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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