ClinMed Exam 6: dysautonomia and spinal injury

CN X (vagus)

PNS also involves CN 3, 7, and 9 + sacral nerves (S2-S4)
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CN X (vagus)

PNS also involves CN 3, 7, and 9 + sacral nerves (S2-S4)
75% of the parasympathetic NS is controlled by _____
dysautonomia (issue with ANS - PNS or SNS)

causes:
1. DM
- others: guillain barre, long standing alcohol abuse, parkinsons

No real cure - just tx symptoms
dysautonomia can affect any aspect of the ANS, usually causing ANS failure rather than ANS excess. What are some of the most common causes and what is the tx?
POTS causes 30 bpm rise in HR with standing (no change in BP)
What is the difference between POTS and orthostatic HOTN?
HR increases 30+ bpm when standing
- weakness, lightheaded, visual darkening/blurring

workup: tilt table test

tx:
- increase salt (avoid dehydration) - similar tx to orthostatic HOTN
- can use midodrine or fludrocortisone (mineralcorticoid to retain Na)
POTs can cause weakness, lightheadedness, vision blurring, and LOC due to their HR increasing by ____ bpm when they stand. What is the workup?
1. weakness/sensory changes (at and below injury)
- can cause flaccid paralysis and loss of sensation

2. radiculopathy (radiating) if nerve root involved

3. can turn into spastic paralysis over time
- hyperreflexia, abnormal babinski, spasms
Spinal cord injuries are usually caused by fracture/dislocation causing compression to the spine. They can also be caused by HOTN/ischemia, tumors, abscesses, or more. How do spinal cord injuries manifest?
AIS A - complete cord injury

AIS B - sensory incomplete cord injury
Explain the ASIA impairment scale (AIS) for spinal cord injuries
false- different injuries effect different sensations so you should do full neuro exam to r/o injury
T/F: for a suspected spinal cord injury, if the neuro exam has normal response to pain and touch, you dont need to do temperature or proprioception
- low back pain
- bilateral lower extremity weakness
- saddle anesthesia
- urinary retention
- fecal incontinence

SURGICAL EMERGENCY
Cauda equina syndrome causes symptoms due to damage to nerve roots from lumbar to sacral spine. What symptoms does it cause?
-MRI most detailed but takes the longest (best for soft tissue)
- if emergent attention needed may need to do CT over MRI
- xray helpful but CT or MRI usually needed

MRI > CT > XRAY
What is the best imaging method for spinal cord injuries?
high dose of IV methylprednisolone started within 8 hours of injury
For acute spinal cord injuries, you should give a high does of IV ______ within _____ hours of injury
syringomyelia - damage to cord around canal causing fluid cyst to form in canal - often causes chiari malformations (cerebellem herniates thru foramen magnum) tx: refer for surgery - craniotomy and upper cervical laminectomy - cord cavity drainage - outlet for 4th ventricle drainageDamage to the cord around the central canal will cause fluid-cyst to form in the canal, what is this called and what is this often associated with?burst (jefferson) fracture: - C1 (atlas) broken in multiple parts due to vertical compression - highly unstable make sure to do open mouth view on patients with cervical injury or you may miss this fracture these pts need a cervical collar and likely surgerywhat type of fracture is this and what causes it?posterior arch fracture - C1 (atlas) fracture at posterior arch - more stable than jefferson (burst) fx but still dangerous due to location these pts need a cervical collar and likely surgeryWhat type of fracture is this?C1 or C2 - odontoid (dens) fx - burst (jefferson) fxopen mouth xrays are important for cervical injuries, especially at _______hangmans fracture - traumatic spondylosis of C2 - due to extreme hyperextension due to abrupt deceleration - bilateral pedicle fx common +/- dislocationtraumatic spondylosis of C2 is a _____ fracture caused by extreme ______ due to abrupt deceleration. What else is common with these fractures?hangmans fracture - traumatic spondylosis of C2 - due to extreme hyperextension due to abrupt deceleration - bilateral pedicle fx common +/- dislocationWhat is this fracture?odontoid (dens) fracture - type I: upper dens - fairly stable - type II: base of dens - unstable (need halo vest immobilization)What is this fracture and what is the difference between type I and type II?halo vest immobilization - needed for type II dens fx (base of dens is fractured and unstable)forced flexion or extension of the head (such as falling onto forehead) can lead to odontoid (dens) fracture, which type needs a halo vest immobilization?clay shovelers fracture - fracture of spinous process - follows direct trauma or sudden forced neck flexion - usually of lower cervical vertebrae (C7)diving into a pool head first (forced neck flexion) may lead to a spinous process fracture, otherwise known as ________ fracture. Where do these usually occur?clay shovelers fracture - fracture of spinous process (usually C7) - will have pain w/ palpation - due to direct trauma or sudden forced neck flexion (ex. diving head first into pool)What is this fracture? what causes this?calcaneal fracture - do spinal xray to look for compression fracture (esp. lumbosacral) since it takes a lot to cause this fractureIf a patient has a _____ fracture, you should do spinal xrays on the patient since it takes a traumatic injury to cause this fracture.spinal cord injury without radiographic abnormality (SCIWORA) - neuro deficits but normal xray = likely ligamentous injury - would still do CT/MRI on pt but if normal just watch and waitA patient with positive neuro deficits (such as tingling/numbness to left arm) but normal xray (no bony injury) usually has what type of injury? What do you do?