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1. Traumatic Spinal Cord Injury

2. Spinal cord injury (SCI) S pinal cord injury (SCI) is a relatively low-incidence, high-cost injury that results in tremendous change in an individual’s life.

3. ■ CLASSIFICATION OF SPINAL CORD INJURIES Spinal cord injuries typically are divided into two broad functional categories: tetraplegia and paraplegia . Tetraplegia refers to complete paralysis of all four extremities and trunk, including the respiratory muscles, and results from lesions of the cervical cord . Paraplegia refers to complete paralysis of all or part of the trunk and both lower extremities (LEs), resulting from lesions of the thoracic or lumbar spinal cord or cauda equina .

4. Designation of Lesion Level It is extremely important for clinicians and researchers to be able to accurately determine the extent of neurological impairment in terms of motor and sensory loss when working with individuals with SCI. he extent of motor and sensory function after injury has a large impact on the medical and rehabilitation needs of the individual. The American Spinal Injury Association ( ASIA ) created the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) in an effort to standardize the way in which severity of injury is determined and documented.

5. ASIA SCALE

6. ASIA Impairment Scale

7. Brown-Sequard syndrome Brown-Sequard syndrome occurs from hemisection of the spinal cord (damage to one side) and is typically caused by penetration wounds, that is, gunshot or stab. Partial lesions (termed Brown-Sequard plus syndrome ) occur more frequently; true hemisections are rare. he clinical features of this syndrome are asymmetrical. On the ipsilateral (same) side as the lesion, there is paralysis and sensory loss. The ipsilateral loss of proprioception, light touch, and vibratory sense is due to damage to the dorsal column; paralysis results from damage to the lateral corticospinal tract.

8. On the side contralateral (opposite) to the lesion, damage to the spinothalamic tracts results in loss of sense of pain and temperature. loss begins several dermatome segments below the level of injury.his discrepancy in levels occurs because the lateral spinothalamic tracts ascend two to four segments on the same side before crossing. Individuals with Brown-Sequard syndrome typically achieve good functional gains during inpatient rehabilitation.

9. Anterior Cord Syndrome Anterior cord syndrome is frequently 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. here is typically compression of the anterior cord from fracture, dislocation, or cervical disk protrusion. his syndrome is characterized by loss of motor function (corticospinal tract damage) and loss of the sense of pain and temperature (spinothalamic tract damage) below the level of the lesion .

10. Proprioception,light touch, and vibratory sense are generally preserved,because they are mediated by the dorsal columns with a separate vascular supply from the posterior spinal arteries.Individuals with anterior cord syndrome often require a longer length of stay during inpatient rehabilitation compared to people with other types of SCI clinical syndromes.

11. Central Cord Syndrome Central cord syndrome is the most common SCI syndrome. It generally occurs from hyperextension injuries to the cervical region.It also has been associated with congenital or degenerative narrowing of the spinal canal. he resultant compressive forces give rise to hemorrhage and edema, producing damage to the most central aspects of the cord. here is characteristically more severe neurological involvement of the upper extremities (UEs) (cervical tracts are more centrally located) than of the LEs (lumbar and sacral tracts are located more peripherally

12. Varying degrees of sensory impairment occur but tend to be less severe than motor deficits. With complete preservation of sacral tracts, normal sexual, bowel, and bladder function may be retained. Patients with central cord syndrome 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.

13. Cauda Equina Injuries The spinal cord tapers distally to form the conus medullaris at the lower border of the first lumbar vertebra. Although some anatomical variations exist, this is the typical termination point of the spinal cord. Below this level is the collection of long nerve roots known as the cauda equina . Complete transections in this area are rare. Cauda equina lesions are frequently anatomically incomplete owing to the great number of nerve roots involved and the comparatively large surface area they encompass (i.e., it would be unlikely that an injury to this region would involve the entire surface area and all the nerve roots).

14. Individuals with cauda equina injuries exhibit areflexic bowel and bladder and saddle anesthesia . Lower extremity paralysis and paresis is variable depending on the extent of the injury to the cauda equina.Cauda equina lesions are peripheral nerve (lower motor neuron [LMN]) injury.

15. NEUROLOGICAL COMPLICATIONS AND ASSOCIATED CONDITIONS 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.

16. Spinal Shock Immediately following SCI there is a period of areflexia that is part of spinal shock . his period of transient reflex depression is not clearly understood. It is believed to result from the very abrupt withdrawal of connections between higher centers and the spinal cord. 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 . In addition to the loss of deep tendon reflexes, there is a loss of the bulbocavernosus reflex, the cremasteric reflex, a Babinski response, and a delayed plantar response.

17. Spinal shock evolves over time. The initial period of total areflexia lasts approximately 24 hours . This is followed by a gradual return of reflexes 1 to 3 days after injury, a period of increasing hyperreflexia lasting 1 to 4 weeks, and final hyperreflexia 1 to 6 months after injury.

18. 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. The clinical presentation of motor and sensory impairments depends on the specific features of the lesion. These include the neurological level and the completeness of the lesion.

19. Autonomic Dysreflexia Autonomic dysreflexia (AD, also referred to autonomic hyperreflexia) is a pathological autonomic reflex that can be life threatening. Typically AD occurs in lesions above T6 (above sympathetic splanchnic outflow). However, it has been reported in patients with lower injuries. Incidence of this problem varies.

20. Autonomic dysreflexia (AD) is a dangerous syndrome involving an overreaction of your autonomic nervous system . It causes a sudden and severe rise in blood pressure , in addition to other symptoms. People who've had a spinal cord injury are most at risk.

21. Spastic Hypertonia Individuals with SCI and other central nervous system disorders such as traumatic brain injury, multiple sclerosis,and stroke often present with spastic hypertonia. Approximately 65% of people with SCI have spasticity, and it is more common in people with cervical-level injuries. Spastic hypertonia is part of upper motor neuron (UMN) syndrome , which encompasses a range of conditions including spasticity, muscle spasms, abnormally high muscle tone, hyperactive stretch reflexes, and clonus.

22. Spastic Hypertonia

23. Cardiovascular Impairment In healthy individuals with an intact spinal cord, cardiovascular function is regulated by the brainstem and hypothalamus via the sympathetic and parasympathetic nervous systems. Parasympathetic signals to the heart arise from the Vagus nerve , decreasing heart rate and contractility . Sympathetic input comes from spinal segments T1 to L2 through the sympathetic trunk, which runs parallel to the spinal cord. Sympathetic input increases heart rate and contractility and peripheral vasoconstriction.

24. A rostral SCI will result in a loss of sympathetic communication between the brainstem and the heart, while parasympathetic input remains intact . This causes bradycardia and dilation of the peripheral vasculature below the level of the lesion. Because of the disrupted balance between sympathetic and parasympathetic input, as well as a lack of or decrease in active muscle contraction and prolonged time in bed, orthostatic hypotension is often experienced during early transitions to a more upright posture. Symptoms of orthostatic hypotension include blurred vision, ringing in the ears, light-headedness, and fainting . # A rostral spinal cord injury (SCI) is an injury to the top end of the spinal cord, which is close to the front of the brain. The term "rostral" refers to the head end of the body

25. To minimize these effects when mobilizing patients early after SCI, the cardiovascular system should be allowed to adapt gradually by a slow progression to the vertical position. his frequently begins with elevation of the head of the bed and progresses to a reclining wheelchair with elevating leg rests and use of a tilt table. Vital signs should be monitored carefully, and the patient should always be moved very slowly. Use of compressive stockings and an abdominal binder may further minimize these effects.

26. Impaired Temperature Control After damage to the spinal cord the hypothalamus can no longer control cutaneous blood flow or level of sweating . his autonomic (sympathetic) dysfunction results in loss of internal thermoregulatory responses. The ability to shiver below the level of the injury is also lost . The degree of impaired thermoregulation will vary depending on the level of the injury and whether the injury is complete or incomplete.

27. Individuals with cervical-level injuries and complete injuries demonstrate more impairment. Initially after injury hypothermia may occur due to peripheral vasodilation. Later, hyperthermia is more likely due to the lack of sympathetic control of sweat glands. Although some improvement in thermoregulatory responses occurs over time, patients with tetraplegia typically experience long-term impairment of body temperature regulation, especially in response to extreme environmental changes.

28. Pulmonary Impairment Ventilatory and respiratory function varies considerably, depending on the level of lesion. In people with high cervical injuries, pulmonary problems are the leading cause of death both in the early and late stages of recovery. Individuals with injuries below T10 are likely to have near-normal ventilatory and respiratory function. Paralysis or paresis of the muscles of respiration leads to poor ventilation, which may then cause impaired respiration leading to atelectasis and pneumonia. Ten percent of people with complete tetraplegia develop pneumonia or atelectasis 1 year after injury.

29. With high spinal cord lesions at C1 and C2 , phrenic nerve innervation and spontaneous respiration are lost. The only muscles of respiration that are intact are accessory muscles: sternocleidomastoid, upper trapezius, and cervical extensors. An artificial ventilator or phrenic nerve stimulator is required to sustain life . Expiration is passive; as a result, individuals with SCI at these levels require assistance for airway clearance. C3- and C4-level injuries have partial diaphragm innervation , as well as scalenes , levator scapulae, and trapezius. In the acute stage of recovery individuals with an injury at these levels will require mechanical ventilation . With recovery and training they will likely be able to breathe on their own.46 However, they may need part-time ventilatory support, especially individuals with C3-level injury.

30. Injuries at C5–C8 have a fully innervated diaphragm , as well as many accessory muscles. Some cough ability is preserved ; however, it is usually weak. Although individuals with paraplegia have better respiratory function than people with tetraplegia, they still have impaired respiratory function compared to healthy individuals without a SCI.

31. Bladder and Bowel Dysfunction Bladder Dysfunction T he effects of bladder dysfunction following SCI pose a serious medical complication requiring consistent and long-term management. Urinary tract infections (UTIs) are a major cause of mortality and morbidity in people with SCI. Spinal cord injury alters the complex reflexive and voluntary control of micturition .

32. As a result, people with SCI often require a catheter to drain the bladder . Spinal control for micturition originates from the sacral segments of S2, S3, and S4.5 the level of the SCI dictates the type of bladder dysfunction. Patients with lesions that occur above the conus medullaris and sacral segments develop a spastic or hyperreflexic bladder .This is also termed a UMN bladder. Following a lesion of the sacral segments or conus medullaris , a flaccid or areflexic,bladder develops. This is also termed a LMN bladder. A spastic or hyperreflexic bladder (UMN lesion ) contracts and reflexively empties in response to a certain level of filling pressure. he reflex arc is intact with this type of injury. he detrusor muscle is generally hyperreflexive . here can be increased tone of the sphincter, contraction of the detrusor with small urine volumes, and lack of coordination between detrusor and sphincters (dyssynergia). A flaccid or areflexive bladder (LMN lesion) is essentially flaccid because there is no reflex action of the detrusor muscle. There are generally two types of bladder dysfunction: failure to store urine and failure to empty urine

33. Bladder Management The primary goal of bladder management is to prevent or minimize urinary tract complications. These include UTIs , hydronephrosis (swelling of kidney due to backup of urine), renal calculi, bladder calculi , and vesicoureteral reflux (backward flow of urine up the ureter). Because urinary incontinence has very strong psychosocial implications for the patient, a coordinated approach to this problem is particularly important. Knowledge of and participation in the bladder management program is an important consideration for the physical therapist .

34. In the early stage of recovery, while the patient is still in spinal shock, the bladder is flaccid and an indwelling catheter is inserted. After the patient is stable during rehabilitation, the most frequently used method of bladder management is intermittent catheterization. Brieflystated , the program involves establishing a fluid intake pattern of approximately 2000 mL/day. Intake is stopped late in the day to reduce the need for catheterization during the nigh t. Initially, the patient is catheterized every 4 hours . A record is maintained of voided and residual urine. While in the hospital, sterile intermittent catheterization should be done; after discharge, a clean technique can be used Although intermittent catheterization is the most common method of bladder management after discharge from the rehabilitation hospital, many males switch to the use of an external, condom catheter. Other methods of bladder management include suprapubic tapping and the Valsalva maneuver . Suprapubic tapping involves tapping directly over the bladder with fingertips, causing a reflexive emptying of the bladder.

35. This technique only works for individuals with an UMN bladder without dyssynergia between the detrusor and sphincter, because the sphincter must open for the bladder to reflexively drain. Individuals with an areflexive bladder can use the Valsalva maneuver, which is done by straining. In some individuals a suprapubic catheter may need to be surgically inserted. he exact method or combination of methods used for bladder management will depend on a variety factors: type of bladder dysfunction, level of injury, functional ability, and personal preference. Whichever method(s) is used, the goal is for the patient to be catheter free, have low postvoid residual volume of urine in the bladder, and be without high bladder pressure during voiding. Urodynamic testing is done after spinal shock resolves, approximately 3 months after injury, to help diagnose the specific type of bladder dysfunction and guide the selection of management strategies.

36. Bowel Dysfunction As with bladder dysfunction, bowel dysfunction is a major concern after SCI. Over 98% of people with SCI report problems with bowel care and 34% require some level of assistance with bowel care. People with SCI report that bowel function has a greater impact on daily life than many other impairments after SCI, including sexual function, bladder function, pain, spasticity, and skin integrity.Bowel function also has a large impact on social activities and quality of life. Neurogenic bowel conditions that develop after spinal shock subsides are of two main types. In spinal cord lesions above S2 there is a spastic or reflex bowel (UMN lesion). Because the parasympathetic and internal sphincter connections from S2–S4 are intact, reflex defecation can occur when the rectum fills with stool. In S2–S4 or cauda equina (peripheral nerves) lesions a flaccid or areflexive bowel (LMN lesion) develops. With an areflexive bowel the parasympathetic connections from S2–S4 are not intact so the bowel will not reflexively empty. his can cause feces to become impacted and, because the external sphincter is flaccid, incontinence can occur.

37. Bowel Management Safety and an appropriate, well-timed bowel care routine are common goals for bowel management. Safety includes continence in order to maintain intact and healthy skin, prevent damage to colorectal structures, and prevent AD due to bowel dysfunction. 53 In addition to type of neurogenic bowel (UMN or LMN), the bowel care program will also depend on presence of other health conditions that may affect gastrointestinal function, medications, dietary habits, fluid intake, and functional ability.

38. A typical bowel program involves establishing a daily (or every other day) pattern of eliciting a bowel movement. the exact time of day is chosen by the patient based on lifestyle needs and should be done consistently at the same time of day. This is usually in the morning or late evening. People with a reflex bowel require the use of suppositories and digital stimulation techniques to cause a reflex defecation. Digital stimulation involves manual stretch of the anal sphincter , either with a lubricated gloved finger or an orthotic digital stimulator. his stretch stimulates peristalsis of the colon and evacuation of the rectum (mediated by S2, S3, and S4). Valsalva maneuver and abdominal massage may also be performed. Nonreflex bowel management relies on manual evacuation techniques and gentle Valsalva . Other factors that can play a role in maintaining a consistent, safe bowel program include eating a diet with appropriate amount of fiber, fluid intake, physical activity, stool softeners, laxatives, and bulking agents.