Sir William Asher ANATOMY

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Nelson Hamilton
6 years ago
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1 SPINAL CORD INJURY BASICS RELATED TO LIFE CARE PLANNING Lesson 1 Sir William Asher Picture the pathetic patient lying long abed, the urine leaking from his distended bladder, the lime draining from his bones, the blood clotting in his veins, the flesh rotting from his seat, the scybala stacking up in his colon, and the spirit draining from his soul British Medical Journal, 13,1947, pages ANATOMY Spinal Column: 33 vertebrae, ligaments, interlocking joints, weight bearing structure Vertebrae: 7 cervical relatively small, very mobile, unique anatomy poses problems 12 thoracic larger, very rigid, attachment for ribs 5 lumber largest & strongest, allow flexion & extension 1

2 ANATOMY Vertebrae 5 sacral fused & forms sacrum 4 coccygeal fused to form the tail bone Intervertebral Disc a shock absorber cartilage between disc, allows mobility, 2 components annulus fibrosis & nucleus pulposus makes up ¼ total height of column ANATOMY Ligaments strong bands of connective tissue, hold vertebrae in place Anterior & Posterior longitudinal are important to stability Calcification of ligaments contributes to stenosis Spinal Canal opening in center of vertebrae that houses & protects the spinal cord ANATOMY Spinal Cord an extension of the central nervous system (CNS). 1. Begins at the base of brain stem, the foramen magnum & ends at L Ends in the shape of a cone, conus medullaris 3. Nerve roots and the filum terminalie continue downward, the cauda equina 2

3 ANATOMY Disparity between the vertebral bodies and spinal cord length is important. Spinal nerve roots exit at each level of the column to supply respective segments of dermatomes, myotomes, effector organs, & to receive afferents from each segment SPINAL CORD FUNCTIONS 1. Send messages from brain to body efferent pathways 2. Receive messages from body afferent messages 3. Initiate protective reflexes 4. The spinal cord typically thought of as a series of telephone cables. Actually it has millions of inter neurons, & proprioneurons that modulate all activities having the capacity to think & interpret information. EPIDEMIOLOGY Traumatic SCI ,000 new cases each year, prevalence of 246,000. Prevalance is increasing to 276,000 by 2014 due to > life expectancy Seasonal variation most occurs in the summer, July has highest incidence, more on W/E days, Twice as many (20%) on Saturday. 80% are males, most common age is 19, ages ranging from make up 42% 50 55% are tetraplegic, and 50 55% are incomplete 3

4 ETIOLOGY of Traumatic SCI Motor Vehicle Accidents 47% Falls 23% Violence 14% Sports 10% Other 7% In some areas violence is the number 2 cause. Louisiana reports 32% due to violence. SC DAMAGE 1. Overstretching or tearing of nerves 2. Direct pressure by boney fragments, disc material, or hematoma 3. Swelling & edema causing increased pressure, & decreased blood flow 4. SCI usually does not cause complete disruption of the cord MECHANISM OF INJURY Can be determined by reviewing the history, examination, & x rays Burst fractures occur with axial loading such as diving injuries Hyperextension of C spine will result in central cord syndrome Wedge or compression fractures occur with flexion Chance fracture occurs with distraction Rotation combined with flexion is the most damaging type of injury in general 4

5 SCI CLASSIFICATION ASIA Scale most accepted. It describes the sensory level, motor level, and degree of SCI incompleteness. It is imperative the Life Care Plan be based on accurate neurological level of SCI The level of SCI gives important clues to anticipated level of function in general ASIA SCALE A complete SCI: no motor or sensory sparing in sacral segments B Incomplete SCI: sensation preserved in sacral segments, no motor C Incomplete SCI: motor preserved below level, with more then half of key muscles at 3 or less D At least ½or more are at 3 or higher, and it is functional E recovery from SCI, reflexes may be abnormal INCOMPLETE SYNDROMES Central Cord S. paralysis greater in UE than LE Brown Sequard S. hemi section, ipsilateral motor & proprioception loss, contralateral sensory impairment 2 segments lower & down Cauda Equina S. nerve root injury below conus Conus medullaris S. injury at conus Anterior Cord S. motor & sensory impairment with spared proprioception Posterior Column S. sensory impairment, but pain & temperature relatively spared 5

6 RECOVERY SCI is a permanent condition, with very few experiencing meaningful recovery. Of those who present with ASIA A 2% will become a D. ASIA B 20% will become a D ASIA C 50% will improve to a D or E Any motor group with 1/5 within first 30 days will likely be 3/5 at one year post SCI Virtually no recovery occurs after 6 12 mos * Christopher Reeves 7 years post injury has had some improvement. UMN VS LMN Upper Motor Neuron injuries are above T12, & characterized by increased tone, and intact reflexes below the level of injury. Lower Motor Neuron injuries typically occur below T12 & result in flaccid paralysis, absent reflexes below the lesion NOMENCLATURE Dermatome a specific area of skin innervated by a single nerve segment Myotome specific muscles innervated by a single nerve root Beevor s Sign abdominal muscle imbalance causing umbilicus to shift when head is lifted Bulbocavernous Reflex signals the end of spinal shock Spinal Shock a period following SCI when all reflexes are absent 6

7 KEY SCI LEVELS C3 & above likely ventilator dependent C6 & above dependent for attendant care T1 & above requires power wheelchair T8 & above have poor sitting balance L3 & lower may be functional ambulator, for short distances on level surfaces 7

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