfunction. - Lesion _______ conus medullaris/sacral segments = spastic/hyperreflexic bladder. (involuntary voiding) - Lesion ______ CM/sacral segments segments = flaccid/areflexic bladder. (overflow and stress incontinence)

- Any level - Level - Above = spastic/hyperreflexic - To = flaccid/areflexic

What are some ways to manage bladder dysfunction? (4)

- External collection devices (catheter) - Intermittent catheterizations - Medication - Surgery (Suprapubic catheter, bladder augmentation)

What is the biggest drawback to catheters?

-Indwelling catheters are a breeding ground for infection. (UTIs often seen if used chronically)

Bowel Dysfunction: - ___% of patients with SCI report bowel dysfunction, and 34% require assistance to manage. - _____ of SCI determines type of dysfunction - Above ___: spastic/reflex bowel (Excrement is involuntary and incomplete). - ___-____: flaccid/areflexive bowel (Bowel overfills and over-distends) - Bowel dysfunction is the 2nd most common cause of ________ ____________. - 40% of individuals with SCI will report significant health problems related to bowel management. What are (3) examples?

- 98% - Level - S2 = spastic/reflex bowel - S2-S4 = flaccid/areflexive bowel - autonomic dysreflexia - rectal prolapse, hemorrhoids, abdominal pain and bloating

What are some ways to manage bowel dysfunction?

-Reflex Bowel Programs (trigger bulbocavernosus reflex through Digital Stim Programs or Bowel Suppositories)

What are the symptoms of bladder and bowel dysfunction? (6)

- Fever/chills - Nausea - HA - Increased spasticity - Autonomic dysreflexia - Dark or bloody urine

Sexual Dysfunction: - Males: Directly related to level and completeness of injury. Erectile capacity spared with _____ lesions, but fertility can be impacted. - Females: Menstruation and fertility more likely to be ________.

- UMN | - spared

Blood Pressure Instability: - What is the most common issue? Why? - ____ dysfunction common - ___ and up: bradycardia, excessive peripheral vascular dilation

- Orthostatic hypotension, due to lack of an efficient muscle tone AND loss of sympathetic vasoconstriction response in the LE's causes Venous Pooling. - Cardiovascular (CV) - T6 and up

What are some ways to manage blood pressure instability?

-TED stockings, abdominal binder**, ace wraps, monitoring fluid intake

Are abdominal binders or LE compression garments more helpful in preventing orthostasis in SCI.

-abdominal binders

Pain: - _________ and __________! - What are some common causes of pain in this population? (4)

- Neuropathic and Orthopedic! | - Irritation and damage to neural elements, mechanical trauma, surgical interventions, poor handling and positioning

- Neuropathic Pain is poorly localized c/o numbness, tingling, burning, shooting, and aching pain and visceral discomfort ______ level of injury. - This can be exaggerated by what things? (5)

- below level of injury | - noxious stimuli, UTI, spasticity, bowel impaction, cigarette smoking

Orthopedic Pain common sites of pain include ______ _______ injuries and __________.

- shoulder overuse injuries - low back **a lot of these are preventative**

Osteoporosis and Renal Calculi: - Due to changes in calcium metabolism. (bone mineral density found to decrease for up to ___ years after injury.) - Decreased ______ may lead to demineralization of bones which can lead to vertebral compression frx and other frx. - Calcium from bones absorbed into blood and deposited into the kidneys which can result in what?

- 3 years - WB - kidney stones

What are some ways to manage Osteoporosis and Renal Calculi?

- Early mobilization - Therapeutic standing - Administration of calcium supplements - Good dietary management

PART 4: THE ASIA EXAM

What is the gold standard for how we pull together diagnostic, clinical and prognostic information about a person's SCI.

-The ASIA Exam

- Do all SCIs have an ASIA exam completed? | - How long does the ASIA Exam take?

- Yes | - 60-90 minutes (no time to do often)

What are the (4) main parts to the ASIA Exam?

- Determine Motor Level - Determine Sensory Level - Determine Neurological Level - Determine ASIA Level

Motor Level: - Refers to the most _______ segment with normal motor function on each side of the body. - Performed by examining ________ in UE and LE, as well as voluntary _____ contraction.

- caudal | - myotomes, anal contraction

Sensory Level: - Refers to the most _______ segment of the spinal cord with normal sensory function on each side of the body. - Evaluated via a key sensory point within each of the ____ dermatomes on the R and L (light touch, sharp/dull) and deep ______ sensation.

- caudal | - 28, anal sensation

Neurological Level: - Refers to the most caudal segment of the spinal cord with normal _______ and _________________ function on both sides, provided there is normal function rostrally. - Helpful in predicting which parts of the body may be affected by paralysis and loss of function. - Used for prognostic indicators and expected ___________ capabilities. - Determined by evaluating integrity of what (3) things?

- sensory and antigravity muscle function - functional capabilities - motor function, sensory function, sacral reflex activity

ASIA Level: - Determine whether lesion is _______ or _________. - ASIA level involves looking at _______/_______ exam, but also considers any preservation of ________ segments. - S4-S5 innervates what?

- Complete or incomplete - sensory/motor, sacral segments (S4-S5) - anus

What are the 5 ASIA Levels?

- A = Complete - B = Sensory Incomplete - C = Motor Incomplete - D = Motor Incomplete - E = Normal

ASIA A: Complete - No ________ or _______ function is preserved in the _________ segments. - ______ may be present.

- sensory or motor, sacral (S4-S5) | - ZPP

ASIA B: Sensory Incomplete - ________ but not _______ function is preserved below the neurological level and includes the _________ segments (light touch/pin prick at S4-5 or deep anal pressure). - AND no motor function is preserved more than ____ levels below the motor level on either side of the body.

- Sensory but not motor, sacral (S4-S5) | - 3 levels

ASIA C: Motor Incomplete - _____ function is preserved at the most caudal sacral segments for voluntary anal contraction. - OR patient meets criteria for _______ ________ status (sensory function preserved at most caudal sacral segments (S4-S5) by LT, PP, or DAP), and has some sparing of motor function more than ___ levels below ipsilateral motor level on either side of the body. (This includes key or non-key muscle functions to determine motor incomplete status.) - For ASIA C - less than half of key muscle functions below the single NLI have a muscle grade ≥ ___.

- Motor function - sensory incomplete status, 3 levels - ≥3

ASIA D: Motor Incomplete -Motor incomplete status as defined above, with at least half (half or more) of key muscle functions below the single NLI having a muscle grade ≥ ___.

- ≥3

ASIA E = _________

-Normal

SCI Prognosis: - ___% of people with SCI who survive the first 24 hours are still alive 10 years later. - Mortality rates are significantly higher in _______ post injury (__-__ more likely to die prematurely than people without SCI). - Life expectancy = ___% of normal and varies based on level of injury. (Higher injury and older age = more negative effects on life expectancy) - What are the 2 leading causes of death in SCI patients? - About ___% of persons with SCI are re-hospitalized one or more times during any given year following injury.

- 85% - first year (2-5x more likely) - 90% - Pneumonoia and Septicemia - 30%

SCI Prognosis: - What are some prognostic indicators for walking? (5) - Which is the #1 prognostic indicator for walking?

- ASIA Level*** - Early exam of reflexes - SCI syndromes - Acquired SCI < Traumatic SCI - Age

Week 3- SCI Intro and Pathophysiology Flashcards

(90 cards)