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211 exam 1

Traumatic Spinal Cord injuries

spinal cord injury Violent, momentary displacement or compression of spinal cord Forceful flexion, extension or rotation force on spine
mechanisms of spinal cord injury Forceful flexion, extension or rotation force on spine Vertebral body can burst, puts pressure on cord Bone fragments can scatter into cord
Usually vertebral ____ along with SCI, but can have one without the other fracture
extent of SCI may not be evident initially due to ____ ___ spinal shock
complete vs incomplete SCI Indicates whether axons in the spinal cord survive
Cord does not have to be ____ to sustain a “complete” injury severed based on ASIA scale:
complete: no motor or sensory at or below S4/5
incomplete: sensory or motor at or below S4/5
tetraplegia/Quadriplegia all cervical injuries
paraplegia thoracic and lumbar injuries
spinal cord concussion transient neurological deficit, fully recovers without apparent structural damage
causes of traumatic SCI Vehicular – decreasing Falls – increasing Acts of violence – primarily GSW Recreation/Sports injuries – relatively stable
most preventable cause of traumatic SCI diving into shallow water (4-6 ft deep) ~ 70% of all sports injuries flexion, cervical, accounts for 70% of injuries
recreational causes of SCI Contact sports: football, wrestling High speed sports: snow skiing, surfing Falls from a height: trampoline, horse Diving into shallow water
what time of year do most traumatic SCI occur? spring and summer
causes of non-traumatic SCI Aortic aneurysms Tumors Radiation induced myelopathies Infections AV malformations Scoliosis / congenital OA, spinal stenosis, spinal surgery Spinal hematoma Cardiac arrest
transverse myelitis infection of the spinal cord
causes of flexion SCI Most common Head hits steering wheel/windshield; blow to back of head, trunk (head-on collision)
causes of compression SCI Closely associated with flexion injuries Vertical/axial blow to back of head (diving, surfing, falling objects)
causes of hyperextension SCI Strong posterior force (rear-end collision) Falls with chin hitting stationary object (older adults)
causes of flexion-rotation SCI P-A force hits rotated vertebral column (rear-end collision with passenger rotated toward driver)
highest frequency of injury in the C spine C5-7
highest frequency of injury in T-L spine T12-L2
NLI neurologic level of injury
ASIA American spinal cord injury association
AIS ASIA impairment scale
SCIs named by ___and assigned an ___ to ‘classify’ injury (letter grade) NLI, AIS
neurologic level of injury (NLI) lowest (most caudal) single segment of normal sensory AND motor function Must assign motor level, sensory level, R and L (can be asymmetrical) then assign overall LOI
complete SCI no or few axons survive
symptoms of complete SCI Complete loss of sensory and motor below LOI May have zones of partial preservation (ZPP) Small areas of intact motor, sensation Cord does not have to be completely transected
causes of complete SCI Cord does not have to be completely transected GSWs, knife wounds, puncture injuries may lead to transection (and complete injury)
incomplete SCI Sparing of some sensory and/or motor function below LOI Not necessarily meaningful, functional sparing
Must have motor and/or sensory function in ____ to be classified as incomplete injury S4-S5
brown Sequard syndrome Damage to one side of cord, or greater damage to one side
what can cause brown Sequard syndrome penetrating injury (GSW, stab wounds) Trauma with vertebral burst fracture
what is lost below the LOI in brown Sequard syndrome Ipsilateral Sensory: light touch, deep pressure, proprioception Motor function (with spasticity) Contralateral Sensory: pain and temperature tend to look like a stroke pt
Relative ____ of symptoms more common than pure form of brown sequard syndrome asymmetry
Preservation of ____ important for functional recovery motor function in dominant hand
what parts of the cord are damaged in brown sequard syndrome one half of cord is damaged (L or R)
what parts of the cord are damaged in anterior cord syndrome? Damage to anterior, anterolateral portions of cord, preservation of posterior columns
what causes anterior cord syndrome Trauma to cord itself: flexion and burst fractures Damage to anterior spinal artery
what is lost below the LOI in anterior cord syndrome? Motor function Sensory – pain, temperature
what is preserved below the LOI in anterior cord syndrome? Sensory – proprioception, light touch, deep pressure
recovery for anterior cord syndrome less functional recovery than other syndromes This syndrome is pretty rare
central cord syndrome is caused by Damage to central portion, sparing of peripheral
where does central cord syndrome most often occur? cervical spine
who is central cord syndrome more common in? in older people following neck extension injuries; can occur at any age, and with flexion injuries
symptoms of central cord syndrome Motor weakness in UE > LE, Distal > proximal Sensory loss variable Pain, temperature > proprioception, vibration Dysesthesias (pain, burning) in UE common Sacral (B&B) sensory sparing usually exists
prognosis for central cord syndrome functional recovery is good But hand function recovery is last, may be incomplete Correlated with age, spasticity, level of education
posterior cord syndrome Rare Preservation of motor,sense of pain and light touch Loss of proprioception-wide base steppage gait pattern
sacral sparing Sacral tracts are spared perianal sensation, "saddle area" toe flexors active First signs that cervical lesion is incomplete
conus medullaris syndrome Damage to sacral cord and lumbar nerve roots within spinal canal
conus medullaris Terminal end of cord, T12-L2 levels TERMINATES about L1)
what does the conus medullaris contain? motor neurons of S4,S5 Important implications for B&B control, some sexual function
symptoms of conus medullaris syndrome Variable motor and sensory loss LE Most people have flaccid paralysis in LE and areflexic (flaccid) bowel and bladder Some retain sacral reflexes Involvement usually bilateral, symmetric
conus medullaris syndrome is typically classified as ____ damage LMN
upper motor neuron lesion above T12, below T12 is LMN
characteristics of UMN spastic injury, usually bowel and bladder maintence
characteristics of LMN no spasticity, areflexive bowel and bladder=just leaks out Changed to LMN damage, usually not mixed
cauda equina syndrome is caused by Injury to bundle of nerve roots (from L2-S5 levels) that extend through canal distal to conus medullaris (may have injury to both) Trauma or compression narrows vertebral canal Lumbar disc herniation, spondylosis
cauda equina is typically a ____ nerve root injury, but can affect cord too (UMN) peripheral (LMN)
variability of cauda equina syndrome Most have flaccid paralysis of LE, areflexic (flaccid) B&B Typically asymmetrical and incomplete
Outcomes with cauda equine syndrome depend on extent of injury, but greater potential for ___ nerve recovery than central peripheral
spinal shock no reflex or sensation or motor activity below lesion
how is temp control impaired with SCI? hypothalamus can no longer control level of sweating. loss of internal thermometer. excessive diaphoresis above the level of lesion.
what level of SCI may need ventilator? C1-3 (spontaneous resp), maybe C4
what affects spasticity? increased positional changes, increased temp, tight clothing, UTI
most common SCI complication UTI often due to self cathing in unsterile environment
signs and symptoms of UTI cloudy urine, incontinence, AD, Smelly, increases spasticity, chunky urine
bowel dysfunction treatment digital stim-nursing
sexual dysfunction after SCI very few men can sire children after SCI, women however, have no problem with fertility. Women may not be able to perceive labor. Psychologist usually discusses sexual issues.
what LOI does autonomic dysreflexia occur in? lesions above T-6
how long does AD last? subsides after 3 years following injury
what causes AD noxious stimulus below level of injury
signs and symptoms of AD increased BP headache, bradycardia, profuse sweating, increased spasticity, HTN.
tx for AD SIT UP, emergency, get rid of noxious stim, do not lie down
what can help with postural hypotension after SCI compression stockings or wraps, abdominal binder
what causes heterotopic bone formation after SCI related to microtrauma, over aggressive ROM
where does HO form? extraarticular and extracapsular adjacent to large joints- hips knees, elbows and shoulders
early symptoms of HO resemble thrombophlebitis-swelling, decrease ROM, erythema, local warmth
complications of SCI contractures, DVT, pain, OA
what are contractures inlfuenced by? spasticity
when is DVT most risk after SCI? first 2 months
pain tx after SCI TENS
what causes pain after SCI damage to nerve roots dysesthesia-painful sensations below level of lesion Musculoskeletal pain
AD signs slide 29
AD intervention Immediately bring patient to upright Identify and remove noxious stimuli Check clothing and catheter tubing for constriction, perform bowel program if impaction suspected
medical intervention for AD Pharmacological management if BP > 150mmHg Address unmet medical need
when can upright activities be started after cervical injury? once fracture site is stable
immobilization for cervical injuries Tongs-Traction device attached to skull-12 weeks Turning frames and beds Stryker Frame-contraind-cardiac or respiratory secondary to being turned prone
roto rest kinetic treatment table Table-continuous side to side rotation; Contraind.-claustrophobic or motion sickness.
halo used the most-12 weeks, than cervical orthosis applied for 6 weeks (also Minerva cervical orthosis)
TSLO Surgical intervention- restore alignment, prevention and stabilize Fx site. Decompression or fusion
3 devices used for spinal alignment, stability, and internal fixation Harrington compression rods Harrington distraction rods Weiss compression springs
respiratory assessment for SCI Chest expansion-circumference at axilla and xiphoid -> Max Inhalation-max exhalation=normal (2.5-3 inches) Breathing pattern-check if using accessory neck muscles Cough (functional, weak functional, nonfunctional) Vital capacity-handheld spirometer
skin assessment for SCI requent position changes and skin inspection, observation and palpation for increase in skin temp. Check also around halo orthotic
how are tone and DTR's measured? 0 = absent 1+ = slight but depressed, low normal 2+ = normal 3+ = Brisk, may not be abnormal 4+ = very brisk, abnormal, clonus
C5,6 tendon reflex biceps, brachioradialis
C7 tendon reflex triceps
C6-T1 tendon reflex finger flexors
L5, S1, S2 tendon reflex hamstrings
L2, L3, L4 tendon reflex quad
S1, S2 tendon reflex Achilles
modified ashworth scale 0 no increase in tone
modified ashworth scale 1 Slight ↑, catch and release, min resistance at end range
modified ashworth scale 1+ Slight ↑, catch, min resistance of < ½ motion
modified ashworth scale 2 Marked ↑ in tone through most ROM but affected parts move easily
modified ashworth scale 3 Considerable ↑ in tone, PROM difficult
modified ashworth scale 4 Rigid flex or extension
MMT restrictions for quads extreme cautions with shoulders
MMT restrictions for paras hips
ROM restrictions for SCI restriction for shoulders past 90
diaphragmatic breathing facilitate expiration-manual contacts on thorax
glossopharyngeal breathing sipping or gulping using facial and neck muscles
lesions above ___ will have paralysis of inspiratory mm C5 - require artificial ventilation
lesions from ___-___ will loose mm of expiration (abs, intercostals) and forced cough to expel secretions (external obliques) C6-T12 (position of diaphragm compromised too)
airshift maneuver max inhalation, close glottis, relax diaphragm allowing air into upper thorax- increase chest expansion by .5-2 inches – Christopher Reeves-
assisted cough therapist pushes quickly inward and upward from epigastric area
ROM contraindications for paras Trunk and hips motion (SLR > 60 degrees and hip flex >90 degrees with knee flex) contraindicated. Acutely
positioning for SCI pts to prone if possible, and position shoulders out of patterns of comfort (IR,Add, Ext of shld; Flex of elbows, Prone of forearm and flex of wrists). May prone people with halo if okay with doc. They need pillows under the chest.
what not to range in SCI pts Low back of Quads- helps with trunk balance Tight finger flexors-tenodesis
how much HS ROM needed for xfers and sitting balance 100 deg
mm to strengthen with caution in quads scap and shoulders
mm to strengthen with caution in paras hips and trunk
mm to strengthen in tetras emphasize ant deltoid, shoulder extensors, biceps and low traps, if present radial wrist ext. triceps and pects
mm to strengthen in quads shoulder depressors, triceps and lat dorsi
benefits of mat programs -improve strength, postural stability, balance and helps determine which functional method will work for specific tasks
requirements for functional ambulation for paras have abdominals and erector spinae MMT grade 3/5 or better. (T-2 -T-8) are excluded usually. Full hip extension is essential. Adequate cardiovascular endurance Not obese
ambulation orthotics for T9-T12 KAFO
ambulation orthotics for L3 and below AFO
SCI standardized tests for pain, tone, ambulation, mobility Pain- VAS, W/C User’s Pain Index Tone – Modified Ashworth Ambulating SCI – SCI-FAI: SCI Functional Ambulation Inventory (copy in Text) Mobility – FIM, SCIM - SCI Independence Measure
Created by: bdavis53102
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