Spinal Cord Injury

Dont forget to go back over your notes from Physical Disabilities Conditions. The assumption here is that you remember that information.

What is Spinal Cord Injury? Etiology

any injury to the neck or back that interrupts spinal cord function. 200,000-500,000 spinal cord injured persons in US 8,000-10,000 new injuries annually that result in paralysis Average age- 16- 30
(19 is most frequent)

Male:female ratio is 4:1

Causes of Traumatic SCI

MVA approx. 37% Falls Violence (i.e. gun shot, stabbing) Sports injury of which 66% are diving accidents

Other Causes of SCI

CA spinal arthritis ankylosing spondylitis Degenerative arthritis or cervical or lumbar- can have compression fractures or bone grown vertebrae resulting in limits to ROM Stenosis-shrinking of space post-polio syndrome-people had polio when child and when they age symptoms show up

Types of Spinal Cord Injuries

Complete- total paralysis and loss of sensation by total destruction of the ascending and descending pathways
Zone of partial preservation (sparing)- areas caudal to level of injury with intact sensation and or motor function= spinal cord completely severed or when spinal tissue deoxygenated,,swellig cn close space and stop o2

Incomplete- partial preservation of sensory and/or motor function

Labeling SCI
The injury is labeled from the last (most caudal) level with INTACT sensory and motor function bilaterally. Below that level is impaired

So tell me about a person with a C5 complete SCI

Lets meet Elva

C5/c6 sc injury.

Tetraplegia v Paraplegia

Tetraplegia (old term quadriplegia)- C8 and higher Paraplegia- below C8

ACUTE SCI
Spinal Shock
Occurs after trauma to spinal cord Usually resolves within a few weeks, but can take up to a few months

Maintain (create airway)- tracheostomy (well talk about respiratory function later) Determine extent and type of injury

Cervical Spinal Stabilization (internal)

Decompress spinal canal by removing all bony and soft tissue elements pressing against the cord (often anterior) Wiring of spinous processes Graft using iliac crest, fibula or tibia Rods Sometimes plates and screws provides internal stabalization to provide stability so it can heal.

Cervical Spinal Traction/Support (external)

Tongs or calipers (Somers, 41) Supportive bed Stryker Frame (Somers, 42) Halo- rigid brace used later, after cervical traction with tongs
Contraindications include severe respiratory problems, chest injuries and burns on the trunk or abdomen

Semi-rigid cervical orthoses- later Cervical collar- later

Thoracolumbar Stabilization
Internal
Usually rods and/or fusions Sometimes screws and plates

External

TLSO
Jewett Brace

Assessment
Sensory Motor
Tone (spasticity- different than CVA) Strength Endurance Posture- alignment and control Soft tissue integrity- skin, joints

Psychosocial
Values, interests, self concept, role performance, coping

Treatment Intervention/Expectations C 1-4

C C C C C
1 2-3

4
2-8 1-7

TEAM/Roles Resp therapy PT Nutrition OT Psychology

Expectation Dependent some/all care; use of assistive technology

C 5-6 I (most tasks)with equipment

C5 C6 Tenodesis- how do you maintain? Respiratory- no obliques/abdominals Spasticity- may need meds Positioning- maintain shortening in low back Medical complication- HO, OH, DVT Too much biceps without triceps
How do you compensate for lack of triceps?

Case Study- WEAK C5 injury

(weak biceps)
Using mobile arm support secondary to limited UE strength; allows flexion at elbow with hand moving toward mouth and extension with hand moving toward table

Write a long term goal (1 month)

C 6-7 I with equipment C8T1

C C
6-7 7-8

C6 extensor carpi radialis longus and brevis C7 triceps C8 flexor digitorum profundus

C 8 T 1 T1 Interossei C8 C8T1

Thoracic, Lumbar and Sacral SCI

T 1-5 T 11 and below- expect to walk with/without braces L 1-4 L 5 S3 S 4-5 S2-5 bowel and bladder

Other Considerations
Respiratory Bowel and Bladder Function Orthopedic Restrictions Spasticity Medical Complications Spinal Cord Injury Syndromes

Respiratory Considerations
Initially after injury- often requires intubation If the lesion is below C5, there is a good chance that the person will eventually be able to breath on his/her own If the lesion is between C3 and C5, may or may not need mechanical ventilation High injury (C3 or higher) need ventilator Incomplete injury? Difficult to predict outcome of respiratory abilities

Tracheostomy what it is and how it works

Trach Placement

Suctioning
NOT dependent on presence of trach tube

Signs of need for suctioning

frightened look flared nostrils restlessness paleness or bluishness around mouth clammy skin sinking in of the chest (retractions)

Other respiratory considerations

Assisted cough Weaning from mechanical ventilation

Bowel and Bladder Function

Spastic v. flaccid bladder (go back over old notes) Bowel program
Equipment

Bladder care and catheterization

Orthopedic Considerations
Cervical injury- placement of halousually restricted to 90 flexion/abduction at shoulders Other?

Spasticity Explain the difference

between the spasticity

seen following SCI v. CVA

Med Complication: Autonomic Dysreflexia

Characterized by sudden severe headache secondary to an uncontrolled elevation in BP Caused by any variety of stimuli creating an exaggerated response of the sympathetic nervous system
Over-distended bladder, bowel impaction, urinary infection, or other infection (like pressure sore, ingrown toe nail)

Occurs mainly when injury is T 4-6 or higher Treatment is to remove the aversive stimuli

Med. Complication: Orthostatic Hypotension

Also called postural hypotension Dramatic fall in BP when upright posture is assumed Disturbed vasomotor control with decreased blood supply returning to heart Occurs mainly with injury T4-6 or higher, with increased incidence at higher levels.

Med. Complications: Deep Vein Thrombosis

Development of a blood clot in the venous structures Why? Tx?
Prevention After occurrence

Med. Complication: Heterotopic Ossification

occurs below the level of the injury usually at major joints (esp. hips, also knees, shoulders, elbows) may present w/ signs of localized inflammation or pain, elevated skin temp, etc. Tx- meds, radiation, operative resection (still risk recurrence)

Central Cord Syndrome

Caused by damage to the central portion of the cervical cord Corticospinal tract fibers are organized with those controlling the arms located most centrally, the trunk intermediately, and the legs laterally UE involvement with LE sparing
Incomplete SCI

Brown Sequard Syndrome

Damage to one side of the cord Loss of function below the level of injury of the portion of the cord that controls voluntary motor pathways on the same side of the body and pain and temperature on the opposite side of the body

Incomplete SCI

Anterior Cord Syndrome

Damage to the anterior portion of the cord Loss of function below the level of injury of the part of the cord that controls voluntary motor pathways and major sensory tracts Sparing of posterior columns, as vascular supply is obtained from different source Preservation of position, vibration, and touch senses
Incomplete SCI

Conus Medularis and Cauda Equina Injuries

Loss of motor function Sensory function NOT markedly impaired Extremely variable pattern with asymmetrical involvement Nerve roots have some recovery potential, so outlook is often favorable
Incomplete SCI

Prevention