JROOZ REVIEW CENTER

SPINAL CORD INJURY

EPI: young pop. 16-30; m>f
white>blacks>Hispanics>others
Etio: May be due to physical impingement of the cord
or interruption of blood supply, actual transaction of
the cord is rare.
Traumatic (70%): MVD; Falls; Violence
Sports and rec: diving- non contact; footballcontact
MC indirect cause of SCI:alcohol
Non traumatic (30%)
Vascular malformations
Vertebral subluxation 2 to RA or DJD
Infection-syphilis; affects post column of SC
Transverse myelitis; spinal neoplasms, syringomyelia,
abscess of SC; Neurological do, spinals stenosis
SC Blood supply
Ant 2/3- Ant. spinal artery
Post 1/3- Post. Spinal artery
Reticular Artery- supplies rest of SC
Artery of Adamkiewicz
Aka: Great Anterior Segmental Medullary Artery
Major Ant. Segmental Medullary Artery
Great Ant. Radiculomedullary Artery
Artery of Lumbar Enlargement
T8 to L1 unilateral; direct from aorta enters left side
of spinal cord
SCI classification:
Complete vs incomplete
Complete- no preserved motor or sensory fxn below
level of lesion and in the lowest sacral segment s4-s5
Zone of partial preservation- dermatome or
myotome below the level of lesion remains partially
innervated but there is no fxn at S4-S5
Incomplete- partial preservation of sensory & motor
fxn below level of lesion which includes lowest sacral
segment S4-S5
Sacral sparing- indicates possibility of SC
recovery with possible partial or complete return of
motor function; most centrally located tracts are
spared; represents partial structure continuity
Hallmark:
SensoryPerianal
sensation,
cutaneous innervations in the saddle area
Motor- rectal sphincter contraction, and active
contraction of toe flexors (sacrally innervated)
Paraplegia vs quadriplegia vs diplegia vs protoplegia
Paraplegia- (pababa) bilat. LE and all or part of trunk
lesion of thoracic, lumbar or cauda equine lesion;
Tetraplegia/quadriplegia-all 4 extremities total
Diplegia-all fours are affected but LE (down) greater
than UE
Protoplegia- high tetraplegia lesion on c4 and above
Designation of levels:

Skeletal level- level with greatest vertebral damage as

noted from radiographic exam
Neurologic level- refers to the most caudal segment of
spinal cord with Normal motor and sensory level
Sensory level= refers to the most caudal
segment of SC with 2/2 sensory fxn on Both
sides of the body (pin prick & light touch); 28
key sensory dermatomes on each side; max
score 224
2-normal, 1-impaired, 0-absent NT for not
testable, face is used as Normal control point
C2-C8 CERVICAL 7
T1-T12 THORACIC 12
L1-L5 LUMBAR 5
SACRAL 4
L
R
2
2
2
2
1
2
0
1
Level: c6
TEST:T1 and above N
T2-L1 impaired
L2 absent
Score: 28 x2 sensationx2 sides= 112
C5
C6
C7
C8

Motor level- most caudal segment with grade 3/5

fair or 4/5 good provided that the immediate rostral
ms. Exhibits 5/5 since most muscles are innervated by
more than 1 segmental n. root
5-N, 4-GOOD, 3 FAIR, 2 POOR, 1 TRACE, 0 ABSENT
Testing for 10 myotomes ue- c5 t1, LE L2to S1
possible score of 100 50 left. 50 right
C5
Sh.abd, elbow flex, FA sup. Sh. ER
C6

Wrist ext. FA pron, sh. Add,IR

C7

Elbow ext. (triceps) wrist flex, Finger ext

C8

Finger flexors, ulnar dev

T1

Finger abd/add- Interossei*

L2
Hip flexors
L3
Knee extensors
L4
Dorsiflexors
L5
Gr. toe ext EHL
S1
Plantar flexors
Test: C6 and above- N
C7to T1 fair
L2toL3 poor
L4 and below absent
Answer: 23 x 2(sides)= 46
ASIA IMPAIRMENT SCALE
A
B
C
D
E

-M
-M
+M<3
+M>or=3
N

-S
+S
+S
+S
N

COMPLETE
INC
INC
INC
N

SPINAL TRACTS:
1. DCML-ipsilateral dorsal column to medulla synapse
with dorsal column nuclei gracilis and cuneatus, cross
at
medial
lemniscal
to
thalamus;
discriminative(sensory modalities that require fine
gradations of intensity
and specific/ precise
localization on the body surface) rapidly conducting
large
diameter
fibers;
epicritic
sensation
(proprioception, vibration, barognosis, stereognosis,
2pt discrimination, kinesthesia, graphesthesia, tactile
localization, discriminative touch, texture recognition,
simultaneous stimulation,)
Crosses at cervico medullary junction
2 tracts: fasciculus gracilis: proprioception of LE
Fasciculus cuneatus- proprioception of UE
2. sPinothalamic tract- contralateral decussates 2-3
segments above the SC
Ant- pressure and touch (APL) (stimulated by tens)
Lat- pain and temp (LPT) enters Sc
lamina 2 substantia gelatinosa- where lat. And ant
spinothalamic tract meets (gate control theory of pain)
3. corticospinal contralateral voluntary movt
Drawing sc and tracts
Clinical syndrome:
1. Brown sequard- spinal hemisection; penetrating
injuries gswounds, stab
Ipsi: paralysis(corticospinal) , loss of vibration and
proprioception, 2 pt discrimination (DCML)
Contra: pain and temp contra ni brown sequard and
pain and temp
2. Ant. Cord syndrome: worse prognosis
Damage to ant 2/3 of Sc; MC Cause: flexion (naiipit)
Only DCML intact all others affected loss of motor fx
(corticospinal), loss of pain and temp (spinothalamic)
3. Central cord syndrome-Walking SCI
MOI: compression, Hyperextension
Damage to spinothalamic, corticospinal, DCML
EU> LE; Motor> sensory
Bladder dysfxn: urinary retention
4. Posterior cord syndrome
Least frequent; loss of proprioception and epicritic
sensation (DCML)
Seen with tabes dorsales (slow degeneration of all
parts of the body and progressive loss of DTR) from
syphillis
5. conus medullaris
umnl
L1
spastic

6. Cauda equine
Lmnl/ peripheral nerve
Injury below L1
flaccid
Regeneration possible

Primary impairments:
1. Spinal shock-temporary phenomenon after trauma
where SC ceases to fxn below level of lesion;

(-)reflexes (-)motor, (-) sensory; (-) autonomic nervous

system (symp/parasympa)
(+)bulbocavernosus reflex- end of spinal shock; tag
catheter or pressure on glans penis/clitoris (+)
contraction of anal sphincter
2. Motor and sensory impairments
3. spasticity- increased voluntary contraction of ms,
increased stretch reflex (ms cntrxn from stretching )
excessive DTR
Can be enhanced by internal and external sources
Med TX: baclofen, dantrium, lioresal
Aggressive: phenol blocks, rhizotomies (n.roots)
myelotomies (SC), myotomy (ms.), neurectomy
(nerve), tenotomy (tendon)
4. pulmonary impairments- diaphragm (phrenic nerve
(c3-C5) may not be active affecting pts breathing
(inhalation)
Affectation of Intercostals and abdominal ms- impair
forced expiration and inhalation
Tidal volume and vital capacity reduced
MC cause of death p SCI- respiratory dysfunction
(inability to cough effectively-secretion build up,
inadequate inhalation, exhalation- decr. Ventilation of
lungs- atelectasis pneumonia respiratory insufficiency)
Above c4- ventilator or phrenic nerve stimulator
C4- capable of respiration diaphragm trapz scapular
elevation
Breathing: glossopharyngeal (frog) breathing 6-7 gulps
or air
C5- needs assistance for manual cough technique
C6 indep manual cough
Coughing: T1-T3 non functional cough
T4-T8 weak(4) coughing(8)
T10 and above- functional (10)
Vital capacity:
C4 30-50%; C5 40-60%; C6 60-80%
Airshift maneuver- to ventilate lungs;
inspiration, hold and feel air in lungs

maximal

5. sexual dysfunctionErection UMNL>LMNL; incomplete>complete

Female fertility is unchanged
Male- likely to become infertile
Reflexogenic
erection
(from
external
physical
stimulation of genitals or perineum) UMNL, intact
reflex arc s2-s4
Psychogenic erection (cognitive activity, erotic
fantasy)- LMNL
6. Bowel and bladder dysfunction- loss of voluntary of
control urination and defecation due to damage to
sacral cords S2-S4
Spastic bladder UMNL
Flaccid bladder LMNL
Reflexive bladder
nOn reflexive bladder
automatic
autonomous
Failure to store-unrinates Failure
to
emptyeven if bladder is not full
cant urinate even
when full

(+) incontinence
Above micturition reflex
center
S2-S4
(above
conus medullaris) sacral
reflex
arc
intact
Parasympathetic
innervation to detrusor ms
and
bladder
neck
sphincter (internal) intact
Reflex
emptyingtriggered
by
manual
stimulation
techniques
stroking
kneading,
tapping suprapubic region
or
thigh
and
lower
abdominal
stroking,
pinching or hair pulling
Spastic bowel
Suppositories and digital
stimulation techniques

Retentive bladder
Damage to conus
medularis or cauda
equine, s2-s4 sacral
micturition
reflex
damage

Valsalva
maneuver
incr. intra abdominal
pressure,
crede
maneuver- manually
compress
lower
abdomen intermittent
catheterization,
timed
voiding
program
Flaccid bowel
Straining of available
musculature
and
manual
evacuation
technique

7. Cardiovascular fxn
SC Injury that blocks communication to brainstem
sympathetic input to heart is lost and parasympathetic
input remains- resulting in bradycardia, peripheral
vasodilation, hypotension
Significant in SCI above T6 resolves within a few
weeks of injury.

2. DVT- formation of bld clot dislodged (embolus)

serious medical condition since can obstruct artery
sci- incr risk for dvt d/t decr. Or loss of active pumping
action of contracting ms
Homans sign- sp test
Prevention: anti coagulant therapy (heparin warfarin),
positioning schedule, ROM, proper positioning to
prevent venous stasis, use of elastic stocking
SX: swelling of LE, pain and warmth in area
Test: Doppler US
TX: no PROM AROMS, bed rest anti coagulant therapy,
surgery
3. Orthostatic hypotension- decr. bp during elevation
to upright position caused by loss of sympathetic
control of vasoconstriction in combination with
severely reduced ms. Tone, (+) venous pooling
S/Sx: decr. Of BP greater than 20 mmhg, dizziness,
light headedness, nausea and blacking out
Prevention:monitor vital signs, elastic stockings, ace
wraps to LE, abdmonial binder, gradual progression to
vertical position (tilt table)
Tx: Return to supine position, elevate legs, ankle
pumps
4. Pressure ulcers/sores- prevention most impt.
Proper positioning every 2 hrs, with pressure sore
every 30 mins; in W/C pressure relief every 15 to mins,
sit on appropriate cushion,
*review pressure sites in different position

8. Thermoregulation: T8- temper8ture dysregulation

SC injury that blocks communication with
hypothalamus can cause hypothermia 2 to peripheral
vasodilation (reflexive tone returns to peripheral
vasculature resolves problem)
Hyperthermia occurs 2 to loss of sympathetic control
of sweat glands- below level of lesion sweating does
not occur, above lesion diaphoresis (compensation)

5. Heterotropic ossificationFormation of new bone in ms or other connective

tissue
(myositis ossificans- trauma to muscle tissue resulting
to bony deposits in muscle)
TBI- shoulder; SCI-hips and knees
Sx: edema, Decr ROM,incr. temp in jt
TX: diphosphates

COMPLICATIONS:
1. autonomic dysreflexia (dysreflesix)- most dangerous
complication of SCI pts with lesion above t6, MC in 1 st
3 yrs
Noxious stimuli below level of lesion triggers
autonomic nervous system causing sudden elevation
in bld pressure caused by: distended or full bladder,
kink or blocked catheter, impacted bowel, bladder
infection, pressure ulcers, extreme temperature
changes, tight clothing, ingrown toe nails
Can lead to convulsions, hemorrhage and death
Sx: high blood pressure, decrease HR severe pounding
head ache. Blurred vision, stuffy nose, profuse
sweating goose bumps below the level of lesion and
vasodilation or flushing above level of injury
Tx: treat as medical crisis- 1st check catheter, check
bowel for impaction, check other possible irritants
Keep pt in sitting position. Lying pt will exacerbate
incr. bp, if still unknown receive immediate medical
attention
T8 temperature dysregulation- temper8ture

6. contractures- from prolonged shortening of

structures around jt, from ms strength imbalance,
spasticity, gravity, habitual postures , immobilization)
Selective stretching- do not stretch wrist extensors
and finger flexors- tenodesis effect- tenodesix c6
intact
C7 can perform self ROM
7. osteoporosis- loss of Ca from bones below level of
lesion incr. risk of fractures
LEVELS
Wheelchair prescription
C1-C3 electric (power) tilt in space, with mouth
control- chin tuck, sip and puff, and seat belt
C5- manual with projection aids (oblique) indoor;
power chair with hand controls for community
C6-C7 manual with friction hand rims (vertical)
C8-T1 manual with standard hand rims
T1-T5 wheelchair sports
Functional

C1-C3 capable of talking, mastication, sipping and

blowing
C4 mobile arm support powered
C5 mobile arm support BFO
C6 tenodesix indep sliding board transfers modified
indep bed mobility
C7 indep all transfers except W/C to floor ; LE ROM;
indep dressing with button hook; able to get W/C in
and out of car
C8 indep at home except for heavy work
T1-T5 physiologic standing (standing table); can
wheelie, W/C to floor; indep in all areas including self
care and car transfers,

T6-T8 (orthosix) swing to in parallel bars

KAFO with walker for short distances, wheelchair
for community
T9-T12 indep floor to Wheelchair; indep tub transfers
KAFO with walker or forearm crutches using swing to
or Swing through on level surface
W/C for outdoor and energy conservation
T12-L3 KAFO with crutches swing to, swing through or
4-pt;
indep home ambulators, can be community
ambulators
L4-L5 AFO, indep community ambulators