Classification of Spinal Cord Injuries

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Classification of Spinal Cord Injuries
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Upper Motor Neuronvs.Lower Motor Neuron
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Upper Motor Neuron Lesions

• Grey Matter
• Tracts in the white matter
• Symptoms include
• Spastic paralysis / paresis
• Hyperreflexia

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Lower Motor Neuron Lesions

• Anterior horn cells
• Final common pathway including the peripheral
  nerves
• Symptoms include
• Flaccid paralysis
• Hyporeflexia

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ASIA StandardsAmerican Spinal Injury Association

• International Standards for Neurological and
  Functional Classification of Spinal Cord Injury

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Purpose

• Develop uniform standards for assessing and
• classifying neurological and functional status
• of a person with SCI between clinicians and
• researchers.

Ensure the standards incorporate results of
current research, as well as, insights from
clinical experience
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Tetraplegia

• Impairment or loss of motor and/or sensory
  function in the cervical segments of the spinal
  cord. Does not include brachial plexus lesions
  or peripheral nerve injuries.

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Paraplegia

• Impairment or loss of motor and/or sensory
  function in the thoracic, lumbar, or sacral
  segments of the spinal cord. Does not include
  lumbosacral plexus lesions or peripheral nerve
  injuries.

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Quadraparesis /Tetraparesisand Paraparesis
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Skeletal/Orthopedic Level

• Radiographic level where greatest vertebral
  damage is found

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Neurological/FunctionalLevel

• Most caudal segment of the spinal cord with
  normal sensory and motor function on both sides
  of the body

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Neurological/Functional Level

• Right
• Sensory Level
• Motor Level

• Left
• Sensory Level
• Motor Level

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Neurological/Functional Level

• Right C7 sensory
• Right C6 motor
• Left C6 sensory
• Left C5 motor

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Sensory Level

• The most caudal segment of the spinal cord with
  normal sensory function on BOTH sides of the body

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Motor Level

• The most caudal segment of the spinal cord with
  normal motor function on BOTH sides of the body

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• Lowest key muscle that has a grade of at least
  3 (fair), providing the key muscles represented
  by segments above that level are judged to be 5
  (normal)

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Motor Level - examples
A
B

• C5 - 5/5
• C6 - 5/5
• C7 - 5/5
• C8 - 3/5
• T1 - 1/5

• C5 - 5/5
• C6 - 5/5
• C7 - 4/5
• C8 - 4/5
• T1 - 3/5

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Motor Level - examples
A
B

• L2 - 4/5
• L3 - 4/5
• L4 - 3/5
• L5 - 2/5
• S1 - 1/5

• L2 - 5/5
• L3 - 4/5
• L4 - 4/5
• L5 - 4/5
• S1 - 3/5

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Incomplete Injury

• Partial preservation of sensory and/or motor
  function below the neurological level and
  includes the lowest sacral segment

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• Sacral sensation includes sensation at the anal
  musculocutaneous junction and/or deep anal
  sensation
• Sacral motor function includes voluntary
  contraction of the external sphincter upon
  digital stimulation and/or great toe flexion

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Complete Injury

• Absence of sensory AND motor function in the
  lowest sacral segment

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Zone of Partial Preservation

• Segments partially innervated caudal to the
  neurologic level (without sacral sparing)
• Term used only with complete injuries

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ASIA Impairment Scale

• A Complete - No sensory or motor function
  preserved in sacral segments
• S4-S5
• B Incomplete - Sensory but no motor function
  below neurologic level and includes S4-S5

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ASIA Impairment Scale

• C Incomplete -Motor function is preserved below
  neurologic level and more than half of key
  muscles below have muscle grades
• lt 3/5
• D Incomplete - Motor function is preserved
  below neurologic level and at least half of key
  muscles below have muscle grades gt/ to 3/5

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Incomplete Syndromes
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Anterior Cord Syndrome

• Damage to the anterior cord
• Variable loss of motor and sensory function
• Proprioception is preserved

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Anterior Cord Syndrome
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Brown Sequard Syndrome

• One side of cord in damaged
• Most common causes are stab and GSW
• Motor paralysis and loss of proprioception,
  vibratory sense, and 2-point discrimination
  ipsilaterally
• Pain and temperature loss contralaterally
• Spasticity likely to be present below the lesion

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Brown Sequard Syndrome
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Central Cord Syndrome

• Damage to the central aspect of the cord
• Variations in the sparing of the peripheral
  portions
• Most common in older population with relatively
  minor trauma
• Clinical presentation is paralysis and sensory
  loss in the upper extremities greater than in the
  lower extremities
• Bowel, bladder and genital functioning is usually
  normal

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Central Cord Syndrome
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Conus Medullaris Syndrome
Injury of the sacral cord (conus) and lumbar
nerve roots within the spinal canal, which
usually results in an areflexic bladder, bowel
and lower limbs.
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Cauda Equina Syndrome
Injury to the lumbosacral nerve roots within the
neural canal resulting in areflexic bladder,
bowel and lower limbs.
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Physical Effects of Spinal Cord Injury
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Motor Control

• Paralysis
• Spasticity in UMN
• Flaccidity in LMN
• Atrophy

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Spasticity

• Areflexive muscles during spinal shock
• Prevalent in higher lesions
• Hypertonia and hyperreflexia
• Evoked by quick stretch
• Possible causes

• Loss of inhibition
• Loss of afferents
• New synaptic terminals
• Hypersensitivity of neurons

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Sensation

• Loss below the level of injury
• Decreased body awareness and other complications

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Respiration

• Degree dependent on level of injury
• Diaphragm C3 - C5
• Accessory muscles
• ? Vital capacity and Tidal volume
• Functional risks
• Vent dependent - glossopharyngeal breathing

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Bowel and Bladder Control

• Loss of voluntary control
• Incontinence

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Genital Function

• Altered functioning
• Unchanged fertility in females
• Males likely to be infertile

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Cardiovascular Function

• Loss of sympathetic input causing
• bradycardia
• hypotension
• orthostatic hypotension
• Decrease in severity with lesions below T6

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Thermoregulation

• ANS and Somatic nervous systems
• Interruption between hypothalamus
• Early concern in HYPOthermia
• Following spinal shock - HYPERthermia is larger
  concern
• Sweating is absent below the level of injury

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Complications
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Pressure Ulcers

• Most common complication
• Cervical injuries most frequent
• Common sites
• Ischial tuberosities
• Greater trochanters
• Sacrum
• Heels
• Factors increasing vulnerability

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Pressure Ulcers

• End results
• osteomyelitis
• sepsis
• death
• PREVENTION

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Respiratory Complications

• Most common cause of death
• Reduced inspiratory and expiratory ability
• Must teach assistive coughing to people with
  respiratory compromise

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Pressure Ulcer Staging

• Stage I Intact skin with non-blanchable redness
  of a localized area. Darkly pigmented skin may
  not have visible blanching its color may differ
  from the surrounding area
• Stage II Partial thickness of dermis presented
  as a shallow open ulcer with a red/pink wound bed
  without slough

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Decreased ROM

• Contractures
• Deformities
• Increase risk of pressure sores
• COMPLETELY PREVENTABLE

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Pressure Ulcer Staging (cont)

• Stage III Full thickness tissue loss.
  Subcutaneous fat may be visible, but bone,
  tendon, or muscle is not exposed.
• Stage IV Full thickness tissue loss with
  exposed bone, tendon, or muscle. Often includes
  undermining, tunneling
• Unstageable Full thickness tissue loss in which
  base of the ulcer is covered by slough and/or
  eschar in the wound bed

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Osteoporosis

• Increased loss of calcium and collagen
• Increased risk of fractures
• Gradually progresses for 5 years then plateaus

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Deep Vein Thrombosis

• Very common
• Greater risk in acute stages
• Predisposing factors

• Peripheral vasodilation
• Absent/reduced LE muscle
• Immobility

• Hypercoagulability
• Sepsis
• Trauma

• 2 -16 die within 2-3 months from emboli

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Gastrointestinal Complications

• Stress ulcers in 5 - 22 of cases
• GI bleeds during the first month
• Paralytic ileus
• Gastric dilation
• Fecal impaction
• Bowel obstruction

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Urinary Tract Complications

• Urinary tract infections
• Kidney and bladder stones
• Hydronephrosis
• Pyelonephritis
• Kidney failure
• Septicemia

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Autonomic Dysreflexia

• MEDICAL EMERGENCY
• Seen with lesions above T6
• Symptoms

• profuse sweating
• nasal congestion
• anxiety

• ? in blood
• pressure
• bradycardia
• pounding
• headache
• flushing

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Autonomic Dysreflexia
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Factors Which Precipitate Dysreflexia

• bladder or bowel distension
• bladder infection
• bowel impaction
• skin breakdown
• ingrown toenail
• ROM - stretching

• muscle spasms
• electroejaculation
• labor
• surgical or diagnostic procedures
• appendicitis

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Results

• Loss of consciousness
• Seizures
• CVA
• Retinal hemorrhage
• Apnea
• Renal failure

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Causes

• Loss of descending inhibition
• Sprouting of new synaptic terminals
• Hypersensitivity of sympathetic neurons

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Treatment

• Immediate removal of noxious stimulus
• Sit up and lower legs
• Check vitals
• GET HELP
• NO meds to mask symptoms

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Heterotopic Ossification

• New bone within muscle and connective tissue
• Occurs in 16 - 63 of all SCI
• Higher occurrence in first 4 months
• Etiology unknown

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Heterotopic Ossification

• Resulting disability
• ? ROM
• Increase risk of pressure sores
• Functional limitations

• Treatment
• Medical intervention by surgery or meds
• Gentle ROM
• PREVENTION

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Pain