Spinal Cord Injury

1. Spinal Cord Injury Don’t forget to go back over your notes from Physical Disabilities Conditions. The assumption here is that you remember that information.

2. What is Spinal Cord Injury?Etiology • any injury to the neck or back that interrupts spinal cord function. • 200,000-500,000 spinal cord injured persons in US • 8,000-10,000 new injuries annually that result in paralysis • Average age- 16- 30 (19 is most frequent) • Male:female ratio is 4:1

3. Causes of Traumatic SCI • MVA– approx. 37% • Falls • Violence (i.e. gun shot, stabbing) • Sports injury– of which 66% are diving accidents

4. Other Causes of SCI • CA • spinal arthritis • ankylosing spondylitis - Degenerative arthritis or cervical or lumbar- can have compression fractures or bone grown vertebrae resulting in limits to ROM • Stenosis-shrinking of space • post-polio syndrome-people had polio when child and when they age symptoms show up

5. Types of Spinal Cord Injuries • Complete- total paralysis and loss of sensation by total destruction of the ascending and descending pathways • Zone of partial preservation (sparing)- areas caudal to level of injury with intact sensation and or motor function= spinal cord completely severed or when spinal tissue deoxygenated,,swellig cn close space and stop o2 • Incomplete- partial preservation of sensory and/or motor function

6. Labeling SCI • The injury is labeled from the last (most caudal) level with INTACT sensory and motor function bilaterally. Below that level is impaired So… tell me about a person with a C5 complete SCI

7. Let’s meet Elva • C5/c6 sc injury.

8. Tetraplegia v Paraplegia • Tetraplegia (old term quadriplegia)- C8 and higher • Paraplegia- below C8

9. ACUTE SCI • Spinal Shock • Occurs after trauma to spinal cord • Usually resolves within a few weeks, but can take up to a few months • Maintain (create airway)- tracheostomy (we’ll talk about respiratory function later) • Determine extent and type of injury

10. Cervical Spinal Stabilization (internal) • Decompress spinal canal by removing all bony and soft tissue elements pressing against the cord (often anterior) • Wiring of spinous processes • Graft using iliac crest, fibula or tibia • Rods • Sometimes plates and screws provides internal stabalization to provide stability so it can heal.

11. Cervical Spinal Traction/Support(external) • Tongs or calipers (Somers, 41) • Supportive bed– Stryker Frame (Somers, 42) • Halo- rigid brace used later, after cervical traction with tongs Contraindications include severe respiratory problems, chest injuries and burns on the trunk or abdomen • Semi-rigid cervical orthoses- later • Cervical collar- later

13. Thoracolumbar Stabilization • Internal • Usually rods and/or fusions • Sometimes screws and plates • External TLSO Jewett Brace

14. Assessment • Sensory • Motor • Tone (spasticity- different than CVA) • Strength • Endurance • Posture- alignment and control • Soft tissue integrity- skin, joints • Psychosocial • Values, interests, self concept, role performance, coping

15. C 1 C 2-3 C 4 C 2-8 C 1-7 TEAM/Roles Resp therapy PT Nutrition OT Psychology Treatment Intervention/ExpectationsC 1-4 Expectation– Dependent some/all care; use of assistive technology

16. C 5-6I (most tasks)with equipment • C 5 • C 6 • Tenodesis- how do you maintain? • Respiratory- no obliques/abdominals • Spasticity- may need meds • Positioning- maintain shortening in low back • Medical complication- HO, OH, DVT • Too much biceps without triceps • How do you compensate for lack of triceps?

17. Case Study- WEAK C5 injury (weak biceps) Using mobile arm support secondary to limited UE strength; allows flexion at elbow with hand moving toward mouth and extension with hand moving toward table Write a long term goal (1 month)

18. C 6-7 I with equipmentC 8 – T 1 • C 6-7 • C 7-8 • C 8 – T 1 • C 8 • C 8 – T 1 C6 extensor carpi radialis longus and brevis C7 triceps C8 flexor digitorum profundus T1 Interossei

19. Thoracic, Lumbar and Sacral SCI • T 1-5 • T 11 and below- expect to walk with/without braces • L 1-4 • L 5 – S 3 • S 4-5 S2-5 bowel and bladder

20. Other Considerations Respiratory Bowel and Bladder Function Orthopedic Restrictions Spasticity Medical Complications Spinal Cord Injury Syndromes

21. Respiratory Considerations • Initially after injury- often requires intubation • If the lesion is below C5, there is a good chance that the person will eventually be able to breath on his/her own • If the lesion is between C3 and C5, may or may not need mechanical ventilation • High injury (C3 or higher) need ventilator • Incomplete injury? Difficult to predict outcome of respiratory abilities

22. Tracheostomywhat it is and how it works Trach Placement

26. Suctioning • Signs of need for suctioning • frightened look • flared nostrils • restlessness • paleness or bluishness around mouth • clammy skin • sinking in of the chest (retractions) NOT dependent on presence of trach tube

27. Other respiratory considerations • Assisted cough • Weaning from mechanical ventilation

28. Bowel and Bladder Function • Spastic v. flaccid bladder (go back over old notes) • Bowel program • Equipment • Bladder care and catheterization

29. Orthopedic Considerations • Cervical injury- placement of halo- usually restricted to 90° flexion/abduction at shoulders • Other?

30. Spasticity Explain the difference between the spasticity seen following SCI v. CVA

31. Med Complication: Autonomic Dysreflexia • Characterized by sudden severe headache secondary to an uncontrolled elevation in BP • Caused by any variety of stimuli creating an exaggerated response of the sympathetic nervous system • Over-distended bladder, bowel impaction, urinary infection, or other infection (like pressure sore, ingrown toe nail) • Occurs mainly when injury is T 4-6 or higher • Treatment is to remove the aversive stimuli

32. Med. Complication:Orthostatic Hypotension • Also called postural hypotension • Dramatic fall in BP when upright posture is assumed • Disturbed vasomotor control with decreased blood supply returning to heart • Occurs mainly with injury T4-6 or higher, with increased incidence at higher levels.

33. Med. Complications:Deep Vein Thrombosis • Development of a blood clot in the venous structures • Why? • Tx? • Prevention • After occurrence

34. Med. Complication: Heterotopic Ossification • occurs below the level of the injury • usually at major joints (esp. hips, also knees, shoulders, elbows) • may present w/ signs of localized inflammation or pain, elevated skin temp, etc. • Tx- meds, radiation, operative resection (still risk recurrence)

35. Central Cord Syndrome • Caused by damage to the central portion of the cervical cord • Corticospinal tract fibers are organized with those controlling the arms located most centrally, the trunk intermediately, and the legs laterally • UE involvement with LE sparing Incomplete SCI

36. Brown Sequard Syndrome • Damage to one side of the cord • Loss of function below the level of injury of the portion of the cord that controls voluntary motor pathways on the same side of the body and pain and temperature on the opposite side of the body Incomplete SCI

37. Anterior Cord Syndrome • Damage to the anterior portion of the cord • Loss of function below the level of injury of the part of the cord that controls voluntary motor pathways and major sensory tracts • Sparing of posterior columns, as vascular supply is obtained from different source • Preservation of position, vibration, and touch senses Incomplete SCI

38. Conus Medularis and Cauda Equina Injuries • Loss of motor function • Sensory function NOT markedly impaired • Extremely variable pattern with asymmetrical involvement • Nerve roots have some recovery potential, so outlook is often favorable Incomplete SCI

39. Prevention