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Spinal Cord Injuries
Dayna Ryan, PT, DPT
Winter 2012
Demographics
• 80-82% of all cases are male
• Mean age at time of injury = early 30’s
http://www.cureparalysis.org/statistics/index.html
Cause of Injury
• MVA is most common cause
• 70% of the time, alcohol is
involved in MVA/MCA
• For those over 45 y.o., falls is
the most common cause
MCA = motorcycle accident
MVA = motor vehicle accident
Sporting Injury Causes
• Most diving accidents occur in water depth of 4-6 feet
http://www.cureparalysis.org/statistics/index.html
Prognosis
• 85% of SCI patients who survive the first 24
hours post-trauma are still alive 10 years later
• Causes of death within 15 years post-trauma
▫ 1st: Pneumonia (also other resp. diseases)
▫ 2nd: non-ischemic heart disease (unexplained heart
attacks)
▫ 3rd: external causes
 Suicide (most common)
 Homocide
 Unintentional injuries
Bony Anatomy Contributions to
Protecting Spinal Cord
Cervical
Thoracic
Lumbar
Vertebral
Bodies
Muscles
Small
Larger
Massive
Small
Larger
Massive
Ligaments
Small
Moderate
Massive
Common sites: at apex of spinal curvatures
C5-6
T11-12
Types of Injuries –
Contusions
• Bruising of SC following fractures and
dislocations of vertebrae
• Clinical Presentation
▫ Initially  severe symptoms from loss of SC
function (compression from swelling, etc.)
▫ Rapid return of function (weeks)
▫ Amount of return depends on severity of injury
Types of Injuries - Compression
• From fractures and dislocations of vertebrae,
tumors (intradural and extradural), disc
herniation
• Clinical Presentation
▫ Permanent severe loss of function is common
▫ Significant improvement is rare
Example Compression Injury
• Traumatic subluxation of the
cervical spine in a 51-year-old man
with quadriparesis following an
automobile crash.
• MRIs show anterior subluxation of
C4 (top arrow) on C5 (bottom
arrow), associated with marked
narrowing of the spinal canal and
compression of the thecal sac and
spinal cord.
• The hyperintensity of the disc and
adjacent prevertebral and ventral
epidural soft tissues likely
represents a combination of
edema and hemorrhage.
Types of Injuries –
Laceration
• From knife, gunshot or other projectile/foreign
entry
• Clinical Presentation
▫ Partial to complete loss of function below level of
lesion
▫ Impairment depends on extent of lesion
Types of Lesions –
Loss of Vascular Supply
• From thrombosis, emboli, arteriovenous
malformation or direct disruption of blood
vessels
• Clinical Presentation
▫ Typically partial loss of SC function below level of
lesion in distribution of blood supply
Non-Traumatic Types of
Spinal Cord Lesions
Congenital
Spina Bifida
Spinal
Muscular
Atrophy

Infectious
Transverse
Myelitis
Syphilis

Disease
Multiple
Sclerosis
ALS
Syringomyelia

Mechanism of Injury –
Flexion
• Most common injury of cervical spine
• Outcome
▫ Combined compression and contusion of S.C.
▫ Or compression of anterior spinal artery 
Anterior Spinal Artery Syndrome
▫ Anterior Cord Syndrome
Mechanism of Injury –
Extension
• More common in cervical spine, but less
common than flexion injuries
• Outcome
▫ Contusion of central region of S.C. producing
Central Cord Syndrome
Mechanism of Injury –
Rotation
• Pure rotation injury is more common in cervical
spine, but occurs most often with flexion injuries
• Outcome
▫ Contusion of one side of the S.C. producing
Brown-Sequard Syndrome
Mechanism of Injury –
Compression
• Most common in thoracic spine
• Usually from burst fracture injury
• Typically results in complete SCIs
• Outcome
▫ Contusion and compression of the S.C. depending
on the amount of axial force
Anterior Cord Syndrome
• MOI: Vascular
occulusion of
anterior spinal
artery  infarction
of anterior 2/3 of
S.C.
Anterior Cord Syndrome
• Lost or Impaired
▫
▫
▫
▫
▫
Motor function
Pinprick
Crude touch
Temperature
Unconscious proprioception
• Intact
▫ Conscious proprioception
▫ Discriminative touch
▫ Vibration
Central Cord Syndrome
• MOI: Contusion of
central region of the S.C.
following a
hyperextension injury
http://www.medinfo.ufl.edu/year2/neuro/review/images/fig03.jpg
Central Cord Syndrome
• Because cervical
axons are most
medial, have greater
loss of sensory and
motor function in
arms compared to
legs
• Prognosis is for
some recovery, but
rarely full recovery
Posterior Cord Syndrome
• Extremely rare
• Seen with Tabes
Dorsalis (condition of
late stage syphilis)
• Clinical Presentation
▫ Loss of conscious
proprioception, vibration,
and fine touch
▫ Wide-based ataxic gait
Brown-Sequard Syndrome
• MOI: Lateral hemisection of
S.C. Most often due to knife or
projectile injury
http://www.medinfo.ufl.edu/year2/neuro/review/sp.html
Brown-Sequard Syndrome
• Lost or Impaired
▫ Ipsilateral motor function
▫ Ipsilateral proprioception
and vibration
▫ Contralateral pain and
temperature
• Intact
▫ Contralateral motor function
▫ Contralateral proprioception
and vibration
▫ Ipsilateral pain and
temperature
Distribution of Injuries
http://www.cureparalysis.org/statistics/index.html
ASIA Classification of Injuries - Sensory
ASIA Classification of Injuries - Motor
ASIA Classification of Injury – Related
Impairment
• A = Complete
▫ No sensory or motor function preserved
• B = Incomplete
▫ Sensory but no motor function preserved
• C = Incomplete
▫ Motor preserved with major muscles graded <3
• D = Incomplete
▫ Motor preserved with major muscles graded >3
• E = Normal
• Every level is SO important!
• More function for every level
lower the injury is
• SCIs are named by the lowest level
that is INTACT!!!
• C3 Quad = C3 is still intact
http://www.cureparalysis.org/faq/spine.gif
Root Escape
• 66-80% of SCI patients will have return of
function at one segmental level below the
initially defined level of function weeks to
months after injury
• Due to return of nerve root function
Spinal Shock
• Cause: may be due to a conduction block from
edema
• Onset: immediately post-injury
• Duration: 1 week – several months (mean = 6
weeks)
• Below level of lesion:
▫ Flaccid paralysis
▫ No reflex activity
▫ Absent bowel and bladder tone
• Prognosis: The longer it lasts, the less likely
normal function will return
Acute Care Issues in SCI
• Due to neurogenic shock may affecting
autonomic NS, may observe:
▫ Decreased blood pressure
▫ Variable heart rate response
▫ Decreased profusion of blood to spinal cord,
potentially causing secondary damage
• Have patient up as much as possible in chair,
but avoid inclined position as this causes
excessive frictional stress on skin of back
Acute Management of SCI
• ABCs: Airway, Breathing, Circulation
• If necessary to move, log roll maintaining spine
in neutral
• Immobilize on backboard
• Monitor BP, ECG for dysrhythmias
• X-ray, CT scan to observe bony canal, MRI
• ASIA classification
Indications for Surgery
• Incomplete lesion with bone fragments and
disk material in spinal canal
• Unstable fracture
• Progression of neurologic deficit (even if
spinal column is stable
Cervical Surgeries
• Posterior Fusion
▫ Realign spine using traction
▫ Wire spinous processes
together 1-2 segments above
and below level of fracture
▫ Bone grafts placed around
facet joints
• Anterior Fusion
▫ Disk space is obliterated
and bone grafts are placed
in the disk space
▫ With combined injuries,
both procedures may be
done
Thoracolumbar Surgeries
• Harrington Rods
▫ Stainless steel rods with
hooks on either end placed
on either side of spine
▫ Distracts spine until proper
alignment is achieved
▫ Bone grafts by facet joints
• Luque Wiring
▫ Similar to Harrington rods
except a wire is passed
beneath the pedicle and
attached to the rod at each
vertebral level to prevent
bowstring effect
▫ Was affecting spinal
alignment because of
bowing of rods
Immobilization
• Stable fracture with no surgery
▫ 6 weeks (usually longer)
• Cervical Fusion
▫ 3-4 months using a halo vest or SOMI (sternooccipital-mandibular immobilizer = Halo)
• Thoracolumbar Fusions
▫ 4-6 months using a rigid body jacket
Immobilization Braces/Orthotics
Physiologic Changes –
Respiratory System
• Phrenic nerve is C3-5, so C1-3 quads are on
respirator because they have no diaphragm
function
• C4 and above = no diaphragm
Physiologic Changes –
Respiratory System
• In Quads, when intercostal and abdominal mm
lost
▫ 20-30% decrease in vital capacity
▫ Diaphragm is less efficient because there is less
negative pressure in pleural cavity (due to sagging out
of abdominal wall)
 This is why quads breath better in supine than sitting
 Decreases effectiveness of cough
 Decreased exhalation force makes audible speech difficult
Physiologic Changes –
Respiratory System
• Complications
▫ Increased risk of atelectasis and pneumonia
▫ Common colds make respiration difficult
• Treatment
▫ Glossopharyngeal (frog) breathing
▫ Abdominal binder to increase efficiency of
diaphragm
▫ Assisted coughing
▫ Postural drainage and percussion
▫ Positive and negative pressure ventilators
Physiologic Changes –
Circulatory System
• Postural hypotension due to:
▫ Loss of sympathetic input below lesion level
▫ Prolonged bed rest decreases vascular tone
• Flaccid muscles during spinal shock do not assist
venous return
• Loss of sympathetic tone in heart produces a
relative excess of vagal nerve input  bradycardia
and dysrhythmias
Physiologic Changes –
Circulatory System
• Complications
▫ Marked increase for DVTs and pulmonary emboli (clot
in lung)
• Treatment
▫
▫
▫
▫
▫
▫
Heparin
Anti-emoblism stockings (TED hose)
Abdominal binder (increases blood flow)
LE elevation (sends blood back to heart)
Tilt table to increase tolerance to upright position
Medications for BP and HR
Physiologic Changes –
Gastrointestinal System
• Gastroparesis
▫ Rarely occurs and it resolves within 1 week
• Loss of bowel control – incontinence
• Complications:
▫ Constipation
▫ Bowel obstructions (sometimes require surgery)
▫ Bowel accidents
Physiologic Changes –
Gastrointestinal System
• Treatment
▫ Put bowels on schedule
▫ Bowel movements stimulated by
 Digital stimulation stimulates gastrocolic reflex
 Gravity
 After meals
▫ Oral medications, e.g. Colace as a stool softener and
Metamucil to produce well-formed soft stool
▫ Suppositories, e.g. Dulcolax, for bowel program
Physiologic Changes –
Urologic System
• Urinary incontinence
• Flaccid Neurogenic Bladder
▫ During spinal shock
▫ Only empties a little when it “overflows” so it must be
artificially emptied
• Spastic Neurogenic Bladder
▫ Detrusor mm becomes spastic and contracts from S2-4
reflexes
▫ Empties at smaller than normal volumes
Physiologic Changes –
Urologic System
• Complications
▫ Frequent infections which lead to
 Kidney stones
 Bladder stones
• Treatment
▫ Intermittent catheterization
 Allows bladder to fill to normal capacity before being emptied
artificially
 Intended as temporary measure
▫ Valsalva, tapping, or anal stretch can stimulate reflex
emptying of bladder on regularly timed basis
Physiologic Changes –
Neurologic System
• Spasticity
▫ Loss of inhibitory input on alpha motor neuron
▫ Interferes with positioning, transfers, maintenance of
joint ROM, and with active motion in incomplete
lesions
• Pain
▫ Experienced by 90% of all SCI patients at least
intermittently below level of lesion
▫ Burning sensation
▫ Unknown etiology
Spasticity: cortical vs. spinal lesions
• Cortical: spasticity will be present but will still
have movement
▫ Synergy patterns with some active control
• Spinal: only spastic – no active or voluntary
movement
▫ Increased DTRs
▫ In complete and some incomplete SCIs
Physiologic Changes –
Neurologic System
• Autonomic Dysreflexia (AD) occurs in persons
with lesions above T6
▫ Consequence of over-activity of ANS
▫ Precipitated by a noxious stimulus
▫ Can result in a stroke
**The higher the SCI, the greater the risk for
complications/poor control with AD
Autonomic Dysreflexia:
Signs and Symptoms
• Pounding headache
(caused by the elevation
in blood pressure)
• Goosebumps
• Sweating above the level
of injury
• Nasal Congestion
• Slow Pulse
• Blotching of the skin
• Restlessness
• Hypertension (blood
pressure greater than
200/100)
• Flushed (reddened) face
Autonomic Dysreflexia:
Signs and Symptoms
• Red blotches on the
skin above level of
spinal injury
• Sweating above level of
spinal injury
• Nausea
• Slow pulse (< 60 beats
per minute)
• Cold, clammy skin
below level of spinal
injury
Autonomic Dysreflexia:
Possible Causes
• Bladder (most common) from overstretch or irritation
of bladder wall
▫
▫
▫
▫
▫
Urinary tract infection
Urinary retention
Blocked catheter
Overfilled collection bag
Non-compliance with
intermittent catheterization
program
• Bowel - over distention
or irritation
▫ Constipation / impaction
▫ Distention during bowel
program
▫ Hemorrhoids or anal
fissures
▫ Infection or irritation (e.g.
appendicitis)
Autonomic Dysreflexia:
Possible Causes
• Skin-related Disorders
▫ Any direct irritant below the level
of injury (e.g. - prolonged
pressure by object in shoe or
chair, cut, bruise, abrasion)
▫ Pressure sores (decubitus ulcer)
▫ Ingrown toenails
▫ Burns (e.g. - sunburn,
burns from using hot
water)
▫ Tight or restrictive clothing
or pressure to skin from
sitting on wrinkled clothing
Autonomic Dysreflexia:
Possible Causes
• Sexual Activity
▫ Over stimulation during
sexual activity [stimuli to
the pelvic region which
would ordinarily be
painful if sensation were
present]
▫ Menstrual cramps
▫ Labor and delivery
• Other
▫ Heterotopic ossification
("Myositis ossificans",
"Heterotopic bone")
▫ Acute abdominal conditions
(gastric ulcer, colitis,
peritonitis)
▫ Skeletal fractures
Physiologic Changes –
NS (Syringomyelia)
▫ caused by a formation of a fluidfilled cavity within the spinal cord
▫ may be a result of S.C. trauma,
tumors of the spinal cord, or
congenital defects
▫ Cavity most often begins in the
neck area in the central cord
▫ Cavity expands slowly, causing
progressive damage to the spinal
cord due to the pressure exerted
by the fluid.
http://www.neuro.wustl.edu/neuromuscular/spinal/syrinx.htm
Syringomyelia
Clinical Presentation
• Typically occurs 4-9 years
post injury
• Occurs in 2% of people with
paraplegia (much less with
quadriplegia)
• Symptoms result from the
spinal cord damage
according to location and
size of the cavity
Physiologic Changes –
Neurologic System
• Treatment
▫ For pain  TENS
▫ For Autonomic Dysreflexia  Emergency




Sit patient up to decrease BP in head
Check for noxious stimulus
Notify nursing station or physician
Do not leave patient unattended
Physiologic Changes –
Integumentary System
• Loss of ability to:
▫ Control body temperature due to inability to sweat
or shiver below level of lesion
▫ Detect injury to body segments affected
▫ Sense when soft tissue has been subject to
pressure for too long a period of time
Physiologic Changes –
Integumentary System
• Complications
▫ Less able to tolerate extremes in temperature
▫ Decubitus ulcers
 Prolong hospital stays
 Some require surgery
 Skin never returns to original state
▫ Cuts, burns, etc. occur before patient is aware of
them
Physiologic Changes –
Integumentary System
• Treatment
▫ Avoid extreme hot/cold temperatures
 Air conditioning may be a necessity
 Dress extra warm in winter
▫ Prevention of pressure sores
 WC and bed cushions
 pressure relief techniques
 good transfer techniques to avoid sheer forces
▫ Teach awareness and protection of insensate body
parts to prevent injuries
Physiologic Changes –
Musculoskeletal System
• Loss of calcium from bone occurs following
injury
• Complications
▫ Hypercalcemia (high blood calcium levels)
 Can cause cardiac dysrhythmias
 Can last days to months
▫ Osteoporosis
▫ Heterotopic ossification (see next slide)
Physiologic Changes –
Musculoskeletal System
• Heterotopic Ossification
▫ From increased blood calcium
▫ Calcium deposition in soft tissues around joints that
receive stress (e.g. hip joints)
▫ Marked limitation of ROM
▫ Treatment of HO
 Didronel and radiation therapy to inhibit osteoblast function
(slows HO, but doesn’t stop it)
 PT must maintain ROM if possible (gentle but firm PROM)
 If surgically removed, likely to come back and be worse
 HO burns itself out over period of months to years
Physiologic Changes –
Musculoskeletal System
• Treatment of osteoporosis
▫ Functional electrical stimulation (FES)
 On stationary bike, e.g. ERGYS
 FES also adds muscle bulk which can help prevent decubiti
 FES is painful so can only use with complete lesions
▫ Weight bearing with KAFO’s at standing table
• Treatment of hypercalcemia
▫ IV hydration (dilutes calcium levels in blood)
▫ Hormone calcitonin
Example FES Treatment for
Osteoporosis and Muscle Bulk
•Strengthens
bones
•Increases muscle
bulk
•Provides
cardiorespiratory
training
http://www.inspire-foundation.org.uk/#Background
Physiologic Changes –
Reproductive System
• Females
▫ Menses typically returns in 3-6 months (some
don’t miss a period)
▫ Intercourse
 Functional, but normal lubrication is decreased
▫ Orgasm
 If sensation is absent in genitalia, give stimulation in
other intact areas (breasts, ear lobes, lips)
▫ Delivery
 Most have normal vaginal delivery
 Autonomic dysreflexia may occur during labor
 C-section to deliver baby quickly
Physiologic Changes –
Reproductive System
• Males
▫ Erections: 3 types possible
 Pyschogenic (controlled at T11-L2)
 Secondary to thoughts and fantasies
 Reflexogenic (controlled at S2-4)
 Secondary to direct stimulation of penis
 Spontaneous
 Secondary to internal stimulation (e.g. full
bladder)
▫ Ejaculation usually does not occur unless
sacral sensation is intact (can use sperm
retrieval techniques if procreation desired)
Physiologic Changes –
Reproductive System
• Males
▫ Intercourse
 Depends on whether erection can be maintained
 External and internal penile implants available
▫ Orgasms
 Possible through stimulation of body parts with
intact sensation if sensation in genitalia is lacking
Psychological Aspects
of Recovery
• Total denial and refusal of treatment is rare
• As long as behavior does not interfere with rehab
goals, allow patient to work through adjustment
period
• Everybody has their bad days, but…
• Goals need to be practical to the patient’s home
situation and lifestyle
Treatment Innovations
An implant known
as the "Freehand
System" stimulates
eight muscles in an
arm to give the
patient the ability to
have both a power
and a key grip.
http://www.inspire-foundation.org.uk/#Background
Rehabilitation!
http://www.spinalcord-injury.com/pt.html
Summary of Complete SCIs
• Paralysis combined with hyperreflexia and
spasticity below the level of the lesion
• Flaccid paralysis at the level of the lesion with
atrophy, hypotonia, hyporeflexia, and
fasciculations
• ANS: Vasoconstriction only and the ability to
shiver and sweat are lost below the level of the
lesion
Summary of Complete SCIs
• Breathing:
▫ C3-5: diaphragm
▫ T1-12: intercostals – muscles of expiration
▫ T6-12: abdominals (controls cough) – muscles of
expiration