Spinal Cord Injury
Don’t forget to go back
over your notes from
Physical Disabilities
Conditions. The
assumption here is that
you remember that
information.
What is Spinal Cord Injury?
Etiology
• any injury to the neck or back that
interrupts spinal cord function.
• 200,000-500,000 spinal cord injured
persons in US
• 8,000-10,000 new injuries annually that
result in paralysis
• Average age- 16- 30
(19 is most frequent)
• Male:female ratio is 4:1
Causes of Traumatic SCI
•
•
•
•
MVA– approx. 37%
Falls
Violence (i.e. gun shot, stabbing)
Sports injury– of which 66% are
diving accidents
Other Causes of SCI
• CA
• spinal arthritis
• ankylosing spondylitis Degenerative
arthritis or cervical or lumbar- can have
compression fractures or bone grown
vertebrae resulting in limits to ROM
• Stenosis-shrinking of space
• post-polio syndrome-people had polio
when child and when they age symptoms
show up
Types of Spinal Cord Injuries
• Complete- total paralysis and loss of
sensation by total destruction of the
ascending and descending pathways
– Zone of partial preservation (sparing)- areas
caudal to level of injury with intact sensation and
or motor function= spinal cord completely severed
or when spinal tissue deoxygenated,,swellig cn
close space and stop o2
• Incomplete- partial preservation of sensory
and/or motor function
Labeling SCI
• The injury is labeled from the last (most
caudal) level with INTACT sensory
and motor function bilaterally. Below
that level is impaired
So… tell me about a person with a
C5 complete SCI
Let’s meet Elva
• C5/c6 sc injury.
Tetraplegia v Paraplegia
• Tetraplegia (old term
quadriplegia)- C8 and higher
• Paraplegia- below C8
ACUTE SCI
• Spinal Shock
– Occurs after trauma to spinal cord
– Usually resolves within a few weeks, but
can take up to a few months
• Maintain (create airway)- tracheostomy
(we’ll talk about respiratory function
later)
• Determine extent and type of injury
Cervical Spinal Stabilization
(internal)
• Decompress spinal canal by removing all
bony and soft tissue elements pressing
against the cord (often anterior)
• Wiring of spinous processes
• Graft using iliac crest, fibula or tibia
• Rods
• Sometimes plates and screws provides
internal stabalization to provide stability so it
can heal.
Cervical Spinal Traction/Support
(external)
• Tongs or calipers (Somers, 41)
• Supportive bed– Stryker Frame (Somers, 42)
• Halo- rigid brace used later, after cervical traction
with tongs
Contraindications include severe respiratory problems,
chest injuries and burns on the trunk or abdomen
• Semi-rigid cervical orthoses- later
• Cervical collar- later
Thoracolumbar Stabilization
• Internal
– Usually rods and/or fusions
– Sometimes screws and plates
• External
TLSO
Jewett Brace
Assessment
• Sensory
• Motor
–
–
–
–
–
Tone (spasticity- different than CVA)
Strength
Endurance
Posture- alignment and control
Soft tissue integrity- skin, joints
• Psychosocial
– Values, interests, self concept, role performance,
coping
Treatment
Intervention/Expectations
C 1-4
•
•
•
•
•
C
C
C
C
C
1
2-3
4
2-8
1-7
•
•
•
•
•
TEAM/Roles
Resp therapy
PT
Nutrition
OT
Psychology
Expectation– Dependent some/all care; use of assistive technology
C 5-6
I (most tasks)with equipment
• C5
• C6
•
•
•
•
•
•
Tenodesis- how do you maintain?
Respiratory- no obliques/abdominals
Spasticity- may need meds
Positioning- maintain shortening in low back
Medical complication- HO, OH, DVT
Too much biceps without triceps
– How do you compensate for lack of triceps?
Case Study- WEAK C5 injury
(weak biceps)
Using mobile arm
support
secondary to
limited UE
strength; allows
flexion at elbow
with hand
moving toward
mouth and
extension with
hand moving
toward table
Write a long term goal (1 month)
C 6-7 I with equipment
C8–T1
•C
•C
6-7
C6 extensor carpi radialis longus and brevis
7-8
C7 triceps
C8 flexor digitorum profundus
• C 8 – T 1 T1 Interossei
•C8
•C8–T1
Thoracic, Lumbar and Sacral SCI
• T 1-5
• T 11 and below- expect to walk
with/without braces
• L 1-4
• L 5 – S3
• S 4-5
S2-5 bowel and bladder
Other Considerations
Respiratory
Bowel and Bladder Function
Orthopedic Restrictions
Spasticity
Medical Complications
Spinal Cord Injury Syndromes
Respiratory Considerations
• Initially after injury- often requires intubation
• If the lesion is below C5, there is a good
chance that the person will eventually be able
to breath on his/her own
• If the lesion is between C3 and C5, may or
may not need mechanical ventilation
• High injury (C3 or higher) need ventilator
• Incomplete injury? Difficult to predict
outcome of respiratory abilities
Tracheostomy
what it is and how it works
Trach Placement
Suctioning
NOT dependent on presence of trach tube
• Signs of need for suctioning
– frightened look
– flared nostrils
– restlessness
– paleness or bluishness around mouth
– clammy skin
– sinking in of the chest (retractions)
Other respiratory considerations
• Assisted cough
• Weaning from mechanical
ventilation
Bowel and Bladder Function
• Spastic v. flaccid bladder (go back
over old notes)
• Bowel program
– Equipment
• Bladder care and catheterization
Orthopedic Considerations
• Cervical injury- placement of halousually restricted to 90°
flexion/abduction at shoulders
• Other?
Spasticity
Explain the difference
between the spasticity
seen following SCI v. CVA
Med Complication:
Autonomic Dysreflexia
• Characterized by sudden severe headache
secondary to an uncontrolled elevation in BP
• Caused by any variety of stimuli creating an
exaggerated response of the sympathetic
nervous system
– Over-distended bladder, bowel impaction,
urinary infection, or other infection (like
pressure sore, ingrown toe nail)
• Occurs mainly when injury is T 4-6 or higher
• Treatment is to remove the aversive stimuli
Med. Complication:
Orthostatic Hypotension
• Also called postural hypotension
• Dramatic fall in BP when upright
posture is assumed
• Disturbed vasomotor control with
decreased blood supply returning to
heart
• Occurs mainly with injury T4-6 or
higher, with increased incidence at
higher levels.
Med. Complications:
Deep Vein Thrombosis
• Development of a blood clot
in the venous structures
• Why?
• Tx?
– Prevention
– After occurrence
Med. Complication:
Heterotopic Ossification
• occurs below the level of the injury
• usually at major joints (esp. hips, also
knees, shoulders, elbows)
• may present w/ signs of localized
inflammation or pain, elevated skin
temp, etc.
• Tx- meds, radiation, operative resection
(still risk recurrence)
Central Cord Syndrome
• Caused by damage to the central
portion of the cervical cord
• Corticospinal tract fibers are
organized with those controlling
the arms located most centrally,
the trunk intermediately, and the
legs laterally
• UE involvement with LE sparing
Incomplete SCI
Brown Sequard Syndrome
• Damage to one side of the cord
• Loss of function below the level of
injury of the portion of the cord
that controls voluntary motor
pathways on the same side of the
body and pain and temperature on
the opposite side of the body
Incomplete SCI
Anterior Cord Syndrome
• Damage to the anterior portion of the
cord
• Loss of function below the level of
injury of the part of the cord that
controls voluntary motor pathways and
major sensory tracts
• Sparing of posterior columns, as
vascular supply is obtained from
different source
• Preservation of position, vibration, and
touch senses
Incomplete SCI
Conus Medularis and
Cauda Equina Injuries
• Loss of motor function
• Sensory function NOT markedly
impaired
• Extremely variable pattern with
asymmetrical involvement
• Nerve roots have some recovery
potential, so outlook is often
favorable
Incomplete SCI
Prevention