spinal cord injury - طـبيـعي للعلاج الطبيعي والتأهـيل الطبي
 
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Spinal cord injury SCI


Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor, sensory, or autonomic function. The International Standards for Neurological and Functional Classification of Spinal Cord Injury is a widely accepted system describing the level and the extent of injury based on a systematic motor and sensory examination of neurologic function. The following terminology has developed around



classification of SCI:

Tetraplegia (replaced the term quadriplegia) - Injury to the spinal cord in the cervical region with associated loss of muscle strength in all 4 extremities

Paraplegia - Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris

SCI can be sustained through different mechanisms with the following 3 common abnormalities leading to tissue damage:

Destruction from direct trauma

Compression by bone fragments, hematoma, or disk material

Ischemia from damage or impingement on the spinal arteries

Edema could ensue subsequent to any of these types of damage. The different clinical presentations of the above causes of tissue damage are explained further below.
Spinal shock
Spinal shock is a state of transient physiological (rather than anatomical) reflex depression of cord function below the level of injury with associated loss of all sensorimotor functions. An initial increase in blood pressure is noted due to the release of catecholamines, followed by hypotension. Flaccid paralysis, including of the bowel and bladder, is observed, and sometimes sustained priapism develops. These symptoms tend to last several hours to days until the reflex arcs below the level of the injury begin to function again (eg, bulbocavernosus reflex, muscle stretch reflex [MSR]).
Neurogenic shock
Neurogenic shock is manifested by the triad of hypotension, bradycardia, and hypothermia. Shock tends to occur more commonly in injuries above T6, secondary to the disruption of the sympathetic outflow from T1-L2 and to unopposed vagal tone, leading to decrease in vascular resistance with associated vascular dilatation. Neurogenic shock needs to be differentiated from spinal and hypovolemic shock. Hypovolemic shock tends to be associated with tachycardia.
Autonomic dysreflexia
See the article Autonomic Dysreflexia.
Motor strengths and sensory testing
The extent of injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale (modified from the Frankel classification), using the following categories:

A - Complete: No sensory or motor function is preserved in sacral segments S4-S5.

B - Incomplete: Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5.

C - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade less than 3.

D - Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have muscle grade greater than or equal to 3.

E - Normal: Sensory and motor functions are normal.

Perform rectal examination to check motor function or sensation at the anal mucocutaneous junction. The presence of either is considered sacral-sparing.
Definitions of complete and incomplete SCI are based on the above ASIA definition with sacral-sparing.

Complete - Absence of sensory and motor functions in the lowest sacral segments

Incomplete - Preservation of sensory or motor function below the level of injury, including the lowest sacral segments

Sacral-sparing is evidence of the physiologic continuity of spinal cord long tract fibers with the sacral fibers located more at the periphery of the cord. Indication of the presence of sacral fibers is of significance in defining the completeness of the injury and the potential for some motor recovery. This finding tends to be repeated and better defined after the period of spinal shock.
With the ASIA classification system, the terms paraparesis and quadriparesis now have become obsolete. The ASIA classification using the description of the neurologic level of injury is used in defining the type of SCI (eg, C8 ASIA A with zone of partial preservation of pinprick to T2). See the entire ASIA Impairment Scale (requires Acrobat reader).
Other classifications of SCI include the following:

Central cord syndrome often is associated with a cervical region injury leading to greater weakness in the upper limbs than in the lower limbs with sacral sensory sparing.

Brown-Séquard syndrome often is associated with a hemisection lesion of the cord, causing a relatively greater ipsilateral proprioceptive and motor loss with contralateral loss of sensitivity to pain and temperature.

Anterior cord syndrome often is associated with a lesion causing variable loss of motor function and sensitivity to pain and temperature, while proprioception is preserved.

Conus medullaris syndrome is associated with injury to the sacral cord and lumbar nerve roots leading to areflexic bladder, bowel, and lower limbs, while the sacral segments occasionally may show preserved reflexes (eg, bulbocavernosus and micturition reflexes).

Cauda equina syndrome is due to injury to the lumbosacral nerve roots in the spinal canal leading to areflexic bladder, bowel, and lower limbs.

Muscle strengths are graded using the following Medical Research Council (MRC) scale of 0-5:

5 - Normal power

4+ - Submaximal movement against resistance

4 - Moderate movement against resistance

4- - Slight movement against resistance

3 - Movement against gravity but not against resistance

2 - Movement with gravity eliminated

1 - Flicker of movement

0 - No movement

Muscle strength always should be graded according to maximum strength attained, no matter how briefly that strength is maintained during the examination. The muscles are tested with the patient supine.
The following key muscles are tested in patients with SCI, and the corresponding level of injury is indicated:

C5 - Elbow flexors (biceps, brachialis)

C6 - Wrist extensors (extensor carpi radialis longus and brevis)

C7 - Elbow extensors (triceps)

C8 - Finger flexors (flexor digitorum profundus) to the middle finger

T1 - Small finger abductors (abductor digiti minimi)

L2 - Hip flexors (iliopsoas)

L3 - Knee extensors (quadriceps)

L4 - Ankle dorsiflexors (tibialis anterior)

L5 - Long toe extensors (extensors hallucis longus)

S1 - Ankle plantar flexors (gastrocnemius, soleus)

Sensory testing is performed at the following levels:

C2 - Occipital protuberance

C3 - Supraclavicular fossa

C4 - Top of the acromioclavicular joint

C5 - Lateral side of antecubital fossa

C6 - Thumb

C7 - Middle finger

C8 - Little finger

T1 - Medial side of antecubital fossa

T2 - Apex of axilla

T3 - Third intercostal space (IS)

T4 - 4th IS at nipple line

T5 - 5th IS (midway between T4 and T6)

T6 - 6th IS at the level of the xiphisternum

T7 - 7th IS (midway between T6 and T8)

T8 - 8th IS (midway between T6 and T10)

T9 - 9th IS (midway between T8 and T10)

T10 - 10th IS or umbilicus

T11 - 11th IS (midway between T10 and T12)

T12 - Midpoint of inguinal ligament

L1 - Half the distance between T12 and L2

L2 - Mid-anterior thigh

L3 - Medial femoral condyle

L4 - Medial malleolus

L5 - Dorsum of the foot at third metatarsophalangeal joint

S1 - Lateral heel

S2 - Popliteal fossa in the midline

S3 - Ischial tuberosity

S4-5 - Perianal area (taken as one level)

Sensory scoring is for light touch and pinprick, as follows:

0 - Absent

1 - Impaired or hyperesthesia

2 - Intact

A score of zero is given if the patient cannot differentiate between the point of a sharp pin and the dull edge.
Motor level - Determined by the most caudal key muscles that have muscle strength of 3 or above while the segment above is normal (= 5)
Motor index scoring - Using the 0-5 scoring of each key muscle with total points being 25/extremity and a total possible score of 100
Sensory level - Most caudal dermatome with a normal score of 2/2 for both pinprick and light touch
Sensory index scoring - Total score from adding each dermatomal score with possible total score (= 112 each for pinprick and light touch)
Neurologic level of injury - Most caudal level at which both motor and sensory levels are intact, with motor level as defined above and sensory level defined by a sensory score of 2
Zone of partial preservation - This index is used only when the injury is complete. All segments below the neurologic level of injury with preservation of motor or sensory findings
Skeletal level of injury - Level of greatest vertebral damage on radiograph
Lower extremities motor score (LEMS) - Uses the ASIA key muscles in both lower extremities with a total possible score of 50 (ie, maximum score of 5 for each key muscle L2, L3, L4, L5, and S1 per extremity). A LEMS score of 20 or less indicates patients are likely to be limited ambulators. A LEMS of 30 or more suggests that patients are likely to be community ambulators.
epidemiology
SCI due to trauma is not a common condition, but it has a major effect on the injured person's functional, medical, financial, and psychosocial well-being.
The most common causes of SCI include the following:

Motor vehicle accidents (44.5%) are the major cause of SCI in the United States.

Falls (18.1%) are most common in persons aged 45 years or older.

Violence (16.6%) is the most common cause of SCI in some urban settings in the United States, with a trend showing a slight decrease in violence as a cause of SCI.

Sports injuries (12.7%) cause many cases of SCI. Diving is the sport in which SCI occurs most commonly.

Other causes of SCI include the following:

Vascular disorders

Tumors

Infectious conditions

Spondylosis

Developmental disorders

The incidence of traumatic SCI in the United States is 30-60 new cases per million population, or 10,000 cases per year in the United States. Some sources cite 8 cases per 10,000 population per year.
Figures on estimated prevalence vary from approximately 183,000 to 230,000 cases in the United States, the equivalent of 700-900 cases per million population.
Race
Incidence among whites is higher than among African Americans, which is higher than among Hispanics in the United States. Current studies indicate whites at 66.4%, African Americans at 21.1%, Hispanics at 8.8%, Asians at 1.6%, Native Americans at 1.1%, and others at 1%.
***
The male-to-female ratio of individuals with SCI in the United States is 4:1, ie, males constituting about 80%.
Age
More than 50% of all cases of SCI occur in persons aged 16-30 years. The median age is 26.4 years, while the mean age is 31.8 years and the mode age at injury is 19 years. Traumatic SCI is more common in persons younger than 40 years, while nontraumatic SCI is more common in persons older than 40 years. Greater mortality is reported in the older patients with SCI.
Associated injuries
Other injuries are often associated with traumatic SCI, and these include bone fractures (29.3%), loss of consciousness (17.8%), and traumatic brain injury affecting emotional/cognitive functioning (11.5%).
Marital status
Single persons sustain SCI more commonly than married persons. Approximately one third of patients with SCI sustained at least 15 years before remain single 20 years after injury. The marriage rate after SCI is about 59% below that of the general population of comparable gender, age, and marital status annually. The divorce rate annually among individuals with SCI within the first 3 years following injury is approximately 2.5 times that of the general population, while that of marriages contracted after the injury is about 1.7 times that of the general population. Marriage is more likely if the patient is a college graduate, previously divorced, paraplegic (not tetraplegic), ambulatory, living in a private residence, and independent in performance of ADL.
The divorce rate among those married at the time of injury is higher if the patient is younger, female, African American, without children, nonambulatory, and previously divorced. The divorce rate among those who were married after the SCI is higher if the individual is male, has less than a college education, has a thoracic level injury, and has been divorced previously.
Educational status
At the time of injury, educational status figures are less than high school graduate at 39.8%, high school graduate at 49.9%, associate degree at 1.6%, bachelors degree at 5.9%, masters or doctorate degree at 2.1%, and other degrees at 0.7%.
Level and type of injury
The most common levels of injury on admission are C4, C5 (the most common), and C6, while the level for paraplegia is the thoracolumbar junction (T12). The most common type of injury on admission is ASIA level A.
Season
SCIs occur most frequently in the month of July and least commonly in February. The most common day when SCIs occur is Saturday. SCIs occur more frequently in the daylight hours, which may be due to the increased frequency of vehicular, diving, and other recreational sports accidents.
Substance abuse
The rate of alcohol intoxication among individuals who sustain SCI is 17-49%.
Injuries by ASIA classification

Incomplete tetraplegia - 29.5%

Complete paraplegia - 27.9%

Incomplete paraplegia - 21.3%

Complete tetraplegia - 18.5%

The most common neurologic level of injury is C5. In paraplegia, T12 is the most common level.
Employment
Patients with SCI classified as ASIA D are more likely to be employed than individuals with ASIA A, B, and C. Persons employed tend to work full-time. Individuals who return to work within a year of injury tend to return to the same job. Those individuals who return to work after a year of injury tend to work for a different employer at a different job requiring retraining.
The likelihood of employment after injury is greater in patients who are younger, male, and white and who have more formal education, higher reported intelligence quotient (IQ), greater functional capacity, and less severe injury. Patients with greater functional capacity, less severe injury, history of employment at the time of injury, greater motivation to return to work, nonviolent injury, and ability to drive are more likely to return to work, especially after more elapsed time following injury.
Life expectancy
Approximately 10-20% of patients who have sustained SCI do not survive to reach acute hospitalization, with approximately 3% of patients dying during acute hospitalization. Patients aged 20 years at the time of sustaining SCI have life expectancies of approximately 33 years as tetraplegics, 39 years as low tetraplegics, and 44 years as paraplegics. Individuals aged 60 years at the time of injury have a life expectancy of approximately 7 years as tetraplegics, 9 years as low tetraplegics, and 13 years as paraplegics. The annual death rate for patients with acute SCI is 750-1000 deaths per year in the United States.
Leading cause of death
The leading cause of death in patients following SCI is pneumonia and other respiratory conditions, followed by heart disease, subsequent trauma, and septicemia. Among patients with incomplete paraplegia, the leading causes of death among incomplete paraplegics are cancer and suicide (1:1 ratio); among complete paraplegic patients, the leading cause of death is suicide, followed by heart disease. Suicide and alcohol-related deaths are also major causes of death in patients with SCI. The suicide rate is higher among the SCI population who are younger than 25 years.

No statistical/epidemiological data have been compiled for nontraumatic SCI, but cancer alone may account for more SCI than trauma. Spondylosis is also a common cause of SCI. Trauma is more common in those younger than 40 years, while nontraumatic injury is more common in persons older than 40 years.

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