This slide for the lecture of Madagascar medical faculties.

2. Contents
• History
• Etiology
• Anatomy and pathophysiology
• Classification
• Acute management
• Rehabilitative goal and multidisciplinary approach
• Complications and management
• Goal of rehabilitation

3. Contents
• History
• Etiology/epidemiology
• Anatomy and pathophysiology
• Classification
• Acute management
• Complications and management
• Rehabilitative goal and multidisciplinary approach

4. Horatio Nelson, 1st Viscount
» The Most Noble Lord Horatio Nelson, Viscount and Baron Nelson, of the Nile and of
Burnham Thorpe in the County of Norfolk, Baron Nelson of the Nile and of Hilboroug
h in the said County, Knight of the Most Honourable Order of the Bath, Vice Admiral
of the White Squadron of the Fleet, Commander in Chief of his Majesty's Ships and V
essels in the Mediterranean, Duke of Bronte in Sicily, Knight Grand Cross of the Sicili
an Order of St Ferdinand and of Merit, Member of the Ottoman Order of the Cresce
nt, Knight Grand Commander of the Order of St. Joachim
• Died at 1805, battle of Trafalgar
https://en.wikipedia.org/wiki/Horatio_Nelson,_1st_Viscount_Nelson

5. 1. With back pain, he commented, ‘My backbone is shot through!’
2. ‘All power of motion below my breast are gone’ and no feeling belo
w the breast
3. Difficulty in breathing was mentioned only in one place despite frac
tures of the second and third ribs and the lung injury.
4. He felt thirsty all the time and asked for ‘fan, fan’ and ‘drink, drink’.
He was agitated and repeatedly shouted that there was ‘a gush of bl
ood’ every minute within his breast.
By Mr W Beatty
D Wang, et al., Admiral Lord Nelson’s death: known and unknown – A h
istorical review of the anatomy, Spinal Cord (2005) 43, 573–576

6. Weakness of limbs
• Paraplegia
• Tetraplegia
• Quadriplegia
• Paraparesis
• Quadriparesis

7. Contents
• History
• Etiology/epidemiology
• Anatomy and pathophysiology
• Classification
• Acute management
• Complications and management
• Rehabilitative goal and multidisciplinary approach

8. Etiology
• Trauma
– Traffic accident
– Fall
– Falling agent at the construction field
– Diving injury
– Violence including gunshot wound

9. Diving injury
• Trauma
– Traffic accident
– Fall
– Falling agent at the construction fiel
d
– Diving injury
– Violence including gunshot wound

10. Etiology
• Neurodegenerative diseases
– Acute transverse myelitis
– Multiple sclerosis
• Combined
– Minor fall down of aged people
• Metastasis
• Others

11. Epidemiology
• In USA
– 40 cases / millions / year of incidence
– 240,000 people of prevalence
• In Korea
– 36,000 people at year of 2000
• In Madagascar?

12. Contents
• History
• Etiology/epidemiology
• Anatomy and pathophysiology
• Classification
• Acute management
• Complications and management
• Rehabilitative goal and multidisciplinary approach

13. Anatomy
Arm & Hand
Leg & Foot

15. X-ray

16. CT

17. MRI

18. Contents
• History
• Etiology/epidemiology
• Anatomy and pathophysiology
• Classification
• Acute management
• Complications and management
• Rehabilitative goal and multidisciplinary approach

19. ISNCSCI
• International Standards for Neurological Classification of SCI
• a.k.a ASIA Impairment Scale
• ISNCSCI Worksheet at http://bitly.kr/okKZzxhU

23. ISNCSCI or ASIA Impairment Scale
– Neurological level of injury: the last(highest) intact level of
dermatome and/or myotome
– AIS A: complete motor and sensory SCI
– AIS B: complete motor SCI, incomplete sensory SCI
– AIS C: incomplete motor and sensory SCI, not functional ambulator
– AIS D: incomplete motor and sensory SCI, maybe functional
ambulator
– AIS E: fully recovered state from spinal cord injury

24. ASIA Impairment Scale
• ASIA A : complete
– Complete loss of sensory and motor function both
– No perianal/deep anal sensation
– Less than 2% of recovery
– (Recovery seems to be error of neurologic exam)
• ASIA B : motor complete, sensory incomplete
– Perianal pinprick (NO), poor prognosis
– Perianal pinprick (YES), possibility of motor recovery
– (possibility of neurological recovery)

25. AIS
• ASIA C : motor incomplete, non-functional
– Maybe non-functional ambulator.
• ASIA D : motor incomplete, functional
– Possibility of functional ambulator.
• ASIA E : normal
– Fully neurologically recovered state from SCI

26. Clinical Syndromes
• Central cord syndrome
• Brown-Sequard syndrome
– Ipsilateral weakness
– Ipsilateral loss of position and
vibration
– Contralateral loss of pain and
temperature
• Anterior cord syndrome
• Conus medullaris syndrome
• Cauda equina syndrome

27. Clinical Syndromes
• Central cord syndrome
– Possibility of functional ambulator
– Dysfunction of hands
• Brown-Sequard syndrome
– Often accompany with central cord syndrome
– Possibility of functional ambulator
• Anterior cord syndrome
– Walking may be impossible
– Maybe with no motor recovery
• Cauda equina or Conus medullaris syndrome
– Bladder or bowel problems

28. Contents
• History
• Etiology/epidemiology
• Anatomy and pathophysiology
• Classification
• Acute management
• Complications and management
• Rehabilitative goal and multidisciplinary approach

29. Acute Management
• Spine board

30. ABC
• Airway: caution at endotracheal intubation
• Breathing
• Circulation
– Spinal shock after initial hypertensive phase
– Fluid resuscitation with foley catheterization for urinary retention

31. Medical problems
• Urinary retention: Foley drainage, intermittent catheterization
• Paralytic ileus
• Stress ulcer (gastric, duodenal): H2b or PPI
• Skin pressure ulcer (sore)

32. Medical problems
• Postural hypotension (orthostatic hypotension)
• Sinus bradycardia
• Deep vein thrombosis and pulmonary embolism
– Prophylactic anticoagulation with warfarin
• Respiratory insufficiency
– Caution at CO2 retention

33. Surgery
• Surgical decompression and fixation
– Surgery to prevent more neurological injury d/t instability at incomplete injury
– No functional/neurological improvement at complete injury
– Surgery decrease medical complication and in-hospital days

34. Decompression & fixation

35. Methylprednisolone (NASCIS protocols)
• Within 3 hours of injuries
– 30mg/kg bolus
– 5.4mg/kg/hr for 24hrs
• Within 8 hours of injuries (3 to 8 hour)
– Maintain same dose for 48 hours

36. Methylprednisolone (NASCIS protocols)
– Improved neurological recovery
– Improved blood flow
– Prevent lipid peroxidation
– Act as free radical scavenger
– Anti-inflammatory effect
– Increased risk of pneumonia

37. Contents
• History
• Etiology/epidemiology
• Anatomy and pathophysiology
• Classification
• Acute management
• Complications and management
• Rehabilitative goal and multidisciplinary approach

38. Common problems
• Cardiovascular
– Orthostatic hypotension
– Bradycardia
– Autonomic dysreflexia
– DVT and PE
• Gastro-intestinal: neurogenic bowel
• Urinary: neurogenic bladder
• Pulmonary dysfunction
• Spasticity
• Pain
• Musculoskeletal
– heterotopic ossification
• Skin: pressure ulcer
• Sexual dysfunction
• etc

39. Spasticity
• Spasticity
– Velocity-dependent muscle contraction
– Increased muscle tone, but with weakness
– Upper motor neuron sign
– Causing stiffness and tightness
– Interfere normal movement
– Some benefits: maintain bone density (prevent osteoporosis), improv
e circulation, prevent DVT

40. Management of spasticity
• Exercise: range of motion exercise, gently, passively
• Medications
– Baclofen
– Dantronene sodium
– Diazepam
– Tizanidine
• Removal of triggering factors
– Stool impaction
– Pressure ulcer
– Ingrowing toenail

41. Orthostatic hypotension
• In complete tetraplegia, high cervical spinal cord injury
• Prevention
– Stocking in lower limbs
– Abdominal bandages
– Symptom control is more important than maintaining the BP
• Medications
– Midodrine (alpha-1 agonist)
– Fludrocortisone (aldosterone analogue)

42. Autonomic dysreflexia
• Usually complete tetraplegia
– Abruptly increased blood pressure (sBP 180~200mmHg)
– Headache
– Nasal congestion
– Piloerection
– Facial flushing
– Bradycardia
– Sweating
– Sphinter constriction
– In severe cases, intracerebral hemorrhage may occur

43. Managemeng of AD
• Fisrt, removal of the causes
– Bladder overdistension
– Constipation
– Ingrowing toe nail
– Pressure ulcer
– Fracture
– Acute abdomen (acute appendicitis, acute cholecystitis, etc)
• Treatment
– Nifedicpine 10mg sublingual
– Emptying the bladder (by catheterization)
– For other causes, firstly lower the BP, then remove the causes

44. Pain
• Pain
– Neuropathic pain
– Visceral pain
– Musculoskeletal pain
– “I have no sense, why I feel the pain?”
– “Everyday before rain, I always suffered”
• Medications: anticonvulsants
– Gabapentin, pregabalin, clonazepam, etc
• Removal of aggravating factors

45. Pressure ulcer
• Position changes q2hrs
• Pressure relief devices
• Cautious for shear forces

46. Neurogenic bladder
• Problems
– Cannot void
– Fail to remove Foley catheter
– Urinary incontinence
– Frequency
– No sense to void
– Urgency and cannot hold
voiding
– Frequent urinary tract
infection such as cystitis,
pyelonephritis

47. Neuroanatomy
• Pelvic nerve (parasympathetic, S2-4)
– Detrusor muscle
– Cholinergic muscarinic receptors
• Hypogastric nerve (sympathetic)
– Alpha adrenergic Rc: sphincter control
– Beta adrenergic Rc: relax bladder wall
• Pudendal nerve
– Somatic sensory

48. Neurogenic Bladder
• Unable to void
• Cause of Incontinence
– Overactivity
– Overflow (capacity 400~500cc)
– Stress
– Urinary tract infection
– Obstructive

49. Neurogenic Bladder
• Solution
– If possible, self voiding
– Prevent infection
– Maintain proper bladder capacity (400-500cc)
– Prevent vesicoureteral reflux
– Decrease intra-vesical pressure
– Anticholinergic medication
– Clean Intermittent Catheterization

50. Neurogenic bladder
• Reflex voiding
– Percussion
– Crede’s method (pressure)
• CIC: Clean intermittent catheteriz
ation
– Maintain bladder capacity
– Maintain low intra-vesical pressure
(detrusor pressure)
– Combined with anticholinergic med
ications
• Indwelling catheter
– Foley catheter
– Suprapubic cystostomy

51. Medications
• Anticholinergics: lower intra-vesical
pressure (prevent incontinence and VUR)
– Oxybutynin (Ditropan)
– Propiverine (BUP-4)
– Solifenacin (Vesicare)
– Tolterodine (Detrusitol)
– Fesoterodine (Toviaz)
• Intravesical instillation
– Capsaicin
– Oxybutynin powder
– Resiniferatoxin
• Botulinum toxin injection
• Alpha-blocker: lessen sphincter
constriction (help self voiding)
– Terazocin (Hytrine)
– Doxazocin (Cardura)
– Tamsulocin (Harnal)

52. Diagnosis: VCUG

53. Urodynamic study
• Cystomanography: direct evaluation of intra-vesical pressure

54. Neurogenic bowel
• Incontinence
– Evacuation problem
• Constipation
– Decreased GI motility (2 to 3 times slower)

55. Management of constipation
• Bowel medications
• Finger evacuation
• Suppository
• Enema
• Use gastro-colic reflex, making bowel habit  most useful

56. Contents
• History
• Etiology/epidemiology
• Anatomy and pathophysiology
• Classification
• Acute management
• Complications and management
• Rehabilitative goal and multidisciplinary approach

59. Goal of Rehabilitation
• Achieve maximal functions
• Prevent complications
• Increase Quality of Life (Social re-integration)

60. Maximal functional gain in complete SCI
• C1-3
– Needs all time mechanical ventilator care
• C4
– Special motorized wheel chair
– Tongue, head, eye, voice, breathe
controller
• C5
– Total assist in bladder/bowel management
• C6
– Propel wheelchair indoor, even surf
ace only
• C7/8
– Propel wheelchair independently
– Bed to wheelchair transfer indepen
dently

61. Maximal functional gain in complete SCI
• T1-T12
– Full time manual W/C
– Gait for exercise only, with KAFO
• L1-S5
– Independent standing
– Functional gait with KAFO, forearm crutch

62. Wheel Chairs

63. Driving
• Paraplegia
– No problem with hand control devices
• Tetraplegia
– C7/8 : need hand control
– C5/6 : specialized device such as joystick
– C1-4 : impossible

66. Sexual Rehabilitation
• For man
– Erectile dysfunction
• Reflex erection
• Psychogenic erection
– Ejaculation failure
– No problem on orgasm
• For women
– Lubrication problem
– Same possibility of pregnancy, delivery
– For complete paraplegia
• Early admission before 32wks
• Consider C-sec

67. Stem cells – not yet

68. Robot

69. Wearable Robot

70. Cause of death
• Past: urinary problems
• Nowadays: pulmonary > cardiovascular > infection
• Future: cardiovascular, malignancy
– may be same with ordinary people

71. Take Home!
• Acute management
• ASIA Impairment Scale and prognosis
• Neurogenic bladder
– Anticholinergic medications
– CIC
2020-02-23 71

72. THANK YOU!
722020-02-23