Epidemiology of Traumatic SCI

Acute Management of
Spinal Cord Injury
 Incidence: 52 per million
 77% Survive (40 per
David R. Gater, Jr., MD, Ph.D., M.S. million)
Rocco Ortenzio Chair & Professor  12,000 new SCIs/year
Physical Medicine & Rehabilitation  Prevalence: 229,000-306,000
Penn State Milton S. Hershey Medical Center  Gender: 4M:1F
Penn State College of Medicine  Incidence: 81.7% Male
Hershey, PA  Prevalence: 71% Male
dgater@hmc.psu.edu  Race: 70%W, 20% B

Epidemiology of Traumatic SCI Age (Years) at Time of SCI

Mean=40.2 y.o.

 Incidence: 52 per million

 77% Survive (40 per million)
 12,000 new SCIs/year
 Prevalence: 1,275,000 (0.4%)
 Gender: 3M:1F
 Incidence: 81.7% Male
 Prevalence: 61% Male
 Race: 77%W, 16% AA, 7% NA

NSCISC Database Since 2005

SCI Current Age (Years) Etiology of Traumatic SCI

NSCISC Database, Since 2005

Total SCI n=1,275,000

1
 SCI by Etiology (CRF 2009) Central Nervous System

Autonomic Somatic
Nervous System Nervous System

Parasympathetic Midbrain
(Cranial Nerves) Medulla
-Heart C3-C5 Diaphragm
-Gastrointestinal C5 Elbow Flexors
C6 Wrist Extensors
C7 Elbow Extensors
C8 Finger Flexors
Sympathetic T1 Finger Abductors
(Thoracolumbar)
-Cardiovascular T2-T8 Intercostals
-Lungs Paraspinals
-Gastrointestinal
-(Ad)Renal T7-T12 Abdominals
-Sweat Glands

L2 Hip Flexors
L3 Knee Extensors
Parasympathetic L4 Ankle Dorsiflexors
(Sacral) L5 Toe Extensors
-Bowel S1 Ankle Plantarflexors
-Bladder

Total SCI n=1,275,000

Autonomic Nervous System Autonomic Nervous System

 Sympathetic Nervous System  Parasympathetic Nervous System
 Origin: Thoracolumbar cord  Origin: Craniosacral neuraxis
 Cholinergic Preganglionic Fibers  Cholinergic Preganglionic Fibers
Long fibers from CN nuclei or
Short fibers arise from



intermediolateral columns sacral intermediate gray columns

 Exit peripheral nerve via white rami  Cholinergic Postganglionic Fibers
& join paravertebral ganglion of  Short fibers from ganlion or plexus
sympathetic chain innervate end organ
 Adrenergic Postganglionic Fibers  Conveys energy conservation, i.e.,
 Long fibers arise from sympathetic trophotrophic influence
chain and travel thru gray rami to
join peripheral nerves  Reduce HR, SV, & vascular tone
 Except Cholinergic fibers to sweat  Bronchiolar constriction
glands  Increased peristalsis & digestion
 Conveys “fight or flight,” i.e.,  Sphincter relaxation, bowel &
ergotrophic response bladder evacuation
 Penile erection

Emergency Management Transport

 Primary Survey  Mode
 Airway, Breathing, Circulation  Ambulance <50 miles
 Protect airway (Chin lift) while  Helicopter 51-150 miles
stabilizing spine
 Fixed-wing aircraft > 150 miles
 Kendrick Extrication Device (KED)
 Multidisciplinary Emergency
 SCI Recognition during Extrication
Department
 Paralysis & Sensory Loss
 Pain, Lacs, Bruises @ Fx site  Emergency Physician
 “Paradoxical” breathing  Trauma Surgeon
 Bowel/bladder incontinence  Neurosurgeon & Orthopedist
 Neurogenic shock  Physiatrist
 Hypotension  Anesthesiologist
 Bradycardia
 Hypothermia
 Respiratory Personnel

2
 Hypotension ER Ventilatory Assessment
 Hypovolemic Shock
 Hypotension
 Hypothermia  Arterial Blood Gas
 Tachycardia  PaO2 > 100 t
 Neurogenic Shock  PaCO2 < 45 t
 Hypotension  Forced Vital Capacity
 Judicious fluids to prevent neurogenic
pulmonary edema  VC < 1000 ml requires Intubation &
 Trendelenburg Positioning Mechanical Ventilation
 Vasopressors with Swan-Ganz monitoring  VC 1000-1500 ml requires close
(MAP>85t) monitoring
 Dopamine 2.5-5 ug/min ( & 1-agonist)
 Levophed 0.01-0.2 ug/min  VC > 1500 ml Stable
 Hypothermia  Secretion Management
 Bradycardia
 Atropine
 Temporary Cardiac Pacing

GI & GU in the ER Neurological Assessment

 Medications
 Methylprednisilone bolus 30 mg/kg, then
5.4 mg/kg/hr x 23 hours
 Nasogastric Tube Placement 


Inclusion: Traumatic SCI w/in 8 hours
Exclusion: <13 y.o., LMN, GSW, Life-
 Prevent emesis & aspiration threatening morbidity, pregnancy,
narcotic addiction
 ASIA Impairment
 Motor & Sensory Function
 Sacral Involvement
 Foley Catheter Placement  Spine Assessment
 Fluid Assessment  Radiographs
AP/Lateral C-T-L-S spine
Spinal Shock also paralyzes


 Open Mouth C-Spine
bladder  Swimmer’s View to visualize C7
 Computed Tomography
 Sagittal Reconstruction
 Magnetic Resonance Imaging

NASCIS 1984, 1990, 1997

Functional Classification of
Frankel Classification of SCI
Spinal Cord Injury
 Completeness of Lesion
 Complete: No Motor or Sensory  A (Complete): No Motor or
function spared below level of Sensory Spared*
injury (BLOI)  * Zone of Partial Preservation
 Incomplete: Partial sparing of Motor (2-3 Below Level Of Injury)
&/or Sensory function BLOI
 B: Sensory, But No Motor
 Frankel Classification Function Spared BLOI
Paraplegia, 1969

 C: Less than 3/5 Motor Strength
 American Spinal Injury Association (Majority ) BLOI
(ASIA)
 D:  3/5 Motor Strength
 1992 (Original) (Majority) BLOI
1996 (Revised)
E: 5/5 Motor & Normal Sensory


2000 (Revised)

BLOI
 2011 (Revised)

3
American Spinal Injury Association
(ASIA) Impairment Scale
 Complete
 A: No Motor or Sensory in Sacrum
 No Sacral Sparing (SS) is noted
 Incomplete
 B: Sensory Spared + SS
 No Motor Spared BLOI
 C:  3/5 Motor (Majority) + SS
 D:  3/5 Motor (Majority) + SS
 E: 5/5 Motor + SS
 Clinical Syndromes
 Central Cord
 Brown-Sequard
 Anterior Cord
 Conus Medullaris
 Cauda Equina Syndrome

ASIA Dermatomes

Zone of Partial Preservation Central Cord Syndrome

Area of Cord T L
Damage Loss of Motor
Power and
 Hyperextension Sensation

 Swelling affects Central >

Peripheral Cord
 Somatotopic Anatomy
 C-T-L-S (MedialLateral)
 Upper > Lower Extremity
Involvement
 UE > LE Weakness Incomplete
C = Cervical Loss
 Sacral Sensory Sparing T = Thoracic
L = Lumbar
S = Sacral

4
 Brown-Sequard Syndrome Anterior Cord Syndrome
Position, Vibration
and Light Touch
Sensation Area of Cord
Area of Cord Damage Damage
 Hemitransection/lesion Motor
 Selective involvement of
 Ipsilateral Impairment
Anterior Spinal Artery, eg.
 Corticospinal (Motor)
Great Arty of Adamkiewicz
 Post Columns (Sensory)
 Position/Vibration
 Variable loss of Motor and
Pain/Temperature
 Contralateral Impairment
discrimination
Loss of voluntary  Spinothalamic (Sensory)
motor control on  Proprioceptive Sparing Pain &
same side as the
 Pain/Temperature Temperature

cord damage
Loss of pain and Loss of motor power,
temperature on pain, and temperature,
opposite side with preservation of
position, vibration and
some light touch
sensation

Conus Medullaris Syndrome Cauda Equina Syndrome

T11
 T12-L2 Burst Fracture
 Involves both UMN (Spinal Cord) T12  Lumbosacral nerve root
& LMN (Nerve Roots) lesion within neural canal
 Sacral Reflexes may be spared L1  Areflexic Bowel, Bladder,
 Typically, LMN Bowel & Bladder Lower Extremities
L2
 Neuropathic Pain

C1-C3 Tetraplegia C4 Tetraplegia

 Sensory
 Ant. Chest/Shoulder
 Motor
 Diapragm
 Trapezius
 Sternocleidomastoid
 Function
 Inhale
 Shrug Shoulders
 Turn head

5
 C5 Tetraplegia C6 Tetraplegia

 Sensory
 Lateral Arm  Sensory
 Motor  Lateral Forearm
 Biceps Brachii  Motor
 Deltoid  Extensor Carpi Radialis
 Infraspinatus
 Subscapularis
 Function
 Function  Extend Wrist
 Flex Elbow  Tenodesis
 Abduct, IR, ER Arm

FES Hand Grasp System C7 Tetraplegia

 Allows grasp/release in  Sensation
C5-C6 tetraplegia  Middle Digit
 Components include:  Motor
 External control unit  Triceps Brachii
 Implanted receiver  Flexor Carpi Radialis
 Implanted electrodes  Extensor Digitorum
Communis
 External transducer
 Function
 Case Western Reserve  Extend Elbow
 11 patients  Flex Wrist
 38/41 successful implants  Extend Fingers

C8 Tetraplegia Thoracic Paraplegia

 Sensation  Sensation
 Medial Hand  See Dermatomes
 Motor  Motor
 Flexor Digitorum Profundus  Intercostals
 Flexor Pollicus Longus  Abdominal Muscles
 Function  Paraspinal Muscles
 Flex fingers  Function
 Flex thumb  Truncal Stability
 Grip  Exhale

6
L2 Paraplegia L3 Paraplegia

 Sensation  Sensation
 Ant/medial thigh midway  Medial femoral condyle
between Inguinal above the knee
Ligament & Medial
femoral condyle  Motor
Quadriceps
Motor


 Adductors
 Iliopsoas
 Function
 Function
 Leg Extension
 Flex hip
 Thigh Adduction

L4 Paraplegia L5 Paraplegia

 Sensation  Sensation
 Dorsum 3rd MTP
 Medial Malleolus
 Motor
 Motor
 Extensor Hallicus Longus*
 Tibialis Anterior
 Gluteus Medius
 Function
 Function
 Dorsi Flexion
 Great Toe Extension
 Thigh Abduction

S1 Paraplegia S2-5 Paraplegia

 LMN Bowel
 Sensation  Constipation
 Bowel Incontinence
 Lateral Heel
 LMN Bladder
 Motor  Bladder Distension
 Gastroc-Soleus  Bladder Incontinence

 Gluteus Maximus  Sexual Dysfunction

 Erectile Dysfunction
 Function  Mal-lubrication
 Plantar Flexion  Sensory
 Thigh Extension  S2 Mid Popliteal Fossa
 S3 Ischial Tuberosity
 S4-5 Perianal 1 cm lateral to
mucocutaneous junction

7
 Spine Assessment:
The 3-Column Spine Mechanism of Spinal Injuries
AC MC PC

 Anatomy  Direct trauma or transmitted forces from violent head

 Anterior Column (AC)
and/or trunk motions
 Ant Longitudinal Ligament  Type and extent of bony injury dependent upon body
 Anterior Vertebral Body position, magnitude, intensity, and duration of the force
 Anterior Disc applied
 Middle Column (MC)
 Posterior Vertebral Body  Distinct patterns of ligamentous/boney injury and
 Posterior Disc neurological loss result from forces applied in certain
 Post Longitudinal Ligament directions
 Posterior Column (PC)  Degree of impingement of vertebrae and/or soft tissues
 Vertebral Arch
 Ligamentum Flavum on the spinal cord, vascular supply, or spinal nerves
 Intraspinous Ligament determines the extent of neurological deficit
 Supraspinous Ligament
 Surgical Stabilization
 Required when ≥ 2 columns
are disrupted

Mechanism of Cervical Injuries Mechanism of Cervical Injuries

 Poor mechanical stability s  Compressive Flexion

vulnerability to trauma  Distractive Flexion
 40% cervical injuries have  Vertical Compression
neurological deficit
 Most are lower cervical  Compressive Extension
 Rarely C1-C2 due to large  Distractive Extension
canal size or death on  Lateral flexion
impact
Allen, BL. A Mechanistic Classification of Closed,
Indirect Fractures and Dislocations of the Lower
Cervical Spine. Spine 1982;7(1). 1-27.

Mechanism of Cervical Injuries Mechanism of Cervical Injuries

 Distractive Flexion
 Compressive Flexion  Hyperflexion with
 Highest incidence of rotation
neurological deficit  Total disruption of
 Rapid deceleration in intervertebral
head-on collisions ligaments/disc with freely
mobile vertebrae
 Anterior compressive
with posterior distraction  Bilateral locked facets
force  Severe neurological
deficit

8
 Mechanism of Cervical Injuries Mechanism of Cervical Injuries
 Compressive Extension
 Vertical Compression
 Anterior Distraction with
 Axial load through Posterior Compression
straight or slightly flexed
 Example:
neck
 Fall, striking chin or forehead
 Examples:
 Rear-end collision
 Diving
 Anatomy
 Ceiling
 Anterior Longitudinal Ligament
 Bony fragments driven Rupture
posteriorly into canal  Vertebrae/disc with anterior
with significant deficit avulsion fx, or no
bony/ligament damage

Mechanism of Cervical Injuries Mechanism of Cervical Injuries

 Lateral Flexion
 Distractive Extension
 Pure lateral flexion is rare
 Hyperextension & Rotation
 Unilateral compression of
 Total disruption of vertebral column with lateral
intervertebral ligaments wedging of the vertebral
&/or disc with freely mobile body/fracture of the arch
vertebrae
 Distraction on opposite side
 Bilateral locked facets with ligamentous disruption
 Severe neurological deficit  May be associated with

brachial plexus injury

Mechanism of Thoracic Injuries Mechanism of Thoracic Injuries

 Stability added by ribs

requires extreme force to
acquire cord injury
 Compressive Flexion
 More likely to be complete  Most common
injuries due to extreme  Natural kyphosis
force, small canal size, and
poor upper thoracic vascular
converts vertical
supply compression forces
 Most common at T12-L1 to flexion
junction where rigid thoracic
meets flexible lumbar spine

9
 Mechanism of Thoracic Injuries Mechanism of Thoracic Injuries

 Distractive Flexion  Vertical compression

 Anterior compression,  Struck by a falling object,
posterior distraction with or fall with landing on
rotation upper thoracic spine,
buttocks, or feet
 Three-column
involvement with bony  Crushed vertebral body
fragments in the canal with fractured arch and
bone in the canal

Mechanism of Lumbar Injuries Mechanism of Lumbar Injuries

 Injury most often at T12-L1

 Distractive Flexion
junction
 Lumbar spine flexed
 Neurological damage is
violently over fulcrum
usually incomplete due to
located anterior to
good vascular supply, large
abdomen
canal, and presence of cauda
 Horizontal ligament, disc,
equina.
and bony injury
 Compressive flexion and
 Lap-belt only
vertical compression no
different from thoracic spine  Abdominal injuries

Need for Surgical Stabilization Goals of Surgical Stabilization

 45.3% none
 49.3% one spine surgery  Restore spinal alignment
 5.0% two spine surgeries  Establish spinal stability
0.4% three or more spine

 Prevent further neurological
surgeries
deterioration
 Surgical stabilization in <24  Enhance neurological
hours decreased acute care recovery(?)
Length of Stay with no
difference in neurological
outcome

10
 Thoracolumbar Injury Classification &
Severity Score (TLICS) TLISS Management

Vacarro et al (2005) Spine 30(20): 2325-2333 Vacarro et al (2005) Spine 30(20): 2325-2333

Surgical Management Surgical Stabilization

 Fusion/Internal fixation 30.4%
 Posterior decompression with/without
Fusion/Internal fixation 9%
 Anterior decompression with/without
Fusion/Internal fixation 7.3%
 Non-penetrating injury 65-72%
surgery
 Penetrating injury 8%-14% surgery
 Bullet removal @ lumbar spine
improves Lower Extremity Motor
Score 12.9 + 6.1 vs 3.3 + 3.6
 Cervical and Thoracic unchanged

Vacarro et al (2005) Spine 30(20): 2325-2333

Post-op Management Spinal Orthoses

 Restrictions?
 Log roll only until spine surgery done
 Halo Vest
&/or spinal orthosis is fabricated  Restricts 90% of
 Spinal Orthosis only as effective as its fit flexion/extension
 Post-surgical restrictions may include:  Restricts all lateral
 Head of bed <30 flexion/rotation
 No hip flexion > 90  Requires well molded
 Orthosis when out of bed vest

11
 Spinal Orthoses (Cont) Spinal Orthoses (Cont)

 Hard Cervical Collar

 Sternal Occipital  Restricts 75% flexion,
Mandibular Immobilizer extension and lateral flexion
(SOMI)  Limits 50% rotation
 Restricts 80% flexion  Soft Cervical Collar
 Restricts 85%  Restricts 5% flexion /
extension/lateral flexion extension
 Limits 60% rotation  Limits 10% lateral flexion
 No rotation restriction

Spinal Orthoses (Cont) Spinal Orthoses (Cont)

 Thoraco-lumbar-sacral orthosis  Lumbosacral Orthosis

(TLSO with hip incorporated) (LSO)
 Restricts 60% flexion /  Restricts 60% flexion /
extension (90%) extension
 Restricts 50% lateral flexion  Restricts 40% lateral
(70%) flexion
 Limits 30% rotation (90%)  Limits 20% rotation

Complications of SCI Pulmonary Dysfunction

 Respiratory Paralysis
 Reduced FVC, TV
 Pulmonary Dysfunction  Heterotopic Ossification  Atelaectasis
 Cardiovascular  Immobilization  Parasympathetic Dominance
Bronchiolar Constriction
 DVT &/or PE Hypercalcemia 

 Mucus Secretions
 Autonomic Dysreflexia  Sexuality/Impotence  At risk for Aspiration

 Neurogenic Bladder  Pressure Sores  Level of SCI predicts respiratory

complications
 Neurogenic Bowel  Spasticity  C1-C4: 84% at least 1
 C5-C8: 60% at least 1
 Thoracic: 65% at least 1

12
 Muscles of Respiration Respiratory Rx in SCI

 Inspiration  Bronchodilators
 Diaphragm (C3-C5)*  Atrovent
 Internal IC (T1-T11)*  Parasympathetic Blockade
 SCM (C1-C3)  Theophyllines
 Trapezius (C1-C4 & CNXI)  Diaphragmatic Contractiliy
Prevents Bradycardia
Scalenes (C4 & CN XI)


 Mucociliary Clearance
 Expiration
 Mucolytic Agents
 Rectus Abdominus (T6-T12)*
 Humabid LA 1200 bid
 Transversus Abd (T2-L1)*
 Mucomyst (bronchospastic)
 Int & Ext Obliques (T6-L1)*
 Dornase 2.5 bid ($2,000/mo)
 Diaphragm (C3-C5)
 O2, Chest PT, Roto Rest Bed
 Int Intercostals (T1-T11)
 Frequent Bronchoscopy

Respiratory Rx in SCI SCI Pulmonary Management (Cont)

 Common Complications (67% Overall)

 Insufflation-Exsufflation (Assisted Deep
Atelectasis (36%)
Breathing)


 Pneumonia (31%)
 (+)35t to (-)35t
 Respiratory Failure (23%)
Secretion Movement 
Acute Ventilator Management


 Indications  Face or Mouth Mask: Add abdominal
 Inability to manage secretions
thrust
 Impending fatigue  Tracheostomy or ETT: No abdominal
 Unresponsive Hypoxemia thrust
 Respiratory Rate > 35 /minute  Airway Secretion Clearance
 MIP < 25, MEP < 20 cm H2O
 Postural Percussion & Drainage (PP&D)
 VC < 2X TVpred, or < 15cc/kg
 Settings  “Quad Cough”
 TV 15-20cc/kg IBW  Rocking Bed
 PEEP 3-4 cm H2O

CV Responses in SCI Orthostatic Hypotension

 Gradual Incline
 Circulatory Hypokinesis
 Recline Wheelchair
 Hypotension on exertion due to:
 Tilt Table
 Reduced Vasoconstriction
 Reduced Venoconstriction  Mechanical Support
 Impaired Venous Pump  Abdominal Binder
 Impaired Cardiac Output (Q=HRxSV)  Elastic Stockings
 Reduced SV due to:  Adequate Hydration
 Adaptive Myocardial Atrophy  Pharmacological Interventions
 Reduced LVEDV  Salt tablets 1g qid
 Blunted HR chronotropic response due to:  Ephedrine 20-30 mg qid
 Incomplete sympathetic drive  Fludrocortisone 0.05-0.1 mg qd
SCI above T3 rarely achieve HR>120 bpm
Midodrine Chloride 2.5-10 mg tid



13
 DVT &/or PE Autonomic Dysreflexia

 Risk Factors
 Hemostasis
 Definition:
 Hypercoagulability  Massive Sympathetic outflow
in response to noxious stimuli
 Diagnosis
below the level of Spinal Cord
PE, Labs, Imaging,
Injury in complete SCI lesions


Venogram/Angiogram
above T6
 Management
 Prophylaxis: Heparin vs LMW
 Complications
Heparin within 72 hours of SCI,  CVA
and continued 8-12 weeks  Seizures
IV Heparin

 Organ Failure
 Coumarin 3-6 months
 IVC Filter

Acute Management of AD

Noxious Stimuli
 Elevate head
 Loosen tight clothing,
Autonomic Dysreflexia
leg bags, etc.
HYPERTENSION!!  Check bladder,
Bradycardia bowel, other sources
 Pharmacological
Intervention

Splanchnic Vasoconstriction

Pharmacological Rx of A.D. Neurogenic Bladder

 Anatomy
 Immediate/Emergent
 Upper Motor Neuron (UMN)
 Procardia 10 mg p.o./s.l.
 Hyperreflexic
 NTG 1/150 s.l. or,
 Detrusor Sphincter Dyssynergia
 Nitropaste 0.5” topically
 Lower Motor Neuron (LMN)
 Clonidine 0.1 to 0.2 mg p.o.
 Flaccid detrusor
 Hydralazine - 10 to 20 mg. IM/IV
 Chronic (Recurrent Episodes)  Renal Dysfunction
 Dibenzyline 10 mg p.o. bid  UTIs
 Prazosin 0.5 -1.0 mg p.o. qd  Calculi
Clonidine 0.2 mg. p.o. b.i.d.

 Bladder Management

14
 Neurogenic Bowel Pressure Sores

 Anatomy  Etiology: Ischemia vs Shear

 UMN: Hyperreflexia  Pressure points
 LMN: Hyporeflexia  Classification of Pressure
 Ileus Sores
 Bowel Care  Management
 UMN  Prophylaxis
 Reflex Evacuation  Medical
 LMN  Surgical
 Passive Evacuation

Spasticity Heterotopic Ossification

 Definition: Abnormal periarticular

 Velocity-dependent tone bone
 Disinhibition of reflex arc
 Incidence: 16-53%
 Classifications
 Diagnosis: PE, Labs, 3-P Bone
 Management
Scan, Xray
 Modalities: Stretch, cold
 Pharmacological: Baclofen,  Management
Valium, Tizanidine, Dantrium  Range of Motion (ROM)
 Neurolysis vs Motor point block  Pharmacological: NSAIDs,
 Surgical: Tenotomy, dorsal Diphosphonates
rhizotomy
 Surgical

Immobilization Hypercalcemia Sexuality

 Men
 Clinical Signs & Symptoms  Erection: Psychogenic
 “Stones, bones, groans, moans” versus reflexic
 Etiology  Ejaculation
 Management  Infertility
Volume repletion & hydration
Women


 Diuresis
 Mithramycin vs calcitonin  Orgasm
 Osteopenia  Birth Control
 Pregnancy, Labor &
Delivery

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 Additional SCI Health Risks Heart Disease in SCI
 Leading cause of mortality in
Chronic SCI
 Pulmonary Complications
 Silent Ischemia
 Coronary Artery Disease
 Risk Factors
 Diabetes Mellitus
 Cigarette Smoking
 Stroke
 Hypertension
 Obesity  Family History
 UE Degenerative Joint Disease  Male Gender
 Osteopenia  Sedentary Lifestyle
 Depression  Insulin Resistance (DM)
 Obesity
 Dyslipidemia

Glucose Intolerance in SCI Dyslipidemia in SCI

 Hyperinsulinemia & Glucose  Bauman et al, 1992
Intolerance has been reported T.Chol HDL
in 50-67% of SCI adults  Tetraplegics 188 40  1
 Bauman & Spungen, 1994  Paraplegics 191 37  1
Duckworth et al, 1983

 AB Controls 210 48  2
 Zhong et al, 1995
 Zlotolow et al, 1992
 Aksnes et al, 1996
 Dissociation between whole
 Serum HDL in SCI veterans
body insulin-mediated glucose was 35 2 vs. 49 2 in age-
uptake & skeletal muscle mass matched AB Controls
in SCI  Tharion et al, 1998
Suggests Insulin Resistance

 58% SCI individuals with 
due to muscle atrophy
HDL; Only 2% with  T.Chol

Ventilatory Responses to Thermoregulatory Responses

Exercise in Spinal Cord Injury to Exercise in SCI
 SCI above T6: Partial Poikilothermic
 Impaired Diaphragmatic Excursion  Reduced Plasma Volume
Impaired countercurrent exchange
Intercostal Muscle paralysis


 Abnormally high fluid shifts
 Abdominal Muscle paralysis
 Preoptic Anterior Hypothalamus (POAH)
 Allows diaphragm to descend,  Reduced sensitivity to increases in local
reducing mechanical efficiency of temperature
contraction  Blunted Output Response to Hyperthermia
 Blunted Ventilatory Responses  Enhanced sweat rates (up to 6x-normal)
above level of SCI
 Impaired Sympathetic Drive
 Impaired Skin Vasodilatation & Sweating
 Impaired Hypothalamic & Medullary Below Level of SCI
responses to chemoreceptor  Overall, Impaired Heat Dissipation
stimulation from muscle & carotid  Thermoregulatory Spinal Reflexes
bodies  Partial but blunted sweat responses below
level of SCI

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 Endocrine Responses in Spinal
Cord Injury Overuse Syndromes in SCI
 Musculoskeletal
 Catabolic Hormones
 Rotator Cuff Impingement
 Blunted Catecholamine response
 Blunted Corticosteroid release  Epicondylitis
 Reduced Glucagon release  DeQuervain’s Tenosynovitis
 Anabolic Hormones  MCP Dysfunction
 Blunted Growth Hormone &  Nerve Entrapment
Somatomedin response
 Ulnar Neuropathy
 Blunted Testosterone release
 Cubital Tunnel
 Blunted (?) Erythropoietin release
 Guyan’s Canal
 Relative Insulin resistance
improved with exercise  Median Neuropathy
 Carpal Tunnel Syndrome

Neurological Change Post-SCI Optimizing Motor Recovery…

 Syringomyelia
 Abnormal, fluid-filled cavity
within the substance of the
spinal cord
 Hematoma
 Trauma (New)
 Tumor

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