TRAUMATIC SPINAL CORD INJURIES - uogqueensmcf.com

TRAUMATIC SPINAL CORD INJURIES

Getachew Azeze (Bsc, MPT)

5/21/2019NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHERAPY

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Objectives

• Understand the causes, clinical manifestations, and possible

complications of spinal cord injury.

• Differentiate between complete and incomplete types of SCI.

• Discuss the various levels of SCI.

• Identify patient problems based on the examination, establish

appropriate goals, and plan individualized treatment programs

for patients with a SCI


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Introduction

• Spinal cord injuries (SCI) is a relatively low-incidence, high-

cost injury that results in tremendous change in an

individual’s life.

• It is insult to SC resulting in a change in the normal motor,

sensory or autonomic function.

• This change is either temporary or permanent


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Introduction…

• SCI occurs when the spinal cord is damaged as a result of

trauma, disease processes, vascular compromise, or congenital

neural tube defect.


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CAUSES

• Motor vehicle accident --- ---41.3%

• Falls -------27.3%

• Violent acts------- 15.0%

• Sports injuries--- 7.9%

• Other -------------8.5%


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Classification of SCI

Can be divided in to two etiological categories :

1. Traumatic injuries (MVA ,fall ,gunshot, violence and sport etc.)

2. Non traumatic damage:

• Thrombosis ,embolus, hemorrhage etc.

• Vertebral subluxation secondary to RA or DJD

• Spinal neoplasm

• Infections

• Neurological diseases


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Classification……

Functional categories :

1) Tetraplegia (preferred to quadriplegia) refers to impairment or

loss of motor and/or sensory function as a result of damage to

the cervical segments of the spinal cord.

• Function in the UE, LE, and trunk is affected.

• It does not include brachial plexus lesions or injury to peripheral

nerves outside the neural canal.


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Classification……

2. Paraplegia refers to impairment or loss of motor or sensory

function as a result of damage to the thoracic, lumbar, or sacral

segments of the spinal cord

• Depending on the level of the damage, function may be impaired

in the trunk and/or LEs. This term is used to refer to cauda

equina and conus medullaris injuries but not to lumbosacral

plexus lesions or injury to PN, which are considered outside of

the CNS


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Anatomy

• Spinal Cord (SC) is the major bundle of nerves that carry

impulses to/from the brain to the rest of the body.

• Most common vertebrae involved are C5, C6, C7, T12, and L1

because they have the greatest ROM


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Anatomy ….

31 pairs spinal nerve

• 8 Cervical

• 12 Thoracic 5 Lumbar

• 5 Sacral

• 1 Coccygeal


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Ascending and descending tracts

• SC Consists of white matters , which consists of ascending sensory tracts, descending motor tracts, and An H-shaped central area of grey matter.

Ascending Tracts (Sensory)

• Spinothalamic Tract

• Dorsal Column Tract

• Spinocerebellar Tract

Descending Tracts (Motor)

• Lateral Corticospinal

• Anterior Corticospinal


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Mechanisms of the injury

Trauma can be precipitated by compression, penetrating injury, and

hyperextension or hyperflexion forces.

• Cervical flexion and rotation

• Cervical hyperflexion :this type of injury frequently severs the anterior

spinal artery and results in an incomplete anterior cord syndrome.

• Cervical hyperextension injuries

• Compression injuries


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Naming the level of lesion

• It promotes better communication between and among

professionals, provides guidance for establishing the prognosis, and

is an important tool for clinical research trials.

• The neurological level is defined as the most caudal level of the SC

with normal motor and sensory function on both sides of the body.

• Motor level is referred to as the most caudal segment of the SC with

normal motor function bilaterally.

• Sensory level is defined in the same way except in terms of sensory

function.


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Types of lesion

ASIA classifies these injuries according to their

impairment scale

1. In a complete lesion is sensory and motor function will be

absent below the level of the injury and in the lowest sacral

segments of S4 and S5.

• Most often the result of complete SC transection,

compression, or vascular impairment


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Types of lesion

2. Incomplete injury: Preservation of motor or sensory function below the neurologic level of injury that includes the lowest sacral segments

• Perianal sensation must be present for an injury to be classified as incomplete

• Zone of partial preservation(ZPP): defined as the “dermatomes and myotomes caudal to the sensory and motor levels (rather than NLI) on each side of the body that remain partially innervated” in complete SCI


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Cont.….

• Sacral sparing : presence of motor function (voluntary

external anal sphincter contraction) or sensory function (light

touch, pinprick at S4/5 dermatome, or anal sensation on

rectal examination) in the lowest sacral segments.

• Dermatome :the area of skin innervated by one sensory

nerve root.

• Myotome: the collection of muscles innervated by one motor

nerve root


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American Spinal Injury Association scale for spinal cord injury(ASIA impairment scale)

ASIA

A

Complete: There is no sensory or motor function preserved in the sacral

segments of S4-S5

ASIA

B

Incomplete : Motor deficit without sensory loss below the neurological level,

including the sacral segments of S4-S5 (light touch, pin sensation or deep anal

pressure at S4-S5), and there is no protected motor function from three levels

below the motor level at each half of the body

ASIA

C

Incomplete: Motor function is preserved below the neurological level and more

than half of the muscles below this level have strength lower than 3/5 (0, 1 or 2)

ASIA

D

Incomplete: Motor function is preserved below the neurological level and at

least half of the muscles (half or more) below this level have strength higher than

3/5

ASIA

E

Normal : Sensory and motor function in all segments are normal and in patients

with pre-existing deficits there is "E'' degree of ASIA.


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Clinical syndrome

1. Brown squared syndrome

2. Anterior cord syndrome

3. Posterior cord syndrome

4. Central cord syndrome


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Brown squared syndrome

• Damage to one half of the SC

• Results from penetrating or stub injures

• Ipsilateral loss of motor function proprioception , vibration

• Contralateral loss of pain and temperature

• Good prognosis


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Brown squared syndrome


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Anterior cord syndrome

• Results from a flexion injury to the cervical spine

• The anterior SC or anterior spinal artery may be damaged.

• Loss of motor function(complete),pain and temperature

bilaterally

• Intact position sense and vibration

• The prognosis is extremely poor for return of bowel and

bladder function, hand function, and ambulation.


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Central Cord Syndrome

• The most common

• Result from progressive stenosis or compression that is a

consequence of hyperextension injuries.

• The UEs are more severely involved than the LEs

• Injury to the central SC damages three different motor and

sensory tracts: the STT, CST and dorsal columns. Sensory

deficits tend to be variable


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Posterior Cord /dorsal column Syndrome

• Is a rare incomplete injury resulting from compression by

tumor or infarction of the posterior spinal artery.

• Loss proprioception, Stereognosis, two-point discrimination,

and vibration sense below the level of the lesion.


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cauda equina injury

• A cauda equina injury usually occurs after the patient sustains

a direct trauma from a fracture-dislocation below Ll.

• Often results in an incomplete lower motor neuron lesion. Flaccidity, areflexia, and loss of bowel and bladder function

Conus Medullaris Syndrome :

• Injury of the sacral cord and lumbar nerve roots within the neural canal results in a clinical picture of LE motor and sensory loss and areflexic bladder and bowel


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CLINICAL MANIFESTATIONS Of SCIs

• The clinical presentation much depends on the level of the

injury and the muscle and sensory function that remains.

• In addition, one must consider whether the injury is complete

or incomplete


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Clinical presen…….

• In general, the following signs or symptoms may be present in an individual who has sustained an SCI:

1. Motor paralysis or paresis below the level of lesion

2. Sensory loss (sensory function may remain intact two spinal cord segments below the level of the injury)

3. Cardiopulmonary dysfunction

4. Impaired temperature control resulting from sympathetic nervous system damage associated with cervical lesions

5. Spasticity, which can develop as the spinal cord recovers

6. Bladder and bowel dysfunction; and

7. Sexual dysfunction


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Clinical presen…….

Spinal shock

• Transient areflexia period immediately SCI

• Characterized by arelexia ,flaccidity and loss of sensory & motor

function below the lesion

• Loss of bulbo cavernosus and cremastric reflex


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One of the first indicator of resolving spinal shock

is the presence of +ve bulbo cavernosus reflex

Complications

• Pressure ulcer

• Autonomic dysreflexia

• Pain

• Postural hypotension

• Contracture

• Heterotrophic ossification

• DVT

• Osteoporosis

• Respiratory compromise

• Bowel and bladder dysfunction

• Sexual dysfunction

• Spasticity


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Prognosis

The potential for recovery from SCI is directly related to :

the neurological level of lesion and

completeness of the injury.

Preservation of pinprick sensation at 4 months after injury in

the LEs or sacral region is associated with a good prognosis

for motor recovery at 1 year after injury.


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Medical intervention

Immobilization

Medication

Surgery if indicated


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Physiotherapy examination

• Before beginning the initial examination, the patient must

be sufficiently stable and the therapist must be aware of

any precautions (Spinal instability, orthotic devices,

concomitant injuries, and need for medical support (e.g.,

ventilator)) may preclude certain movements or positions.


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PT examination

The primary areas of focus during t early stage of recovery are , examinations of :

Sensory and motor function

Respiratory function

Diaphragm and intercostal muscles strength

Respiratory rate

Maximum chest expansion

Integument

PROM

Early mobility skills


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Physical therapy intervention: acute care

The acute care management of the patient with an SCI centers

around the following goals:

• Prevention of joint contractures and deformities.

• Improvement of muscle and respiratory function.

• Acclimation of the patient to an upright position.

• Prevention of secondary complications.


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Physical therapy interventions

• The application of interventions is dependent on :

• The medical stability of the patient

• Stability of healing fracture and surgical sites

• Status of other injuries that may have occurred during the initial

event that caused the SCI.


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Respiratory management

Depends on the levels of lesions

• Goals

• Improved ventilation

• Increased effectiveness of cough

• Prevention of chest tightness and

• Ineffective substitute breathing patterns

• Interventions • Deep breathing exercises

• Glossopharyngeal Breathing

• Lateral expansion

• Respiratory Muscle Strengthening/incentive spirometer

• Assisted cough techique

• Postural drainage

• Abdominal binding

• Manual stretching


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Acute care

• Early ROM exercises

• Early Strengthening exercise

• Acclimation to upright/early mobility

• Skin care

• Education


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Active rehabilitation

• The overarching goal of physical rehabilitation is for the patient

to become as independent as possible and to achieve the

functional mobility necessary for everyday living, work, and

recreation.


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Active rehabilitation……

Independent mobility can be achieved in a way that:

1. Either uses new movement strategies to compensate for neuromuscular impairments. Compensation or

2. Uses the neuromuscular system to accomplish the task with a movement pattern similar to that before the injury. Recovery

•


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Active rehabilitation ….

Physical examination

• In as much as greater patient mobility is now allowed, more complete testing of

• Muscle strength,

• ROM, and

• Functional skills can be performed

• Pain

• Gait ,locomotion and balance

• Self care and home management


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During active rehabilitation

• During this phase of the patient's recovery, the emphasis is on

maximizing functional potential.

• The goals of intervention much depends on the patient's level

of innervation and resultant muscle capabilities


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Goals

1. Increased strength of key muscle groups.

2. Independence in skin inspection and pressure relief.

3. Increased passive range of motion of the hamstrings and shoulder extensors.

4. Increased vital capacity and tolerance to upright positioning in bed and the wheelchair.

5. Independence in transfers or independence with directing a caregiver.

6. Independence in bed and mat mobility or independence with directing a caregiver.

7. Independence in wheelchair propulsion on level surfaces.

8. Independence in the operation of a motor vehicle (if appropriate). Return to home, school, and work.

9. Independence home exercise program performance.

10. Patient and family education


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Intervention

• Mat activities

• Transfers

• Independent ROM exercises

• Cardiopulmonary training

• Ambulation training

• Orthosis

• Gait training

• Patient and family training


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Immobilization

Cervical orthosis Thoracolumbosacral

orthosis5/21/2019

NEUROLOGICAL REHABILITATION FOR THIRD YEAR PHYSIOTHERAPY

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Factors that affect functional outcomes

• Motor level

• Age

• Concomitant injury

• Preexisting health conditions

• Secondary complications

• Body type

• Psychosocial support


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• Quiz

• Explain about

1. Anterior cord syndrome ?

2. Brown cord syndrome ?


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