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List in order (most common to least) the causes of SCI:
- Sports injury
What association sets the neurological classification of SCI?
American Spinal Injury Association (ASIA)
What types of evaluations are included in ASIA?
- sensory evaluation (28 dermatomes)
- motor evaluation (tested by myotomes)
Extensor carpi radialis L and B
flexor digitorum profundus (middle finger)
Abductor digiti minimi
extensor hallicus longus
Main innervation: C1-3
main innervation: C4
main innervation: C5
main innervation: C6
main innervation: C7
main innervation: C8
main innervation: T1
Which level does the client gain full arm function?
main innervation: T2-T12
main innervation: T7-L1
main innervation: T11-L2
main innervation: L2
main innervation: L3
main innervation: L4-L5
hamstring - knee
main innervation: L4-S1
main innervation: S2
main innervation: S2-S3
bowel and bladder
How do you name a SCI?
- designate R v L if function is different
- designate sensory v motor if function is different
- SCI is named by the last NORMAL level of function
What would you expect in an individual w/ quadriplegia w/ C7 motor right, C6 motor left, and C8 sensation?
What would you expect in an individual with T1 motor and sensory paraplegia?
What would you expect in an individual w/ L2 motor paraplegia w/o any corresponding sensory disturbance?
impairment or loss of motor and/or sensory function in UE and LE, trunk, and pelvic organs
Quadri/tetraplegia is a result of lesion in the:
impairment or loss of motor and/or sensory function due to damage in the thoracic, lumbar, or sacral segments of the spinal cord. Function may be impaired in the trunk and/or LE
an injury resulting in a total absence of sensory and motor function in the lowest sacral levels (4-5)
How do you test the lowest sacral level?
- by inserting a finger into the rectum
- if the pt feels it, sensation is intact
- if the pt can squeeze the anal sphincter, motor is intact
What causes a complete lesion?
- complete severing of the cord
- transection of the cord
- vascular impairment to the cord
How long should professionals wait before making a diagnosis of complete v incomplete?
Why should professionals wait before making a diagnosis of complete v incomplete?
to allow pt to recover from spinal shock
How many phases of spinal shock are there?
Phase 1 of spinal shock:
- complete loss or weakening of all reflexes below the level of injury
- usually lasts 24-48 hours
- SC loses descending facilitation
- neurons in reflex arcs normally receive a basal level of excitatory stimulation from the brain
- after SCI, these cells lose this input, the neurons become hyperpolarized, and less responsive to stimuli
Phase 2 of spinal shock:
- occurs over 2-3 days
- some return of some reflexes
- 1st reflexes to reappear are polysynaptic
- monosynaptic reflexes that only involve SCI are not restored until phase 3
- restoration of reflexes proceeds from polysynaptic to monosynaptic
Phase 3 and 4 of spinal shock:
- 1-4 weeks for phase 3
- 1-12 months for phase 4
- characterized by hyperreflexia, or abnormally strong reflexes usually produced w/ minimal stimulation
- phase 3 - hyperreflexia is due to axon-supported synapse growth
Will patient's w/ SCI have spasticity?
yes, every pt will have spasticity
What happens to nerve roots in SCI?
- often damaged as they exit the foramen
- frequently happens at site of lesion
- function of mm innervated by these can be expected to return w/in 6 months of injury
- nerve roots can escape injury
What is the prognosis for recovery for people w/ complete SC lesions?
there is no prognosis at this point
Zone of Partial Preservation
- used only w/ complete injuries
- refers to partial preservation of motor or sensory function below the neurological level of injury
one in which there is partial preservation of sensory and/or motor function below the neurological level and in the lowest sacral segment
An incomplete lesion indicates that some viable neural white matter tracts are crossing the area injured and
innervating more distal segments
In an incomplete lesion, damage from the original injury frequently precedes secondary damage to the:
- spinal cord
- --this includes hemorrhage, edema, ischemia, and hypoxia
In an incomplete lesion, when is secondary damage usually complete?
w/in 24-72 hours post trauma
The National Acute SCI study used methylprednisolone to:
enhance the flow of blood to injured cords, preventing some of the associated hypoxia and ischemia
When is methylprednisolone effective?
only if given less than 8 hours after the injury
What are the types of incomplete lesions?
- central cord syndrome
- anterior cord syndrome
- brown sequard syndrome
- conus medularis lesions
- cauda equina lesions
What is the most common type of incomplete lesions?
central cord syndrome
What causes central cord syndrome?
- anterior and/or posterior cord compression
- acute hyperextension injury
- chronic or congenital condition that results in progressive stenosis
- osteophytes can create a pincher effect
- damage is from microvascular compromise of the center of the cord
What happens in central cord syndrome?
- central gray matter is compromised first b/c its metabolic and perfusion needs are greater, thus is more at risk during periods of comprised circulation
- central white matter is also compromised
- any hemorrhage or edema begin in the center of the cord and spread to the periphery
- resolution occurs in the opposite manner
Which tracts are least affected by this central cord syndrome?
- sacral tracts in all but the posterior (dorsal) columns
- followed by lumbar, thoracic, and lastly cervical
What is the clinical picture of central cord syndrome?
- bilateral flaccid paralysis and sensation loss due to loss of the grey matter AT the level of the injury
- BELOW the level of injury, the client will have spastic paralysis
- clients can re-gain motor and sensation and will do so first in the sacral, then lumbar, then thoracic and finally cervical tracts
- progress may stop at any time
What is the prognosis for central cord syndrome?
- 77% regain ambulation
- 53% regain bowel, bladder, and sexual function
- 42% regain hand function
What is the prognosis for anterior cord syndrome?
extremely poor for return of motor function, bowel, bladder, or sexual function
What causes anterior cord syndrome?
- flexion injuries
- bone or cartilage compromises the integrity of the anterior spinal artery
- frequently caused by teardrop or burst fractures of the vertebral body
What happens with anterior cord syndrome?
- anterior spinal artery vascularizes the entire anterior 2/3 of the spinal cord
- the posterior spinal AA only vascularize the posterior columns -- which carry conscious proprioception, stereognosis, deep pressure, etc.
What is the clinical picture of anterior cord syndrome?
- bilateral flaccid paralysis and sensation loss due to loss of the gray matter AT the level of the injury
- BELOW the level of the injury, the client will have spastic paralysis w/ voluntary motor and sensory loss
- posterior column function remains intact on both sides
What is the cause of Brown Sequard Syndrome?
- stabbing wounds, gunshot wounds, or penetrating injuries
- unilateral facet lock injuries
- burst fractures at the lateral body of the vertebrae
What happens with Brown Sequard syndrome?
one half of the spinal cord is damaged
What is the clinical picture of Brown Sequard syndrome?
- ipsilateral flaccid paralysis and sensation loss due to loss of the grey matter AT the level of the lesion
- BELOW the level of the lesion
- - white matter damage leads to ipsilateral loss of motor and posterior column function. The paralysis will be spastic.
- - white matter damage also leads to contralateral loss pain and temperature, sensation several levels below the level of the injury
What is the prognosis for Brown Sequard syndrome?
- very good
- nearly all pts are able to walk (some w/ orthotics and cane)
- 80% regain hand function
- 100% regain bladder function
- 80% regain bowel function
What causes conus medularis lesions?
injury to the bottom of the spinal cord and lumbar nerve roots
What happens with conus medularis lesions?
results in flaccidity and a lack of return of bowel, bladder, or sexual function
What is the prognosis of conus medularis lesions?
if the bottom of the cord is damaged, there will be no return of function
Where do cauda equina lesions occur?
- L1 vertebrae or below
- occurs at cauda equina, not the spinal cord
What is the clinical picture of cauda equina lesions?
- injures peripheral nn
- flaccid paralysis w/ no spasticity
- do have severe amounts of pain, parasthesia, burning, and tingling occurs
What is the prognosis of cauda equina lesions?
- peripheral injuries regenerate
- pain can be a limiting factor to return of strength and funciton
- will not regain calf and foot intrinsic strength and may require orthotics
ASIA Impairment Scale
complete - no sensory or motor function is preserved in the sacral segments S4-5
ASIA Impairment Scale
incomplete - sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5
ASIA Impairment Scale
incomplete - motor function is preserved below the neurological level and more than 1/2 of the key muscles below the neurological level have a muscle grade less than 3
ASIA Impairment Scale
Incomplete - motor function is preserved below the neurological level, and at least half of key mm below the neurological level have a muscle grade of 3 or more
ASIA Impairment Scale