SPINAL CORD INJURY I. MEDICAL BACKGROUND A.

Definition Spinal cord injury (SCI) a traumatic insult to the spinal cord that can result in alteration of normal motor, sensory and autonomic functions. Tetraplegia (Quadriplegia) partial or complete paralysis of all four extremities and trunk including legs, pelvic organs and the respiratory muscles resulting from lesions of the cervical spinal cord Paraplegia partial or complete paralysis of all or part of trunk and (B) LEs resulting from lesions of the thoracic or lumbar spinal cord or sacral roots A. Epidemiolog vibrant, young, active, ell!educated persons young adults ith "#$% in &' to ($ y)o range males " females and usually younger most common level at admission is *+, *#, *' tetraplegia " paraplegia incomplete " complete B. Etiolog Traumatic (most common cause to least common) ,-. falls / usually "+# y)o violence sports Non-traumatic disease or pathological influence B. P!t"ome#"!ni#$ %Me#"!ni$m of In&'( ) usually occurs more to direct forces producing movement of head and trunk rather than direct in0ury to vertebra Flexion most common ,12 typically results in anterior cord syndrome *+ to *3 / most susceptible in cervical region 4&5 to L5 / most susceptible in thoracolumbar region Compression excessive axial loading forces closely associated ith flexion in0uries Hyperextension most common ,12 in elderly (falls ith chin hitting a stationary ob0ect) usually results in central cord syndrome Flexion- otation flexion in0ury directed at a rotated vertebral column S!earing hori6ontal force is applied to ad0acent vertebral column segment "istraction least common ,12 usually applied as a traction force hich is common in hiplash in0uries

C. Clini#!l M!nife$t!tion$ Spinal S!oc# period of areflexia immediately follo ing 7*2 due to sudden ithdra al of connections may last from several hours to eeks but typically subsides ithin 5+ hours early resolution is a good prognostic sign ends hen (8) bulbocavernosus reflex is elicited ! may be (8) before 94:s in LEs return $otor and Sensory Impairments motor function is either partially or completely lost belo the level of the lesion due to disruption of descending tracts sensation is either impaired or absent belo the level of the lesion due to disruption of ascending tracts clinical manifestation of motor and sensory impairments is dependent of specific features of the lesion Impaired Temperature Control loss of autonomic sympathetic control of the follo ing; i. cutaneous blood flo ! <(!) vasoconstriction to cold= (!) vasodilatation to heat> ii. s eating ! compensatory diaphoresis (excessive s eating) occurs above level of lesion ! if incomplete lesion / spotty areas of s eating iii. shivering more fre?uent in cervical lesions usually long!term impairment in tetraplegia 4@ / highest level at hich pt can maintain rectal temp of (3 * if higher level / poikilothermic (body temperature varies and is influenced by external environment like a cold!blooded animal) espiratory Impairment acute and chronic respiratory failure due to; i. instability of costal insertions of the diaphragm ii. increased ork of breathing ! 5 to increased intra!abdominal pressure caused by unusually large excursions of the diaphragm life!threatening manifestation of 7*2 ! brings about 5 pulmonary complications responsible for high mortality rate in early stages of tetraplegia varies considerably depending on level of lesion inspiration ! in thoracic lesions / intercostals are affected (decreased chest expansion) ! in higher lesions / diaphragm and accessory muscles of inspiration are affected expiration ! normally passive through recoil of lung and thorax ! in thoracic lesions / abdominals and internal intercostals are affected (lo ered expiratory volume)

additional factors that may impair respiratory function i. additional trauma sustained at the time of in0ury ii. pre!morbid respiratory problems Spasticity due to release of intact reflex areas from all *A7 control characteri6ed by; i. hypertonicity ii. hyperactive stretch reflexes iii. clonus typically occurs belo level of lesion after spinal shock subsides gradually increased by internal and external stimuli if minimal or moderate involvement / has positive effects on .9L; i. at times assist in functional activity <e.g. provides knee stability in upright position (reflex basis)> ii. expulsion of urinary bladder content iii. maintains bone density by tor?ue force on bone if strong involvement / affects many aspects of rehabilitation and .9L %ladder "ys&unction occurs in ''% of paraplegics and 3$% of tetraplegics Brinary 4ract 2nfection (B42) / most fre?uent medical complication during initial rehabilitation period ! flaccid urinary bladder / during spinal shock conus medullaris / spinal integration center for micturition (75, 7(, 7+) ! B,ALC / lesion above conus medullaris ! L,ALC / lesion to conus medullaris or cauda e?uina Capplies to bladder, bo el and sexual dysfunctions types; i. :eflex Aeurogenic Bladder (B,AL) ! spastic bladder / reflexes are intact ii. .utonomous ) Aon!reflex Aeurogenic Bladder (L,AL) ! flaccid bladder / reflex action of detrussor muscle is absent %o'el "ys&unction develops after spinal shock subsides types; i. :eflex Aeurogenic Bo el (B,AL) ii. .utonomous ) Aon!reflex Aeurogenic Bo el (L,AL) Sexual "ys&unction male response i. erectile capacity ! mediated by parasympathetic nervous system ! higher incidence in L,AL and incomplete lesions ! mechanisms a. reflexogenic erection ! for B,AL ! external stimulation of genitals and perineum b. psychogenic erection ! for L,AL ! cognitive activity mediated from cerebral cortex through thoracolumbar or sacral cord segments

e0aculation ! mediated by sympathetic nervous system ! higher incidence in L,AL, lo er level lesions and incomplete lesions ! cauda e?uina lesion / dribbling e0aculation rather than pro0ectile ! e0aculation vs. orgasm a. e0aculation / physical occurrence b. orgasm / psychogenic cognitive event iii. fertility ! lo level of fertility & due to impaired spermatogenesis 5 due to inability to e0aculate ! L,AL and incomplete lesions / least affected female response i. sexual arousal ! B,AL / intact reflexogenic stimulation but absent psychogenic response ! L,AL / intact psychogenic response but absent reflexogenic stimulation ii. menstruation ! menstrual cycle is interrupted &!( mos. follo ing 7*2 but returns to normal after ards iii. fertility and pregnancy ! can still conceive ! lesion above 4&$ / high!risk pregnancy since uterine contractions signifying start of labor cannot be felt ! 4+ / 4# lesion / may develop autonomic dysreflexia during labor Indirect Impairments and Complications i. 2ntegumentary *omplications ! pressure sores ii. .utonomic Aervous 7ystem *omplications ! autonomic dysreflexia iii. *ardiovascular *omplications ! orthostatic hypotension ! decreased endurance 5 to lo increase in heart rate and oxygen uptake ! 9-4 iv. Dastrointestinal *omplications ! decreased D24 motility including s allo ing ! D2 bleeding ! pancreatitis ! superior mesenteric artery syndrome (vomiting) v. ,usculoskeletal *omplications ! heterotopic ossification (commonly at hips, knees E elbo s) ! contractures ! osteoporosis ! overused upper extremity syndrome vi. :espiratory *omplications ! pulmonary embolism

ii.

! pneumonia ! decreased voice ?uality vii. 7ystemic *omplications ! fever ! infections viii.:enal *omplications ! hypercalciuria ! renal calculi ix. Fost!traumatic 7yringomyelia x. Fain ! traumatic pain ! nerve root (radicular) pain ! spinal cord dysesthesias ! musculoskeletal pain C. Di!gno$i$ Functional Classi&ication i. 4etraplegia ii. Faraplegia Types usually diagnosed 5+ / +@ hours post!in0ury incomplete lesions have (8) sacral sparing ( tests for sacral sparing; ! perianal sensation, anal ink, big toe flexion as to clinical syndromes i. *omplete ! no sensory and motor function belo level of in0ury ! (!) sacral sparing ii. 2ncomplete ! preservation of some sensory or motor function belo in0ury ! (8) sacral sparing
Fain E 4 (5 / + levels belo ) 7pinothalamic 4ract
Bro n / 7e?uard 7yndrome .nterior *ord 7yndrome Fosterior *ord 7yndrome *entral *ord 7yndrome 2psi *ontra

level of

*onscious Froprioception E 7tereognosis 9orsal *olumn

2psi *ontra

Light 4ouch 7pinothalamic 4ract E 9orsal *olumn

2psi *ontra

Bnconscious Froprioception 7pinocerebellar 4ract

2psi *ontra

,otor *orticospinal 4ract

2psi *ontra

(!) (!) (!)

(8) (8)

(8) (!) (8)

(!)

7 7 7 7

(8) (8) (!) (!)

(!)

(8) (8) (!)

(!)

(8) BE " LE

(8) BE " LE

Legend;

(!) G unaffected (8)G affected 7 G slightly affected

(e)els as to neurological level; ! motor / last motor level at least grade ( provided that the motor level above is at least grade + ! sensory / last normal sensory level (grade 5) ! is determined per side <i.e. (:)!sensory, (L)!sensory, (:)!motor, (L)! motor> ! 6one of partial preservation (HFF) / dermatomes and myotomes caudal to the neurological level that remain partially innervated ! used only in complete lesions as to .72. 2mpairment 7cale; - all motor and sensory function A *1,FLE4E absent belo 6one of partial preservation - preservation of any demonstrable, 2A*1,FLE4E, F:E7E:-E9 unproducible sensation, excluding B 7EA71:I phantom sensations JBA*421A.L - absent voluntary motor function - preservation of any demonstrable, 2A*1,FLE4E, unproducible sensation, excluding F:E7E:-E9 C phantom sensations ,141: - voluntary motor function less than A1AJBA*421A.L grade ( - preservation of any demonstrable, 2A*1,FLE4E, unproducible sensation, excluding F:E7E:-E9 D phantom sensations ,141: - voluntary motor function at least JBA*421A.L grade ( - return of all motor and sensory E *1,FLE4E function - possible abnormal reflexes as to skeletal level; ! level in radiographic examination that sho s greatest vertebral damage D. P(ogno$i$ $ortality causes; i. respiratory problems (e.g. pneumonia) ii. heart disease iii. subse?uent trauma iv. septicemia Potential &or eco)ery depends on; i. degree of pathologic changes imposed by trauma ii. precautions taken to prevent further damage during rescue iii. prevention of additional compromise of neural tissue from hypoxia and hypotension during acute management complete lesions ithout recovery after ( months / no further recovery

incomplete lesions / recovery may be seen up to a year or slightly more after hich no recovery is expected Functional *utcomes LE-EL 2A4.*4 ,B7*LE7 JBA*421A.L 1B4*1,E7 *& / *( - trape6ius - ventilator dependent - upper cervical muscles - communication E heelchair mobility through voice or mouth! controlled modifications - tilt table possible - dependent in all other .9L *+ - diaphragm - communication E heelchair mobility through voice or mouth! controlled modifications - heelchair ith lo er headrest - if some function present in shoulder E elbo , adaptive e?uipment (e.g. mobile arm support) may make self!feeding and facial hygiene possible - dependent in all other .9L *# - elbo flexors - transfers, mat)bed - deltoids activities, self!feeding, facial hygiene E upper body dressing possible using adaptive e?uipment - lo er body dressing ith greater challenge - heelchair mobility ith 0oystick or ith obli?ue handrim pro0ections (?uad pegs) but limited to even surfaces - independent pressure relief - dependent in all other .9L *' - rist extensors - transfers, pressure relief, - serratus anterior mat)bed activities E self! feeding possible ithout adaptive e?uipment - heelchair mobility ith coated standard handrims and possibly negotiate minor obstacles, slightly uneven terrain E 5!inch curb - all other .9L possible ith

*3

- triceps - latissimus dorsi - sternal pectorals

*@ - finger flexors 4& / 4+ - full BE function - erector spinae above level of lesion -

4# / 4&5 - erector spinae above level of lesion - 4# / upper abdominals - 4&5 / full innervation of rectus abdominis -

- full innervation of internal E external abdominal obli?ues - L& / partial innervation of iliopsoas - Fartial innervation of ?uadratus lumborum L( / L# - L( / ?uadriceps femoris - alking ith .J1 - L+ / partial tibialis anterior - independent in all other E posterior, E9B)E9L, FL, .9L FB II. MEDICAL MANAGEMEN* A. P"!(m!#ologi#!l + Non,$'(gi#!l +cute Care ithin @ hours post!in0ury ,ethylprednisolone / 2- administration of ($ mg)kg over a &#!min period follo ed by a gap of +# mins, then #.+ mg)kg)hr for 5( hrs. Spasticity 9ia6epam / acts at *A7 level Baclofen / acts at 7* level (best) 9antrolene 7odium / acts on skeletal muscles & intrafusal fibers %ladder "ys&unction :eflex Aeurogenic Bladder (B,AL) i. intermittent catheteri6ation ii. fluid intake restricted to 5$$$ mL)day or &#$!&@$ mL)hr

L& / L5

adaptive e?uipment heelchair mobility possible on ascending)descending steeper ramps E +!inch curb independent in all other .9L independent heelchair mobility independent in all other .9L alking ith K.J1 E Lofstrand crutches or alker but limited to even surfaces independent in all other .9L alking ith K.J1 E Lofstrand crutches possible ith obstacles but limited to even surfaces independent in all other .9L alking ith K.J1 E Lofstrand crutches ith +! point gait independent in all other .9L

.utonomous ) Aon!reflex Aeurogenic Bladder (L,AL) i. timed voiding program

%o'el "ys&unction :eflex Aeurogenic Bo el (B,AL) i. suppository ii. digital stimulation .utonomous ) Aon!reflex Aeurogenic Bo el (L,AL) i. diet ii. fluid intake iii. stool softeners iv. suppository v. digital stimulation vi. manual excavation vii. *rede maneuver Sexual "ys&unction pregnancy i. hospitali6ation prior to expected delivery date to monitor for cervical dilatation Indirect Impairments and Complications pressure sores i. prevention ii. turning schedules iii. skin condition monitoring iv. pressure relief e?uipment E procedures v. patient education autonomic dysreflexia ! considered as a medical emergency i. immediate assessment of drainage system ii. release catheters iii. lo er BF by bringing patient to sitting position iv. check for irritating stimuli v. medical)nursing assistance vi. anti!L4A medication (if above unsuccessful) orthostatic hypotension i. upright tolerance retraining ii. compression garments for LEs (less for abdominals) iii. liberal salt E fluid intake iv. cessation of exercise once symptoms are felt superior mesenteric artery syndrome i. repositioning to (L)!sidelying or sitting hypercalciuria E renal calculi i. decreased calcium intake ii. vigorous hydration iii. increased protein intake 9-4 i. elevation of LEs above heart level ii. thigh!high compression garments to LEs iii. lo !dose heparin, arfarin, coumadin, aspirin traumatic pain

i. ii.

immobili6ation analgesics

nerve root (radicular) pain i. analgesics spinal cord dysesthesias i. *arbanna ) Epine ii. Fhenytoin musculoskeletal pain i. prevent 5 shoulder movement ii. positioning program B. S'(gi#!l ,mergency Care if 7*2 is suspected; i. spinal backboard or full!body ad0ustable backboard ii. supporting cervical collar iii. assistance of multiple personnel in moving patient to safety Fracture Sta-ili.ation Doals; i. establishment of a properly aligned and stable spine ii. removal of any bone fragment that may be compressing the spinal cord cervical in0uries; i. cervical tongs ii. turning frames and beds iii. halo devices iv. vertebral body bone grafting ith) ithout posterior iring of spinous processes thoracic ) lumbar in0uries i. bed rest ii. body cast or 0acket iii. internal fixation device ith) ithout vertebral body bone grafting III. P-YSICAL *-ERAPY ASSESSMEN* AND MANAGEMEN* A. P* A$$e$$ment /se&ul Forms i. .72. 2mpairment 7cale ii. .72. 7tandard Aeurological *lassification of 7pinal *ord 2n0ury iii. Junctional 2ndependence ,easure (J2,) Important Points to +ssess i. :espiratory .ssessment a. function of respiratory muscles b. chest expansion c. breathing pattern d. cough e. vital capacity ii. 7kin .ssessment iii. 7ensory .ssessment ! key dermatomes;

*5 / occipital protuberance *( / supraclavicular fossa *+ / top of acromioclavicular 0oint *# / lateral side of the antecubital fossa *' / thumb *3 / middle finger *@ / little finger 4& / medial side of the antecubital fossa 45 / apex of axilla 4( / (rd 2*7 4+ / +th 2*7 (nipple line) 4# / #th 2*7 (mid ay bet een 4+ E 4') 4' / 'th 2*7 (level of xiphisternum) 43 / 3th 2*7 (mid ay bet een 4' E 4@)

4@ / @th 2*7 (mid ay bet een 43 E 4M) 4M / Mth 2*7 (mid ay bet een 4@ E 4 &$) 4&$ / &$th 2*7 (umbilicus) 4&& / &&th 2*7 (mid ay bet een 4&$ E 4&5) 4&5 / inguinal ligament at midpoint L& / mid ay bet een 4&5 E L5 L5 / mid!anterior thigh L( / medial femoral condyle L+ / medial malleolus L# / dorsum of the foot at the (rd ,4F 0t. 7& / lateral heel 75 / popliteal fossa in the midline 7( / ischial tuberosity 7+!7# / perianal area

iv. 4one and 94:s v. :1, ! complete assessment may be difficult during acute phase 5 to; a. limited mobility (deviations from standard position may be necessary and should be properly documented) b. spinal instability (observe extreme caution) ! complete assessment is necessary during subacute phase of rehabilitation vi. ,,4 ((8 is considered functional) ! complete assessment may be difficult during acute phase 5 to; a. limited mobility (deviations from standard position may be necessary and should be properly documented) b. spinal instability (observe extreme caution) ! key myotomes (for use ith .72. and during the acute phase only);
*# / elbo flexors *' / rist extensors *3 / elbo extensors *@ / finger flexors (distal phalanx of middle finger) 4& / finger abductors (little finger) L5 / hip flexors L( / knee extensors L+ / ankle dorsiflexors L# / long toe extensors 7& / ankle plantarflexors

! complete assessment is necessary during subacute phase of rehabilitation vii. Junctional .ssessment ! usually must be delayed until patient is cleared for activity ! complete assessment is necessary during subacute phase of rehabilitation viii.7acral 7paring B. P* M!n!gement +cute P!ase :espiratory ,anagement i. deep ii. glossop breathing haryngeal exercises breathing

iii. maneuver iv.

airshift

vi.

strength ening exercises v. assisted coughing

abdomi nal support vii. stretchin g

:ange of ,otion and Fositioning ! selective stretching to; a. finger flexors / for *3 or higher levels (tenodesis grasp) b. lo back / to allo transfer of head E shoulder motions to lo er body ! preserve full hip extension if functional ambulation possible by doing prone!lying E prone mat)bed activities hen possible ! &&$!&5$ of 7L: ill facilitate many .9L so stretch hamstrings in supine to preserve lo back tightness ! at ankle, dorsiflexion to neutral is re?uired for heelchair users and full dorsiflexion is re?uired if ambulation is possible 7elective 7trengthening ! emphasis on the follo ing muscles as they are used for most functional activities; a. elbo extensors (tetraplegia) b. shoulder flexors E hori6ontal adductors (tetraplegia) c. scapular protractors E depressors (tetraplegia) d. hip E trunk muscles (paraplegia) ! emphasi6e bilateral BE exercises in acute phase to prevent asymmetric rotational stresses on spine 1rientation to the -ertical Fosition ! done once there is radiographic evidence of stability of fracture site or early fracture stabili6ation methods are complete Su-acute P!ase 7kin 2nspection *ontinuing .ctivities ,at Frograms i. rolling v. pull!ups ii. prone! (tetraplegia) on!elbo s vi. sitting iii. prone! vii. ?uadrup on!hands ed (paraplegia) viii. kneeling iv. supine! ix. transfer on!elbo s s Nheelchair Frescription E Nheelchair 4raining (tetraplegia) .mbulation (paraplegia) i. orthotic prescription ii. JE7 iii. gait training a. putting on and removing orthoses

b. c. d. e. f. g. h. i. 0. k. l. m.

sit!to!stand activities trunk balancing push!ups turning around 0ack!knifing ambulation activities in parallel bars standing from the heelchair ith crutches crutch balancing ambulation activities travel activities elevation activities falling