Spinal Cord Injury - Management of Neurological Disorders

ASIA impairment Scale Category E

E = Normal Motor and sensory functions are normal in all segments, and the patient had prior deficits.

Dorsal column/ posterior cord: rare (Strong ligament and natural tendency to bend forward)

Incomplete injury that results from damage to the posterior spinal artery by a tumor or vascular infarct.. Loses ability proprioception and vibration sensation The ability to move and to perceive pain remains intact RARE

Brown-sequard syndrome:

Occurs from hemisection of the spinal cord (damage to one side) and is typically caused by penetration wounds (gunshot or stab). Partial lesions occur more frequently. Clinical features are asymmetrical. On the ipsilateral (same side)as lesion, there is paralysis and sensory loss.

T10-L2

innervation of lower ab muscles assist with respiratory function - pt able to initiate cough therapeutic ambulation and ambulate in home with orthoses and assistive devices possible if incomplete WC is primary locomotion mode

cervical flexion/rotation injury

most common injury in cervical region (SCI)

Cervical flexion and rotation injury:

most common, rear end mva fq produce (ROTATION OPENS UP A LITTLE MORE = MORE INSTABILITY) posterior spinal ligaments rupture, displace uppermost vertebra over the one below rupture if intervertebral (IV) disc

Stabilization, regardless of the method of stabilization employed, recovery for the individual will depend on (3),,,

(1) the extent of pathologic changes caused by the trauma, (2) the prevention of further trauma, and (3) the prevention of secondary medical complications

Surgery is indicated in the following situations(4):

(1) to restore the alignment of bony vertebral structures (2) to decompress neural tissue (3) to stabilize the spine by fusion or instrumentation (4) to allow the individual earlier opportunities for mobilization

hyperextension injury

-horizontal force moves vertebrae forward -vertebrae is angulated -spinal cord is compressed

SCI caused by (mostly)

1. MVA 2. falls 3. violence 4. sports-related

There is a gradual increase in spastic hypertonia during the first ___ months and a plateau is usually reached 1 year after injury.

6

Medical intervention: following an acute sci, the pt should be immobilized and transferred to a trauma center. Acute med. Mngmt, admin of GM-1, ganglioside (similar to TPA) When admin w/in the 1st __ hours can limit the extent of the initial injury by decreasing the effects of the post traumatic ischemia and enhancing blood flow.

8

How long before bony fusion is usually complete

8 weeks

ASIA impairment scale Category A

A = Complete No motor or sensory function in the sacral segments (S4-S5). usually result of complete spinal cord transection, spinal cord compression, or vascular impairment

Autonomic Dysreflexia: input and output

Afferent input from these stimuli reach the lower spinal cord (lower thoracic and sacral areas) and initiate a mass reflex response resulting in elevation of blood pressure. Impulses from the vasomotor center cannot pass the site of the lesion to counteract the hypertension by vasodilation. The lack of inhibition from higher centers, hypertension will persist if not treated promptly. Can cause life threatening complications

ASIA impairment scale Category B

B = Sensory Incomplete Sensory but not motor function is preserved below the neurologic level and includes the sacral segments S4-S5, And no motor is preserved more than three levels below the motor level on either side of the body.

Spasticity is generally managed through a variety of methods including stretch, modalities and medications. Such as:

Baclofen (implanted pump delivers small amount directly at the spinal cord level to minimize side effects)..Pts may develop a tolerance to prolonged use of individual drugs. Surgical approaches may be used to combat spasticity in more severe cases and are only considered after all other alternative interventions have been tried.

Initiating stimuli of Autonomic dysreflexia

Bladder and bowel distention/irritation (most common) common bladder issues to trigger AD are UTI, distended bladder, blocked catheter, kidney stores, irritation of bladder or urethra during cath or other procedures

ASIA impairment Scale Category C

C = Incomplete Motor function below the neurological level, and more than half of key muscles below the neurological level have a muscle grade of less than 3.

Certain areas of the spinal column are more susceptible to injury than others.

C1, C2, and C5 through C7 thoracolumbar area, T12 through L2 are most often affected... Movement (rotation EXCEPT ABOVE C1) is greatest at these segments and leads to instability with the regions

Trauma is the most frequent cause of injury in adult rehabilitation populations...

Can be precipitated by compression, penetrating injury, and hyperextension or hyperflexion forces..Resultant injury to the spinal cord can be temporary or permanent...Severe injuries to the vertebral column can also result in partial or complete transection of the spinal cord

Central Cord Syndrome: Most common SCI syndrome

Can result from progressive stenosis or compression that is consequence of hyperextension injuries to the cervical region... Bleeding into the central gray matter causes damage to the spinal cord... also associated with congenital or degenerative narrowing of the spinal canal.... Involvement of UE is greater than LE involvement Varying degrees of sensory impairment occur but tend to be less severe than motor deficits. Spinothalamic tract, corticospinal tract, dorsal column damage With complete preservation of sacral tracts, normal sexual, bowel and bladder function may be retained. Patients typically recover the ability to ambulate. Some distal UE weakness and loss of fine motor control remain, which can result in moderate to severe limitations in the ability to perform functional tasks... Functional independence in ADLs depends on the amount of upper extremity innervation the patient regains

Tetraplegia (quadriplegia) incomplete= 39%; complete= 16%

Complete paralysis of all four extremities and trunk, including the respiratory muscles-results from lesions of the cervical cord. Individuals with injuries to the cervical region of the spine Functional impairments in the upper extremities, trunk and pelvic organs

Paraplegia complete= 22%; incomplete= 21%

Complete paralysis of all or part of the trunk and both lower extremities, resulting from lesions of the thoracic or lumbar spinal cord or cauda equine. Injuries involving the thoracic spine.. Upper extremity function is spared, but there are varying degrees of lower extremity, trunk, and pelvic organ involvement

ASIA impairment Scale Category D

D = Incomplete Motor function below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.

spinal cord lesions

Decrease in sensation below a sharp band in the abdomen/trunk, pinprick felt above this level but not below it Lesion is a general term for tissue that has been injured, destroyed, or otherwise has a problem.

Sensory level is defined in the same way except in terms of sensory function:

Determined by testing sensitivity to light touch and pinprick on the left and right side of the body at key dermatomes

Symptoms of AD:

Hypertension; Bradycardia; Headache (often severe and pounding), Profuse sweating; Increased spasticity; Restlessness; Vasoconstriction below the level of lesion; Vasodilation (flushing) above the level of the lesion; Constricted pupils; Nasal congestion; Runny nose; Piloerection (goose bumps); Blurred vision; Rise in systolic blood pressure of 20 to 30 mm HG; SCI typically lower normal resting blood pressure (systolic 90-110 for above T6 level).. (maybe not related but ensure recovery post exertion) During AD systolic BP may rise to 250 to 300 and diastolic to 200 to 220 mm Hg.

L3-L5

I for household ambulation may become independent in community ambulation at L3 level KAFO or AFO are necessary orthoses

Naming the level of injury: To name the level of an individual's injury, the health care professional first identifies the vertebral or bony spine segment involved.

Identify spinal level using letters(C, T, L, S) Identify last spinal nerve root segment that's innervated (such as C4) ASIA classification - complete or incomplete

Intervention for Autonomic dysreflexia

Immediate recognition of these signs or symptoms is essential... Notify the primary nurse and physician ASAP... try to determine likely source of noxious stimulation (last time you cathed, had a bm?) ... If the source of the problem cannot be identified immediately, try lowering the pt's blood pressure by sitting or standing the patient. If lying flat, the patient should be brought to an upright position, as BP will be lowered in this position. Loosen any tight clothing or restricted devices.. BP and pulse should be monitored... The individual should be questioned as to possible triggers, starting with urinary system.. Catheter should be checked to make sure it is not blocked. If any blockage is found, it should be removed... The patient should be questioned about when the last bowel movement occurred and checked for an impaction. The patient's body should be examined for triggering stimuli such as tight clothing, restriction of catheter by straps, abdominal binders (Low BP could be a problem) or anything that may be a noxious stimulus... Education related to AD triggers, signs and symptoms and management of AD is critical

Cauda Equina Injuries

Injuries at L1 or below

Traumatic:

MVA 40% (MOSTLY REAREND- CERVI/ ROTATIONAL) ; Falls 27%; Violence 15%( STABBING, SHOT) ; Sports 8%

Clinical manifestations: In general, the following signs or symptoms may be present in an individual who has sustained an SCI:

Motor paralysis or paresis below the level of the injury or lesion; Sensory loss (sensory function may remain intact two spinal cord segments below the level of the injury- MULTIPLE SUPPLY LINES ); Cardiopulmonary dysfunction; Impaired temperature control resulting from sympathetic nervous system damage associated with cervical lesion; Spasticity, which can develop as the spinal cord recovers; Bladder and bowel dysfunction; Sexual dysfunction

SCI is a relatively low-incidence, high cost injury that results in tremendous change in an individual's life systems affected:

Musculoskeletal system, Cardiopulmonary, Integumentary. Gastrointestinal, Genitourinary, Sensory systems.

Besides bladder bowel of initiating stimuli of Autonomic dysreflexia:

Other precipitating stimuli include pressure sores, noxious cutaneous stimuli below the level of the lesion, kidney malfunction, electrical stimulation below the level of the lesion, sexual activity, labor and skeletal fracture below the level of the lesion; environmental temperature changes and a passive stretch applied to the patient's hip

Spastic hypertonia as a tool:

Patients with minimal to moderate involvement may learn to trigger the spasticity or muscle spasm at appropriate times to assist in functional activities

Complications/ associated conditions:

Pressure sores Autonomic dysreflexia postural hypotension pain (from overuse) contractures heterotopic ossification DVT from immobility osteoporosis (dec bone mineral density) respiratory compromise (atelectesis and pneumonia) bowel/bladder dysfunction sexual dysfunction spasticity

SCI definition

Spinal cord injury results in a disruption of communication from higher centers in the central nervous system to the periphery. This disruption results in loss of motor and sensory function, as well as impaired autonomic function.

Orthostatic hypotension (postural hypotension) is usually only significant with SCI above what level

T6

respiratory compromise

The inability of the body to move gas effectively. C3-C5 diaphragm T1-T12 external intercostals/inspiration (lift diaphragm and expand thoracic cavity) increases T7-9 upper abs T9-12 lower abs abdominals involved - decreased forceful expiration, accumulation of secretion (teach patient to cough) __ diaphragm strengthening, corset, abdominal binders

Brown-sequard:

The ipsilateral loss of motor function, proprioception, light touch, and vibratory sense is due to damage to the lateral corticospinal tract and dorsal columns do not cross at the spinal cord level... On the contralateral (opposite) to the lesion, damage to the spinothalamic tracts results in loss of sense of pain and temperature. This loss begins several dermatome segments below the level of injury...Individuals with Brown-Sequard syndrome typically achieve good functional gains during inpatient rehab. Many become independent in ADL and are continent of bowel and bladder

T1-9

Upper extremities fully intact; limited upper trunk stability; endurance increased secondary to innervation of intercostals operate manual WC all levels and surfaces transfer in/out of WC to floor limited therapeutic ambulation in the // bars with assistance and orthoses if incomplete

Cauda equine injuries

Usually direct trauma from a fracture-dislocation below L1. INCOMPLETE Exhibit flaccidity, areflexia, loss of bowel and bladder and saddle anesthesia. Lower extremity paralysis and paresis is variable depending on the extent of the injury to the cauda equina.

Spastic hypertonia:

Various stimuli including positional changes, cutaneous stimuli, environmental temperatures, tight clothing, bladder or kidney stones, fecal impactions, catheter blockage, urinary tract infections, decubitus ulcers, and emotional stress may trigger or increase spasticity and muscle spasms.

functional outcome depends on

age level and type of injury motor/sensory function preserved pt general health preinjury activity level and overal status body build support systems financial security motivation access to medical and rehab services personality traits neurologic level is most important factor

How is complete injury determined?

anal sensation and voluntary external anal sphincter contraction

Cervical hyperflexion injury: A pure hyperflexion force causes

anterior compression fracture of the vertebral body with stretching of the posterior longitudinal ligaments. wedge-type fracture of vertebral bodies frequently severs the anterior artery and results in an incomplete anterior cord syndrome... * head on collision or a blow to the back of the head

Non traumatic injury examples:

arteriovenous malformation; thrombosis, embolus, or hemorrhage; vertebral subluxations; spinal neoplasms; syringomelia (forms inside spinal cord cyst, inside pushing out), abscess of the spinal cord; infections; neurological diseases

symptoms of orthostatic hypotension

blurred vision ringing in the ears light-headed fainting *usually only significant with SCI above T6

Surgery may include

bone grafting from iliac crests placement of internal fixation devices

C8

can live independently like C7 but with increased finger control perform wheelies and negotiated 2-4 inch curbs with WC

Motor level is referred to as the most

caudal segment of the spinal cord with normal motor function bilaterally. MMT

Areas of enlargement in spinal cord

cervical enlargement corresponds to the segment C4-T1 lumbar enlargement corresponds to segments L1 to S3. And it's in these areas where the nerve plexuses, which innervate the upper and lower limbs respectively, emerge

Compression injuries:

combo of compression and flexion forces; a fall from an elevated surface or diving accident also can be caused/ compounded effects of osteoporosis, oa, or ra in older adults fracture of the vertebral end plates and movement of the nucleus pulposes into the vertebral body

hyperextension injury:

common in older adults as a result of a fall chin often strikes a stationary object/ground, and this leads to neck hyperextension (OPTION A= POSTERIOR FALL FIXED KYPHOTIC POSTURE, BACK HITS AND HEAD FLUNG BACK; Option B forward fall hits object) rupture of anterior longitudinal ligament (ALL) and compression/rupture of IV disc Spinal cord becomes compressed between ligamentum flavum and vertebral body, resulting central cord injury type

Complete injury is most often the result of

complete spinal cord transection, spinal cord compression, or vascular impairment

types of spinal lesions

complete, incomplete

Meds that decrease impact of hemorrhagic shock

corticosteroid methylprednisolone drugs that block opiate receptors

compression injury

due to degenerative conditions or traumatic compressive forces

Spastic hypertonia is thought to be a result of altered input at the spinal segmental level, which causes an imbalance between

excitation and inhibition of the spinal motor neurons

When surgery is not indicated:

external fixation with halo, hard cervical collar (aspen collar, Philadelphia collar), rigid body jacket (thoraco-lumbar) may be all that is needed to stabilize the involved spinal segments

61yrs + make up 10% of population. Increase may be due to increase in

falls as a cause of injury

bladder training

goal is to gain control of urination done as directed by nurse and care plan person uses toilet/pan at frequent regular intervals and is slowly increased. Intermittent catheterization, timed voiding programs, manual stim Person has catheter which is clamped to prevent urine flow for periods of time (1-2hrs at first then up to 3-4hrs) to train bladder Nursing trains

C5

has deltoid, biceps and rhomboid function (may not have strength) likely can flex/abduct shoulders, flex elbows and adduct scap should be able to raise arms to assist w/rolling and bring hand to mouth power WC with hand control use adaptive equipments, splints, built-up ADL devices to perform ADL provided minimal assist with sliding board transfers perform independent pressure relief by leaning forward in WC or looping 1 of their UE over the push handles on the back of WC to perform weight shift

Complete injury defined as

having no sensory/motor fx in the lowest sacral segments (s4& s5)

Incomplete injury Defined as

having partial motor and/or sensory function below the neurological level including sensory and/or motor function at S4 and S5. An incomplete lesion is a good prognostic indicator of greater likelihood of recovery of motor function

hyperflexion injury

head is suddenly, forcefully accelerated forward

pathologic changes that occur following injury

hemorrhage into gray matter necrosis of axons edema within white matter exerts pressure on nerve fiber tracts ischemia, hypoxia, and biochemical changes deprive white and gray matter of oxygen myelin sheathes disintegrate axons begin to shrink spinal shock

bowel training

high-fiber diet, adequate fluid intake, stool softeners, manual stimulation or evac may be suggested Nursing does this

bowel and bladder problems

hyperreflexic or spastic bladder/bowel: injury above S2 empty reflexively when pressure reaches a certain level sacral reflex arc intact likely to develop UTI nonreflexive/flaccid bladder/bowel flaccid bowel / bladder, requires manual emptying on schedule sacral reflex arc is not intact

Motor and sensory impairments: Following SCI there will be either complete (paralysis) or partial (paresis) loss of muscle function below the level of the lesion. Disruption of the ascending sensory fibers following SCI results in

impaired or absent sensation below the level of the lesion

Perianal sensation must be present for an injury to be classified as

incomplete. Have a tendency to display more abnormal tone or muscle spasticity than complete injuries

Severe cervical flexion & rotation injury

injury to anterior longitudinal ligament transection of spinal cord

C6

innervation of wrist ext, pec major, teres major able to be independent with rolling, feeding and UE dressing should be able to propel manual wc independently with rim projections; potential to be I with sliding board transfers drive a care with adaptive controls gainful employment

C4

likely to have some diaphragm innervation - may not need vent operate power WC with chin/mouth, but needs sufficient ROM to drive WC require full time attendances - completely dependent in transfers and ADLs

C1-C3

limited muscle innervation because diaphragm is only minimally innervated by C3 most likely require mechanical ventilation, may be able to tolerate ESTIM to phrenic nerve to reduce reliance on vent require full time attendants totally dependent in all ADLs power wheelchair with reclining feature needed for pressure relief and rest pt should have adequate breath support or neck ROM to operate a power WC by a sip and purr mechanism or with a chin cup (30 deg active cervical ROM)

brown-sequard contralateral

loss of pain and temperature sensations (cross closer to sensory level than ipsilateral symptoms do)

Neurological level is defined as the

most caudal level of the spinal cord with intact sensation and antigravity (3 or more) muscle function strength, provided that there is normal intact sensory and motor function rostrally respectively

clinical manifestations of spinal cord injury

motor paralysis or paresis below level of injury or lesion sensory loss (sensory function may remain intact 2 (two) spinal cord segments below the level of injury) cardiopulmonary dysfunction impaired temperature control due to sympathetic nervous system damage associated with cervical lesion spasticity can develop as spinal cord recovers bladder and bowel dysfunction sexual dysfunction

areflexia

muscles do not respond to stimulus

postural hypotension

often develop low BP due to lack of efficient skeletal muscle pump, combined with absent vasoresponse in the lower extremitites, leading to venous pooling can develop when transferred to sitting or upright standing, also during exercise careully monitor BP responses during treatment blood pressure must not drop below 70/40 (may result in cardiac arrest) application of abdominal binder before upright activities to promote venous return - minimize drop in intraabdominal pressure elastic stockings can be worn to prevent venous pooling

When is spastic hypertonia more common?

people with cervical-level injuries

spinal shock

period of flaccidity, areflexia, loss of bowel and bladder function, and autonomic deficits inc decrease arterial blood pressure and poor temperature regulation below the level of injury

Immediately following SCI the pt exhibits spinal shock. Characterized by a

period of flaccidity, areflexia, loss of bowel and bladder function. It is characterized initially by an absence of all reflex activity, impairment of autonomic regulation resulting in hypotension and loss of control of sweating and piloerection (goose bumps). Spinal shock normally lasts for approximately 24 to 48 hours; however, certain sources state that it may last up to several weeks. poor temperature regulation below level of injury

Root escape: Damage to the nerve root within the vertebral foramen can lead to a

peripheral nerve injury Patient may experience some improved function or a return of function in the muscles innervated by the peripheral nerve several months after the initial injury. This increased motor or sensory return should not, however, be mistaken for return of spinal cord function

pneumonia and septicemia in SCI

potential causes of death, significantly affect life expectancy

C7

potential for living independently triceps are innervated WC pushups for pressure relief self care activity independent independent with WC - bed - mat transfer self ROM to LEs drive car with adaptive controls

Once pt is medically stable, a primary concern of the physician is stabilization of the spine to

prevent further spinal cord or nerve root damage.

Anterior cord syndrome

related to flexion injuries of the cervical region with resultant damage to the anterior portion of the cord and/or its vascular supply from the anterior spinal artery. Fracture-dislocation of the cervical vertebrae occurs. typically compression of the anterior cord from fracture, dislocation, or cervical disk protrusion Characterized by loss of motor function and loss of the sense of pain and temperature bilaterally below the level of the lesion. Injury to the corticospinal and spinothalamic tracts Proprioception, light touch, and vibratory sense are generally preserved, because they are mediated by the dorsal columns with a separate vascular supply from the involved posterior spinal arteries. probable longer length of stay during inpatient rehab compared to people with other types of SCI clinical syndromes. Prognosis for functional return is limited because all voluntary motor function is lost.

As spinal shock resolves, reflex activity below the level of the lesion will

return, and if motor and sensory tracts have been salvaged, function in these areas will also be evident. Additional muscle tightness and shortening become evident as a result of static positioning and muscle imbalances (that true for any lengthened period of immobility)

two factors that increase susceptibility to SCI in certain areas

rotation enlargement

Hypertension triggered by Autonomic Dysreflexia can result in

seizures, renal failure, retinal hemorrhage, cardiac arrest, subarachnoid hemorrhage, stroke or even death

Spinal shock, It is extremely important to monitor the patient's level of injury for the first 24 to 48 hours after the injury. If loss of function is apparent more than 2 spinal cord segments above the initial level of the injury, it may mean that the

spinal cord was damaged in more than one place. Immediate notification of the patient's primary nurse and physician is necessary.

Lesion Level: The American Spinal Injury Association (ASIA) created the International Standards for Neurological Classification of Spinal Cord Injury, in an effort to

standardize the way in which severity of injury is determined and documented. It determines the extent of motor and sensory function loss after a SCI. Score is based on a 3-point ordinal scale 0=absent; 1=impaired and 2=normal

Classification of spinal injury

tetraplegia paraplegia cauda equina

Cauda equina injuries are peripheral nerve injuries. As such, they have the same potential to regenerate as peripheral nerves elsewhere in the body. It depends on the extent of initial damage. However, full return of innervation is not common because

there is a large distance between the lesion and the point of innervation; the rate of regeneration slows and finally stops after about 1 year

Types of sci:

tramatic (most common), non-traumatic complete. Incomplete

Autonomic dysreflexia: AD is a pathological autonomic reflex that can be life threatening.

typically occurs with lesion above T6... More common in chronic stage of recovery, it may also occur in the early stages... More common with complete injury. This clinical syndrome produces an acute onset of autonomic activity from noxious stimuli below the level of the lesion.

Spastic hypertonia is part of _______ ______ ______ _______, which encompasses a range of conditions including spasticity, muscle spasms, abnormally high muscle tone, hyperactive stretch reflexes, and clonus

upper motor neuron syndrome