SPINAL CORD INJURY

GENERAL MEDICAL BACKGROUND

 Brown Sequard syndrome
I. DEFINITION - Contralateral: pain & temperature below level
of lesion
- Traumatic/ non-traumatic type of injury in spinal - Gunshot/ stab wound directly on spinal cord
cord that will lead to problems in: motor,
sensory, automatic dysfunction.  Anterior Cord Syndrome
- Low incidence but high cost injury. - Hyperflexion injury
- Motor problem
II. EPIDEMIOLOGY
 Central Cord Syndrome
 Male>Female (4:1) - Walking SCI
 Traumatic>non traumatic - Hyperextension injury
 Age: 16-30 Years Old - M, elderly
 Race: Whites, African Americans, Hipanics,
Native Americans  Posterior Cord Syndrome
 Region: Most Common CERVICAL - Hyperextension injury
 Mechanism: Flexion Injuries - Sensory problem

 Cauda Equina Syndrome

III. ETIOLOGY
- (+) LMNL
 Traumatic 60% - Areflexive bladder
o MVA- mc direct cause 40.4%
o Falls- elderly 27.9% Reflexive Areflexive
o Violence- African-Americans 15% UMNL LMNL
o Sports- diving 8% Spastic bladder Flaccid bladder
o Others Intermittent Time voiding
 Non-traumatic 40% catheterization (4 hrs) Crede’s maneuver
o Vascular dysfunction Suprapubic tapping Pressure on lower
o Vertebral subluxation (reflex emptying) abdomen
o Infection Control urine output &
o Tumor water input
o Neurological disease
A. Spinal Shock
 Bulbocavernosus reflex
IV. PATHOPHYSIOLOGY  Pinch: M- Glans Penis
F- Clitoris
B. Motor and/or Sensory Loss

C. Impaired Temperature Control

Hypothalamus
Anterior Alis init (shiver)
Posterior Pasok init (sweat)
Lateral Lamon (hungry)
Medial Satiety

D. Impaired Respiration
Diaphragm C3-C5
Intercostals T2-T12
Abdominals T6-T11

E. Spasticity
V. CLINICAL MANIFESTAION
F. Bowel & bladder
Syndromes: - Areflexive bowel: reflex emptying, digital
 Brown Sequard Syndrome stimulation, suppositories
 Anterior Cord Syndrome
 Central Cord Syndrome
 Posterior Cord Syndrome
 Cauda Equine Syndrome

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G. Sexual dysfunction
Males Females
 Erection: - Menstrual cessation (1- VI. CLASSIFICATION
Reflexogenic- actual 3 months)
stimulation; UMNL, A. According to Level of Injury:
incomplete *complications:  Tetraplegia – refers to complete paralysis
Psycogenic- LMNL, - Respiratory dysfunction of all four extremities and trunk, including
incomplete - Cannot contract muscle respiratory muscles, and results from
lesions of the cervical cord.
 Ejaculation
 Paraplegia – refers to complete paralysis
- LMNL, incomplete
of all or part of the trunk and both lower
extremities, resulting from lesions of the
Mechanism of Injuries: thoracic or lumbar spinal cord or cauda
equina.
I. Flexion
- Head on collision or rapid deceleration B. According to Completeness of Injury:
- Frequent at C4-C7 and T12-L2  Complete injury - defined within the
ISNCSCI as an injury in which there is the
May Result in: lack of any sensory or motor function in
a. Anterior Dislocation of the Vertebra the lowest sacral segment; this includes
b. Teardrop or wedge fracture due to compressive pressure sensation within the anus,
forces anteriorly sensation at the anal mucocutaneous
c. Fractures may impinge neural tissue junction, or a voluntary contraction of the
d. Soft tissue tears due to distractive forces external anal sphincter.
posteriorly  Incomplete injury - idefined as an injury in
which there is at least partial sensory or
II. Vertical Compression motor function in the lowest sacral
- Related sports such as diving and impact of falling segment.
objects  If an individual has motor and/or sensory
- Frequent at C4-C5 function below the neurological level but
does not have function at S4 and S5, then
May Result in: the areas of intact motor and/or sensory
a. Fractures function below the neurological level are
b. Neurologic Damage termed zones of partial preservation.

III. Hyperextension C. According to Severity:

-With Rear End Collision - The ISNCSCI also includes a scale of
- Frequent at C4-C5 impairment called the ASIA Impairment
- Common also among elderly Scale (AIS), which classifies an SCI into five
categories of severity, labeled A through E,
May Result in: based on the degree of motor and sensory
a. Fractures due to compressive forces posteriorly loss.
b. Soft tissue tears due to distractive forces
anteriorly ASIA IMPAIRMENT SCALE
c. Neurological Damage
A = Complete: No motor or sensory function is
preserved in the sacral segments S4-5.
IV. Later Flexion
-Rare B = Incomplete: Sensory but no motor function
- Usually referred and involves the brachial plexus preserved below the neurological level and includes
the sacral segments S4-5.
V. Flexion with Rotation
C = Motor function is preserved below the
May Result In: neurological level, and more than half of the key
a. Fractures and Soft tissue Tears due to muscles below the neurological level have a muscle
compressive and distractive forces respectively grade of <3.

VI. Shear D = Incomplete: Motor function is preserved below the

-Falls on uneven surfaces neurological level, and at least half of the key muscles
- Impact from behind below the neurological level have a muscle grade of 3
or more.

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E = Normal: Motor and sensory function are normal.
D. Clinical Syndromes (Incomplete SCI Syndromes)
 Central Cord Syndrome (CCS)
- is the most common, accounting for
approximately 50% of incomplete
injuries and 9% of all traumatic SCI.
CCS is characterized by motor
weakness in the UE greater than the LE,
in association with sacral sparing.
 Brown-Sequard Syndrome (BSS)
- Is defined as a lesion similar to a
hemisection of the spinal cord, and
accounts for 2% to 4% of all traumatic
SCI (55,61–63). In the classic
presentation:
o ipsilateral loss of all sensory
modalities at the level of the lesion;
o ipsilateral flaccid paralysis at the
level of the lesion;
o ipsilateral loss of position, sense,
and vibration below the lesion;
o contralateral loss of pain and
temperature below the lesion; and
o ipsilateral motor loss below the level
of the lesion.
 Anterior Cord Syndrome
- Involves a lesion affecting the anterior
two thirds of the spinal cord while
preserving the posterior columns. There
is a variable loss of motor as well as pin
prick sensation with a relative
preservation of light touch,
proprioception, and deep-pressure
sensation.
 Posterior Cord Syndrome (PCS)
- There is a loss of proprioception and
vibration sense, but with preservation of
muscle strength, temperature, and pain
sensation due to a selective lesion of the
posterior columns. PCS has been linked
to neck hyperextension injuries, PSA
occlusion, tumors, disk compression,
and vitamin B12 deficiency.
 Conus Medullaris and Cauda Equina (CE)
Injuries
- The conus medullaris, which is the
terminal segment of the adult spinal
cord, lies at the inferior aspect of the L1
vertebrae. The segment above the
conus medullaris is termed the
epiconus, consisting of spinal cord
segments L4-S1. Lesions of the
epiconus will affect the lower lumbar
roots supplying muscles of the lower
part of the leg and foot, with sparing of
reflex function of sacral segments. The
bulbocavernosus (BC) reflex and
micturition reflexes are preserved,
representing an UMN or suprasacral
lesion. Spasticity will most likely develop
in sacral innervated segments (e.g., toe
flexors, ankle plantar flexors, and
hamstring muscles).
VII. COMPLICATIONS
 Spinal shock:
 Motor and sensory impairments
 Autonomic Dysreflexia
o Aka autonomic hyperreflexia
o Lesions above T6
o Characterized by:
Increased BP
Bradycardia
Severe pounding headache
Profuse sweating
Increase spasticity
Restlessness
Vasoconstriction below the lesion
Vasodilation above the lesion
Pupil constriction
Nasal congestion
Piloerection
Blurred vision
 Cardiovascular impairment
 Poikilothermia.
 Pulmonary complications:
o Atelectasis
o Pneumonia
o Respiratory failure
o Pleural complications
o Pulmonary embolism (PE)
 Bladder and Bowel Dysfunction
 Sexual Dysfunction
- temporary amenorrhea in women; erectile
dysfunction in men
 Secondary medical complications:
o Pressure sores
o DVT
o Pain (nociceptive, neuropathic)
o Cintractures
o Heterotopic (ectopic) ossification
o Osteoporosis and Skeletal fractures
VIII. DIAGNOSIS
- X-rays
- Computed tomography (CT) scan
- MRI
- Neurologic examination (ASIA Impairment
Scale

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IX. DIFFERENTIAL DIAGNOSIS
Motor Neuron Diseases
Amyotrophic Characterized by weakness and
Lateral Sclerosis wasting in the limbs caused by
genetic mutation.
Spinal Muscular Characterized by degeneration
Atrophy of spinal cord motor neurons,
atrophy of skeletal muscles, and
generalized weakness caused
by gene deletion, conversion, or
mutation.
Spondylotic Myopathies
Spinal Stenosis Characterized by pain, tingling,
numbness, muscle weakness,
and may affect bladder or bowel
function. Most commonly caused
by wear and tear changes in the
spine related to osteoarthritis.
Disk herniation A herniated disk can irritate
nearby nerves and result in pain,
numbness and weakness of the
extremities. Often, the cause is
simple wear and tear of the disk
from repetitive movement.
Infectious and Inflammatory Diseases
Multiple Sclerosis Early symptoms include
weakness, tingling, numbness,
and blurred vision. Cause is still
unknown but may be linked to
immunologic, genetic and
environmental factors.
Epidural Caused by infection and may
Abscesses manifest fever, localized or
radicular pain, muscular
weakness, sensory loss,
sphincter dysfunction, and
paralysis.
Osteomyelitis Usually starts with malaise,
general weakness and aching
followed quickly by fever and
intense pain in the area of
affectation. The most common
infecting agent is the
staphylococcus aureus.
MEDICAL, SURGICAL AND PHARMACOLOGICAL
MANAGEMENT
I. MEDICAL MANAGEMENT
- The ideal management of acute SCI is a
combination of pharmacological therapy, early
surgery, early rehabilitation and cellular
therapies.
- Guidelines in medical management includes:
 Cardiac, hemodynamic, and respiratory
status are closely monitored.
 A urinary catheter typically is inserted,
and secondary injuries are addressed.
 High doses of methylprednisolone may
be given early after the injury. The anti-
inflammatory effect of this steroid may
have an effect by lessening secondary
damage due to the inflammatory
process.
 Fracture Stabilization to stabilize the
spinal column to prevent further damage
to the cord.
 Reduction and immobilization of spinal
injuries can be achieved via
conservative or operative methods.
II. SURGICAL MANAGEMENT
- Surgery to treat spinal cord injury (SCI) may
be performed immediately after the injury, or
at a later time. Urgent surgical intervention is
more common in patients with incomplete
SCI. Urgent surgical intervention is also done
if neurologic dysfunction worsens.
- Surgical approaches are:
 Decompression: In people with acute,
traumatic SCI, early (within 24 hours)
surgical decompression is
recommended.
 Stabilization: Approximately 60% of
patients with SCI admitted to model SCI
system centers underwent surgical
stabilization.
o Decompression
o Bony fusion 

o Myotomy 

o Neurectomy 

o Tenotomy 

- Indications for surgical stabilization are:
 unstable fracture site
 gross malalignment
 cord compression
 deteriorating neurological status
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 - Closed reduction: is indicated for patients o ROM

with cervical subluxation or fracture o MMT

dislocation injuries. It is achieved with the o MBT 

use of traction devices.
 Postural assessment 

POST-SURGICAL MANAGEMENT  Gait assessment 

 Balance & tolerance 

 Functional assessment
 Fracture stabilization 

 Use of orthosis 

o Knight–Taylor FIM
o Jewett
o Halo 
  7 point scale
 Use of skeletal traction devices 
  Covers 18 items
 Use of turning frames & beds 
  Measure of physical, psychological & social
functions
III. PHARMACOLOGIC MANAGEMENT
FIM Grading

 Steroids
7 – complete independence, no helper
o methylprednisolone
6 – modified independence (device)
 Antispasticity
o baclofen Helper – Modified Dependence
o dantrolene 5 – supervision (subject = 100%)
o diazepam 4 – min assistance (subject = 75% of >)
o peripheral nerve blocks 3 – mod assistance (subject = 50% or >)
o intrathecal injections
Helper – Complete Dependence
 Laxatives & suppositories 2 – max assistance (subject = 25% or >)
 Ephedrine 1 – total assistance (subject = 25% )
 Diphosphates
 Anticoagulants II. PROBLEM LIST
 Analgesics
1. Loss of sensation 

OTHER HEALTHCARE MANAGEMENT 2. Motor impairment and weakness 

3. Complications 

 Occupational therapy 4. Contractures 

 Speech therapy
 5. Respiratory problem 

 Respiratory 6. Pain 

 Cardiovascular 7. Dependence in ADLs 

 Orthopedic
 8. Pressure sores 

9. Bladder and bowel problems 

PHYSICAL THERAPY EXAMINATION,
EVALUATION, & DIAGNOSIS III. PROGNOSIS

I. POINTS OF EMPHASIS ON EXAMINATION  Mortality

- causes:
o respiratory problems (e.g. pneumonia)
 Inspection

o heart disease
o Orientation 
 o subsequent trauma
o Communication 
 o septicaemia
 Cardiopulmonary assessment 

o Vital signs
 - Depends on:
o Respiratory (chest expansion,  Degree of pathological changes due to
breathing 
pattern coughing) 
 trauma
 Neurologic assessment 
  Precautions taken to prevent further damage
o Sensation 
  Prevention of additional compromise of
o Reflex 
 neural tissue
 Early appearance of reflex activity
 Musculoskeletal assessment
o Joint play

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  Neurological level of lesion and
Completeness of the injury
o Incomplete lesion (ASIA B, C, D) has a
greater likelihood of recovery of motor
function
- ASIA D injuries has greater
functional independence than
that of ASIA B and C injuries
o Complete lesion (ASIA A), 70% Pt.’s
with cervical level injuries are likely to
experience one level of motor recovery
below the original neurological level
 Degree of Independence
o Above C6 = Complete Dependence
o C6-T6 = Incomplete Independence
o Below T6 = Marked Degree of Independence
 Functional Outcomes
Triceps, Latissimus Dorsi
o AVOID stretching of the
shoulders during acute period
but UE positioned in Sh.
EXADIR, Elbow Flexion,
Forearm Pronation and Wrist
Flexion
o Full ROM exercises in LEs
o Selective Strengthening
o Maximal strengthening of all
remaining muscles
o AVOID strengthening ms of
scapula & shoulders
(tetraplegia) and ms in the trunk
& pelvis (paraplegia)
o Bilateral UE Activities
Bed
Positioning

T2↑ SO – Standing Only Orientation to o Use of Abdominal Binder and

Vertical Elastic Stockings
T3 – T11 TA – Therapeutic Ambulation Position o Elevating the head of bed
o Tilt Table
T12 – L2 HA – Household Ambulation o Very Gradual Acclimation to
Upright Postures
L3↓ CA – Community Ambulation o Monitor BP

Skin Care o Positioning

o Consistent and Effective
IV. PT DIAGNOSIS Pressure Relief
o Skin inspection and education
Neuromuscular Pattern H: Impaired Motor Function,
Peripheral Nerve Integrity, and Sensory Integrity Pt. and Family
Associated With Nonprogressive Disorders of the Education
Spinal Cord

PLAN OF CARE AND INTERVENTIONS
Acute Management
Respiratory o Deep Breathing Exercises
Management o Glossopharyngeal Breathing
o Airshift Maneuver
o Assisted Coughing
o Abdominal Support/Binder
o Manual Stretching of Pectoral
and other chest wall muscles
o Strengthening of Intact
Respiratory Muscle through
manual contacts or weights
o Manual Stretching of Pectoral
and other chest wall muscles
o Postural Drainage
Active Rehabilitation
Specific Functional
Goals for Each Level
Skin Inspection
Continuing Activities
Mat Programs o Rolling: clasping
hands, hook lying
o Bilat. UE Rocking
o Crossing the leg
o Sidelying to Prone
o Supine to Prone
o Sidelying to Supine
Siting Balance

ROM and o Selective Stretching Strengthening

Positioning Tetraplegia : Ant. Deltoid, Sh. Exercises
Flexors, Biceps, Lower Trapz, if
with Radial Extensors, Triceps, Transfers
Pectorals
Paraplegia: Sh. Depressors,

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Cardiovascular/
Endurance Training
Locomotion Training o Locomotion Training
for individuals with
Motor Complete SCI
o Locomotion Training
for individuals with
Motor Incomplete SCI
Ambulation
Activity-Based Upper
Extremity Training
Pt. Education
Secondary Complications
Acute Hospital o PROM exercises
Setting o Splinting
o Positioning
o Selective strengthening
Physical Skill o ROM exercises
Training o Resistance exercises
o Postural training
o Mat exercises
o Transfer training
Edema o Elevation
o Massage
o Use of Compression
Garments
Deep Vein o Early mobilization
Thrombosis o Use of Compression
Stockings & Boots
o Pneumatic Compression
Sleeves
Pulmonary o Postural Drainage
Management o Chest Percussion or
Vibration
o Manually Assistive
Cough
Orthostatic o Application of elastic
Hypotension stockings and abdominal
binders
o Gradually progressive
daily head-up tilt
Pressure Ulcers o Position changes
o Proper bed and
wheelchair positioning
o Hydrotherapy
o Wet-to-Dry dressings
Pain o Massage
o Stretching
o Strengthening
o Optimizing posture
o Desensitization
techniques
Autonomic o Pt. should be sat up
Dysreflexia o Constrictive clothing &
garments should be
loosened
o Call emergency
Bowel Management o Scheduling of a bowel
routine after a meal
o High Fiber diet
o Fluid Intake
o Stool softeners
o Suppositories
o Digital Stimulation
o Manual Evacuation
Reflex Bladder o Intermittent Bladder
(Bladder Catheterization
Management) o Fluid Intake Pattern
~2000 mL/d
o Monitored at 150-180
mL/hour from AM-early
PM
o Stopped late in the day
to reduce the need for
catheterization at night
o Initially, catheterization
every 4 hrs.
o Pt. attempts to void prior
to catheterization
o Maintain a Record of
Voided and Residual
Urine
Non Reflex Bladder o Timed Voiding
(Bladder
Management)
Spasticity o Stretching
o ROM exercises
o Proper bed and
wheelchair positioning
Contractures o Proper bed positioning
o PROM exercises
o Stretching exercises
Fitness & Exercise o Upper Limb Ergometry
o Cycling, using FES
o Regular, vigorous
exercise or wheelchair
sports program
Wheelchair Skills o Proper sitting position
o Wheelchair mobility
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Functional Electrical Pt.s also need to practice controlled falls out
Stimulation for of the wheelchair and floor-to-wheelchair
Therapeutic Exercise transfers.
 It is also important for wheelchair users to
Upright Walking on a learn how to ask for help and how to direct
Treadmill with Partial helpers who might be touching them or the
BWS provided by a wheelchair.
Suspending Harness

Body Weight Support WHEELCHAIR MOBILITY

Ambulation
C1 – C3  Powered W/C controlled by
Pt. and Family breathing motions such as:
Education o sip & puff or head, chin, power
reclining for pressure relief
o with a portable respirator,
seatbelt & trunk support
Prescriptive Wheelchair C4  Electric with head, mouth & chin,
breath or sip& puff controls
- Many people with SCI will use a wheelchair C5  Independent pressure relief with
as their primary means of mobility. power tilt in space wheelchair
- A wheelchair both acts as a mobility base  Manual with plastic coated handrim
and serves to provide postural support. projections
C6  Projections/Friction surface
General Considerations: handrims
 2” curb
 Seat depth should be approx. 1-2 in. (2.54-5.1
cm) back from the popliteal space to allow an C7  Uneven terrain
even weight distribution on the thighs and to  4” curb
prevent excessive pressure on the ischial  Manual with friction surface
tuberosities. handrims
 Floor-to-seat height is important. There C8 – T1  Manual wheelchair with standard
should be 2 in (5.1 cm) clearance from the handrims
floor to the foot pedals and provide slightly
0
greater than a 90 angle at the hips. T4 – T6  Bilat. KAFOs with spinal
 If the Pt. will not be pushing the wheelchair, a attachment
high back may be desired for added comfort T9 – T12  Scott Craig Orthosis (KAFO with
and stability. For Pt.s who will be pushing the crutches)
wheelchair, back height should be below the  Walker
inferior angle of the scapula so that the axilla  Swing-to Gait Pattern
is free of the handles during functional L2 – L4  Bilat. KAFOs & Crutches
activities.  4-point Gait Pattern (T12-L3)
 Seat width and depth are variable and should L4 – L5  Bilat. AFOs with crutches or canes
be fitted to the anthropometric characteristics  2-point Gait Pattern
of the Pt.
 Removable armrests and detachable swing-
away leg rests are important components of
wheelchairs used by many Pt.s with SCI.
 Additional wheelchair accessories may be
required to meet specific Pt. needs.

Wheelchair Training Strategies

 During the training period, the individual will

learn how to propel the chair in all directions;
operate the different parts of the wheelchair;
and transfer in and out of the chair with the
least possible assistance.
 Pt.s who are capable of independent
community mobility benefit from learning to
do wheelies to negotiate existing curbs.
 Pt.s who drive need to practice transfers
from the wheelchair to the car seat. Active

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