Spinal Cord Injuries and their management

it is available presentation about spinal cord injuries and their management

1. \ »
| À ere Cord Injury
= (SCI)

2. SCI Epidemiology

+ Incidence: 11,000 new cases per year.
[ + Prevalence: 225,000-296,000 persons in
\ the USA living with SCI.
= + Traumatic SCI is most common in people
a aged 16-30 (more than 50% of cases).
+ Most common cause of traumatic SCI:
+ Motor vehicle accidents — 47%
+ Falls— 23%
+ Violence (esp. gunshot wounds) — 14%
« Sports accidents — 9%
« Other - 7%
« 78% male, 63% Caucasian.

3. + 48% paraplegic and 52% tetraplegic, 52%
emulate and 48% complete.
\ e expectancy for paraplegics (in those who
e for one year) is near normal.

ife expectancy for tetraplegics is reduced by
: Se aga by ~20 years if ventilator

4. Spinal Cord Anatomy

C1 Cervical spinal nerve roots C1 - C7

correspond with upper aspects of
vertebral bodies.
à Sensation of C7 nerve is for
Bone notch al the base CB the middie finger.
‘of the neck is C7. 7

C8 and lower spinal nerve roots
Ioave below the corresponding
verlebral body.

TA Sensation of T4 spinal nerve is
imately lavel with the

TAO Sonsation of T10 norve root is,
‘approximately level with the abdomen.

‘112 Sensation of T12 spinal nerve root is
‘The spinal cord ends LA SBprocimately level wit the
Deere L2. = °

‘Tho sonsations of lumbar nerves.

(81-55 "Cauda Equina") are over the legs.
are level with TI2-L1

‘The sacral vertebrae
are fused lo make up ‘Sensation of S3,S4 & S5 nerves is the
the sacrum. ss Porinoal (genital) area.

he.

are fused to make

tho
“tail bone".

5. Types of Injury

- Upper motor neuron injury: injury to the neurons in
Da a Seh
— Increased tone, brisk reflexes.
oh — Involuntary spasms, preserved muscle bulk.
_ = Occurs in brain injury and SCI down to the conus
e medularis

180, fractures above L1 usually give upper motor
neuron picture).

6. Types of Injury

- Lower motor neuron injury: nerves
“they synapse inthe spinal cord. u

7. Spinal Cord Tracts

+ Corticospinal: descending tracts (also called the

pyramidal tracts).
— Motor control.
« Spinothalamic: Ascending tracts

— Pain and temperature.
« Dorsal columns: ascending (also called the posterior

put
E Vibration, proprioception,

2 and light touch.

à
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8. « Central Cord Syndrome-
— Occurs with cervical level injuries.

— Typically results in greater weakness in upper
limbs than lower.

— Bowel/bladder usually preserved.

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« Brown-Sequard Syndrome - Results from
- hemisection).
F an loss of motor function, light touch,
~ Mbration, and proprioception.
— Contralateral loss of pain and temperature
| ‚sense.

va

A
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9. + Anterior cord syndrome — usually vascular cause
from damage to the anterior spinal artery.
— Loss of motor function (with spasticity).

— Loss of pain and temperature sense.

— Some loss of light touch.
— Vibration and proprioception are preserved.

— Poor prognosis for motor recover

a
‘ 2

| A
A

=

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10. Blood Supply to Cord

Blood supply to the spinal cord: horizontal distribution
Posterior

Posterior
spinal artery

)
”

Central

Peripheral

Anterior spinal artery

Anterior

The central area supplied only by the anterior spinal artery is
predominantly a motor area

11. — damage to dorsal

Posterior Cord Syndrome

columns.
— Loss of vibration and proprioception
— Can see spastic weakness and bladder
ficiency.

dysfunction.
— Causes in

LE ES

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A
me

Pa

12. + Conus medullaris: the end of the

spinal cord, contains the sacral reflex Tea
— Weakness in lower limbs. ac
— Areflexic bowel and bladder
(sometimes with preserved reflexes)

« Cauda Equina: “Horse's Tail” lumbosacral nerve
roots within the spinal canal.

WAreflexic bowel, bladder, and lower limbs.
‘= “Saddle Horse” Anesthesia

N

ay
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za
;

ES

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13. Acute Events s/p SCI

First few hours patients experience neurogenic shock
Mens Pre

Exam at this time is not prognostic due to other
le injuries present and neurogenic shock (must
it least 72 hours to evaluate)

14. _ Transient Paralysis/Spinal Shock

oy a oe

Aedes, anesthesia, absent bowel and bladder
N loss of reflexes

NIET may opel u SRE CES

the cord leading to an accumulation of

15. Medical Management

+ Cardiovascular
+ Autonomic dysregulation results in Triad of:
Hypotension, Bradycardia, and Hypothermia
Must maintain BP for adequate perfusion to the
- I and transfusions

16. + Initially High Risk of: PE, respiratory failure,
- pulmonary edema, pneumonia
+ Highest incidence of the above with cervical lesions
+ Decreased strength of diaphragm and chest wall
entrada dera ae
hypoventilation

17. + DVT/PE
+ Occurs in 50-100% of untreated patients
_ * Most common in first 72 hours to 14 days
+ All pts should receive DVT prophylaxis
\ . as o cc ee

1 IVC filters required in patients when anticoagulation is
¡ted autoregulation of skin capillaries and

ased sensation increases risk of skin breakdown
sure sores develop quickly, especially on heels and

18. + Neurogenic Bladder
+ Detrusor-sphincter dyssynergia (DSD)
[ + Lack of sphincter relaxation during bladder
- contraction
A ie in urinary retention and vesicoureteral
r

19. + Neurogenic Bowel
_ * Loss of bowel reflexive function results in ileus
iron.
___ * Stool softeners (Colace), rectal stimulant
- (Ducolax), and colonic stimulant (Senna)
+ Goal is to create a bowel regiment that allows for
- control of the timing of bowel emptying

21. Heterotropic Ossification

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pedia. comimagos/1/11/H01 jpg

22. a

+ Sexual Fuction/Fertility

« EDis more common acutely after SCI, but
resolves with time. Many men are able to
maintain an erection suitable for sexual

A + LMN injury — lack of erection

+ UMN injury — reflexogenic erection
ertility may be reduced in males who have
ze ejaculation or impaired

owever, labor maybe difficult due to lack of
oluntary muscle control

IM

23. * Glucocorticoids — Methylprednisolone
_ © Limited evidence (mainly animal studies) have shown
[ that when given in first 8 hours after SCI, better
outcomes are achieved
+ May reduce edema, intracellular K* depletion, and
improve neurologic recovery
+ Timing is crucial: late administration may actually
2 rfere with the initial healing process

24. ASIA Exam

ISCeS

Patient Name
Examiner Name Date/Time of Exam.
LEA, STANDARD NEUROLOGICAL CLASSIFICATION
OF SPINAL CORD INJURY
MOTOR
ney uoscies
Re ong seem am, want En
S À Hire LES EE
er Elbow extensors a
cs Finger exons (area pres semana, CI
Tr DI El Ange abctucrore me o =
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=
rm
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à ES
3
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& roe enanos u
a 5 Log te entenrorr St
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Vota ana’ sonore | a
u | O morenos

rom DORE. D

COMPLETE OR INCOMPLETE? Zone OF

ASIA MPAIRMENT SCALE [IT

DZ

PARTIAL A £
E E IL]

25. Level Terminology

* Neurological Level: The unifying level to describe the
Ngee cee combines a
on the last level of the cord that is normal.
+ For C1-C4 and T2-L1 use the sensory level to define the
__ neurological level
_ + Complete Injury: No sensory or motor fxn preserved
/ ) neurological level
ate Injury: If any sensory fxn and/or motor fxn
urological level

26. ‘a Impairment Scale

+ ASIA A: Complete (no motor or sensory)

+ ASIAB: Incomplete sensory, but no motor fxn

C: Motor and sensory fxn Incomplete, with

of more than half of the key muscles below the
EN Tanga muscle grado ~¢

27. + ASIA Exam at 72 hours predicts short-term prognosis (2-

3 months)
« ASIA Exam at 1 month predicts long-term prognosis (1

year)

5

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28. Fe

AN

+ C5: Can feed self with adaptive equipment

« C6: Highest level of complete injury consistent
with independent living without aid. Tendonesis
orthosis (aids in grasp) and short opponens
orthosis with utensil slots. Can drive adaptive
van:

- C7/C8: Completely independe
wheelchair level
faits: Gait becomes function

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29. Works Cited

= Spinal cord injury — definition, epidemiology,
pathophysiology. (2011, Nov 10) Medscape Reference.

cc medscane comia iew#ta3t
jury. In: UpToDate, Aminoff, M.J., Man ATER mae
de Cn Women Pe M.

A) Sugar, R., David, E.F., Shatzer, M., Krabak,
I dater
tpedia fi 97-102). na Lippincott Williams &

30. + Kelbine, P., Lindsey, L. (2007, May). Spinal Cord Injury
Information Network a

- Sins, S. G Goldstein, B.-Hammeha, Mie OF
(2008) Soipal Chord Injury Medicines Resta oi
Rehabilitation, and Preventative Care. In J. Merritt, & S.
(Eds). Physical Medicine and Hehabiltdlien Secrets
| (pp. 456-465). Philadelphia; Mosby Elsevier.