SCIs

• Spinal Cord Injury (SCI)


  Divided into traumatic (result of external physical impact) and nontraumatic (result of disease, infection, or tumour) categories

  
• Common causes of traumatic SCI

  • Motor vehicle and motorcycle crashes (50% of cases)
  • Falls and work-related injuries (30-40%)
• Falls are more typically causes of SCI in the older person, whereas motor vehicle crashes are a more common cause among young adults
• Almost half of new traumatic injuries occur in people (mainly male) 15 to 39 years of age as a result of motor vehicle accidents, sporting accidents, and other external causes
• Pathophysiology of SCI


  Biphasic - Initial mechanical injury (primary injury) followed by a second phase (secondary injury) involving vascular dysfunction, edema, ischemia, electrolyte shifts, inflammation, free radical production, and apoptotic cell death

  
• Mobility


  The ability of an individual to move freely and independently within their environment, encompassing physical movement, range of motion, coordination, balance, and functional ability to perform daily activities
• Scope of mobility


  Extends beyond the physical domain to include psychological and social dimensions, contributing to autonomy, confidence, well-being, participation in community activities, interaction with others, and engagement in work or leisure pursuits
• Risk factors for impaired mobility

  • Traumatic injuries (SCI, fractures, musculoskeletal injuries)
  • Neurological conditions (stroke, MS, Parkinson's)
  • Chronic health conditions (arthritis, osteoporosis, chronic pain)
  • Age-related changes (muscle weakness, joint stiffness, decreased balance)
  • Obesity
  • Environmental factors (architectural barriers, lack of assistive devices)
• Consequences of impaired mobility

  • Functional limitations in activities of daily living
  • Increased risk of falls and subsequent injuries
  • Reduced social participation and isolation
  • Decline in mental health due to feelings of dependence or frustration
  • Economic burden from healthcare expenses, caregiver support, or loss of employment
• Causes of altered mobility

  • Musculoskeletal disorders (osteoarthritis, rheumatoid arthritis, fractures, muscle weakness)
  • Neurological disorders (stroke, SCI, cerebral palsy, peripheral neuropathy)
  • Traumatic injuries (falls, sports injuries, motor vehicle accidents)
  • Degenerative conditions (Parkinson's, Alzheimer's, multiple sclerosis)
  • Systemic illnesses (diabetes, cardiovascular disease, COPD)
  • Environmental barriers (lack of accessibility features)
• The extent of the neurological damage caused by an SCI results both from primary injury or damage (actual physical disruption of axons) and from secondary injury damage (ischemia, hypoxia, microhemorrhage, and edema)
• Because secondary injury processes occur over time, the extent of injury and the prognosis for recovery are most accurately determined at 72 hours or longer after injury
• Spinal shock


  Temporary neurological syndrome characterized by decreased reflexes, loss of sensation, and flaccid paralysis below the level of the injury, lasting days to months

  
• Neurogenic shock


  Hemodynamic syndrome of massive vasodilation without compensation, resulting from the loss of sympathetic nervous system vasoconstrictor tone caused by spinal cord injury, characterized by hypotension, bradycardia, and loss of sympathetic innervation
• Mechanisms of spinal cord injury

  • Flexion
  • Hyperextension
  • Flexion-rotation
  • Extension-rotation
  • Compression

  
• The flexion-rotation injury is the most unstable of all injuries because the ligamentous structures that stabilize the spine are torn, often implicated in severe neurological deficits

  
• Levels of spinal cord injury

  • Cervical
  • Thoracic
  • Lumbar

  
• Tetraplegia


  Paralysis of all four extremities, resulting from cervical cord involvement
• Paraplegia


  Paralysis resulting from thoracic cord or conus in the lumbar spine damage
• Degrees of spinal cord injury

  • Complete (ASIA grade A - total loss of sensory and motor function below the level of the lesion)
  • Incomplete (ASIA grades B-D - mixed loss of motor and sensory function)

  
• Incomplete spinal cord injury syndromes

  • Central cord syndrome
  • Anterior cord syndrome
  • Brown-Séquard syndrome
  • Posterior cord syndrome
  • Cauda equina syndrome
  • Conus medullaris syndrome

  
• Central cord syndrome


  Damage to the central spinal cord, resulting in motor weakness and sensory loss in both upper and lower extremities, with the upper extremities more affected

  
• Anterior cord syndrome


  Damage to the anterior spinal artery, resulting in motor paralysis and loss of pain and temperature sensation below the level of injury, with touch, position, vibration, and motion sensations intact

  
• Brown-Séquard syndrome


  Damage to half of the spinal cord, resulting in loss of motor function, proprioception, and vibration on the same side as the lesion, and loss of pain and temperature sensation on the opposite side below the level of the lesion

  
• Posterior cord syndrome


  Compression or damage to the posterior spinal artery, resulting in loss of proprioception but with intact pain, temperature sensation, and motor function below the level of the lesion

  
• Conus medullaris syndrome


  Damage to the very lowest portion of the spinal cord, resulting in motor and sensory impairment, as well as bladder and bowel dysfunction

  
• Cauda equina syndrome


  Damage to the lumbar and sacral nerve roots, resulting in nerve root symptoms dependent on the level of the lesion, with typically affected bowel and bladder function

  
• In general, sensory function closely parallels motor function at all levels of spinal cord injury
• Respiratory complications of spinal cord injury

  • Total loss of respiratory muscle function with cervical injuries above C4, requiring mechanical ventilation
  • Respiratory insufficiency with injuries below C4 due to spinal cord edema and hemorrhage
  • Impaired coughing and atelectasis/pneumonia from paralysis of abdominal and intercostal muscles
  • Neurogenic pulmonary edema from increased sympathetic nervous system activity
• Cardiovascular complications of spinal cord injury

  • Bradycardia and peripheral vasodilation leading to hypotension with injuries above T6
  • Need for cardiac monitoring and interventions like atropine, IV fluids, and vasopressors

  
• Urinary complications of spinal cord injury

  • Initial urinary retention followed by hyperirritability and reflex emptying, requiring indwelling catheterization initially and transitioning to intermittent catheterization

  
• Gastrointestinal complications of spinal cord injury

  • Hypomotility leading to paralytic ileus, gastric distension, and delayed gastric emptying
  • Stress ulcers and intra-abdominal bleeding

  
• Integumentary complications of spinal cord injury

  • Increased risk of pressure injuries due to lack of movement
• Thermoregulation in spinal cord injury

  Poikilothermism or inability to regulate body temperature due to interruption of sympathetic nervous system function, particularly vulnerable in high cervical injuries
• Metabolic complications of spinal cord injury

  • Metabolic alkalosis from nasogastric suctioning
  • Metabolic acidosis from decreased tissue perfusion
  • Increased nutritional needs with high-protein diet and positive nitrogen balance
• Peripheral vascular complications of spinal cord injury

  • Thromboembolism, with pulmonary embolism a leading cause of death
• Diagnostic studies for spinal cord injury

  • Complete spine radiography
  • MRI for neurological tissues and spinal cord assessment
  • CT for bony injury and spinal canal compromise
  • Comprehensive neurological examination
  • Vertebral angiography for cervical injuries with altered mental status

  
• Criteria for early surgery include evidence of cord compression, progressive neurological deficit, compound vertebral fracture, bony fragments, and penetrating wounds
• Common surgical procedures for spinal cord injury

  • Decompression
  • Realignment
  • Stabilization with instrumentation (performed posteriorly or anteriorly)
• CT


  • Used to assess the degree of bony injury and the degree of spinal canal compromise