Steven Shatzer and Adam Copp Spinal Cord Injury Steven Shatzer and Adam Copp

What is a spinal cord injury? The spinal cord extends from the medulla oblongata to ~L1/L2, and is located within the vertebral canal Spinal cord injuries (SCIs) are generally the result of trauma to cord and vertebrae followed by instability Vertebral instability exists when 2 of 3 columns using the 3 column spine model are damaged The spinal cord does NOT have to be severed for irreversible damage to occur! Actual anatomic transection is rare. Usually, pts’ SCs are bruised instead of severed, however, trauma resulting in bruising or hemorrhaging in the SC can and often does cause neurological damage that is just as complete and permanent as when cord is transected. Spinal cord strokes: aka spinal infarction or spinal artery syndrome (SAS)- interrupted blood flow to specific region of SC resulting in paralysis/sensation deficits

Spinal Cord Injury Stats ~10,000 people per year in the US sustain an SCI In 2000, there were ~200,000 people living with SCIs in the US MVAs are the most common cause of SCIs on US soil (~37%), followed by acts of violence (~27%), falls (~21%), sports injuries (~8%), with another ~8% caused by miscellaneous injuries ~80% sustained by males, with most between 16- 30 years of age at time of injury “The prevalence of SCI among young males is not the result of any anatomic or physiologic vulnerability peculiar to this population. It is simply due to the fact that these are the people who are most prone to participating in such high-risk activities as driving too fast (and too drunk), joining gangs, riding motorcycles, playing football, and diving into unfamiliar waters where stumps and boulders are hidden beneath the surface.” -quote from a book published in 2001

Example ICF model of patient with SCI

Classifying SCIs SYNDROMES Central cord Brown-Sequard Anterior cord Conus medullaris Cauda Equina SC concussion Asia A: complete Asia B: incomplete, sensory but no motor below level Asia C: incomplete, motor preserved below, >½ of key muscles below have MMT <3 Asia D: incomplete, motor preserved below, >½ of key muscles below have MMT >3 Asia E: all neurologic function has returned after injury Incomplete SCIs Central cord: most common type of cervical SCI; generally bilateral motor weakness (UE>LE), intact sensation above and below Brown-Sequard: ipsilateral loss of voluntary muscle and vibration/proprioception, loss of contralateral pain and temp 2-3 levels below lesion (knife and bullet wounds) Anterior cord: bilateral, paraplegia, pain and temp, sphincter dysfunction: (anterior spinal artery infarct, disc herniation) Conus medullaris: bladder and rectal dysfunction, saddle anesthesia (can have UMN and LMN signs) (disc herniation, trauma, tumors) Cauda equina: saddle anesthesia!! Assymetric multiradicular pain, leg weakness (LMN) and sensory loss, decreased reflexes, bowel and bladder dysfunction. (disc herniation, tumor lumbar spine stenosis) Spinal cord concussion: aka cervical cord neurapraxia, transient sensory & motor dysfunction, episodes last <24 hrs, e.g., football players

Types of spinal Orthoses for stabilization Halo- Used for C1-T3 fractures and dislocations. Used for 3 months to allow for adequate healing. Provides greatest motion restriction.

Minerva Used for minimally unstable fractures. Greatest motion restriction at C5-7 with poor motion restriction at C1-2. Tend to control flexion better than extension.

SOMI May be used for Atlantoaxial instability caused by RA and neural arch fractures of C2. Most effective in restricting flexion between C1-5. Motion restriction is less than that of both halo and Minerva, especially extension.

Cervical collars No collar can effectively immobilize the spine so shouldn't be used in significant vertebral instability

Molded plastic body jacket Used mainly for fractures between T6 and L3. Also used for other Thoracic/Lumbar post operations and diseases. Provides maximal stability to the trunk, limiting motion in all planes

Jewett Used for same indications as plastic jacket. Restrict flexion and encourage hyperextension of lower thoracic and upper lumbar spine.

Knight-Taylor Allows unrestricted rotation and provides an intermediate degree of restriction of flexion, extension, and lateral bending in the thoracic region

Complete SCI Orthoses Considerations C8 and higher- Functional ambulation not feasible. T1-12- KAFOs with locked knees and ankles held in slight dorsiflexion are required for ambulation. (Alternative Orthoses could include HKAFOs) L1- KAFOs with locked knees and ankles held in slight dorsiflexion are typically required for ambulation. (Alternative Orthoses could include HKAFOs) L2- KAFOs with locked knees and ankles held in slight dorsiflexion are typically recommended for ambulation with potential for ambulation with ground-reaction AFOs

Complete SCI Orthoses cont. L3- AFOs with plantar flexion stops or dorsiflexion assists are required to allow toe clearance during swing. Dorsiflexion stops are needed to prevent excessive ankle dorsiflexion during late stance. KAFOs recommended if inadequate quad strength. L4- AFOs with dorsiflexion stops are required to prevent excessive ankle dorsiflexion during late stance. Dorsiflexion assist may be required for inadequate dorsiflexion strength. L5- AFOs with dorsiflexion stops are indicated to prevent excessive ankle dorsiflexion during late stance

Complete SCI Orthoses cont. S1- AFOs with dorsiflexion stops are indicated if plantar flexor strength is inadequate. S2- You're good.

Incomplete SCI Orthoses Considerations As you will see in the case study, uses of Orthoses for incomplete SCIs can vary depending on the classification of your patient and their functional limitations and impairments.

Exoskeletons- the wave of the future? Allow for safe ambulation in real-world settings at a physical intensity conducive to prolonged use and known to yield health benefits: Increased CV fitness, muscular fitness, and bowel movement regularity, minimized bone density decline, decreased self-report of spasticity Adjustable resistance/support, so technology doesn’t result in early fatigue like with older orthotics (HKAFOs & RGOs)

Case Study 55 yr old male who fell 6 m down a flight of stairs Disk herniation and fractures to C5-C6 Subsequently had central cord and Brown-Sequard syndromes Incomplete SCI at C5-6 and ASIA class D Gait deviations of vaulting, hip hiking, and shoulder and elbow extension were used to clear right foot during swing. AFO on right leg was used to help correct those deviations

References Behrman, A. L., Lawless-Dixon, A. R., Davis, S. B., Bowden, M. G., Nair, P.,Phadke, C., Hannold, E. M., Plummer, P., & Harkema, S. J. (2005). Locomotor Training Progression and Outcomes After Incomplete Spinal Cord Injury. Physical Therapy, 85(12), 1356-1371. Accessed July 15, 2016. Retrieved from http://ptjournal.apta.org/content/85/12/1356. Center For Prosthetics Orthotics, Inc website. http://cpo.biz/. Accessed July 18, 2016. Miller L, Zimmermann A, Herbert W. Clinical effectiveness and safety of powered exoskeleton-assisted walking in patients with spinal cord injury: systematic review with meta-analysis. MDER. 2016:455. doi:10.2147/mder.s103102. Somers M. Spinal Cord Injury. Upper Saddle River, N.J.: Prentice Hall; 2001.