physiotherapist point of view

1. Management of
spinal cord injury
(SCI)
BY
ADEAGBO, CALEB A.
adewummy007@yahoo.com

2. Case scenario
 47 y/o male involved in RTA 4/12 ago.
 Admitted via A&E in LUTH and
transferred to National Hospital for further
mgt.
 Sensation intact on both ULs & LLs.
 Muscle power 0/5 below the Umbilicus.
 No bladder / bowel control.
 Diagnosed of C-spine injury and
presenting now with paraplegia LLs and
paraparesis ULs
4/3/2012 2

3. Outline
 Overview  Diagnosis
 Key terms  Neurological
 Anatomy assessment and
 Causes classification
 Type  Management
 Pathophysiology  References
 Clinical
syndromes
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4. Overview
 SCI is damage to the spinal cord that
results in loss of functions such as mobility
or feeling.
 The fourth leading cause of death in the US.
 Spinal Cord (SC) is the major bundle of
nerves that carry impulses to/from the brain
to the rest of the body.
 Spinal Cord is surrounded by rings of bone-
vertebra and function to protect the spinal
cord.
 Most common vertebrae involved are C5,
C6, C7, T12, and L1 because they have the
greatest ROM
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5. Key terms used in SCI
 SCI is insult to spinal cord resulting in
a change in the normal motor, sensory
or autonomic function. This change is
either temporary or permanent.
 Tetraplegia The impairment or loss of
motor and/or sensory function in the
cervical segments of the spinal cord
due to damage of neural elements
within the spinal canal.
 Paraplegia The impairment or loss of
motor and/or sensory function in the
thoracic, lumbar, or sacral segments
of the spinal cord due to damage of
neural elements within the spinal
canal.
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6. Key terms used in SCI
 Dermatome The area of skin
innervated by one sensory nerve root.
 Myotome The collection of muscles
innervated by one motor nerve root.
 Neurological Level of Injury The most
caudal segment of the spinal cord
with normal motor and sensory
function on both sides.
 Skeletal Level The radiographic level
of greatest vertebral damage.
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7. Key terms used in SCI
 Motor level The most caudal key muscle group
that is graded 3/5 or greater with the segments
cephalad to that level graded normal (5/5)
strength.
 Sensory level The most caudal dermatome to
have normal sensation for both pinprick and
light touch on both sides.
 Complete injury The absence of sensory and
motor function in the lowest sacral segments.
 Incomplete injury Preservation of motor or
sensory function below the neurologic level of
injury that includes the lowest sacral
segments.
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8. Key terms used in SCI
 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.
 Zone of partial preservation All
segments below the neurologic level of
injury that have preserved motor or
sensory findings; used only in complete
SCI.
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9. Anatomy
Spinal cord: foramen magnum  1st/2nd
lumbar vertebrae.
Gray matter: central (cell bodies)
White matter: peripheral (ascending and
descending tracts)
On the surface :
 Deep anterior median fissure
 Shallower posterior median sulcus
Spinal cord segment :
 Section of the cord from which a pair of
spinal nerves are given off
31 pairs of spinal nerves: 8 cervical, 12
thoracic, 5 lumbar, 5 sacral, 1 coccygeal
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10. Anatomy
 Dorsal root – sensory fibres
 Ventral root – motor fibres
 Dorsal and ventral roots join at
intervertebral foramen to form the spinal
nerve
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11. Longitudinal section of SC
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12. Tracts of SC
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13. Clinically important ascending
tracts and where they decusate
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14. Clinically important descending
tracts and where they decusate
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15. Causes of SCI
 RTA  Tumors
 Falls  Infectious
 Gunshot Injuries conditions
 Blunt Assault  Spondylosis
 Diving Accidents  Vertebral
 Stab Wounds fractures
 Sport Injuries secondary to
 Vascular osteoporosis
disorders  Development
disorders
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16. Type of SCI
 Transient concussion - is due to extreme
vibration of the cord and may cause
temporary loss of function lasting 24 to 48
hours. No neuropathologic changes are
present.
 Contusion - is a bruising that includes
bleeding, subsequent edema, and possible
necrosis from the edematous
compression. The neurological
involvement depends on the severity of
contusion and necrosis
 Laceration
Compression of cord substance
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

17. Pathophysiology
 Hemorrhage: Blood flows into the
extradural, subdural, or subarachnoid
spaces of the spinal cord
 Injury to spinal cord vasculature causes
nerve fibers to swell and disintegrate
 Blood circulation to the gray matter of
the spinal cord is impaired
 Secondary chain of events: Ischemia,
hypoxia, edema, and hemorrhagic
lesions
 These secondary events result in
destruction of myelin and axons.
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18. Pathophysiology
 These secondary reactions, are believed to
be the principal causes of spinal cord
degeneration .
 The damage may be reversible within the
first 4 to 6 hours after the injury.
 The consequence of spinal cord injury
depends on
 The type of SCI injury
 The neurologic level (lowest level at
which sensory and motor functions are
normal)
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19. Clinical Syndromes
 Central Cord Syndrome: Cervical injury with
sacral sparing and greater weakness in the arms
than the legs.
 Brown-Sequard Syndrome: An injury that causes
greater ipsilateral weakness and proprioceptive
loss and contralateral pain and temperature loss.
 Anterior Cord Syndrome: Injury to the spinal cord
causing loss of pain and temperature sensation
with preserved proprioception.
 Posterior Cord Syndrome: Injury to the spinal
cord causing loss of proprioception with
preserved pain and temperature sensation.
 Conus Medullaris Syndrome: Injury of the sacral
conus and lumbar nerve roots
 Cauda Equina Syndrome: Injury to the
lumbosacral nerve roots within the neural canal.

20. 4/3/2012 20

21. Diagnosis
 X-rays of cervical spine to establish level
and extent of vertebral injury
 CT scan and MRI: changes in vertebrae,
spinal cord, tissues around cord
 Arterial blood gases to establish baseline
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22. Neurological assessment and
classification
 The most widely tool for classifying SCI is “the
American Spinal Injury Association (ASIA)
classification,” this assessment requires manual
muscle testing of 10 key muscles bilaterally,
sensory testing for light touch and sharp/dull
discrimination in all dermatomes, and a rectal
exam for sensation and presence of voluntary
anal contraction. These tests are used to
classify injury levels and ASIA Impairment
Scale (AIS) grade
4/3/2012 22

23. ASIA Sensory Testing
Sensory Testing:
 0 = Absent
 1 = Impaired
 2 = Normal
 NT = Not testable

24. ASIA Dermatones
 C2-Occipital Protruberance  T6 – Xyphoid
 C3 –Supraclavicular fossa  T10 – Umbilicus
 C4 – A.C. Joint  T12 – Inguinal ligament
 C5 – Lateral antecubital fossa  L2 – Mid thigh
 C6 – Thumb  L3 – Medial femoral condyle
 C7 – Middle finger  L4 – Medial Malleolus
 C8 – Little finger  L5 – 3rd MTP joint
 T1 – Medial antecubital fossa  S1 – Lateral heel
 T2 – Apex of the axilla  S2 – Mid popliteal fossa
 T4 – Nipple line  S3 – Ischial tuberosity
 S4-5 – Perianal area

25. ASIA Motor Testing
0 = No movement
1 = Trace contraction
2 = Full AROM gravity eliminated .
3 = Full AROM against gravity
4 = Full AROM against gravity with resistance
5 = Normal power

26. ASIA Myotomes
 C5 – Elbow flexors  L2 – Hip flexors
 C6 – Wrist extensors  L3 – Knee extensors
 C7 – Elbow extensors  L4 – Ankle dorsiflexors
 C8 – Finger flexors  L5 – Long toe extensors
 T1 – 5th digit abductors  S1 – Ankle plantar flexors

30. ASIA Impairment Scale
 A = Complete: No motor or sensory
function in the lowest sacral segment.
 B = Incomplete: Sensory but no motor
function is preserved in the lowest
sacral segment.
 C = Incomplete: Less than ½ of the key
muscles below the (single) neurological
level have a grade 3 or better.
 D = Incomplete: At least ½ of the key
muscles below the (single) neurological
level have a grade 3 or better.
 E = Sensory and motor function are
normal.

31. Management
 Immediate
management at the
scene is critical.
 Improper handling can
cause further damage
and loss of functioning
 Always assume there is
a spinal cord injury
until it is ruled out
 Immobilize
 Prevent flexion, rotation
or extension of neck
 Avoid twisting patient
4/3/2012 31

32. Management
 Management consists of
emergency treatment following an
A-B-C-D-E sequence.
 Airway
 Breathing
 Circulation
 Disability
 Expose
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33. Medical management
 High dose corticosteroids
(Methylprednisolone) - improves the
prognosis and decreases disability if
initiated within 8 hours of injury.
Patient receives a loading dose and
then a continuous drip.
 High dose steroids, Mannitol, Dextran
 Neurological/orthopedic management
includes methods a surgeon may use to
treat unstable spinal cord injuries:
 Reduction
 Fixation
 Fusion
4/3/2012 33

34. Reduction
 With reduction, the spine is
realigned through the application
of a skeletal traction devise (such
as Gardner-Wells tongs, Minerva
vest, Halo traction) or Soft and
hard collars.
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35. Gardner-Wells tongs
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36. Minerva vest and halo-vest
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37. Soft and hard collars
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38. Fixation and Fusion
 Fixation involves  Fusion involves
stabilizing attaching injured
vertebral vertebrae to
fractures with uninjured
wires, plates, and vertebrae with
other types of bone grafts, and
hardware. steel rods to help
maintain
structural
integrity.

39. Physiotherapy Goals
 Relieve pain
 Maintain optimal level of wellness
 Maintain optimal functioning
 Minimal or no complications of
immobility
 Learn new skills, self care
 Return to home
 Integrate back into community

40. Physiotherapy techniques
 Therapeutic exercises: Passive
movement, Free active exercises,
Auto assisted exercises, Assisted
resisted exercises, Resisted
exercises
 Soft tissue manipulation
 Positioning
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41. Physiotherapist teaches
 Mobility
 Self care
 Functional activities
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42. Mobility
 bed mobility (i.e. turning from side
to side, moving from supine to
sitting).
 sitting balance.
 wheelchair transfers (i.e. from
wheelchair to bed, wheelchair to
car, and wheelchair to floor).
 standing balance.
 ambulation (wheelchair or
walking).
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43. Self care
Along with increasing mobility,
minimizing the need for assistance in
self-care is a major step toward
independence for those with SCI.
 Self-care includes feeding, bathing,
dressing, grooming, and toileting.
Those with motor-complete injuries at
the C-7 level or below can usually
achieve independence in all of these
activities.
4/3/2012 43

44. Functional activities
 Living skills (e.g. meal
preparation, shopping, cheque
writing, housekeeping, etc) are
necessary tasks of everyday life
and must be relearned and
adapted to a patient’s needs.
These skills are often reacquired
with the help of occupational
therapists.
4/3/2012 44

45. …….THANK YOU