Final case presentation sci (kimberly walsh)

Case Presentation
on Cervical
Myelopathy&
Spinal Cord Injury
By: Kimberly Walsh SPT
Kingston Public Hospital

Objectives
Definition of Spinal Cord Injury
Anatomy
Definition - Cervical Myelopathy
Aetiology - Cervical Myelopathy
Pathophysiology -Cervical Myelopathy
Epidemiology - SCI
Aetiology - SCI

Pathophysiology- SCI
Clinical Manifestations- SCI
Signs and Symptoms - SCI
Diagnosis - SCI
Complications - SCI
Management -SCI
Medical Mx

Surgical Mx
Physical Therapy Mx
Prognosis
Case Study

Definition
Spinal Cord Injury- is an insult to the spinal
cord resulting in a change, either
temporary or permanent, in the cord’s
normal motor, sensory, or autonomic
function

Anatomy
Spine – it is a series of vertebrae
extending from the skull to the back,
enclosing the spinal cord and providing
support for the thorax and abdomen.

Anatomy
The spinal column
consist of 33 vertebrae:
7 cervical
12 Thoracic
5 Lumbar
5 Sacral
4 Coccyx

Cervical Spine
C1-supports the skull
C2 - a blunt peg-like
structure (called the
Odontoid Process or
“dens”) that projects
upward into the ring
of the Atlas.

Cervical Spine
The other
cervical vertebra
(C3-C7) are
shaped like
boxes with small
spinous
processes that
extend from the
back of the
vertebrae.

Ligaments
Cruciate Ligament Complex
These ligaments help to stabilize the Atlantoaxial (Axis)
complex:
Transverse Ligaments: Connects the lateral masses of the
atlas, and in doing so anchors the dens in place
Superior Longitudinal Fascicles
Inferior Longitudinal Fascicles

Ligaments
Occipitoatlantal Ligament Complex (Atlas): run
between the Occiput and the Atlas:
Anterior Occipitoatlantal Ligament
Posterior Occipitoatlantal Ligament
Lateral Occipitoatlantal Ligaments (2)
Occipitoaxial Ligament Complex (Axis): connect
the Occiput to the Axis:
Occipitoaxial Ligament
Alar Ligaments (2)
Apical Ligament

Altantoaxial Ligament Complex (Axis): extend
from the Atlas to the Axis:
Anterior Atlantoaxial Ligament
Posterior Atlantoaxial Ligament
Lateral Ligaments (2)

 Nuchal ligament
(Ligamentum
Nuchae):
A continuation of the
supraspinous
It attaches to the tips
of the spinous
processes from C1-C7,
and also provides the
proximal attachment
for the rhomboids and
trapezius.

Superficial
Muscles
Trapezius
Levator
Scapulae
Rhomboid
major & minor
Latissimus Dorsi

Intermediate
Muscles
Serratus
Posterior
Superior
Serratus
Posterior Inferior

Deep Muscles
Splenius
Capitis
Semispinalis
Capitis

Deep Muscles
Splenius
Cervicis

Deep Muscles
Erector Spinae
Iliocostalis
Longissimus
Spinalis

Spinal Cord
Spinal Cord - the cylindrical bundle of
nerve fibres and associated tissue which
is enclosed in the spine and connects
nearly all parts of the body to the brain,
with which it forms the central nervous
system.

Ascending Tracts
 Lateral Spinothalamic Tract-
pain and temperature
 Anterior Spinothalamic Tract -
touch, pressure
 Dorsal White Column -
conscious proprioceptive
sense, discriminative touch,
vibratory sense

Ascending Tracts
 Ventral and Dorsal Spinocerebellar
Tracts - muscle joint information
from muscle spindles, tendons and
joint receptors of trunk and lower
limbs
 Transmit unconscious
proprioceptive information to the
cerebellum

Descending
Tracts
 Lateral Reticulospinal Tract –
Important in reciprocal
movements required for walking
and involved in postural control
responses
 Lateral Corticospinal Tract –Fine
skilled movements
 Rubrospinal Tract - Innervates UE
flexors

Descending Tracts
 Vestibulospinal Tract- relay the
signal to the motor neurons in
antigravity muscles.
 Tectospinal Tract- Involved in
orientation of head and eyes
(turning the eyes and the head) to
contralateral visual stimuli

CERVICAL MYELOPATHY
Cervical myelopathy is the result of
spinal cord compression in the cervical
spine.
Chronic cervical degeneration is the most
common cause of progressive spinal cord and
nerve root compression

Aetiology of Cervical Myelopathy
Cervical spondylotic myelopathy is the most
common disorder of the spinal cord in
persons older than 55 years of age.
Both sexes are affected equally. Cervical
spondylosis usually starts earlier in men (50
years) than in women (60 years)

The causes of cervical myelopathy can be
divided into different categories:
Static and Dynamic factors

 Static Factors -: A narrowing of the spinal canal
size can result from disc degeneration,
spondylosis, stenosis and osteophyte formation
at the level of facet joints
Dynamic Factors- Due to mechanical
abnormalities of the cervical spine or instability.

Pathophysiology of Cervical Myelopathy
The underlying cause of the condition is compression of the
long tracts in the spinal cord. The normal diameter of the
cervical spinal canal is between 17 mm and 18 mm.
 When this diameter falls below 12 mm to 14 mm for any
reason this is likely to cause stenosis and myelopathic
symptoms. The average diameter of the spinal cord in the
cervical spine is 10 mm.

Spondylosis.
CSM is the result of degenerative changes which
develop with age, including ligamentum flavum
hypertrophy, facet joint hypertrophy and disc
protrusion

One or all of these changes contribute to an
overall reduction in canal diameter which may
result in cord compression

Epidemiology - SCI
According to WHO, every year around the world,
between 250,000 and 500,000 people suffer from a
Spinal Cord Injury (SCI)
There is no reliable estimate of global prevalence but
estimated annual global incidence is 40- 80 cases per
million population
Up to 90% of these cases are due to traumatic
causes, though the proportion of non- traumatic
spinal cord injury appears to be growing.

Males are most at risk in young adulthood
(20-29 years) and older age (70+)
Females are most at risk in adolescence (15-
19) and older age (60+).
Studies report male- to- female ratios of at
least 2:1 among adults, sometimes much
higher.

Aetiology - SCI
Traumatic Non- Traumatic
Motor Vehicle Accidents Degeneration of the Spinal
Column
Slips/falls Infections
Violence Cancer/ Tumors
Sports – related injuries Vertebral fractures secondary
to osteoporosis
Medical / Surgical

Spinal cord injury can be sustained through
different mechanisms, with the following 3
common abnormalities leading to tissue
damage:
1. Destruction from direct trauma
2. Compression by bone fragments, hematoma,
or disk material
3. Ischemia from damage or impingement on
the spinal arteries

Pathophysiology - SCI
In all acute cord syndromes, the full
extent of injury may not be apparent
initially.
 Incomplete cord lesions may evolve into
more complete lesions.

Spinal Shock - a state of temporary physiologic (rather than
anatomic) reflex depression of cord function below the level of
injury, with associated loss of all sensorimotor functions. It
involves the complete loss of all neurologic function, including
reflexes and rectal tone, below a specific level that is associated
with autonomic dysfunction.
Duration: 24hrs – 6mths

3 Stages
1. Hyporeflexia/ areflexia
2. Return of reflexes
3. Hyperreflexia

Primary SCIs
Primary spinal cord injuries arise from
mechanical disruption, transection, or
distraction of neural elements. This injury
usually occurs with fracture and/or dislocation
of the spine.

Secondary SCIs
Vascular injury to the spinal cord caused by arterial
disruption, arterial thrombosis, or hypoperfusion
due to shock are the major causes of secondary
spinal cord injury. Anoxic or hypoxic effects
compound the extent of spinal cord injury

Complete Lesions
A complete cord syndrome is characterized
clinically as complete loss of motor and
sensory function below the level of the
traumatic lesion.

Incomplete Lesions
Incomplete cord syndromes have variable
neurologic findings with partial loss of sensory
and/or motor function below the level of
injury; these include the anterior cord
syndrome, the Brown-Séquard syndrome, and
the central cord syndrome

Incomplete Spinal Cord Injury Syndromes
Central Cord Syndrome
Anterior Cord Syndrome
Posterior Cord Syndrome
Brown Sequard Syndrome
Cauda Equina Syndrome
Conus Medullaris Syndrome

Clinical Manifestations
C1-4: HIGH TETRAPLEGICS
No significant strength in any limb
Many are vent-dependent
Phrenic nerve is supplied by C3,4,5
Dependent for ADL, bowel and bladder,
transfers

Clinical Manifestations
Power WC mobility
Rehab is more focused on training caregivers,
using adaptive technologies, and teaching
patient to direct his own care

CERVICAL C5 LEVEL
• Have shoulder shrugs and elbow flexion
• Possible goals – independence with daily
activities with assistance in setting up
specialized equipment to do ADL – eating,
drinking, washing, and shaving face, brush
teeth and hair care

C6
Able to extend the wrist
Tenodesis effect
Transfers with assistance
Can be modified independent for dressing and
bathing
Males may be able to do own intermittent
catheterization
Can use manual wheelchair or power WC
May be able to drive a modified van

• Have triceps (elbow extension)
• Functional goals include use of a manual
wheelchair and ability to do wheelchair push
ups for pressure relief

• There is greater ease in performing ADL
• Less need for assistance and adaptive aids
• Independent transfers

CERVICAL C8 – T1 LEVELS
• Total independence in everyday activities
• Will be able to live independently without
assistive devices in feeding, bathing,
grooming, oral and facial hygiene, dressing,
transferring, bladder and bowel management

CERVICAL C8 – T1 LEVELS
• T1 will have hand function versus C8 who will have
limited hand function
• Will need hand controls for driving
• Use of a manual wheelchair and ability to do
wheelchair push ups for pressure relief

THORACIC T2 – T6 LEVELS
• Normal motor function in the head, neck,
shoulders, arms, hands and fingers
• Depending on the level functional goals for injuries
between T2 and T6 include the use of ribs and chest
muscles or trunk control


• Increased abdominal control
• Functional goals may include improving
cough effectiveness and increasing ability to
perform unsupported seated activities


Individuals with injuries from T7– T12 are capable of
very limited walking with adapted devices. Extremely
high energy is required and the stress that is put on
the upper body offer no functional advantages.

• Attempts to walk lead to damage of the
upper joints
• Manual wheelchair is used for primary
mobility

LUMBAR L1 – L5 LEVELS
Walking can be a viable functional goal for
some people with the help of specialized leg
and ankle braces

LUMBAR L1 – L5 LEVELS
• Level of injury is also a factor as individuals with
lower levels of injury will walk with greater ease
with the help of assistive devices
• Use of wheelchair for primary mobility

SACRAL S1 – S5 LEVELS
• Increased ability to walk with fewer or no
supportive devices
• Depending on the level of injury there are
also various degrees of return of voluntary
bladder, bowel and sexual functions
• Greater improvements in function occur the
lower the level of injury

Signs & Symptoms
Symptoms of spinal cord injury include:
loss of movement
loss of sensation
loss of bowel or bladder control
Exaggerated reflexes or spasms
Changes in sexual function or sensitivity
Pain or stinging due to nerve damage
Difficulty breathing, coughing, or clearing the throat

Diagnosis
History
Physical Examination
Sensory + Motor Function Test
Diagnostic Test

ASIA Scale – Test for Sensory & Motor
Function
Neurological Level and Extent of Injury
ASIA Examination
Sensory level
 Motor level
 Neurological level of injury
Zone of Partial Preservation

Diagnostic Test
Plain X-Rays
Computed tomography (CT) scanning -
Reserved for outlining precisely bony
abnormalities or fracture.
Magnetic resonance imaging (MRI) - Used for
suspected spinal cord lesions, ligamentous
injuries, and other soft-tissue injuries or
pathology

Complications
Autonomic Dysreflexia
Respiratory issues
Bowel & Bladder Dysfunction
Pressure Sores
Contractures
DVT
Osteoporosis
Urinary Tract Infection (UTIs)

Management
Medical Management
Cervical Brace
Thoraco-lumbar brace
NSAIDS
Anti-coagulants

Surgical Mx
Disectomy – surgical removal of intervetebral disc
Laminectomy – surgical removal of lamina
Foraminotomy – decompression surgery to
widen foramen and relieve pressure on spinal
nerve root
Laminotomy – removal of part of the lamina

Physical Therapy
Mx
Education
Bed Mobility
Training

Physical Therapy
Mx
Balance
Training

Physical Therapy
Mx
Muscle
strengthening in
the available
groups

Physical Therapy
Mx
W/C Mobility

Physical Therapy
Mx
Transfer
Training

Physical Therapy
Mx
Gait Training

Physical Therapy Mx
ACTs
RMT

Prognosis
Prognosis for patients with spinal cord
injuries varies and depends largely on the
degree of damage. The completeness
and location of the injury will determine
the prognosis.
Also a pt prognosis can be determine
after a spinal shock.

Demographic Information
Pt : X
Age :67 years old
Sex: M
Dx: Cervical Myelopathy with Traumatic
Tetraplegia
Date: May 3, 2017

Docket Summary
Alert 67 year old pt with unknown
chronic illnesses was seen at A&E and
reported that he fell of a motorbike on
April 27, 2017. The pt sustained multiple
abrasions to face and had neck pain

Docket Summary
Pt was then admitted to General Sx the same day
where X- rays where done + revealed that the pt
has hyperinflated lungs + bil streaky infiltrates.
There was an increase in muscle tone in the UE +
4/5 muscle strength at the R + L elbow flexors +
0/5 in the LLE.


Docket Summary
The Dr did the ASIA where it revealed that that
the pt has normal sensation for both pin prick
+ light touch from C2-C5 but altered
sensation from T5-T7 + no sensation from T8-
S5 bil. Also, there is total paralysis of in motor
function from C6-S5 on both sides

Docket Summary
On the 30/04/17, the pt was transferred to
Steventon Ward. On May 3, 2017, the pt was
referred for chest + limb physiotherapy.


HPC
 On Thursday, April 27, 2017, the pt was riding
a bike, hit a pothole, fell from the bike +
landed on his stomach + face; he had on a
helmet. He reported that a passerby was at the
scene in which the individual assisted by going
into the pt's pocket + call his son.


HPC
He stated that he gave appropriate
instructions to the passerby to get in contact
with his son. He was on his side when his son
arrived at the scene in one hr + took him to
KPH.


HPC
The pt reported that on Monday/ Sunday, CT
scan was done on his back + waist. For the
past 3/7, he stated that there was no feeling in
his legs but presently has feeling in the legs?

PMH
PMH:
Sx/ Hospitalization: In 1987, the pt L thumb was
chopped off with a machete + he stated that a skin
graft was done on the thumb.
Medications: Nil
Chronic Illnesses: Nil
Allergies: Nil


SFH
Occupation: Farmer
Hnd Dominance: L Hnded Religion:
Rastafarian
Drink √: pt stated that he is drinking rum + alcohol
for many years
Smoke: √ 15 years smoke marijuana + stated that he
is smoking tobacco, dry cocoa leaves + banana trash
when he was 5 years old.
Hobby: Playing Dominoes
Family History: Nil

SFH
Pt lives with son in a modern convenient
house , good road access located on flat
terrain, no stairs + the yard is of grass.
The pt has 7 children but one recently died.

The pt reports that he passes urine frequently
+ large amount of urine. In addition, he stated
that he has not pass stool in days and do not
know whether or not if he can control his
bowel or can feel whether or not he wants to
pass stool.

Pt Goals: The pt would like the pain in the
neck to go away.
P: Continue Evaluation

4/05/17
PC: Pt voiced nil complaints
O: Alert male pt seen in sup. ly. with neck rotated to
the L. Bil fingers in flexed position.
BP: 117/65 mmHg PR: 52 bpm O2Sat: 95% RR: 17
bpm
Skin: bruises on the face
MM: pink + moist
Nil cyanosis, Nil clubbing of the fingers

Nil tracheal deviation
Nil chest expansion for upper + lower chest ant.
RR rhythm: Regular
RR depth: Normal
RR type: Abdominal
Nil dyspnea
Nil chest pain

Auscultation: Decreased BS, Nil adventitious
breath sounds
Cough: Non- productive + weak

AROM PROM END FEEL MMT TONE
R L R L R L R L R L
Sh. flexion 0 0 WNL WNL N N 0 0 0 0
Sh ext 0 0 0 0
Sh abd WNL WNL 4 4
Sh add 0 0 0 0
Sh Int Rot
Sh Ext Rot
Elbow Flex 4 4
Elbow ext WNL WNL 0 0
Forearm Pro 0 0
Forearm
Wrist Flex
Wrist Ext
Wrist rad
dev

AROM PROM END FEEL MMT TONE
R L R L R L R L R L
Wrist Ulnar
Dev
0 0 WNL WNL N N 0 0 0 0
Hip Flexion
Hip Ext
Hip Abd
Hip add
Hip Int Rot
Hip Ext Rot
K Flex
K Ext
Ank Dorsiflex
Ankle
Plantarflex
Ankle Inver
Ankle Ever

Pt does not have AROM for bilat. fingers
and PROM were in WNL and the end feel
were normal.
Sensation : Normal sensation present
with pin prick from C2-C5 and altered
sensation from C6- T4 and no sensation
from T5- S1.
LE: Nil sensation; absent throughout

Coordination : Poor Bilat. UE+ LE
Proprioception: UE: absent LE: absent
 Bed Mobility : Dependent in all
movements
Balance : Poor
Reflex: Normal bilat. for bilat. UE+ LE
Babinski Sign: (-) bilat. UE+LE
Ankle Clonus: (0) bilat. UE+ LE

A: Summary – The pt is a good candidate
for PT due to the fact that the pt has
elbow flexors which can assist him in bed
mobility + ADLs. However, the pt does
not follow instructions + is not very
compliant even though he is interested in
getting better. Also, it seems that the pt
has altered mental status.

Diagnosi
s
Body
Structure +
Function
Activity
Limitation
Participation
Restriction
Contextual Factors
Dx:
Traumatic
Tetraplegi
a with
Cervical
Myelopath
y
CNS: Spinal
Cord
Musculoskeletal:
↓ Ms. Strength
↓ ROM
Somatosensory:
Pain, absent
proprioception
Cardiopulmonar
y: Hyperinflated
lungs
Grooming
Brushing
Teeth
Donning and
Duffing
clothes
Feeding one’s
self
Reaching and
lifting stuff
Grasping
objects
Bathing
Working
Playing
dominoes
With friends
Personal
Factors
Religion (+)
Financial
support (+)
Altered
mental status
(-)
Drink (-)
Smoke(-)
Environmenta
l Factors
Good road
access (+)
1 storey
house (+)
House
location(+)
Modern
convenient
house (+)
Neuromuscular: Does not Access to free

STG :Pt should be able to perform bed
mobility (from sup.lying to R + L s. Lying
)with +2 mod assist in 1/52
↑ ms strength in elbow flexors + sh.
Abductors by 1 grade in 3/12

LTG: Functional ms strength in 6/12
Independent Bed Mobility in 6/12
P: Bed Mobility training, MS
strengthening excs for the available ms
groups, PROM for the UE + LE

Rx Sessions
PC: Pt voiced nil complaints
O: Alert pt in sup.Ly with nasal cannily
attached + Branula attached to R
forearm. Urinary catheter attached
BP: 117/72 mmHg PR: 59bpm O2Sat:
99% RR: 20 bpm

Bilat. UE + LE PROM excs X 30reps each
Turn Pt from sup.Ly to ¼ turn R s. Ly with 2
max assist X 1 hr
A: Pt was a bit confused + irritated today
P: Continue Mx

8/05/17
PC : Pt voiced nil complaints. He stated that
he is doing much better today.
O: Alert male pt seen in sup.Ly with nasal
cannily attached + Branula attached to the R
dorsal forearm. Urinary catheter attached.

BP: 112/66 mmHg PR: 54 bpm O2Sat: 96% RR:
20 bpm
Cardiopulmonary: Nil secretions, weak + non-
productive cough
Auscultation: ↓ BS throughout

Rx: Assisted Coughing excs ( Heimlich)X 5
reps
Bilat.UE PROM excs X 30 reps each
 bilat. LE PROM excs X 30 reps each
Turn pt from sup.lying to ¼ turn R s. lying
with 2 max assist X 2 hers ( Nurse instructed
to turn pt in 2 hrs)

Rxn to rx: Pt tolerated rx well. Nil adverse
effects to Rx.
A: Pt was compliant with execs today
P: Continue Mx.

On May 9, 10, 11 + 16, Rx focused on
Bilat. PROM UE + LE excs X 30 reps each
Pt attempted to reach therapist hand with
bilat. hand X 2”
Assisted Coughing techniques
P: Continue Mx

Outpatient – JUNE 13th @ 3:00 pm
S: It was reported that the pt almost blocked out in
OPD when the w/c was adjusted in the upright position.
O: Male elderly pt seen in a w/c with daughter in OPD.
O/E: same as before (same findings when he was
admitted on Steventon ward), at the L heel there was
bleeding.

Rx: Pt’s daughter was shown how to do PROM excs for
the bilat. UE+ LE and was told to let the pt do AROM for
the available ms groups (bilat. elbow flexors + bilat. sh
abductors
Pt was told that anytime that the w/c is adjusted to an
upright position and seeing signs of pt blocking out,
then she should adjust the w/c to a lying position.

Bandage was applied to L Heel.
Pt’s daughter was encouraged to get special
cushioning for the pt’s bilat. heel
Rxn to Rx: Nil adverse effects to rx.
A: Pt rehab potential is guarded due to the fact
that when he was admitted to KPH
(Steventon)ward, he refused to do sx in which
he would have benefitted from.

In addition, while he was at home he was not
being supervised regularly in the day ( due to
the fact that his son works)

Diagnosi
s
Body
Structure +
Function
Activity
Limitation
Participation
Restriction
Contextual Factors
Dx:
Traumatic
Tetraplegi
a with
Cervical
Myelopath
y
CNS: Spinal
Cord
Musculoskeletal:
↓ Ms. Strength
↓ ROM
Integumentary:
bruising at the L
heel
Somatosensory:
Pain, absent
proprioception
Cardiopulmonar
y: Hyperinflated
Grooming
Brushing
Teeth
Donning and
Duffing
clothes
Feeding one’s
self
Reaching and
lifting stuff
Grasping
objects
Bathing
Working
Playing
dominoes
With friends
Personal
Factors
Religion (+)
Financial
support (+)
Altered
mental status
(-)
Drink (-)
Smoke(-)
Environmenta
l Factors
Good road
access (+)
1 storey
house (+)
House
location(+)
Modern
convenient
house (+)

References
 The bone school. Retrieved from http://www.boneschool.com/spine/cord-
injury/spinal-cord-injury
 http://emedicine.medscape.com/article/793582-
overview?pa=xPBz%2FpIJrArTArMuUPEXOMy5PxXI1hYBEnwIVTLlRdovNTVFEsi7HW
9pKZGnBlHAVmJZNokOBZ7e1B7ezKUMkE3B6KLODm2MpyHuPkYf%2Bs0%3D
 Understanding Spinal Cord Injury. Retrieved from
http://www.spinalinjury101.org/details/levels-of- injury
 https://www.slideshare.net/QuanFuGan/spinal-cord-injury-sci-rehab
 http://www.physio-pedia.com/Cervical_Myelopathy
 http://www.boneandjoint.org.uk/content/focus/cervical-myelopathy

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