Respiratory Impairment in SCI
Disease/Disorder Definition Spinal cord injury (SCI) commonly results in some degree of respiratory dysfunction due to weakness or paralysis of the respiratory muscles, reduced vital capacity (VC), increased respiratory secretions, ineffective cough, reduction in lung and chest wall compliance, and increased oxygen […]
SCI Traumatic Part One: Disease/Disorder and Essentials of Assessment
Disease/Disorder Definition Traumatic spinal cord injury (SCI) refers to a traumatic insult to the spinal cord that results in impaired motor, sensory, and/or autonomic function below the injured spinal cord level. Injury to the cervical segments through the first thoracic segment results in impaired function in both the arms and the legs, referred to as tetraplegia, while injury to the thoracic, lumbar or sacral segments of the spinal cord causes paraplegia, characterized by impaired function in the legs but sparing of the arms. Etiology Motor vehicle accidents are the most common cause of SCI, followed by falls, acts of violence and sports injuries. Motor vehicle accidents are consistently the leading cause of SCI in the general population and rates have remained relatively steady. The proportion of injuries due to falls increases with advancing age, and falls are the leading cause of injury in persons older than 65 years of age. Epidemiology including risk factors and primary prevention In the United States (US), there are approximately 18,000 new cases each year. Although traumatic SCI historically primarily affects young males between the ages of 15 and 35, the average age at injury has been steadily increasing. The most common injury category is incomplete tetraplegia followed by similar rates of incomplete and complete paraplegia, with complete tetraplegia the least common. Of all injuries, ~30% are complete and ~70% are incomplete, and about 60% are tetraplegia. The proportion of incomplete injuries, high cervical injuries and ventilator dependence is increasing. In the US, violence is a more common cause of SCI than in most countries. SCI due to sports injuries has been declining, whereas injuries due to falls have been increasing.1 Patho-anatomy/physiology SCI can be characterized as follows: Primary insult is disruption of neural and vascular structures of the spinal cord at the time of initial trauma. Secondary injury refers to a cascade of events following the initial injury that cause further tissue damage. Possible mechanisms include inflammation, ischemia, increased vascular permeability, and release of free radicals and neuroexcitatory neurotransmitters. These events cause spinal cord swelling, cell death and neurological deterioration. SCI without radiological abnormalities (SCIWORA) refers to an acute SCI that occurs without evidence of vertebral fractures on plain radiographs or on computed tomography (CT) scans. Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) Onset of motor, sensory and autonomic dysfunction after traumatic SCI is usually sudden. Spinal shock occurs in the initial hours post injury and may last days to weeks. It is defined as the loss of reflexes below the level of injury. Motor and sensory recovery depend on the extent and location of the insult; persons with incomplete SCI recover faster and to a greater extent than do those with complete injuries. Patients with a higher impairment score (indicating a less severe injury) experience greater and faster rates of motor recovery. Regardless of level and completeness of injury, most recovery occurs within the first 6 months after injury. Additional recovery, however, can occur up to 18 months after SCI although rate of progression is slow and may not yield functional gains. Acute SCI often results in a disruption of autonomic regulation of the bowel and bladder as well as reduction of cardiopulmonary reserve, characterized by a decline in blood pressure and lung volumes. SCI exacerbates the normal physical and physiological decline associated with aging; persons with SCI manifest medical, cognitive, and functional problems associated with aging at an earlier age. Specific secondary or associated conditions and complications SCI is associated with complications involving every organ system. Inspiratory muscle weakness results in loss of lung volumes and expiratory muscle weakness results in impaired cough, difficulty clearing secretions, and mucous plugging. Individuals with cervical and high thoracic injuries are more likely to have respiratory impairment and lung infections. Ventilatory failure due to diaphragmatic impairment may occur in people with high tetraplegia. Impaired sensation, mobility, and nutritional status, along with increased moisture due to bowel and bladder incontinence, can result in pressure injury, skin breakdown, and infection. Autonomic impairment results in loss of bowel and bladder control, impaired thermal and cardiovascular regulation, and sexual dysfunction. Fertility rates are generally preserved in females after an acute period of amenorrhea. Males with SCI may have lower sperm count and poor motility. Cardiovascular complications include low resting blood pressure, orthostatic hypotension, coronary artery disease, and reduced cardiovascular fitness. Individuals with spinal cord injury above T6, particularly those with complete injuries, are predisposed to developing autonomic dysreflexia, which is defined as an abrupt rise in blood pressure due to a noxious stimulus below the level of injury. SCI can result in a variety of endocrine and metabolic conditions, including electrolyte disturbances (e.g., hyponatremia), impaired lipid metabolism, metabolic syndrome, and osteoporosis. Body composition changes including loss of skeletal muscle and increased adipose tissue can result in insulin resistance and dyslipidemia. Urinary tract infections are the most common source of infections in individuals with SCI and a leading cause of hospitalization. Individuals with SCI are also at higher risk of pneumonia and sepsis, which are leading causes of mortality.2 Constipation, incontinence, and hemorrhoids are common consequences of impaired bowel control. Genitourinary complications include renal or bladder stones and higher rates of bladder cancer in those who catheterize.3 Late neurological decline may result from multiple causes, including central causes such as post-traumatic syringomyelia or new stenosis and compression due to spondylosis, as well as peripheral causes, such as peripheral neuropathy or a focal compressive mononeuropathy (e.g. carpal tunnel syndrome). Pain is common after SCI and can be neuropathic or nociceptive in origin. Overuse syndromes are common causes of musculoskeletal pain; shoulder pain is common in both tetraplegia and paraplegia. Incidence of depression is significantly increased in persons with SCI; the most common risk factor is depression prior to injury.4 There are also higher rates of anxiety and post-traumatic stress disorder, particularly acutely. Alcohol and substance use disorders are also more common in individuals with SCI.5 Essentials of Assessment History The mechanism of injury determines the extent of SCI and likelihood of other significant injuries. Details of the trauma, including mechanism, speed of impact, and loss of consciousness can be helpful. Concomitant rheumatoid arthritis, atlanto-odontoid subluxation (e.g., as seen in Down’s syndrome), osteoarthritis, ankylosing spondylitis, and spinal stenosis predispose individuals to SCI. Physical examination The spine should be palpated for focal tenderness. Tone and reflexes should be evaluated. A careful neurological examination must be performed according to the International Standards for Neurological Classification of SCI (ISNCSCI). The International Standards outline details of the neurological examination and classification. The level and completeness of SCI should be determined with a careful sensory examination for light touch and pin prick at key sensory points, and motor examination of designated key muscles bilaterally. The neurological completeness of SCI is classified according to the American Spinal Injury Association (ASIA) Impairment Scale. The ASIA Impairment Scale (AIS) is used to describe neurological severity and predict recovery. Serial examinations track neurological progress. The classifications are as follows: A = Complete. No sensory or motor function is preserved in the sacral segments S4-S5. B = Sensory Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5, AND no motor function is preserved more than three levels below the motor level on either side of the body. C = Motor Incomplete. Motor function is preserved at the most caudal sacral segments for voluntary anal contraction OR the patient meets the criteria for sensory incomplete status and has some sparing of motor function more than three levels below the ipsilateral motor level on either side of the body. Non-key muscles can be used for this designation. Less than half of key muscle functions below the single neurological level of injury have a muscle grade >/ 3. D = Motor function is preserved in at least half of key muscle functions below the single neurological level of injury with a muscle grade >/ 3 . E = Normal sensation and motor function in person with prior deficits Autonomic function can be assessed by presence/ absence of neurogenic shock, cardiac dysrhythmias, orthostatic hypotension, autonomic dysreflexia, temperature dysregulation and hyperhidrosis Functional assessment […]
Polytrauma, Debility and Burns
[…] state of low muscle mass.4 Burns: extensive burn injuries are often seen in the setting of trauma, brain injury, or spinal cord injury. Burn wounds are classified as superficial, partial-thickness, and full-thickness depending on the extent and depth of the injury. Superficial […]
SCI Traumatic Part Two: Treatment and Practice
[…] The Paralyzed Veterans of America (PVA) have sponsored the development of clinical practice guidelines for the management of those with spinal cord injury (SCI). Entitled the Consortium for Spinal Cord Medicine, they are based on literature reviews and expert panel consensus.1-12 The […]
Thoracic Radiculopathy/Myelopathy
[…] or abdominal wall usually along a single dermatome is suggestive of thoracic radiculopathy. Neuropathic pain may be exacerbated by trunk movements. Spinal cord injury is classified according to the American Spinal Injury Association (ASIA) Impairment Scale which can be found on its web […]
Shoulder Problems – Pain in the Wheelchair Athlete
[…] location, radiation, aggravating or alleviating factors such as repetitive movement, uphill WC propulsion, overhead activities, and transfers).35 For patients with spinal cord injury, identify motor and neurologic level of injury.36 Treatment to date, current medications. Handedness. Wheelchair type (manual, power-assist, power) and […]
Natural Recovery and Regeneration of the Central Nervous System
[…] that central nervous system (CNS) axons have limited regenerative capacity following stroke, brain injury, cerebral palsy, degenerative brain diseases, or spinal cord injury, several advances in the understanding of natural recovery and regeneration of CNS tissue represent exciting developments for the fields […]
Pediatric Syringomyelia
[…] Tethered cord syndrome Chiari malformations (Type I most common) Acquired: Post-infectious: Meningitis, arachnoiditis Post-inflammatory: Transverse myelitis, sarcoidosis, multiple sclerosis Post-traumatic: Spinal cord injury, postsurgical, arachnoid scarring Neoplastic: Spinal cord tumors (ependymomas and hemangioblastomas) Extramedullary tumors Idiopathic Familial The most common etiology of […]
Upper Gastro-intestinal Problems in Patients with Disorders of the CNS (Excluding Dysphagia)
[…] topic and will not be addressed here. Etiology Several disorders or injuries of the CNS, including traumatic brain injury (TBI), spinal cord injury (SCI), or severe stroke can be associated with development of erosive gastritis (stress ulcers) in the acute stage.2,3,6 Acute […]
Peripheral Neurological Recovery and Regeneration
Overview and Description The peripheral nervous system includes all nerves and ganglia located outside of the brain and spinal cord and is divided into the somatic and autonomic nervous systems. The somatic nervous system is made up of both motor […]