6.SCI_CONDITION, mobility, sign symptom, treatment

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1. SPINAL CORD INJURY Acknowledge to elearnSCI , Md. Iqbal Hossain, Junior consultant and Julker Nayan , Associate Professor, OTD Shamima Akter Assistant Professor Department of Occupational Therapy Bangladesh Health Professions Institute Centre for the Rehabilitation of the Paralysed

2. Learning Objectives At the end of this overview you will be able to: analyse the historical perspectives of spinal cord injury (SCI) list the incidence and causes of SCI explain how SCI differs from other medical ailments discuss the different types of SCI including complete and incomplete injuries and their implications analyze why SCI substantially affects the life of not only people with SCI but the whole family summaries the basic principles of management

3. Spinal Cord The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain. The brain and spinal cord together make up the central nervous system. The spinal cord is the main pathway for information connecting the brain and peripheral nervous system. The human spinal cord is divided into 31 different segments. At every segment, right and left pairs of spinal nerves (mixed; sensory and motor) form.

4. Continue... It extends from the level of the upper border of the atlas (1 st cervical vertebra) to the level of the lower border of the 1 st lumber vertebra or the upper border of the 2 nd lumber vertebra. The cord is continuous above with the medulla oblongata and below with the filum terminale .

5. Continue... Measurement for adult: Length: 45 cm (18 inches). Breadth: 1.25 cm (0.5inch). Weight: 30 gm.   Coverings: The Spinal cord is protected by three membranous coverings. From the outside to inside they are:- Dura mater. Arachnoid mater. Pia mater. The meninges are separated from each other by spaces containing fluid. The spaces are – Subdural space: The space between dura mater and arachnoid mater. This space contains a thin film of serous fluid. Subarachnoid space: The space between arachnoid mater and pia mater. It contains Cerebro Spinal Fluid.

6. Anatomy of the Spine  The vertebral column provides a protected passageway for the spinal cord as it comes down from the brain. At each vertebral level a pair of spinal nerves come out and supply a respective part of the body.  

7. Functions Mediated by the Spinal Cord movement sensation autonomic functions bowel / bladder function sexual function hemodynamic stability and temperature control respiratory function

8. Spinal Cord Injury An injury to the vertebral column can result in an injury to the spinal cord which can affect all of its functions below the level of injury. Spinal Cord Injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function. International Standard for Neurological Classification of Spinal Cord Injury (ISNCSCI)

9. SCI – how is it different? Lack of inherent ability of neurons to regenerate effectively for functional improvement. The main determinants of degree of disability are: site of injury completeness of lesion

10. Level of lesion Cervical injury results in paralysis of all 4 limbs and torso. Such paralysis is termed as tetraplegia : tetra (Greek) = 4 plegia (Greek) = paralysis Thoracic, thoracolumbar or lumbar injury results in paralysis of the torso and legs. Such paralysis is termed as paraplegia: para (Latin) = 2 like parts plegia (Greek) = paralysis

11. Tetraplegia Loss or impairment in motor and/or sensory function in the cervical segments of the spinal cord resulting in functional impairment in the arms, trunk, legs and pelvic organs (ASIA, 2000). Patient becomes tetraplegic due to damage of neural elements within the spinal canal. It does not peripheral nerves outside the neural canal.

12. Paraplegia Loss or impairment in motor and/or sensory function in the thoracic, lumber or sacral segments of the spinal cord resulting in functional impairment in the trunk, legs and pelvic organs and sparing of the arms (ASIA, 2000). The person becomes paraplegic secondary to damage of neural elements within the spinal canal. The term is used in referring to cauda equina and conus medullaris injuries, but not to lumbosacral plexus lesions or injury to peripheral nerves outside the neural canal.

13. Level of lesion C5 or above injuries can affect the phrenic nerve (segmental innervation : C3-5). This may result in diaphragmatic paralysis; chest muscles are not working in people with C5 or above injuries anyway.  Such patients often need ventilatory support.

14. Complete injury   Absence of sensory and motor functions in the lowest sacral segments, i.e., S4-5. International Standard for Neurological Classification of Spinal Cord Injury (ISNCSCI) Disabilities are fairly predictable. Recovery is unlikely.

15. Incomplete injury Preservation of sensory or motor function below the level of injury, including the lowest sacral segments, i.e.,  S4-5. International Standard for Neurological Classification of Spinal Cord Injury (ISNCSCI) Presents with a complex array of symptoms. Recovery is likely.

16. Causes of SCI Traumatic Non traumatic Motor Vehicular Accident ( Leading cause globally) Arnold-Chiari malformation Fall From Height ( Second leading cause globally ) Spinal dysraphism Violence – Bullet / Stab Injury Hereditary spastic paraplegia Fall of Load from height Adrenomyeloneuropathy Attack by animals (e.g. cow, bull) Leukodystrophies Sports Injury Spinal muscular atrophy Diving in shallow water metabolic disorder

17. Non traumatic

18. Arnold- Chiari malformation , is a relatively common congenital malformation of the spine and posterior fossa characterised by myelomeningocoele ( lumbosacral spina bifida aperta ) and a small posterior fossa with descent of the brainstem and cerebellar tonsils. Spinal dysraphism involves a spectrum of congenital anomalies resulting in a defective neural arch through which meninges or neural elements are herniated, leading to a variety of clinical manifestations.They are divided into aperta (visible lesion) and occulta (with no external lesion).

19. Hereditary spastic paraplegia is a general term for a group of rare inherited disorders that cause weakness and stiffness in the leg muscles. Symptoms gradually get worse over time. Spinocerebellar ataxia type 1 (SCA1) is a condition characterized by progressive problems with movement. Adrenomyeloneuropathy (AMN) is an inherited condition that affects the spinal cord. It is a form of X-linked adrenoleukodystrophy .

20. Leukodystrophies are a group of rare, progressive, metabolic, genetic diseases that affect the brain, spinal cord and often the peripheral nerves. Each type of leukodystrophy is caused by a specific gene abnormality that leads to abnormal development or destruction of the white matter (myelin sheath) of the brain.

21. Spinal muscular atrophy (SMA)  is a genetic disease affecting the part of the nervous system that controls voluntary muscle movement. A metabolic disorder can happen when abnormal chemical reactions in the body alter the normal metabolic process. It can also be defined as inherited single gene anomaly, most of which are autosomal recessive.

22. Causes of Spinal Cord Injury in Bangladesh: There are many causes of spinal cord injury in Bangladesh. According to Claque & Sym (2003-04), the most common causes of spinal cord injury are in Bangladesh are – Fall from height Road traffic accident Fall while carrying heavy load on head Bull attack Bullet injury / gun shot injury Physical assault Disease process e.g. Pott’s disease, spinal tumor, transverse myelities , Syringiomeylia , cervical Spondylosis etc. Diving in shallow water

23. Zone of partial Preservation: The term Zone of partial preservation is used for patients with complete injuries who have partial innervation in dermatomes below the neurological level (ASIA, 2000

24. Patterns of Incomplete SCI Four special types: Anterior cord syndrome Central cord syndrome Posterior cord syndrome Brown- Sequard syndrome

25. Centre Cord Syndrome Anterior Cord Syndrome Posterior Cord Syndrome Brown Squared Syndrome

26. Central cord syndrome It is the most common of the clinical syndromes, often seen in individuals with underlying cervical spondylosis who sustain a hyperextension injury (most commonly from a fall); and may occur with or without fracture and dislocations. This clinically will present as an incomplete injury with greater weakness in the upper limbs than in the lower limbs. Damage Innermost central fibers damaged Outermost lateral (fibers Intact) Effect Arm movement affected leg movement possibly unaffected

27. Central Cord Syndrome (Continue...) Presentation symptoms weakness with hand dexterity most affected hyperpathia burning in distal upper extremity  physical exam loss motor deficit worse in UE than LE (some preserved motor function)  hands have more pronounced motor deficit than arms preserved sacral sparing late clinical presentation UE have LMN signs (clumsy) LE has UMN signs (spastic)

28. Anterior Cord Syndrome The anterior cord syndrome is a relatively rare syndrome that historically has been related to a decreased or absent blood supply to the anterior two-thirds of the spinal cord. The dorsal columns are spared, but the corticospinal and spinothalamic tracts are compromised. The clinical symptoms include a loss of motor function, pain sensation and temperature sensation at and below the injury level with preservation of light touch and joint position sense. A condition characterized by motor dysfunction dissociated sensory deficit below level of SCI

29. Continue... Damage Anterior cord syndrome Anterior artery infracted, stopping blood supply to anterior two-thirds Posterior third unaffected Effect loss of voluntary and reflex motor activity loss 0f pain and temperature sensations Ability to sense position, vibration Light pressure unimpaired

30. Continue... Pathophysiology injury to anterior spinal cord caused by direct compression (osseous) of the anterior spinal cord anterior spinal artery injury  anterior 2/3 spinal cord supplied  by anterior spinal artery Mechanism usually result of flexion/ compression injury Exam lower extremity affected more than upper extremity loss LCT (motor) LST (pain, temperature) preserved DC ( proprioception , vibratory sense) Prognosis worst prognosis of incomplete SCI most likely to mimic complete cord syndrome 10-20% chance of motor recovery

31. Centre Cord Syndrome Anterior Cord Syndrome Posterior Cord Syndrome Brown Squared Syndrome

32. Posterior Cord Syndrome Introduction  very rare Exam loss proprioception preserved motor, pain, light touch

33. Brown Sequard Syndrome Damage One side of cord damaged Opposite side of cord undamaged Effect Complete motor loss on damaged side of body ( ipsilateral molor loss) Complele loss of pain and temperature sensation on undamaged side of body ( contralateral sensation loss)

34. Exam of BSS ipsilateral deficit LCS tract motor function dorsal columns proprioception vibratory sense  contralateral deficit LST pain temperature spinothalamic tracts cross at spinal cord level (classically 2-levels below)

35. Continue... Prognosis excellent prognosis 99% ambulatory at final follow up best prognosis for function motor activity

36. Cauda equina syndrome Cauda Equina syndrome involves the lumbosacral nerve roots of the cauda equina (Figure 3), and may spare the spinal cord itself. Injury to the nerve roots, which are, by definition, lower motor neurons, will classically produce a flaccid paralysis of the muscles of the lower limbs(muscles affected depend upon the level of the injury), and areflexic bowel and bladder. All sensory modalities are similarly impaired, and there may be partial or complete loss of sensation. Sacral reflexes i.e. bulbocavernosus and anal wink will be absent.

37. Conus medullaris syndrome ConusMedullaris Syndrome may clinically be similar to the Cauda Equina Syndrome, but the injury is more rostral in the cord (L1 and L2 area), relating to most commonly a thoraco -lumbar bony injury. Depending on the level of the lesion (Figure 3), this type of injury may manifest itself with a mixed picture of upper motor neuron (due to conus injury) and lower motor neuron symptoms (due to nerve root injury). In some cases, this may be very difficult to clinically distinguish from a cauda equina injury. Sacral segments may occasionally show preserved reflexes (i.e. bulbocavernosus and anal wink) with higher lesions of the conusmedullaris .

38. SCI Management The salient features of SCI management are: it is most expensive as compared to that of any other ailment it requires prolonged hospitalisation and lifelong follow-up it requires a multidisciplinary team approach

39. Multidisciplinary Team SCI consultant emergency medicine physicians / technicians nurse physiotherapist occupational therapist orthotist psychologist peer counselor social worker vocational counselor patient & family

40. Comprehensive Management of SCI - Components prehospital care extrication first aid at site transfer acute management comprehensive evaluation management of vertebral fracture prevention and management of complications   comprehensive rehabilitation physical psychosocial sexual vocational predischarge planning home care services community inclusion life long follow-up prevention