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Inciong, MD
1
Integration, Coordination & Behavior
OS 211
Rehabilitation of Neurogenic Bowel and Bladder and the Spinal Cord
Lecture Outline
I. Spinal Cord
A. Anatomy
DEFINITIONS
B. Definition of terms A. Spinal shock
C. Pathophysiology of SCI
D. Epidemiology of SCI • A state of transient physiological (rather than
E. Classification of SCI anatomical) reflex depression of cord function
F. Syndrome of SCI
G. Assessment of SCI below the level of injury with associated loss of all
H. Systemic changes after SCI sensorimotor functions
I. Functional Outcome
J. Prognosis • Flaccid paralysis, including the bowel and bladder
II. Neurogenic Bladder
A. Bladder Innervation • Symptoms tend to last several hours to days until
B. Receptors of the Bladder the reflex arcs below the level of the injury begin
C. Micturition
D. Functional Classification of Voiding Dysfunction to function again (eg, bulbocavernosus reflex,
E. Evaluation of Voiding Dysfunction muscle stretch reflex [MSR]).
F. Diagnostics
G. Laboratory Examinations
H. Management Goals of Voiding Dysfunction B. Neurogenic shock
I. Management of Voiding Problems
III. Neurogenic Bowel • Manifested by the triad of hypotension,
A. Evaluation of Bowel Dysfunction bradycardia, and hypothermia
B. Management Goals of Bowel Dysfunction
C. Management of Bowel Dysfunction • Shock tends to occur more commonly in injuries
above T6, secondary to the disruption of the
SPINAL CORD sympathetic outflow from T1-L2 and to
unopposed vagal tone, leading to decrease in
vascular resistance with associated vascular
Main functions:
dilatation
• Sensory – Spinothalamic tract
• Neurogenic shock needs to be differentiated from
• Motor – Corticospinal tract spinal and hypovolemic shock.
• Autonomic: Bowel, bladder
• Hypovolemic shock (due to hemorrhage) tends to
Case Scenario be associated with reflex tachycardia (there is
sympathetic shut down, so parasympathetic will
• 25 yo sustained C5 cervical fracture secondary to
dominate, resulting to bradycardia)
fall last March 2, 2010
• No associated problems
PATHOPHYSIOLOGY OF ACUTE SCI
• Spontaneous breathing, follows commands, both Series of biochemical processes causing further neuronal
UE and LE = 0/5 damage
• Sensory evaluation (via pinprick): intact C2-C4, Vasoactive substances
LT and PP
• + BCR (bulbocavernosus reflex)
Vasoconstriction
• Determine the extent of damage using ASIA
• Determine the motor score, sensory score, motor
level, sensory level
Ischemia of gray matter
SYNDROMES
A. Incomplete Cord Syndromes
• Anterior Cord Syndrome
• Brown Sequard Syndrome
• Central Cord Syndrome
• Conus Medullaris Syndrome
• Cauda Equina Syndrome
EPIDEMIOLOGY
• Annual incidence US: 40 cases/million
• Lowest in age <15 yrs; highest in 16-30 yrs
• Mean age: 35.9 years
• 80% males
• Causes: Vehicular accidents 50.4%
Falls 23.8%
Figure 2. Anterior cord syndrome
Violence 11.2%
Sports/Recreation 9.0%
Others 5.6%
2. BROWN-SEQUARD SYNDROME
• Extent Of Neurologic Deficit
• A relatively greater ipsilateral loss of
Tetraplegia 51.7%
proprioception and motor function (may affect
Incomplete 29.4%
ambulation)
Complete 20.7%
Paraplegia 45.9% • With contralateral loss of pain and temperature
Incomplete 18.6% sensation (sensory deficit may also lead to gait
Complete 26.3% problem)
Unconfirmed 2.4% • Recall: motor functions governed by the
Thus: Incomplete lesions > complete lesions corticospinal tract decussates at the cortico-
• Life Expectancy / Mortality / Factors medullary junction, while sensory functions
governed by the spinothalamic tract decussates
o Highest mortality 1st yr post-injury at two spinal segments above the exit of the nerve.
6.3% then declines For example: If the damage is in L2, L2 will not
o Predictors: older, male (more prone to be affected. L4 will be affected because it
suicide when they cannot perform social crosses at L2
functions), injured by violence, complete • A zone of partial preservation or segmental
injury, ventilator dependence (prone to ipsilateral lower motor neuron weakness and
having infections), high neurologic level analgesia may be noted.
o Top 3 Causes of Mortality:
• Loss of ipsilateral autonomic function can result
1. Pneumonia – for higher cervical/thoracic injuries; in Horner syndrome.
inadequate ventilation and clearance of mucus
• May range from mild to severe neurologic deficit.
secretions
• Bowel and bladder function preserved because
2. Heart Disease – individuals confined to a wheelchair,
the unaffected half can still serve these functions
so no physical exertion
3. Genitourinary system diseases – regular monitoring of
bacteria through urine culture every 3 months or KUB
ultrasound every year
CLASSIFICATION
• Immediate loss of neurological level, and at least half of key muscles below
1. Sensation the neurological level have a muscle grade of 3 or more.
2. Motor function E = Normal: motor and sensory functions are normal.
3. Muscle tone
4. Reflex activity Importance of Comprehensive Neurological Exam - ASIA
• Ends after return of bulbocavernosus reflex • Evidence-based
o Patients are usually on polycatheter. • Valid, reliable, consistent
While wearing glands, pull the • Allows for prognosis
polycatheter with your right hand and o Neurological
feel for the bulbocavernosus response/ o Functional (Rehabilitation goals)
”anal wink” • Allows study of interventions
o Rehabilitation
Terminologies o Drugs
1. Zone of partial preservation – dermatomes and
myotomes caudal to the neurological level that 1. ASIA Sensory Exam
remain partially innervated • Sensory Exam
2. Rectal examination o 28 sensory “points” do the
• Sensation present if deep anal sensation or
inching/dangkal/Inciong method
sensation of anal mucocutaneous junction is
Test T2 on the axilla, not on the
present
thorax because there is
• Complete lesion - absence of sensory/motor
overlapping
function in lowest sacral segment
T3 is located 2 fingerbreadths
• Incomplete lesion - either sensory/motor function
above the nipple
is present (Sacral sparing
Umbilicus is T10, below
3. Motor level - Determined by the most caudal key umbilicus, use 3 fingerbreadths
muscles that have muscle strength of 3 or above o Test light touch & pin/pain
while the segment above is normal (= 5) o Dermatomal areas
4. Motor index scoring - Using the 0-5 scoring of C2 – occipital protuberance
each key muscle with total points being C3 – supraclavicular fossa
25/extremity and a total possible score of 100 C4 – top of the acromioclavicular joint
C5 – lateral side of antecubital fossa
5. Sensory level - Most caudal dermatome with a C6 – thumb
normal score of 2/2 for both pinprick and light C7 – middle finger
touch (there are 31 spinal nerves, only 28 T1 – medial antecubital fossa
dermatomes, S3-S5 merge, and no C1) T2 – apex of axilla
T3
6. Sensory index scoring - Total score from T4 – nipple
adding each dermatomal score with possible total T5
score (=112 each for pinprick and light touch) T6
Note: multiply the number of all the dermatomes (28) by 2 (to T7 – 7th intercostal space
account for laterality) = 56. Since the highest possible grade for
a dermatome is 2/2, 56 x 2 = 112. T8 – 8th intercostal space
7. Neurologic level of injury - Most caudal level at T9 – 9th intercostal space
which both motor and sensory levels are intact, T10 – umbilicus
with motor level as defined above and sensory T11 – 11th intercostal space
level defined by a sensory score of 2 T12 – inguinal ligament
8. Skeletal level of injury - Level of greatest L1 – upper anterior thigh
L2 – mid anterior thigh
vertebral damage on radiograph
L3 – medial femoral condyle
9. Lower extremities motor score (LEMS) - Uses L4 – medial malleolus
the ASIA key muscles in both lower extremities L5 – dorsum 3rd MTP joint
with a total possible score of 50 (i.e., maximum S1 – lateral heel
score of 5 for each key muscle L2, L3, L4, L5, S2 – popliteal fossa
and S1 per extremity) S3 – ischial tuberosity
a. A LEMS score of 20 or less indicates S4, S5 – perianal area
patients are likely to be limited o Importance of sacral pin testing
ambulators (limited ambulation = only o 3 point scale (0,1,2)
able to stand; will be dependent on 0 - absent
braces). 1 - imparied/hyperesthesia
b. A LEMS of 30 or more suggests that 2 - intact
patients are likely to be community • “Optional”: proprioception & deep pressure to
ambulators (3/5 on both sides, able to index and great toe (“present vs. absent”)
resist gravity) • Deep anal sensation recorded “present vs.
absent”
American Spinal Injury Association (ASIA) Impairment
Scale 2. ASIA Motor Exam –Myotomes: 10 “key” muscles
A = Complete: No motor or sensory function is preserved • C5 - Biceps L2 – Iliopsoas
in the sacral segments S4-S5 (0/5, no sensation at all) • C6 - ECRL L3 - Quadriceps
B = Incomplete: Sensory but not motor function is • C7 - Triceps L4 – Tibialis anterior
preserved below the neurological level and includes the
sacral segments S4-S5.
• C8 – FDP (3rd) L5 - EHL
C = Incomplete: Motor function is preserved below the • T1 – ADM S1 – Gastrocsoleus
neurological level, and more than half of key muscles • Sacral exam: voluntary anal contraction
below the neurological level have a muscle grade less (present/absent)
than 3. • “Optional m’s: diaphragm (VC), abdominal
D = Incomplete: Motor function is preserved below the (Beevors test), hip adductors
NEUROGENIC BLADDER
adrenergic and alpha-adrenergic receptors stimulation
Bladder full
Any pathologic CNS/PNS condition Triggers stretch reflex by receptors in walls
Affects the nervous system Sacral segments of cord (PN)
Control of nerves to bladder/bowel Parasympathetic fibers (efferents) back to bladder
Neurogenic bladder and bowel Detrusor contraction
Common Causes of Neurogenic Bladder Micturtion / voiding
(Neuropathic Voiding Dysfunction)
1. Brain lesions above pontine micturition center FUNCTIONAL CLASSIFICATION OF VOIDING DYSFUNCTION
- Stroke patients because of vascular problems
2. Brain lesions below pontine micturition center and in spinal cord
3. Conus medullaris and cauda equina lesions • Failure to STORE (INCONTINENCE)
4. Peripheral neuropathy / other neuropathies, such as in diabetes • Suprapontine lesions
5. Bladder overdistention with disruption of intramural nexus • Suprasacral lesions below the pons
Note: Neurogenic bladder/bowel is not limited to spinal cord injuries
• Failure to EMPTY (RETENTION)
BLADDER INNERVATION • During spinal shock
Pelvic Nerves (PN) • Peripheral lesions (polyneuropathies)
PN • Failure of sphincter relaxation during bladder contraction
(Sensory/Motor - parasympathetic) 3. Combination
• Incomplete emptying
Spinal Cord S2-S3 (in some books, S2-S4)
EVALUATION OF VOIDING DYSFUNCTION
Detrusor Muscles (contraction) History
• Voiding/defecating complaints
Pudendal Nerves • Cognitive deficits: patients with spinal cord injuries also have
- Somatic nerve fibers to voluntary skeletal muscles & associated contusions, etc.
external bladder sphincter • Past history
- So we can control our urgers, enabling us to pee at the • Associated medical problems
right place and time
Physiatric Health
Hypogastric Nerves • Hand function: will have a bearing for future management
- Sympathetic innervation (independent catheterization program)
- Spinal cord T11-L2 • Dressing skills
- Sympathetic stimulation facilitates bladder • Sitting balance
storage/ retention
• Ability for transfers/ambulation
• Also evaluate patients’ reactions/coping mechanisms to stigma
RECEPTORS OF THE BLADDER
Physical Examination
• In a flaccid bladder, there is overdistention. We • Abdomen
want the flaccid bladder to contract, so the drug • External genitalia: check for indwelling catheters (retention),
to use can be a cholinergic agonist (to promote) diapers (incontinence)
or a parasympathomimetic (to block) • Perineal skin: check for bed sores prone to infection in the
• Flaccid bladder = high volume, low pressure setting of incontinence
• Spastic bladder = low volume, high pressure • Rectum
Neurologic Examination
Beta Adrenergic (part of sympathetic) (β for BODY) 1. Motor and sensory examination
• Predominate in superior portion of bladder (body) 2. Cutaneous reflexes
------------------------END OF TRANS------------------------
Trans concerns? Nic: 09189178361
Greetings!
Hazel: Merry Christmas, 2014! Happy birthday Marj!
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