Case Study: SPINAL CORD INJURY

1. Case Study:SPINAL CORD INJURY Cueto, Cunanan, Dadgardoust, Daguman, Damo, David, H., David, H., De Guzman, J., De Guzman, R., De Leon, De Mesa, De Vera, Dela Cruz, C., Dela Cruz, F., Dela Cruz, I., Dela Rosa

2. Salient Features • excruciating pain • could not move his trunk and lower extremities immediately after hitting his head on the floor of the pool (sustained neuromuscular injury) • MMT • normal muscular strength (5/5) on both elbow flexor • moderate resistance (4/5)on both elbow extensors • both finger flexors can perform full range of motion with gravity eliminated (2/5) • trace muscle contraction (1/5) of both finger extensors • no muscle contraction (0/5) on both lower extremities (hip flexor, knee extensor, ankle dorsiflexor, long toe extensor, and ankle plantar flexor)

3. Salient Features - 80% sensory deficit from little fingers for pinprick (fast pain) and light touch bilaterally - normal muscle stretch reflexes (MSR) on both upper extremities - absent muscle stretch reflexes on both lower extremities Imaging: fracture dislocation of C7 to C8

4. 1. What is the patient’s neurological level?

5. NEUROLOGIC LEVEL • Most caudal neurologic segment of the SC that retains normal sensory & motor function in both sides of the body • PE must record most caudal sensory and motor level on each side • Key muscles/ dermatomes should be tested on each side (10 myotomes,28 dermatomes/side) • Muscles are graded 0-5 (rostral to caudal) • MOTOR SCORE (max: 50/ side) • Sensory : light touch/pinprick score: 0-2 • SENSORY SCORE (max: 56/ side)

7. NEUROLOGIC LEVEL • RECTAL EXAM – sensation in mucocutaneous region • COMPLETE LESION – absence of sensory/motor function in the lowest sacral segments • INCOMPLETE LESION – either sensory/motor function is preserved (SACRAL SPARING)

8. In the Patient • Sensory: • 80% sensory deficit from little fingers for both pinprick & light touch bilaterally • MSRs: ++ (B) UE 0 (B) • (-) Bulocavernosus reflex • Xray: C7-8 fracture dislocation

10. Neurological level: MOTOR 5 5 4 2 1 5 5 4 2 1 C7 C7 0 0 0 0 0 0 0 0 0 0 No

11. Neurological level: SENSORY • maximum: 56/side, 112/bilateral • 80% sensory deficit from little fingers for both pinprick & light touch bilaterally

12. C7 C7 C7 C7

13. NEUROLOGICAL LEVEL of the Patient C7 C7 C7 C7

14. 2. In what ASIA classification does the patient belong?

15. 5 5 5 5 4 4 2 2 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0

16. 5 5 5 5 4 4 2 2 1 1 34 17 17

17. 0 0 0 0 0 0 0 0 0 0 0 0 0

18. 2 2 2 2 1 1 1 1 0 0 0 0 33 33 66 33 33 66

20. X

21. 3. What is the patient’s pertinent prognosis in terms of:

22. Feeding and Grooming • Ability to feed self independently during mealtimes. Food may need cutting. • Able to make hot drinks , may require an adapted kettle using a "kettle tipper". • Independent in upper body showering and dressing, lower body dressing and showering may need assistance. • Independent in grooming, usually without palm straps.

23. Upper Extremity dressing • Independent in upper body showering and dressing • Easier to dress upper body while in wheelchair • Some methods will be easier if you have good shoulder strength and relatively good balance • Independent in oral/facial hygiene

24. Lower extremity dressing • lower body dressing and showering may need some assistance • May need help with bladder care (e.g. intermittent catheterization) • Shower chair is needed for safe bathing • Rectal stimulation for bowel movement

25. Bed Mobility • Independence in bed mobility transfers • May benefit from full electric hospital bed or full to king standard bed

26. Transfer - ability to transfer independently (bed to chair, chair to car) - car transfers may need assistance depending on upper body strength (transfer board) - may require assistance moving over uneven surfaces

27. Wheelchair Propulsion Manual wheelchair : independent propulsion in the community ( short distances of flat surfaces) Electrical wheelchair : for long independent travel or uneven outdoor surfaces (going over curbs)

28. Standing • Independent in standing (standing frame) • May need some assistance depending on body strength

29. Ambulation • Independent level surface transfers (although they may require assistance with moving over uneven surfaces) • Wheelchair use outdoors (power chair for school and work) • Manual wheelchair propulsion in the community (with the exception of going over curbs) • Propel chair (curbs and wheelies) • Wheelchair-to-car transfers

30. 4. What is the FIMS classification of this patient?

31. Functional Independence measurement (FIM) • The FIMTM instrument refers to a scale that is used to measure one's ability to function with independence • score is collected within 72 hours after admission to the rehabilitation unit, within 72 hours before discharge, and between 80 to 180 days after discharge. • score ranges from 1 to 7, with 1 (Total Assistance) being the lowest possible score and 7 (Complete Independence) being the best possible score.

33. FIM

35. Keith RA, Granger CV, Hamilton BB, et al. The functional independence measure: a new tool for rehabilitation. Adv Clin Rehabil. 1987;1:6-18.

36. Keith RA, Granger CV, Hamilton BB, et al. The functional independence measure: a new tool for rehabilitation. Adv Clin Rehabil. 1987;1:6-18.

37. 5. What is spinal shock? How will you know when an SCI patient is out of spinal shock already

38. Spinal Shock • Phenomena surrounding physiologic or anatomic transection of the spinal cord that results in temporary loss or depression of all or most spinal reflex activity below the level of the injury. • Reflex arcs above level of injury may be severely depressed  Schiff-Sherrington phenomenon • Hypotension due to loss of sympathetic tone is a possible complication • Mechanism of injury that causes spinal shock is usually traumatic in origin • Flaccid paralysis (bowel and bladder) and occasionally, sustained priapism develops

40. End of the spinal shock phase of spinal cord injury is signaled by the return of elicitable abnormal cutaneospinal, bulbocavernosus reflex or muscle spindle reflex arcs

41. Phases of Spinal Shock PHASE 1 • Characterized by a complete loss -- or weakening -- of all reflexes below the SCI. • The neurons involved in various reflex arcs normally receive a basal level of excitatory stimulation from the brain. • After an SCI, these cells lose this input, and the neurons involved become hyperpolarized and therefore less responsive to stimuli.

42. Phases of Spinal Shock PHASE 2 • Characterized by the return of some, but not all, reflexes below the SCI. The first reflexes to reappear are polysynaptic in nature, such as the bulbocavernosus reflex. • Restoration of reflexes is not rostral to caudal as previously (and commonly) believed, but instead proceeds from polysynaptic to monosynaptic. The reason reflexes return is the hypersensitivity of reflex muscles following denervation -- more receptors for neurotransmitters are expressed and are therefore easier to stimulate.

43. Phases of Spinal Shock PHASE 3 • Monosynaptic reflexes, such as the deep tendon reflexes, are not restored until Phase 3. • Phases 3 and 4 are characterized by hyperreflexia, or abnormally strong reflexes usually produced with minimal stimulation. • Interneurons and lower motor neurons below the SCI begin sprouting, attempting to re-establish synapses. The first synapses to form are from shorter axons, usually from interneurons.

44. Phases of Spinal Shock PHASE 4 • is soma-mediated, and as it takes longer for axonal transport to push growth factors and proteins from soma to the end of the axon, it takes longer.

45. Thank you!