spinal cord injury.complete

Spinal cord injury (SCI)

Introduction

Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function.

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Brief History

Edwin Smith Papyrus

earliest of the person with spinal cord injury (1700 BC )

During the 1940s, specialized centers were developed for the person with SCI.

Guttmann in England and Munro in United States were the pioneers in their respective countries. These units were develop to eliminate the piecemeal care

Etiology

Spinal cord injuries occur when blunt physical force damages the vertebrae, ligaments, or disks of the spinal column, causing bruising, crushing, or tearing of spinal cord tissue, and when the spinal cord is penetrated (eg, by a gunshot or a knife wound).

Definition of Terms

* Tetraplegia (replaces the term quadriplegia) - Injury to the spinal cord in the cervical region, with associated loss of muscle strength in all 4 extremities

* Paraplegia - Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris

EPIDEMIOLOGYCauses Bradom Delisa

motor vehicle accident 45.4% 48%

acts of violence 14.6% 15%

Sports 16.3% 14%

Falls 16.8% 21%

Age Goups 25-44 year old (26 y/o) 16-30 years of age

Males vs Female 2.4:1 to 4:1 80% are male

White vs. non-white 8:1 (urban ratio 3:1)

Prevalence 525 per 1 million, or 128941 persons, to 1124 cases per million, or 276,057 persons. The most recent survey estimated 721 per 1 million or 176,965 persons in 1998. Less than 5000 are estimated to be institutionalized.

500- 900 per million. Thus, the national incidence varies between 7,000 to 10,000 , the prevalence of 150,000-200,000.

Incidence 29.4 cases per 1 million to 50 cases per million

55 per million person per year with 35 per million per year surviving long enough to be hospitalized.

EPIDEMIOLOGY

Quadriplegia -55% paraplegia -45% Other causes of SCI include the following: * Vascular disorders * Tumors * Infectious conditions * Spondylosis * Vertebral fractures secondary to osteoporosis * Developmental disorders * Cancer

Other Factors

Race Sex Age Associated injuries Marital status Level and type of injury Substance abuse Season Educational status Employment

Life expectancy

10-20% of patients who have sustained an SCI do not survive to reach acute hospitalization, while about 3% of patients die during acute hospitalization

People 20 years have a life expectancy of approximately 33 years (patients with tetraplegia), 39 years (patients with low tetraplegia), or 44 years (patients with paraplegia).

Individuals aged 60 years at the time of injury have a life expectancy of approximately 7 years (patients with tetraplegia), 9 years (patients with low tetraplegia), and 13 years (patients with paraplegia).

The annual death rate for patients with acute SCI is 750-1000 deaths per year in the United States.

Leading cause of death

pneumonia and other respiratory conditions, followed by heart disease, subsequent trauma, and septicemia. Suicide and alcohol-related deaths are also major causes of death in patients with SCI. In persons with SCI, the Among patients with incomplete paraplegia, the leading causes of death are cancer and suicide (1:1 ratio), while among persons with complete suicide rate is higher among individuals who are younger than 25 years.

paraplegia, the leading cause of death is suicide, followed by heart disease.

Spinal Cord Injury: Pathophysiology

Mechanisms of Injury Clinical Syndromes Dermatomes and Myotomes Effects of Spinal Cord Injury

Definition of Terms

Avulsion fx- tearing of a piece of bone away from the main bone by the force of mm. contraction.

Burst fx- a comminuted vertebral fx associated with p° along the long axis of the vertebral column.

Teardrop fx- a bursting type fracture of the cervical region that produces a characteristic anterior-inferior bone chip.

Dysesthesias- bizarre, painful sensations experienced below the level of the lesion following SCI; described as burning, numbness, pins and needles, or tingling sensations.

Mechanisms of Injury

Flexion injury Hyperextension injury Compression injury Flexion-Rotation injury

Flexion Injury

Head-on collision in which head strikes steering wheel or windshield.

Blow to back of head or trunk. Most common mechanism of SCI

Flexion Injury

Associated Fractures

1. Wedge fx of anterior vertebral body

2. High percentage of injuries occur from C4-C7 and from T12-L2

Potential Associated Injuries

1. Tearing of posterior ligaments.

2. Fractures of posterior elements

3. Disruption of disk

4. Anterior dislocation of vertebral body.

Hyperextension Injury

Strong Posterior force such as rear-end collision.

Falls with chin hitting a stationary object

Hyperextension Injury


1. Fractures of posterior elements.

2. Avulsion fx of anterior aspect of vertebrae.

Potential Associated Injury

1. Rupture of ALL.

2. Rupture of disk.

Compression Injury

Vertical or axial blow to head

(e.g diving, surfing, or falling objects) Closely associated with flexion injuries.

Compression Injury


1. Concave fx of endplate

2. Explosion or burst fx (comminuted).

3. Teardrop fx.


1. Bone fragments may lodge in cord.

2. Rupture of disk.

Flexion-Rotation Injury

Posterior to anterior force directed at rotated vertebral column. (e.g rear-end collision with passenger rotated toward driver.)

Flexion-Rotation Injury


1. Fracture of posterior pedicles, articular facets, and laminae.


1. Rupture of posterior and interspinous ligaments.

2. Subluxation or dislocation of facet joints.

3. In thoracic and lumbar regions, facets may “lock”

Clinical Syndromes

Brown- Sequard Syndrome Anterior Cord Syndrome Central Cord Syndrome Posterior Cord Syndrome Conus Medullary Syndrome Cauda Equina Syndrome

Brown- Sequard Syndrome

Hemisection of the cord caused by penetration wounds.

Ipsilateral: loss of sensation in the dermatome segment corresponding to the level of lesion, paresis, impared joint position sense and touch localization.

Brown- Sequard Syndrome

Contralateral: loss of pain and temperature sensation below the level of the lesion, dysesthesia.

Anterior Cord Syndrome

Trauma on the anterior part of the cord or damage of anterior spinal artery

Loss of motor function Loss of sense of pain and

temperature.

Central Cord Syndrome

Occurs from hyperextension of cervical spine

More severe neurological involvement of the UE than the LE.

Cord is pressed anteriorly by vertebral body and posteriorly by bulging of the ligamentum flavum.

Posterior Cord Syndrome

Rare Motor function, sense of pain and light

touch preserved Loss of proprioception and epicritic

sensation below the level of the lesion. Wide based step gait.

Conus Medullaris Syndrome

Compression of inferior end of conus medullaris

Causes: trauma, herniation, neoplasm, and iatrogenic infections

Effects: Lumbar stenosis, spina bifida, areflexia of the bladder, bowel and lower limbs.

Cauda Equina Syndrome

Radiculopathies Causes: Same as Conus Medullaris

Syndrome Effects: Paraplegia, urinary dysfxn,

dec. rectal tone, sexual dysfxn, saddle anesthesia, pain and absence of ankle reflex.

Dermatomes and Myotomes

Dermatome map Segmental spinal cord and functions

Dermatomes

Are strip-like areas of the skin innervated by a single nerve root.

Dermatomes

C1: - C2: occiput C3: supraclavicular fossa C4: acromion process C5: lateral arm C6: thumb C7: middle finger C8: little finger T1: medial arm T2: axilla T4: nipple area

T6: xiphoid process T10: umbilicus L1: inguinal area L2: anterior thigh L3: medial aspect of the

knee L4: medial malleolus L5: dorsum of foot S1: lateral malleolus S2: popliteal fossa S3: groin, medial thigh to

knee S4-5: around the anus

Myotomes

Each muscle in the body is supplied by a particular level or segment of the spinal cord and by its corresponding spinal nerve

Myotomes

C3, 4 and 5 supply the diaphragm (the large muscle between the chest and the belly that we use to breath).

C5 also supplies the shoulder muscles and the muscle that we use to bend our elbow.

C6 is for bending the wrist back. C7 is for straightening the elbow. C8 bends the fingers. T1 spreads the fingers.

Myotomes

T1 –T12 supplies the chest wall & abdominal muscles.

L2 bends the hip. L3 straightens the knee. L4 pulls the foot up. L5 wiggles the toes. S1 pulls the foot down. S3, 4 and 5 supply the bladder, bowel and

sex organs and the anal and other pelvic muscles.

Segmental Spinal Cord and Function

Level Function

C1-C6 Neck Flexors

C1-T1 Neck Extensors

C3-C5 Diaphragm

C5, C6 Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates).


C6, C7 Extends elbow and wrist (triceps and wrist extensors); pronates wrist

C7, T1 Flexes wrist and supply small muscles of the hand

T1-T6 Intercostals and trunk above the waist

T7-L1 Abdominal Flexion

L1-L4 Thigh Flexion


L2-L4 Thigh adduction

L4-S1 Thigh abduction

L5-S2 Extension of leg at the hip (Gluteus Maximus)

L2-L4 Extension of the leg at the knee (quadriceps femoris)

L4-S2 Flexion of the leg at the knee (hamstrings)

L4-S1 Dorsiflexion of the foot (tibialis anterior), Extension of toes

L5-S2 Plantar flexion of the foot and flexion of toes

The Effects of Spinal Cord Injury

Types of Injury Level of Injury

Complete Injury- means that there is no function below the level of the injury; no sensation and no voluntary movement.

Incomplete Injury- means that there is some functioning below the primary level of the injury.

Types of Injury

Cervical Injury

C3 vertebrae and above : Typically lose diaphragm function and require a ventilator to breathe.

C4 : May have some use of biceps and shoulders, but weaker

C5 : May retain the use of shoulders and biceps, but not of the wrists or hands.

C6 : Generally retain some wrist control, but no hand function.

C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the hand and fingers. C7 is generally the level for functional independence.

Thoracic Injury

T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury.

T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good.

Lumbar and Sacral Injury

The effect of injuries to the lumbar or sacral region of the spinal canal are decreased control of the legs and hips, urinary system, and anus.

Functional Loss from SCI

Based on Compete Lesions

C1-4

Motor function Sensory function Respiratory fxn.

Tetraplegia: loss of all motor function from the neck down

Loss of all sensory function in the neck and below (C4 supplies the clavicle)

Loss of involuntary and voluntary respiratory function; ventilatory support and a tracheostomy needed

C5


Tetraplegia: Loss of all function beow the upper shoulders

Intact: SCM, cervical paraspinal mm., trapezius; can control head.

Loss of all sensation below the clavicle and most portions of the arms, hands, chest, abdomen, and LE

Intact: head, shoulders, deltoid, clavicle, portions of the forearms.

Phrenic nerve intact but not the intercostal muscles

C6


Tetraplegia: Loss of al function below the shoulders and upper arms; lacks elbow, forearm, and hand control.

Intact: deltoid, biceps, ER mm. of shoulders.

Loss of everything listed for a C5 lesion, but greater arm and thumb sensation

Intact: head, shoulders, arms, palms of the hands, and thumbs

Phrenic nerve intact, but not the intercostal muscles

C7


Tetraplegia: loss of motor control to portions of the arm and hands.

Intact: voluntary strength in shoulder depressors, abductors, IR mm. and radial wrist extensors

Loss of sensation below the clavicle and portions of the arms and hands.

Intact: head, shoulders, most of the arms and hands.


C8


Tetraplegia: loss of motor control to portions of the arms and hands.

Intact: some voluntary control of elbow extensors, wrist, finger extensors and finger flexors.

Loss of sensation below the chest and in portions of the hands.

Intact: sensation to face, shoulders, arms, hands, and a part of the chest.


T1-6


Paraplegia: loss of everything below the midchest region, including the trunk mm.

Intact: control of fxn. to shoulders, upper chest, arms and hands.

loss of sensation below the midchest area

Intact: everything to the midchest region including the arms and hands.

Phrenic nerve functions independently

Some impairments of the intercostals

T6-12


Paraplegia: loss of motor control below the waist

Intact: shoulders, arms, hands, and long trunk muscles.

Loss of everything below the waist

Intact: shoulders, chest, arms, and hands.

No interference with respiratory function

L1-3


Paraplegia: loss of control to most of the legs and pelvis.

Intact: shoulders, arms, hands, torso, hip rotation and flexion, and some leg flexion.

Loss of sensation to the lower abdomen and legs.

Intact: all sensations above the lower abdomen plus some sensation to the inner and anterior thigh.

No interference with respiratory function.

L3-4


Paraplegia: loss of control of portions of lower legs, ankles, and feet.

Intact: all of the above, plus increased knee extension.

Loss of sensation to portions of the lower legs, feet, and ankles

Intact: al of the above, plus sensations to the upper legs.

No interference with respiratory function.

L4-S5

Motor function Sensory function

Paraplegia: degree varies

Segmental motor control:

L4-S1: abduction and IR of hip, ankle dorsiflexion, and foot inversion.

L5-S1: foot eversion.

L4-S2: knee flexion.

S1-2: plantar flexion, ankle jerk

S2-5: bowel/bladder control

Lumbar sensory nerves innervate the upper legs and portions of the lower legs.

L5: medial aspect of the foot

S1: lateral aspect of the foot

S2: posterior aspect of calf or thigh

-sacral sensory nerves innervate the lower legs, feet, and perineum.

Voluntary bowel and bladder function

C1-4 to L3-4: no bowel or bladder control

L4-S5: bowel and bladder control possibly impaired. *S2-4 segments control urinary continence*S3-5 segments control bowel continence (perianal muscles)

SPINAL CORD INJURY

DIFFERENTIAL DIAGNOSIS

Prepared by: Manalang, Al Victoria R. BSPT III-1

Non-traumaticMotor Neuron Disease Amyotrophic Lateral Sclerosis Spinal Muscular Atrophy

Spondylotic Myelopathies Spondylosis Spondylolisthesis Spinal Stenosis

Infectious & Inflammatory Diseases Multiple Sclerosis

Neoplastic Diseases

1. Intradural Intramedullary Ependynoma

2. Intradural Extramedullary Meningioma

3. Extradural Neuroblastoma

Congenital/Developmental Disorder Spina Bifida

Disease Signs & Symptoms

SPINAL CORD INJURY •Areflexia, Motor & Sensory Impairments, Spasticity, Bladder & Bowel Dysfunction, Sexual Dysfunction

AMYOTROPHIC LATERAL SCLEROSIS

•Painless weakness in hand, foot, arm & leg•Speech, swallowing, walking difficulty•Atrophy & Fasciculations•Depressed mm stretch reflexes•Muscle cramping

SPINAL MUSCULAR ATROPHY

•Muscle weakness, poor mm tone, weak cry, limpness or tendency to flop, difficulty sucking/swallowing

SPONDYLOSIS •Back pain•Sphincter & Bowel Dysfunction

SPONDYLOLISTHESIS

•Tingling & Numbness•Slipping sensation when moving into an upright position

SPINA BIFIDA

(SPINA BIFIDA OCCULTA)•Dimple, depression, birthmark, hairy patch over the affected part

(SPINA BIFIDA MANIFESTA)•Swelling over the affected spine/ exposed spinal nerves @ the back

SPINAL STENOSIS •Numbness & Weakness•Cramping or pain in legs, feet or buttocks

MULTIPLE SCLEROSIS •Weakness, paresthesia, gait difficulty, optic neuritis, diplopia, ataxia, disturbed nutrition, vertigo

EPENDYNOMA

•Frequent headaches•Seizures•Frequent nausea & vomitting•Loss of balance/trouble walking

MENINGIOMA

•Seizures•Headaches that worsen with time•Memory loss•Changes in vision, such as seeing double or blurriness•Hearing loss•Weakness in your arms/legs

NEUROBLASTOMA

•Lump in the abdomen, neck or chest•Bulging eyes•Dark circles around the eyes (“black eyes”)•Bone pain•Swollen stomach & trouble breathing in infants•Painless, bluish lumps under the skin in infants•Weakness or paralysis (loss of ability to move a body part)

DISEASE CAUSE AFFECTATION

SPINAL CORD INJURY

Sudden severe blow to the spine. (Car accident, fall, gunshot, or sporting accident. Sometimes the SC is damaged by infection/spinal stenosis

Spinal Cord

AMYOROPHIC LATERAL

SCLEROSIS

Mutation of a specific gene, the SOD1 gene.

Both upper and lower motor neuron that causes degeneration of throughout the brain & SC.

SPINAL MUSCULAR ATROPHY

Loss of the SMN1 gene from chromosome 5

Only a portion of one limb such as forearm & hand, shoulder or thigh

SPONDYLOSIS & SPONDYLO

LISTHESIS

Stress fracture of the bone.(Spondylosis) degenerative changes in the IV disks & vertebral bodies(Spondyloisthesis)

Defect in the pars articularis- “sliding off of vertebra”)

(Spondylolisthesis)I. Dysplastic- inf. L5 facetII. Isthmic- L5- S1III. Degenerative- L4-5 followed by L3-4IV. Traumatic- facet joints, lamina, pediclesV. Pathogenic

SPINAL STENOSIS

due to the natural process of spinal degeneration that occurs with aging, caused by spinal disc herniation, osteoporosis or a tumor.

Legs

MULTIPLE SCLEROSIS

Immune system attacks the central nervous system leading to demyelination

Nerve cells in the brain and in the spinal cord

EPENDYNOMA

Malignant cells form in the tissues of the brain and spinal cord

4th ventricle and septum pellucidum in the spinal cord

MENINGIOMA

meningiomas are inactivation mutations in the neurofibromatosis 2 gene ; radiation

Arachnoidal cells

NEURO

BLASTOMA

Malignant cells form in the nerve tissue of the adrenal gland, neck, chest or spinal cord

Abdomen, chest, spinal cord, neck, head,

Hip and legs

SPINA BIFIDA

Occurs when the tissue surrounding the developing spinal cord of a fetus doesn’t close properly

Neural tube

COMPLICATIONS OF SPINAL CORD INJURY

RESPIRATORY:

Represents a particularly serious and life threatening feature of SCI.

Greater loss of respiratory function with higher lesion level.

Diaphragm and External Intercostals: Diaphragm-Innervated by Phrenic

Nerve (C3-C5).

C1-C3 lesion –respiratory are impaired or lost.

External Intercostals – Intercostal nerve

- Paralysis results to decreased chest expansion and lowered inspiratory volume.

Accessory muscle for inspiration SCM Trapezius Scalene Pectoralis Minor Serratus anterior-muscles that assist in elevation of the

ribs.-can sustain acutely injured patient.

Muscle of Expiration Assist in maintaining the position of the

diaphragm Decreased ERV Decrease cough effectiveness

External Oblique

Normal Function:- Depresses the ribs and compresses

the chest wall.- Decrease the ability to cough and

expel secretion.

CARDIOVASCULAR:

DVT

- Risk factor: Loss of pumping mechanism provided by active contraction of LE musculature

Autonomic Dysreflexia

Massive sympathetic discharge that is triggered by noxious stimuli.

Most commonly seen in person with injuries above T6.

Metabolic:

Hypercalcemia- d/t immobilization in bone resorption.

- Exceeds the ability of the kidney to excrete calcium.

Bladder dysfunction

Micturition – voiding of urine:urination Conus Medullaris-spinal integration

center for micturition UMNL lesion – generally involving

T11-T12 LMNL lesion – no reflex action of

detrussor muscle.

Skin

Pressure ulcer

-ulceration of soft tissue caused by unrelieved pressure and shearing forces

-Most common

Risk factor: impaired sensory function and inability to change position.

Spasticity

After acute SCI and phase of spinal shock, development of reflex or tone begins to increase

Incidence is higher in cervical and upper thoracic

may contribute to improve function.

Pain

Types of pain: Traumatic pain- Arise from fracture ligamentous or soft

tissue damage; acute pain

Nerve root pain

-arise from nerve root or near the cord damage.

-sharp, stabbing, burning or shooting pain.

-follows a dermatomal pattern.

-most common in cauda equina injury.

Spinal cord dysesthesias

Painful sensation below the level of lesion.

Do not follow a dermatomal distribution Burning or numbness, pins and

needles or tingling feeling.

Musculoskeletal pain

Above the lesion of level Frequently involve shoulder joint Related to: faulty positioning

-inadequate ROM

-tightening of joint capsule and surrounding tissue.

spinal cord injury.complete

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