MVA=38% SCIs, Falls=30.5% (less than 38% of all SCI are non-traumatic- most are traumatic)

⭐Tetraplegia: Impairment or loss of motor and/or sensory function in cervical segments including arms, trunk, leg and pelvic organs

⭐ Paraplegia: Impairment or loss of motor and/or sensory function in the thoracic, lumbar or sacral segments of the spinal cord

C3-6= vital capacity is 20% normal, cough is weak and ineffective

T2-T4= vital capacity is 30-50% normal, weak cough but the lower the injury respiratory function improves

T11 and Below: minimal dysfunction, vital capacity is essentially normal and cough is strong

How to? ⏩ ASIA - American Spinal Injury Association (ISNCSI) and use of AIS (ASIA Impairment Scale)

Sensory:
-28 dermatomes
-testing LT and PP
Scoring
0= if unable to distinguish sharp vs dull
1= can discriminate but not the same as the face (greater or less intensity) (must be 8/10 correct)
2= intensity if sharpness is same as the face

Motor:
-10 key muscles (20 total) (C5-T1 and L2-S1)
-To determine motor level is the lowest myotome with key muscle has 3/5 provided that the muscle function in the key muscle rostral (above) is 5/5 or normal sensory 2/2 if no key muscle there then use that intact sensory level to assume motor intact there too.

If contracture present: if pt exhibits >50% of normal ROM, the muscle function can be graded thru pt available range with same 0-5 scale. If ROM limited to <50% normal ROM, then NT should be documented

‼If NLI in C1-C4, T2-L1 and S2-S5 the motor level is defined as the same as the sensory level ‼

Special Grading = a * on the number indicates non-SCI injured reason for strength difference THEN must explain in comment box

ZPP: only use when absent motor (VAC) OR sensory (no DAP, LT or PP in S4-5) bc means injury is complete

AIS B: Sensory Incomplete - Sensory but not motor function is preserved below the NLI and includes sacral segments (even a 1) and can be DAP

AIS C: Motor Incomplete - Motor function is preserved at the most caudal sacral segment for VAC (a yes) OR pt mets criteria for sensory incomplete with some motor function greater than 3 levels below IL motor level on either side (but less than half of the key muscles below NLI are grade 3 or greater) OR another way to think about it is more than half the muscles have a grade 1-2 3 levels below

AIS A: Complete - No motor or sensory function is preserved in the sacral segments S4-5

AIS D: Motor Incomplete - Motor is incomplete as defined above with at least half or more than half of key muscles functions below the single NLI have a muscle grade 3 or greater

AIS E: Normal- Motor and sensory function is normal in somebody diagnosed with SCI

AIS ND- Not determined - Unable to doc motor, sensory , NLI AIS and/or ZPP based on examination results

Anterior Cord Syndrome: often due to flexion injury of C-spine, Loss of motor function (corticospinal tract) and loss of pain and temperature (spinothalamic tract) but dorsal columns is preserved

Central Cord Syndrome: Most common incomplete injury, caused by hyperextension or narrowing of the spinal canal, the UE are more affected than the LE and pt MAY be able to walk and may have some sacral tract preservation but UE fine motor will remain impaired

Brown Sequard Syndrome: IL sensory loss at and below level of lesion (Dorsal columns) and CL loss of pain and temperature starting a few levels below the lesion (spinothalamic tract)

Cauda Equina Injury: Spinal cord tapers to from Conus medullaris and ends at L1-2 below is the cauda equina
Cauda equina injury is often incomplete due to number of nerve roots running there and large surface area, will result in LMN injury with peripheral nerve damage
There is chance of recovery

Define: follow immediately after SCI, period of areflexia

-Absent of all reflex activity, flaccidity, and loss of sensation and motor function below level of injury and may last 72hrs to weeks
-Absence of reflex activity and impaired autonomic regulation

Return of bulbspongious (cavernous) will indicate spinal shock is resolving and will appear much before DTRs retur

Sacral Sparing: signs of perianal sensation (DAP) or external anal sphincter contraction (VAC) and is the first sign an injury is incomplete

Defined as: Uncontrolled sympathetic response in pt with SCI T6 and above (50-70%) and occurs in BOTH ISCI and Complete SCI. May result from NON-traumatic causes

💢Pathophysiology: Dramatic rise in blood pressure, usually due to noxious stimuli and bc loss of signal from brain getting to areas below injury there is unregulated SNS response below NLI there is unregulated PSNS response above the lesion = medical emergency of imbalanced NS drive

⚠ Signs and Symptoms of AD: ⚠

• Hypertension (rise by 20-40mmHg in SBP)
• Bradycardia
• Headache
• Nasal Congestion!
• Flushing and sweating of skin above lesion
• Pale/dry skin below lesion and maybe goosebumps
  

Things that may cause a pt to go into A.D.:
-Bladder distention = #1 in most cases
-Fecal impaction or rectal distension
-Fractures, dislocations or HO
-Any noxious stimuli --> ingrown toenail, toes cramped in shoes, fold in pants, PDE5 meds,

Intervention:

• Bring them to sitting (if in supine) 90 deg and lower legs
• Check BP every 5 min
• Check bladder and then bowel
• Loosen tight clothing - wraps, abdominal binders, shoes
• Check body for irritating stimuli
• Drug therapy- apply (with gloves) 1 in of nitropaste one inch above injury and wait till BP normalizes and then wipe off! This is now better than sublingual nifedipine since that will decrease BP but then pt passes out
  

UMN Syndrome: spasticity, muscle spasms, abnormally high tone, hyperactive stretch reflexes and clonus = all terms are INTERCHANGEABLY used

Defined as: imbalance btwn excitation and inhibition, anterior horn cell may become hyperexcitable, descending suprasegmental signals altered/eliminated after SCI and there is changes in afferent input

• There is gradual increase in first 6 mos. after injury but plateau reached at 1 year

Velocity Dependent- increase in resistance to passive stretch

Stretch - no clinical evidence but also we can get contractures and worse limitations of ROM if we don't

Medications: Baclofen, Intrathecal baclofen and botox all used

Surgeries: myotomy, tenotomy, selected dorsal rhizotomy

Cardiovascular Impairments:

• in Cervical SCI - loss of sympathetics and PSNS is unreigned
• PSNS causes bradycardia, dilation of peripheral vasculature below level of lesion and often results in orthostatic hypotension during early transitions
  
  

-Postural hypotension: caused by loss of vasoconstriction control and lack of muscle tone for muscle pump. Results in dizziness and fainting due to reduced cerebral blood flow

-Related to edema of legs/ankles/feet
-Allow slow progression for adaptation --> elevate HOB, reclining w/c,, tilt table, standing frame

-Medications: Midodrine used to increase BP by blocking ephedrine for BP

Tachycardia is NOT a common symptom during an AD episode it is mostly bradycardia

The autonomic imbalance leads to splanchnic vasoconstriction (below level of lesion)

AD is caused by a overactive/increased reflex activity after synaptic re-organization

Resting BP for pt with SCI is normally lower 90-110mmHg for SBP

AD occurs can occur in SCIs that are complete, Incomplete, traumatic or atraumatic

Radiographs are a form of management for AD as a pt may have a fracture and so will need to be done to r/i or r/o

Spinal anesthesia is STILL needed for pt with SCI bc they may not be able to sense what the procedure is but it still is a noxious stimuli and can throw the pt into AD

After SCI pt can no longer control cutaneous blood flow or level of sweating

Vasodilation does not occur in response to heat nor vasoconstriction in response to cold

Pulmonary complications are a leading cause of death in pt with SCI especially high cervical

Primary muscles of inspiration:

• diaphragm (only if at least a C5 injury)
• Scalenes and intercostals
• Accessory muscles: SCM, pecs, serratus, traps, levator, abs

Primary muscles of expiration: Abdominals (T6-12) and internal intercostals

Without abdominal wall support, abdominal viscera shifts down and so there is a lower resting position of the diaphragm and makes expiration less passive

• Decreased expiratory reserve volume
• Decreased cough effectiveness
• Decreased ability to expel secretions

❗ DVT= 2.5%

• loss of "pumping" from LE
• slow flow of blood allows higher concentration of procoagulants to develop.
  -Prophylaxis: early mob, turning program, PROM, IVC filter, compression stockings, heparin
  

Others include:

• Contractures: often can turn into capsular restrictions
• HO: bone in soft tissue, usually near joints
• MO: injury to mm and then bone deposits there
• Fractures/osteoporosis
• Syringomyelia: fluid filled cyst in spinal cord

⚠Risk Factors include:

1. Tetraplegia
2. Spasticity
3. Bladder/Bowel incontinence
4. Limited mobility and self-care
5. Nutritional deficiencies
6. Prolonged immobilization during recovery
7. Smoking
8. Noncompliance with skin care

💥Pain💥

• 26-98% pt with SCI report Chronic Pain
• Nociceptive pain: caused by damage to body tissue (MSK or visceral) - Treated with Opioids
• Neuropathic pain: Caused by injury to central or peripheral nervous system (nerve root, spina cord dysesthesias) - Treated with Neurotin or Lyrica