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Spinal Cord Injury
Terms in this set (79)
Spinal Cord Anatomy
C5, C6, T12, L1
3 causes of spinal cord injury (SCI)
penetrating or blunt trauma (shear, twist, bend)
bone fragments, disc material, hematoma, neoplasm
damage of / clot in spinal artery (Artery of Adamkiewicz T4-T9)
Injury to the cervical region of the spinal cord with associated loss of muscle strength in all 4 extremities
Most common location of injury - C5
Injury to the
thoracic, lumbar or sacral
segments of the spinal cord, including the cauda equina and conus medullaris.
quadriplegia / tetraplegia, reuslts in complete paralysis below the neck
results in partial paralysis of hands and arms as well as lower body
Paraplegia - results in paralysis below the chest
Paraplegia, results in paralysis below the waist
L-1 Compression fracture with vertebral fragments displaced anteriorly + vertebral body displaced posteriorly
what is a Sciwora and where do you see it most often?
spinal cord injury without radiologic abnormality
most often in
mechanism behind no radiologic findings in a Sciwora
elasticity in pediatric cervical spine allows spinal cord injury to occur in absence of x-ray findings
kids are made of jello
causes of Sciwora
fracture through the
cartilaginous end plates
(which are not visualized by x-rays), unrecognized interspinous
Sciwora in adults
C-spine trauma occurs w/
to spine when vertebral canal is already compromised by
; typically, pts are managed nonsurgically
where does the spinal cord terminate?
what can you say about injuries in lower thoracic area?
Level of injury below upper T-spine does not usually correlate with neurologic level
Most common Quadriplegia level
C5 - most common
followed by C4 and C6
most common level for paraplegia
do both UMN and LMN lesions result in paralysis?
what is spinal shock in SCI?
Transient depression/loss of
reflex activity & cord function below the level of injury
due to acute spinal cord injury
what is lost in spinal chock in SCI?
Temporary loss of all ascending and descending communication past the injured segment of cord
Flaccid paralysis (hypotonia), including bowel & bladder
lasting injuries in spinal shock in SCI
Lasting injuries will "evolve" to demonstrate hyperreflexia, spasticity.
long term prognosis of spinal shock in SCI
Long term prognosis cannot be determined until spinal shock has resolved
Chronic spinal shock issues in trauma
Digestive / elimination systems are less motile
bladder emptying problems
immobility: skin - pressure ulcers
digestive/elimination system issues in spinal shock
Can't feed until bowel sounds heard, malnutrition risk
May need tube feedings
Long term care may require aggressive bowel measures: suppositories, digital stimulation
Bladder emptying issues in spinal shock
Catheterization predisposes to frequent urinary tract infections
Immobility issues in spinal shock
skin - pressure ulcers
Major risk for Infected bedsores
Neurogenic shock in SCI
Loss of sympathetic vasomotor tone
resulting in a triad of:
hypotension, bradycardia and hypothermia
from T1 - L2
loss of sympathetic tone means your arteries have no tone so all of the blood is pooling in the arterial side (S-ANS controls arterial tone)
what does neurogenic shock result in?
Disruption of sympathetic outflow from T1-L2
leading to unopposed vagal tone
what is always an emergency in neurogenic shock / anytime?
treatment of hypotension
support BP - IV fluids and vasopressors
spinal immobilization until radiographic image
high dose steroids are no longer recommended
when does neurogenic shock occur?
30 min cord injury level T 5 or above
last up to 6 weeks;
also due to effect some drugs that effect vasomotor center of medulla as opioids, benzodiazedines
spinal shock vs neurogenic shock diagram
different types of shock
neurogenic shock - loss of sympathetic vasomotor tone
spinal shock - Transient depression of reflex activity & cord function
what must you evaluate in any new SCI patient?
Chest: Pneumothorax / hemothorax
Other fractures: pelvic, femur
emergency neurologic exams for new SCI
- Glasscow Coma Scale
Motor (level at which 3/5 strength) - can hold up against gravity
Cerebellum / proprioception
eye opening response GCS scale
Verbal response GCS scale
Motor response for GCS scale
what must a neuro exam for a new SCI patient test?
3 long spinal tracts
Corticospinal tract (descending)
Spinothalamic tract (ascending)
Posterior dorsal columns (ascending)
Complete SCI lesion
Absence of sensory and motor function in the lowest sacral segments
Incomplete SCI lesion
Partial motor or sensory below the injury level, including the lowest sacral segments
how do you name the level of injury?
The most caudal neurologic level with
at least 3/5 muscle strength
(muscle can contract against gravity through its full ROM, but not against resistance) and
Normal sensation to pinprick (based on dermatomes)
ASIA scale with sacral sparing
what does it mean?
what do you need to perform to check for it?
Perform rectal exam - Sacral sparing is the presence of either motor function or sensation at the anal mucocutaneous junction.
Sacral sparing reflects the continuity of long tract fibers and is a predictor of future recovery
Complete loss of sacral sparing
No motor and no sensation in the perineal region (poor prognosis)
Incomplete sacral sparing
Preservation of sensory or motor function below the level of injury, including the lowest sacral segments.
Likely to require ventilator support
Phrenic nerve provides motor to diaphragm arises C3+C4
Potential of independence in transfers, mobility and ADL
Have ability to extend elbow and grip
can get out of wheelchairs and lift themselves
low thoracic paraplegia
Partial abdominal strength and may be able to walk short distances with equipment
L1 - L3
Potential household and community ambulator if has L3 motor function (Quadriceps)
potential use of legs
hazards of inactivity in SCI
Skin- pressure ulcers
DVT and PE
Pulmonary function decreased
Problems due to lack of neuronal control
Bladder - neurogenic bladder (increased urinary and renal infections)
Insensate (lack of physical sensation) areas of skin
what is autonomic dysreflexia
a syndrome of massive imbalanced reflex sympathetic discharge occurring in patients with SCI above the splanchnic sympathetic outflow (T5-T6)
when can autonomic dysreflexia occur?
This phenomenon can occur after the phase of spinal shock in which reflexes return.
what does uncontrolled sympathetic outflow cause?
as in autonomic dysreflexia
Uncontrolled sympathetic outflow causes release of various neurotransmitters; vasoconstriction in arterial vasculature.
what does autonomic dysreflexia lead to?
Leads to dramatic BP elevation, bradycardia (vagus), sweating, piloerection, headache
what should you look for in autonomic dysreflexia?
Look for "irritants" - bladder, bowel, skin, other
bladder distention, pressure ulcer, fecal impaction, UTI, fracture
treatment of autonomic dysreflexia
Empty bladder and bowel; Rx: benzodiazepine, antihypertensives.
complete transection (transverse) lesion characteristic signs
Complete loss of motor and sensory function below level of lesion (Quadriplegia or paraplegia);
: flaccid, areflexia (spinal shock)
: spasticity, hyper-reflexia, Babinski's signs, spastic bladder
Hemisection lesion characteristic signs
KNOW ABOUT THIS SYNDROME
Crossed sensory & motor deficit:
ipsilateral loss of vibration, propriocep.
Contralateral loss of pain, temperature below level of lesion
Central Cord Syndrome
(narrowed spinal canal)
Weakness, atrophy, fasciculations, loss of reflex in arms>>legs
Variable sensory loss: "cape" sensory loss over shoulders from cervical lesion most common
Loss of pain and temperature, sparing of vibration and proprioception ("dissociated" sensory loss)
How does a Hemisection of spinal cord usually happen?
usually penetrating trauma, tumor, disc bulge
what do you see in Brown-Sequard Syndrome?
Ipsilateral motor and proprioceptive loss
- Corticospinal and dorsal columns cross in brainstem
Contralateral pain and temperature loss
- Spinothalamic tracts cross 1-2 levels above
what usually causes central cord syndrome?
Usually seen in hyperextension injuries in the elderly
where is the lesion located in central cord syndrome?
what does it cause?
central gray/white matter
causes arm weakness moreso than leg weakness
what is spared in central cord syndrome?
sacral sensory sparing
Often return of bowel/bladder
Anterior Spinal Cord Injury
Loss of motor function below level of lesion, flaccid quadriplegia or paraplegia.
Loss of pain and temperature sensation below level of lesion with preservation of vibration, proprioception.
Loss of bladder and bowel control
Cauda Equina Syndrome
Urinary retention, fecal incontinence &
Pain & loss of sensation in saddle distribution of the perineum
where is the lesion in anterior cord syndrome?
what is spared?
Lesion of anterior 2/3rds of spinal cord posterior (Dorsal) columns are spared
what is absent in anterior cord syndrome?
what is intact?
Absent pinpricks/sharp sensation and motor function
Light touch, deep pressure and proprioception intact
vascular etiology of anterior cord syndrome
Artery of Adamkiewicz: Thoracic ASA @T7
type and location of lesion in cauda equina syndrome
mixed lesion - Combination of UMN and LMN: injury of cord segments from S2, S3, S4 and sacral roots
Or just LMN - injury of cauda equina alone
major finding in cauda equina syndrome
thermoregulation in SCI
Body is poikilothermic below level of injury. High risk for hyper / hypo-thermia.
things to consider in Asensate patients
Need to limit sun exposure, abrasive bedding
Scrupulous monitoring of skin by caregivers-
Pressure sores, decubitus ulcers
"minor" cuts and wounds can become infected
SCI Review Points
SCI Review Points - Cord syndromes
SCI Review Points - Special problems
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