management of spinal cord injury

physiotherapist point of view

1. Management of spinal cord injury (SCI) BY ADEAGBO, CALEB A. [email protected]

2. Case scenario 47 y/o male involved in RTA 4/12 ago. Admitted via A&E in LUTH and transferred to National Hospital for further mgt. Sensation intact on both ULs & LLs. Muscle power 0/5 below the Umbilicus. No bladder / bowel control. Diagnosed of C-spine injury and presenting now with paraplegia LLs and paraparesis ULs 4/3/2012 2

3. Outline Overview Key terms Anatomy Causes Type Pathophysiology Clinical syndromes Diagnosis Neurological assessment and classification Management References 4/3/2012 3

4. Overview SCI is damage to the spinal cord that results in loss of functions such as mobility or feeling. The fourth leading cause of death in the US. Spinal Cord (SC) is the major bundle of nerves that carry impulses to/from the brain to the rest of the body. Spinal Cord is surrounded by rings of bone-vertebra and function to protect the spinal cord. Most common vertebrae involved are C5, C6, C7, T12, and L1 because they have the greatest ROM 4/3/2012 4

5. Key terms used in SCI SCI is insult to spinal cord resulting in a change in the normal motor, sensory or autonomic function. This change is either temporary or permanent. Tetraplegia The impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal. Paraplegia The impairment or loss of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord due to damage of neural elements within the spinal canal. 4/3/2012 5

6. Key terms used in SCI Dermatome The area of skin innervated by one sensory nerve root. Myotome The collection of muscles innervated by one motor nerve root. Neurological Level of Injury The most caudal segment of the spinal cord with normal motor and sensory function on both sides. Skeletal Level The radiographic level of greatest vertebral damage. 4/3/2012 6

7. Key terms used in SCI Motor level The most caudal key muscle group that is graded 3/5 or greater with the segments cephalad to that level graded normal (5/5) strength. Sensory level The most caudal dermatome to have normal sensation for both pinprick and light touch on both sides. Complete injury The absence of sensory and motor function in the lowest sacral segments. Incomplete injury Preservation of motor or sensory function below the neurologic level of injury that includes the lowest sacral segments. 4/3/2012 7

8. Key terms used in SCI Sacral sparing Presence of motor function (voluntary external anal sphincter contraction) or sensory function (light touch, pinprick at S4/5 dermatome, or anal sensation on rectal examination) in the lowest sacral segments. Zone of partial preservation All segments below the neurologic level of injury that have preserved motor or sensory findings; used only in complete SCI. 4/3/2012 8

9. Anatomy Spinal cord: foramen magnum  1 st /2 nd lumbar vertebrae. Gray matter: central (cell bodies) White matter: peripheral (ascending and descending tracts) On the surface : Deep anterior median fissure Shallower posterior median sulcus Spinal cord segment : Section of the cord from which a pair of spinal nerves are given off 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal 4/3/2012 9

10. Anatomy Dorsal root – sensory fibres Ventral root – motor fibres Dorsal and ventral roots join at intervertebral foramen to form the spinal nerve 4/3/2012 10

11. Longitudinal section of SC 4/3/2012 11

12. Tracts of SC 4/3/2012 12

13. Clinically important ascending tracts and where they decusate 4/3/2012 13

14. Clinically important descending tracts and where they decusate 4/3/2012 14

15. Causes of SCI RTA Falls Gunshot Injuries Blunt Assault Diving Accidents Stab Wounds Sport Injuries Vascular disorders Tumors Infectious conditions Spondylosis Vertebral fractures secondary to osteoporosis Development disorders 4/3/2012 15

16. Type of SCI Transient concussion - is due to extreme vibration of the cord and may cause temporary loss of function lasting 24 to 48 hours. No neuropathologic changes are present. Contusion - is a bruising that includes bleeding, subsequent edema, and possible necrosis from the edematous compression. The neurological involvement depends on the severity of contusion and necrosis Laceration Compression of cord substance Complete transection of the cord 4/3/2012 16

17. Pathophysiology Hemorrhage: Blood flows into the extradural , subdural, or subarachnoid spaces of the spinal cord Injury to spinal cord vasculature causes nerve fibers to swell and disintegrate Blood circulation to the gray matter of the spinal cord is impaired Secondary chain of events: Ischemia, hypoxia, edema, and hemorrhagic lesions These secondary events result in destruction of myelin and axons. 4/3/2012 17

18. Pathophysiology These secondary reactions, are believed to be the principal causes of spinal cord degeneration . The damage may be reversible within the first 4 to 6 hours after the injury. The consequence of spinal cord injury depends on The type of SCI injury The neurologic level (lowest level at which sensory and motor functions are normal) 4/3/2012 18

19. Clinical Syndromes Central Cord Syndrome: Cervical injury with sacral sparing and greater weakness in the arms than the legs. Brown- Sequard Syndrome: An injury that causes greater ipsilateral weakness and proprioceptive loss and contralateral pain and temperature loss. Anterior Cord Syndrome: Injury to the spinal cord causing loss of pain and temperature sensation with preserved proprioception . Posterior Cord Syndrome: Injury to the spinal cord causing loss of proprioception with preserved pain and temperature sensation. Conus Medullaris Syndrome: Injury of the sacral conus and lumbar nerve roots Cauda Equina Syndrome: Injury to the lumbosacral nerve roots within the neural canal .

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21. Diagnosis X-rays of cervical spine to establish level and extent of vertebral injury CT scan and MRI: changes in vertebrae, spinal cord, tissues around cord Arterial blood gases to establish baseline 4/3/2012 21

22. Neurological assessment and classification The most widely tool for classifying SCI is “the American Spinal Injury Association (ASIA) classification,” this assessment requires manual muscle testing of 10 key muscles bilaterally, sensory testing for light touch and sharp/dull discrimination in all dermatomes, and a rectal exam for sensation and presence of voluntary anal contraction. These tests are used to classify injury levels and ASIA Impairment Scale (AIS) grade 4/3/2012 22

23. ASIA Sensory Testing Sensory Testing: 0 = Absent 1 = Impaired 2 = Normal NT = Not testable

24. ASIA Dermatones C2-Occipital Protruberance C3 – Supraclavicular fossa C4 – A.C. Joint C5 – Lateral antecubital fossa C6 – Thumb C7 – Middle finger C8 – Little finger T1 – Medial antecubital fossa T2 – Apex of the axilla T4 – Nipple line T6 – Xyphoid T10 – Umbilicus T12 – Inguinal ligament L2 – Mid thigh L3 – Medial femoral condyle L4 – Medial Malleolus L5 – 3 rd MTP joint S1 – Lateral heel S2 – Mid popliteal fossa S3 – Ischial tuberosity S4-5 – Perianal area

25. ASIA Motor Testing 0 = No movement 1 = Trace contraction 2 = Full AROM gravity eliminated . 3 = Full AROM against gravity 4 = Full AROM against gravity with resistance 5 = Normal power

26. ASIA Myotomes C5 – Elbow flexors C6 – Wrist extensors C7 – Elbow extensors C8 – Finger flexors T1 – 5 th digit abductors L2 – Hip flexors L3 – Knee extensors L4 – Ankle dorsiflexors L5 – Long toe extensors S1 – Ankle plantar flexors

27. ASIA Impairment Scale A = Complete: No motor or sensory function in the lowest sacral segment. B = Incomplete: Sensory but no motor function is preserved in the lowest sacral segment. C = Incomplete: Less than ½ of the key muscles below the (single) neurological level have a grade 3 or better. D = Incomplete: At least ½ of the key muscles below the (single) neurological level have a grade 3 or better. E = Sensory and motor function are normal .

28. Management Immediate management at the scene is critical. Improper handling can cause further damage and loss of functioning Always assume there is a spinal cord injury until it is ruled out Immobilize Prevent flexion, rotation or extension of neck Avoid twisting patient 4/3/2012 31

29. Management Management consists of emergency treatment following an A-B-C-D-E sequence. Airway Breathing Circulation Disability Expose 4/3/2012 32

30. Medical management High dose corticosteroids ( Methylprednisolone ) - improves the prognosis and decreases disability if initiated within 8 hours of injury. Patient receives a loading dose and then a continuous drip. High dose steroids, Mannitol , Dextran Neurological/orthopedic management includes methods a surgeon may use to treat unstable spinal cord injuries: Reduction Fixation Fusion 4/3/2012 33

31. Reduction With reduction, the spine is realigned through the application of a skeletal traction devise (such as Gardner-Wells tongs, Minerva vest, Halo traction) or Soft and hard collars . 4/3/2012 34

32. Gardner-Wells tongs 4/3/2012 35

33. Minerva vest and halo-vest 4/3/2012 36

34. Soft and hard collars 4/3/2012 37

35. Fixation and Fusion Fixation involves stabilizing vertebral fractures with wires, plates, and other types of hardware. Fusion involves attaching injured vertebrae to uninjured vertebrae with bone grafts, and steel rods to help maintain structural integrity.

36. Physiotherapy Goals Relieve pain Maintain optimal level of wellness Maintain optimal functioning Minimal or no complications of immobility Learn new skills, self care Return to home Integrate back into community

37. Physiotherapy techniques Therapeutic exercises: Passive movement, Free active exercises, Auto assisted exercises, Assisted resisted exercises, Resisted exercises Soft tissue manipulation Positioning 4/3/2012 40

38. Physiotherapist teaches Mobility Self care Functional activities 4/3/2012 41

39. Mobility bed mobility (i.e. turning from side to side, moving from supine to sitting). sitting balance. wheelchair transfers (i.e. from wheelchair to bed, wheelchair to car, and wheelchair to floor). standing balance. ambulation (wheelchair or walking). 4/3/2012 42

40. Self care Along with increasing mobility, minimizing the need for assistance in self-care is a major step toward independence for those with SCI. Self-care includes feeding, bathing, dressing, grooming, and toileting. Those with motor-complete injuries at the C-7 level or below can usually achieve independence in all of these activities. 4/3/2012 43

41. Functional activities Living skills (e.g. meal preparation, shopping, cheque writing, housekeeping, etc) are necessary tasks of everyday life and must be relearned and adapted to a patient’s needs. These skills are often reacquired with the help of occupational therapists. 4/3/2012 44

42. …….THANK YOU