Spinal Cord Injuries

1
Spinal Cord Injuries

• Physical Disabilities, Rehabilitation and
  Employment (BCE 542)
• November 5, 2002

2
The Spinal Cord and the Spinal Column

• The spinal cord is an extension of the nervous
  system running from the brain to the level of the
  navel there are nervous branches of the spinal
  cord below the navel inside the spinal column.
• The spinal cord is divided into segments, each of
  which correspond to a set of nerves that transmit
  messages from the brain to specific muscle groups
  in the body, as well as touch-sensation.
• The spinal cord has channels leading from the
  brain to the body (anterior horns) and from the
  body to the brain (posterior horns).

3
Spinal Anatomy (Cont.)

• The cord itself is about the thickness of a
  finger, and is made of tough, fibrous tissue. It
  is very sensitive to any type of injury or
  pressure.
• The spinal cord is protected from injury by the
  spine or spinal column, made up of about two
  dozen vertebra and extending from the skull to
  the lowest extremity of the back.
• The segments of the spinal cord are numbered
  according to the level and number of
  corresponding vertebra

4
Spinal Anatomy, Cont.

• Cervical Spine, 8 Segments (C1-C8) (highest
  level)
• Thoracic Spine, 12 Segments (T1-T12)
• Lumbar Spine, 5 Segments (L1-L5)
• Sacral Spine, 5 Segments (S1-S5)
• Coccyx (Tailbone) 1 Segment (Coc1)

5
Spinal Anatomy, Cont.

• Spinal nerves enter and exit the spinal column
  and vertebra from apertures between the vertebra
  called intervertebral foramina.
• Spinal nerves exit and enter at the same level as
  the spine segment until about the level of L1
  from this point downward, the spinal nerves exit
  indirectly at a lower level of the spine than
  their corresponding segment in the spinal column
  this lower area of the spine is referred to as
  the cauda equina (Name means horses head).

6
Spinal Trauma

• Although the spinal cord is a sensitive organ, it
  is heavily protected by the vertebra.
• Spinal cord are a result of tremendous force or
  trauma to the body
• Automobile Accidents
• Falls from High Places
• Gunshot Wounds
• Sporting Accidents
• Incidence of SCI is higher among younger persons
  who are more likely to be active in dangerous and
  irresponsible activities.

7
Spinal Trauma, Cont.

• Trauma may involve cutting, bruising, tearing,
  puncturing or pressure against the cord.
• Spinal cord injuries may be complete (the cord is
  severed) or incomplete.
• Completed SCIs result in complete paralysis and
  loss of sensation (anesthesia) to spinal nerves
  at and below that level of injury.
• Incomplete spinal cord injuries may allow some
  nerve impulses to continue to be transmitted
  individual may have weakness (paresis) instead of
  paralysis may retain some sensation however,
  these injuries can also result in complete
  paralysis and anesthesia as well.
• Severity of trauma as well as extent of trauma
  (i.e., were anterior/posterior horns damaged?)
  will determine the effects of SCI.

8
Medical Management of Spinal Trauma

• Immobilization of the spine.
• Prevention of swelling in the spinal column (to
  prevent swelling from putting additional pressure
  on the spine).
• As swelling decreases, many persons have
  spontaneous recovery of some spinal nerve
  activity.

9
Effects of Spinal Cord Injury

• The higher the lesion, the greater the effect.
• Involvement of extremities
• Quadriplegia Involvement of the lower
  extremities and any or all of the upper
  extremities--spinal trauma from C1-T1.
• Paraplegia Involvement of only the lower
  extremities--spinal trauma from T2-S5.
• The examples that follow would be the result of
  complete spinal lesions--individuals can vary
  greatly in regard to effect of injuries.

10
Quadriplegia (C1-C2 Level)

• An injury at C1/C2 is unsurvivable unless there
  is rapid and near-miraculous medical
  intervention--musculature of breathing is
  compromised.
• Individuals would only be able to move the eyes
  and perhaps some facial muscles--speech not
  possible.
• Extremely rare to survive these injuries.
• Rehabilitation is not feasible skilled nursing
  environment necessary for remainder of life.

11
Quadriplegia C3/C4

• Still involve nerves controlling muscles of
  breathing, particularly the diaphragm.
• C3 Survival is more likely, but still requires
  heroic measures due to damage to the nerves of
  respiration. Persons surviving C3 trauma will be
  ventilator-dependent for the rest of their life.
• At C4, breathing is usually possible without a
  ventilator. Individual will only have control of
  facial and head muscles can speak, can move
  objects with a mouth stick can operate electric
  wheelchair with chin cup control/sip puff.

12
Quadriplegia C5/C6

• At C5, full use of diaphragm but has no movement
  of upper extremities. Ambulation possible with
  electric wheelchair powered splints can allow
  persons some movement of upper extremities for
  gross manipulation of objects placed in front of
  them.
• At C6, person use the Deltoids (shoulder muscles)
  and Biceps (flexing arm muscle). Can move the
  arm at the elbow and shoulder, but wrist and hand
  is immobile. Allows for some independence in
  transfers, rudimentary writing with splints.
  Driving and use of manual wheelchairs are
  possible for some persons.

13
Quadriplegia C7

• Individual has control of wrist (Extensor Carpi
  Radialis, lifting the hand at wrist Pronator
  Teres, putting palm down Triceps, straightening
  the elbow). Can move wrist but not the hands.
  Driving and use of manual wheelchair possible.
  Splinting of wrists allows for some manipulation,
  use of keyboard, writing. This is the highest
  level at which total independence is possible
  without attendant care.

14
Quadraplegia C8-T1

• At C8, it is possible to extend the knuckles
  (Extensor Digitorum Communis), clench a fist
  (Flexor Digitorum Superficialis) and touch the
  thumb and little finger (Opponens Pollicis).
  Grasp is not possible, but can be accomplished
  with surgery. Sensation is present in all of
  hand except little finger.
• At T1, there are still problems with the ability
  to spread the fingers (paralysis of intrinsic
  muscles). Grasp is possible but weak, but can be
  improved with surgery. Dexterity is poor.

15
Paraplegia (T2 and below)

• Full use of upper extremities.
• Major functional difficulty will be in ambulation
  (walking).

16
Paraplegia T2-T6

• Full use of upper extremities.
• Intercostal muscles (rib muscles) affected, which
  can interfere with breathing capacity in
  situations of oxygen debt (heavy exertion) and
  with coughing.
• Ambulation is possible with manual wheelchair.

17
Paraplegia T7-T12

• Spinal nerves connected to lower intercostals and
  abdominals (aid in setting up, posture).
• Less concern with breathing/coughing.
• Possible for person to ambulate with long braces
  and canes (knee ankle foot orthoses, or KAFOs,
  but amount of exertion necessary relegates most
  to manual wheelchair except for very short
  distances or exercise purposes.

18
Paraplegia L1-L4

• Muscles affected Iliopsoas (brings thigh toward
  chest) Adductors (keeping thighs together),
  Quadraceps (extending the leg at the knee),
  Gluteus Medius (separating the legs, moving thigh
  to the side).
• Ambulation possible for short/moderate distances
  with KAFOs wheelchair is necessary for longer
  distances.

19
Paraplegia (L5-S2)

• Gluteus Medius (see above), Tibialis Anterior
  (standing on heels), Gluteus Maximus (standing
  up, aligning thigh), Gastrocneumius (tilts foot
  down, standing on toes).
• Shorter braces (Ankle-Foot Orthoses, or AFOs)
  and canes can be used by many persons for
  ambulation some abandon wheelchair entirely.
  Operation of automobiles possible without hand
  controls for many, especially at lower levels of
  this range of spinal injury

20
Paraplegia S3-S5

• Anal and Urethral Sphincters are affected.
• Lack of bladder and bowel control is most
  significant problem.
• Walking is possible, since muscles of ambulation
  are unaffected. There is some loss of sensation
  in the backs of the legs.

21
Coccyx (Tailbone), Coc1

• Injuries that affect only the tailbone do not
  affect spinal nerves--although they may be quite
  painful.

22
Bowel and Bladder Control

• All serious injuries to spinal cord will affect
  bowel and bladder control to some extent.
• T7-S5 Control is better. Abdominal pressure can
  be used to assist in voiding and more intact
  sphincter reflexes. Absorbent pads or external
  collection systems can assist with leakage.
• T2-T6 Catheterization/external collection
  systems are more likely to be necessary,
  especially in women, although for many
  stimulation of the anal/urethral sphincter can
  allow for better control of voiding.
• C6-T1 Catheterization/collection systems and
  stimulation of bowel/bladder reflexes. Bowel
  voiding requires use of finger splint.
• C5 and above Same as C6-T1, but attendant must
  provide sphincter stimulation.

23
Sexual Functioning Men

• Erectile difficulties are present with spinal
  cord injuries.
• Three methods of achieving an erection through
  reflex, physical stimulation, and psychic
  imagery/fantasization.
• Reflex erections may occur at T12 and above are
  less likely with injuries in the cauda equina
  area.
• Weak erections are possible, however in many
  persons with lower lumbar/cauda equina injuries
  through use of psychic imagery.

24
Sexual Function in Men, cont.

• Ejaculation does not occur at any level of spinal
  cord lesion, although there is still emission of
  seminal fluid and it is possible to father
  children, either through intercourse or
  artificial insemination.
• Orgasm does not technically occur due to lack of
  ejaculation and loss of sensation/muscle control,
  but most men with spinal cord injuries report a
  release of tension on seminal emission that is
  similar to orgasm.
• Viagra has been of help in some cases of SCI
  also, erectile pumps and implants.

25
Sexual Functioning in Women

• Vaginal lubrication can be inconsistent, may
  require use of additional lubricant.
• Clitoral erection through reflex or psychic
  imagery is seen in a pattern similar to penile
  erection for men.
• Orgasms do not occur, but similar release of
  tension experience is seen in women as in men.
• Pregnancy is possible, but must be closely
  monitored.

26
Sexual Functioning--Both Sexes

• Retain the capacity for sexual interest, sexual
  attractiveness, sex drive.
• May develop hypersensitive areas in body
  locations not affected by the SCI--stimulation of
  these areas can produce orgasm-like sensations.
• May retain other means for providing stimulation
  to a partner aside from traditional sexual
  intercourse.
• Lack of muscle movement decreases the ability for
  sexual gymnastics.

27
Spinal Cord Injury Complications

• Infections to respiratory and genitourinary
  tract.
• Thrombophlebitis.
• Contractures
• Osteoporosis
• Decubitus Ulcers, or Pressure Sores
• Autonomic Dysreflexia Sudden rise in blood
  pressure with extreme headache and sweating,
  sometimes severe enough to cause strokes,
  seizures, heart attacks. Can be caused by
  blocked catheters, painful stimulation to
  certain areas of the skin. Most often seen in
  persons with higher level spinal lesions. A
  medical emergency that requires prompt attention.

28
Rehabilitation Implications

• Physical restrictions of SCI will limit
  vocational options to sedentary and some light
  work.
• Intellect is generally not impaired--individual
  will be capable of functioning at a level
  equivalent to that present before the injury.
• Academic training should be encouraged as the
  best occupations at these levels require
  schooling.
• Workplaces and learning places must be
  accessible.
• Avoid dusty or fumy environments in those with
  injuries at or above T6 (respiratory
  difficulties).
• Assistive Technology
• In paraplegia, greatest concern usually selection
  of proper wheelchair.
• In quadraplegia, AT may be necessary for wide
  variety of activities in home, school, and
  workplace.