NBCOT REVIEW Ch 5: Spinal Cord Injury

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What is the ASIA Impairment Scale?

A scale that grades the degree of impairment and severity of injury of a patient.

What is ASIA A?

Complete SCI, no sensory or motor function preserved in the sacral segments S4-S5.

What is ASIA B?

Incomplete SCI, sensory but no motor function preserved below the neurological level, and extends through the sacral segments.

What is ASIA C?

Incomplete SCI, motor function is preserved below the neurological level, and the majority of key muscle groups below the neurological level have a muscle grade level less than 3/5.

What is ASIA D?

Incomplete SCI, motor function preserved below the neurological level, and the majority of key muscle groups below the neurological level have a muscle grade greater than or equal to 3/5.

What is ASIA E?

Normal, no SCI. Sensory and motor function are normal.

Precautions in SCI.

1. Respiratory complications (weak cough and shallow breathing). Do not overdo therapy b/c person does not have control of stomach muscles
2. Skin breakdown: redness, Decubitus ulcers
3. Orthostatic Hypotension: excessive fall in BP when assuming upright position, light-headedness, dizziness, sudden weakness (usually occurs at T6 and above)
4. DVT: swelling in legs, localized redness, low-grade fever. Compression stockings to tx.
5. Autonomic Dysreflexia: exaggerated response of ANS, body's way of telling something is wrong below level of injury: resulting in extreme rise in BP, pounding headache, profuse sweating. Check for obstructions and drain bladder. A medical emergency if not reversed quickly.
6. Genitourinary problems: UTI - cloudy urine, excessive particles, fever, chills, increase in spasticity
7. Heterotopic ossofication: formation of bone in abnormal anatomical locations. Sym: pain, swelling, decrease in A/PROM.

List the types of SCI disease.

Central cord syndrome
Brown-Sequard syndrome
Anterior cord syndrome
Conus medullaris syndrome
Cauda equina syndrome

Central Cord Syndrome (Syringomyelia)

- Incomplete SCI
- Commonly occurs in elderly with narrowing/stenotic changes in the spinal canal (of the neck) related to arthritis and hyper extension of the neck
- Bilateral loss of pain & temperature
- Flaccidity of the UE (affects UE more than LE)

Brown-Sequard Syndrome.

Hemi-section of the cord
- ipsilateral (same side) spastic paralysis and loss of position sense
- contralateral (opposite side) loss of pain and thermal sense

Anterior Cord Syndrome.

- caused by flexion injuries
- occurs when 2/3 of the anterior cord is lost
- motor function, pain, and temperature sensation lost bilaterally below the lesion (flaccidity below the lesion)

Conus Medullaris Syndrome.

- of the sacral cord and lumbar nerve roots
- LE motor and sensory loss
- reflexic bowel/bladder (ability to void only possible by reflex)

Cauda Equina Syndrome.

- LMN lesion
- flaccid paralysis
- NO spinal reflex activity

Upper Motor Neuron Lesion

- Includes all SCI injuries and diseases that affect the cord between the levels of C1 - T12.

Signs of UMN Lesion.

Below the lesion level:
- Spasticity
- Clonus
At the lesion level:
- Flaccidity

Lower Motor Neuron Lesion

- Carries motor information to skeletal muscles.
- Lesions at the L1 vertebra and lower are LMN injuries.
- All lesions to peripheral nerves are also considered LMN injuries.

Signs of LMN Lesion.

- Flaccidity
- Hyporeflexia
- Within a few weeks of LMN injury, muscles begin to atrophy.

Group the levels of SCI as they are grouped according to functional ability.

C1-C3
C4
C5
C6
C7
C8-T1
T1-T6
T6-T12
T12-L4
L4-L5

C1-C3

Preserved: Head and neck sensation, some neck control
Respiratory dependent
ADL: Dependent in all

C4

Preserved: Good head and neck sensation, neck flexion/extension, rotation, scapular elevation; inspiration
ADL: Max assist in all

C5

Preserved: Full head and neck control and sensation, some shoulder strength, shoulder ER, Abd to 90 degrees, elbow flexion and supination
ADL: self-feeding with AE (long opponens splint), limited self-care with AE (brushing teeth, grooming - long opponens splint)

C6

Preserved: Fully innervated shoulder movement, forearm pronation, wrist extension, tenodesis
ADL: self-feeding with AE (tenodesis splint), UE/LE dressing with AE, requires greater assist with LE dressing, self-care with AE

C7

Preserved: elbow extension, wrist flexion, finger extension
ADL: Independent in self-feeding, dressing, grooming with AE, Independent bed mobility and transfers, meal prep with AE, driving with hand controls

C8-T1

Preserved: All UE muscles, FMC present, full grasp
ADL: Independent in all self-care, grooming, and meal prep with AE, driving with hand controls

T1-T6

Preserved: top half of intercostal muscles allowing increased respiratory reserve, long muscles of back for improved trunk control
ADL: standing possible with assist but not practical for dynamic ADL, independent self-catheterization

T6-T12

Preserved: all intercostal muscles and lower abdominals, providing improved trunk control and endurance
ADL: limited ambulation possible with LE orthotics and AD.

T12-L4

Preserved: hip flexion, adduction, knee extension
ADL: Functional ambulation possible with Bilateral LE orthotics and AD, w/c for energy conservation

L4-L5

Preserved: knee extension present but weak, ankle dorsiflexion
ADL: functional ambulation possible with Bilateral LE orthotics, w/c for energy conservation

Sexual function in SCI

- Mediated by S2-S4 segments of SC.

In T12/L1 or higher SCI (UMN injury):
- Pt still has sexual arousal due to touch but not mental stimulation
In L2-S1 SCI (LMN injury):
- Pt has sexual arousal from touch (cannot feel erection/lubrication) and mental stimulation

Disorders of Bladder Function in SCI

UMN Lesion:
- Spastic bladder: no voluntary control of voiding but can still have involuntary voiding reflexes, which can cause incontinence and inability to completely empty the bladder
LMN Lesion:
- Flaccid bladder: cannot void voluntarily or involuntarily, urine leakage occurs

Disorders of Bowel Function in SCI

SCI above S2-S4:
- Pt has spastic defecation reflex
- loses voluntary control of the external anal sphincter but can still defecate with involuntary stimulation
SCI at the S2-S4 level
- Pt has flaccid defecation reflex (peristaltic movements cannot evacuate the stool)
- loses anal sphincter tone

UMN Lesions are associated with what type of muscle tone?

Spasticity

LMN Lesions are associated with what type of muscle tone?

Flaccidity

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