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Spinal C ord Injury

Spinal C ord Injury. Etiology of Traumatic Spinal Cord Injury. MVA- most common cause Other: falls, violence, sport injuries SCI typically occurs from indirect injury from vertebral bones compressing cord SCI frequently occur with head injuries

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Spinal C ord Injury

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  1. Spinal Cord Injury

  2. Etiology of Traumatic Spinal Cord Injury • MVA- most common cause • Other: falls, violence, sport injuries • SCI typically occurs from indirect injury from vertebral bones compressing cord • SCI frequently occur with head injuries • Cord injury may be caused by direct trauma from knives, bullets, etc

  3. Etiology of Traumatic Spinal Cord Injury • 78% people with SCI are male • Typically young men – 16-30 • Number of older adults rising (>61 yr) • Greater complications • Life Expectancy 5 years less than same age without injury • 90% go home

  4. Pathophysiology • anatomy of the spine

  5. PathophysiologyNormal Spinal Cord • Spinal cord begins at the foramen magnum in the cranium • Cord ends at the L1-L2 vertebra level • Spinal nerves continue to the last sacral vertebra

  6. PathophysiologyNormal Spinal Cord • Vertebral Column • 8 Cervical • 12 Thoracic • 5- Lumbar • 5- Sacral

  7. Protection of Spinal Cord from Injury • Bones- vertebral column • Discs- between vertebra • Internal and external ligaments • Dura

  8. Protection of Spinal Cord from Injury • Internal and external ligaments • Dura • Meninges • CSF in subarachnoid space allow for movement within spinal canal

  9. Nervous System and the Spinal Cord • ANS can be affected by SCI • Sympathetic chains on both sides of the spinal column • Parasympathetic nervous system is the cranial-sacral branch

  10. Normal Spinal Cord

  11. Normal spinal cord Dermatones • Skin innervated by sensory spinal nerves

  12. Normal Spinal Cord Reflex Arc • Where sensory and motor nerves arise from cord • Sensory fibers enter posterior • Motor fibers leave from anterior • Once outside cord join form spinal nerve • reflex movement

  13. Normal Spinal Cord • White tracts send messages to and from the brain • Pyramidal- Voluntary movements • Posterior column (Dorsal)- touch, proprioception, and vibration sense • Lateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord) • voluntary movement

  14. Spinal Cord Injury- SCI • Compression • Interruption of blood supply • Traction • Penetrating Trauma

  15. Spinal Cord Injury • Primary • Initial mechanism of injury • Secondary • Ongoing progressive damage • Ischemia • Hypoxia • Microhemorrhage • Edema

  16. Spinal Cord Injury • Hemorrhage and edema occur in the cord post injury, causing more damage to cord • Extension of the cord injury from cord edema can occur over the first few days- watch the phrenic nerve! • Initially SCI experience spinal shock- depression of all cord & ANS function below injury. Lasts from few min to wks

  17. Classifications of SCI • 1. Mechanism of Injury • 2. Skeletal and Neurologic Level • 3. Completeness (degree) of Injury

  18. Classifications of SCIMechanism of Injury • 1. Mechanism of Injury • Flexion • Hyperextension • Flexion Rotation • Compression

  19. Classifications of SCIMechanism of Injury Flexion (hyperflexion) • Most common because of natural protection position. • Generally cause neck to be unstable because stretching of ligaments

  20. Classifications of SCIMechanism of Injury Hyperextention • Caused by chin hitting a surface area, such as dashboard or bathtub • Usually causes central cord syndrome symptoms

  21. Classifications of SCIMechanism of Injury Compression • Caused by force from above, as hit on head • Or from below as landing on butt • Usually affects the lumbar region

  22. Classifications of SCIMechanism of Injury Flexion/Roatation • Most unstable • Results in tearing of ligamentous structures that normally stabilize the spine • Usually results in serious neurologic deficits

  23. Classification of SCI- Level of Injury Spinal cord level • When referring to spinal cord level, it is the reflex arc level not the vertebral or bone level. • Note that the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of there respective vertebral bone

  24. Classification of SCI- Level of Injury • Spinal cord injuries are described by the level of the injury– the cord segment or dermatome level • Such as C6; L4 spinal cord injury

  25. Classifications of SCICompleteness (Degree) of Injury • Complete • Incomplete • Central cord syndrome • Anterior Cord syndrome • Brown-Sequard Syndrome • Posterior Cord Syndrome • Cauda Equina and Conus Medullaris

  26. Classification of SCI Completeness (degree) of Injury Complete (transection) • After spinal shock: • Motor deficits- spastic paralysis below level of injury • Sensory- loss of all sensation perception • Autonomic deficits- vasomotor failure and spastic bladder

  27. Classification of SCI Completeness (degree) of Injury Incomplete Central Cord Syndrome • Injury to the center of the cord by edema and hemorrhage • Weakness in both upper extremities- legs are spared • Varied loss of sensation

  28. Classification of SCI Completeness (degree) of Injury Incomplete Brown-Séquard Syndrome • Hemisection of cord • Ipsilateral paralysis • Ipsilateral superficial sensation, vibration and proprioception loss • Contralateral loss of pain and temperature perception

  29. Classification of SCI Completeness (degree) of Injury incomplete • Anterior Cord Syndrome • Injury to anterior cord • Loss of voluntary motor (Pyramidal track) below • Loss of pain and temperature perception • Retains posterior column function

  30. Classification of SCI Completeness (degree) of Injury incomplete • Posterior Cord Syndrome • Least frequent syndrome • Injury to the posterior columns results in proprioceptive loss (dorsal columns) • Pain, temperature, touch are preserved. Motor function is preserved to varying degrees.

  31. Classification of SCI Completeness (degree) of Injury incomplete • ConusMedullaris Syndrome • Injury to the sacral cord (conus) and lumbar nerve roots within the spinal canal, usually results in are-flexic bladder and bowel, and lower limbs (in low-level lesions) • CaudaEquina Syndrome • Injury to the lumbosacral nerve roots within the neural canal, results in areflexic bladder, bowel, lower limbs

  32. Common Manifestations/Complications • Terms used to describe motor deficits • Prefix: para- meaning two extremities; tetra- or quadra- all four extremities • Suffix –paresis meaning weakness; -plegia meaning paralysis • Quadraparesis means what?

  33. Common Manifestations/Complications • C1-3 usually fatal- • Loss of phrenic innervation ventilator dependent • No B/B control • Spastic paralysis • Electric w/c with chin/mouth control

  34. Common Manifestations/Complications • C6- weak grasp • Has shoulder/biceps to transfer & push w/c • No bowel/bladder control. • Considered level of independence

  35. Common Manifestations/Complications • T1-6- full use of upper extremity • Transfer • Drive car with hand controls and do ADL’s • No bowel/bladder control

  36. Clinical Manifestations of SCI • Skin: pressure ulcers • Neuro: pain; sensory loss; upper/lower motor deficits; autonomic dysreflexia • Cardio: dysrhythmias; spinal shock; loss of sympathetic nervous system control over blood vessels (vasomotor control)- decreased venous return, orthostatic hypotension, poikilothermic (takes on temp of room)

  37. Clinical Manifestations of SCI • Respiratory: decrease chest expansion; cough reflex & vital capacity; diaphragm function-phrenic nerve • GI: stress ulcers; paralytic ileus; bowel- impaction & incontinence • GU: upper/lower motor bladder; impotence; sexual dysfunction • Musculoskeletal: joint contractures; bone demineralization; osteoporosis; muscle spasms; muscle atrophy; pathologic fractures; para/tetraplegia

  38. Spinal and Neurogenic shock • Spinal Shock • Decreased reflexes and loss of sensation below the level of injury • Motor loss- flaccid paralysis below level injury • Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury • Lasts days to months

  39. Spinal and Neurogenic Shock Neurogenic shock • Due to loss of vasomotor tone • SNS loss results in parasympathetic dominance with vasomotor failure • Loss of SNS innervation causes peripheral pooling and decreased cardiac output • Hypotension and Bradycardia • Orthostatic hypotension and poor temperature control (poikilothermic- takes on temp of environment)

  40. How do you know spinal shock is over? • Clonus is one of the first signs • Hyperreflexia of foot • Test by flexing leg at knee & quickly dorsiflex the foot • Rhythmic oscillations of foot against hand • clonus

  41. Common Manifestation/Complications Upper and Lower Motor Deficits • Upper motor deficits result in spastic paralysis • Lower motor deficits result in flaccid paralysis and muscle atrophy

  42. Diagnostic Studies for SCI • X-ray of spinal column • CT/MRI • Blood gases

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