SCI-Lecture 1

1) Know the injury so you can treat and educate
2) Be a movement expert
3) Foster autonomy and control

12 different hospitals across the country that submit data on all SCI each year

Motor accidents

Young males 18-30, but now ave age of 40

1) Traumatic with or without vertebral injury (75-85%)
2) Non-traumatic (20-25%)

Often presents without vertebral injury
SCIWORA

Spinal Cord Injury Without Radiographic Abnormality

Direct vs Indirect (Penetrating v Non-penetrating)

Injury that penetrates the dura and injures the spinal cord (CSW, knife wounds)

Stretch or bruise to the spinal cord

1) 20-50% SCI accompanies TBI
2) Chest fracture
3) Multiple extremity fractures

1) OA
2) Ankylosing Spondylitis
3) fusion and inflammation of spine
4) cervical stenosis
5) RA

1) Tumors/neoplasms
2) Transverse myelitis
3) Syringomyelia
4) Amyotrophic Lateral Sclerosis (ALS)
5) Multiple Sclerosis (MS)

1) Extradural--outside the dura
2) Intradural--underneath the dura, bot not in SC
3) Intramedullary--inside SC (maggie)

localized inflammation at a certain spinal segment (both side of the level) and symptoms go across the dermatome or myotome and below

Damage to the spinal cord due to a cyst

disease of the nerve cells in the brain and spinal cord that voluntarily control muscle movement

An autoimmune disease that affects the brain and spinal cord damaging the myelin sheath surrounding nerve cells

Incomplete tetraplegia (38%)

1) Distraction or stretch
2) Contusion or crush
3) Laceration or cut

Goes from localized area to something that looks like a tube and expands horizontally, rostral and caudally

1) Ischemia
2) Excitotoxicity
3) Wallerian degeneration
4) Apoptosis of oligodendrocytes (myelinating cells)
5) Inflammation

The lowest level of a CNS injury and also parts of the PNS (last member of motor AMN and first member of sensory afferents)

PNS symptoms (LMN symptoms)

CNS symptoms (UMN symptoms)
Still have active SC below depending on how disconnected it is from the supraspinal structures (BWS treadmill, e-stim to manipulate the system)

At the level of the lesion there is some form of anesthesia, depending on which pathways are affected like pain and temp

1) bowel/bladder
2) respiratory
3) sexual
4) cardiovascular
5) temp regulation

1) AMN
2) GMN
3) Whatever primary afferents come in (pain/temp, touch, prop)

1) Corticospinal
2) Anterolateral systems
3) Dorsal columns

1) Corticospinal
2) Anterolateral systems
3) Dorsal columns

Voluntary motor

Pain, temp and crude touch (sensory)

Proprioception, light touch (discriminative touch), deep pressure and vibration (sensory)

Cervical is lateral (sacral medial)

Cervical is medial (sacral lateral)

Cervical is medial (sacral is lateral)

1) ALS
2) CST

No movement (CST)
No pain/temp (ALS)
Can feel light touch and knows where they are below

1) No contralateral pain/temp at the lesion level
2) DC--ipsilateral prop, light touch info in cord
3) ALS--contralateral pain, temp and crude touch info
4) CST--ipsilateral voluntary motor info

Severe motor and proprioceptive deficits on side of lesion and more severe loss of pain/temp on contralateral side of lesion

Small lesion in the middle of the cervical spine that typically grows out

No UE movement
LE can still get through

Mostly dorsal columns are affected

No proprioception
Has pain, temp and crude touch
Has some movement

By radiographic imaging

By the lowest segment with normal motor and sensory function bilaterally

28 dermatome points are tested

The lowest motor level that tests as a 3/5 with all rostral segments testing at least 5/5; normal nerve root is in tact rather than normal muscle

Want to look for the lowest level of normal functioning nerve roots (2 nerve roots)

Want to look for the lowest level that tests as a 2 (normal); easier to do due to only 1 nerve root going to the skin

C1-C4
T2-L1
Below S2-S5

Elbow flexors

Wrist extensors

Triceps

Finger flexors (distal phalanx of middle finger)

Finger abductors (little finger)

Hip flexors

Knee extensors

Ankle dorsiflexors

Long toe extensors

Ankle plantarflexors

In supine

If the patient has sensation and motor function at S4-S5 and has most lateral tracts intact with brain (pt must feel it and move it voluntarily; no bowel reflex)

C1-C8 Loss of motor and/or sensory function in UE/LE, trunk and pelvic organs

T1-S5 Loss of motor and/or sensory function in thoracic, lumbar or sacral regions

Evidence of sacral sparing; connections of segments below the lesion still in tact with the brain by demonstrating either anal sensation or contraction

Function below the lesion that may still vary in preservation (i.e. muscle grades 2 or 1; sensory 1s and maybe some 2s)

Complete injuries, because they don't have sacral sparing

Complete injury--no motor or sensory in S4-S5

Incomplete injury--sensory, but no motor in S4-S5

Incomplete injury--motor and sensory in S4-S5 with motor function below lesion being <3/5 grades

Incomplete injury--motor and sensory in S4-S5; half the muscles are > or = 3/5 below the lesion level

A vertebral injury to L1 or L2 exhibiting flaccid paralysis of LE and have areflexive bowel and bladders (all LMNs)

T12-L2 exhibiting flaccid paralysis of LE and have areflexive bowel and bladders

Occurs after trauma to the SC in the first 24hrs up to 6-8 wks stopping all functioning

1) Areflexia
2) Flaccid paralysis (no motor)
3) No sensation
4) No autonomic control (can't regulate temp, etc)

Orthostatic hypotension

Neurons below may be hyperpolarizing, losing their excitability due to the absence of descending tracts

1) Reflexes return 1st--S4-S5 reflex then works up
2) Cutaneous reflex (flexor withdrawl)
3) DTRs
4) ANS reflexes
5) Additional reflexes to early hyper-reflexia and spasticity

1) Nerve root recovery (return)
2) Spinal cord tract return

Nerve roots (C5 will be C6 within a year)

1) Healing
2) Plasticity

1) Spontaneous/"Inactivity" dependent plasticity--reflexive changes
2) Activity dependent plasticity

1) Interneuron which adds more synapses
2) AMN remodel (hyperreflexia can occur)
3) Sensory afferents remodel to AMN (e-stim)

Rehab--try to get the descending inputs to communicate to AMNs and create the most optimal active environment to create plasticity (i.e. use movement, e-stim)

ASIA levels are predictive of the future and the more you have at 72hrs the more you will get back later

7%

55%

Community ambulators

1) Skeletal
2) Motor
3) Sensory

1) Respiratory
2) Temperature
3) Cardiovascular
4) Sexual
5) Bowel/bladder
6) Skin
7) UMN/LMN

T1-L2 (can be cut off from the brain if cervical lesion)

Craniosacral (S2-S4)

1) Stabilize the neck and spine
2) Prevent secondary complications
3) Prevent further neuro damage (secondary problems)
4) Getting out for rehab

Use to diagnose the skeletal level damage

Clinical diagnosis is done using ASIA test

1) Corticosteroids
2) Ganglioside GM-1
3) Systemic Hypothermia

Decrease inflammation (all secondary problems) if given within 8hrs of injury; otherwise it is harmful

Not an anti-inflammatory
Can be given after 8hrs to promote axonal sprouting

Decreases secondary problems like apoptosis and excitotoxicity

1) Re-alignment or reduction
2) Decompression of SC
3) Stabilization

Closed reduction or traction with Gardener Wells-Tongs

Closed reduction or traction with Gardener Wells-Tongs

Bed rest and orthoses

Internal reduction (facet jump)

Discectomy--ANT approach
Laminectomy--POS approach

1) Halo
2) Minerva brace
3) Philadelphia
4) Aspen
5) Soft collars

1) Thoracolumbrosacral orthoses (TLSO)
2) Jewett

1) Explain the injury
2) Show evidence for treatment
3) Encourage patient that 90% of SCI pts will go home
4) ASIA categories change over time