Paraplegic Exam

[explenture]

Had a paraplegic patient who stated they had a broken femur. Of course one of the things to during an exam is pulse, movement and sensation in the leg. This is not possible with a paraplegic.

How would you all handle such a scenario?

[MedicRN]

All you can really do is monitor pedal pulses and vital signs. Depending on the level of the SCI/paraplegia, you might see some autonomic dysreflexia due to the body's altered response to pain.

[AnatomyChick]

Yep... I agree.. Skin Colore, Temp, integrity is a good thing to look for as well.

[EMT001]

Just curious, how did he say he broke his femur?

[Ace844]

Just curious, how did he say he broke his femur?

Walking around of course......

[Ace844]

Hello Everyone,

Here's some good refrences for info on this 'topic'.

[web:13e3f7e0db]http://www.uic.edu/com/ferne/pdf2/saem_0501/chanmugan_stroke_saem_0501.pdf[/web:13e3f7e0db]

http://www.canparaplegic.org/national/leve...&var2=44.00

Spinal Cord Injury In Detail

05/01/2000

The following passages were excerpted from

Standards for Neurological and Functional Classification of Spinal Cord injury, published

by the American Spinal Injury Association (ASIA)

source: CPA

Classifications and terminology of spinal cord injury.

The spinal cord is the "highway" through which motor and sensory information travels between the brain and body. It contains spinal tracts (white matter) which surround central areas (gray matter) where most neuronal cell bodies are located. Gray matter is organized into segments comprising sensory and motor neurons. Nerves in the spinal cord connect to the body through nerve "roots" that exit the spinal column and supply the nerves in the legs, bladder, etc.

Each root receives sensory information from skin areas called dermatomes. Each root supplies nerve control to a group of muscles called a myotome. While a dermatome usually represents one specific skin area, most roots supply nerve control to more than one muscle, and most muscles are innervated by more than one root.

Spinal cord injury (SCI) affects conduction of sensory and motor signals across the site(s) of lesion(s). By systematically examining the dermatomes and myotomes, health care practitioners can determine the cord segments affected by spinal cord injury.

Spinal cord injured patients are classified into two basic schemes:

Quadriplegia - if there is evidence of functional loss of motor and sensory function at or above the C8 neurological level with demonstrable loss in the upper extremities

Paraplegia - functional loss below the C8 level and represents a wide range of neuromuscular dysfunction.

An injury is classified into two basic categories:

Complete - no functional motor or sensory preservation in the sacral segments

Incomplete - preserved motor or sensory function at the sacral levels

Definitions

Tetraplegia (preferred to "quadriplegia")

Impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal. Tetraplegia results in impairment of function in the arms as well as in the trunk, legs, and pelvic organs. It does not include brachial plexus lesions or injury to peripheral nerves outside the neural canal.

Paraplegia

Refers to impairment of loss of motor and/or sensory function in the thoracic, lumbar or sacral (but not cervical) segments of the spinal cord, secondary to damage of neural elements within the spinal canal. With paraplegia, arm functioning is spared but depending on the level of injury, the trunk, legs, and pelvic organs may be involved. There are some types of paralysis involving the legs that are described by the impairment they cause (see Clinical Syndromes).

Dermatome

Refers to the area of the skin innervated by the sensory axons with each segmental nerve (root).

Myotome

Refers to the collection of muscle fibers innervated by the motor axons within each segmental nerve (root).

Neurological Level

Refers to the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body. In fact, the segments at which normal function is found often differ by side of body and in terms of sensory vs. motor testing. Thus, up to four different segments may be identified in determining the neurological level. In cases such as this, generally each of these segments is separately recorded and a single "level" is not be used.

Sensory Level and Motor Level

When the term "sensory level" is used, it refers to the lowest segment of the spinal cord with normal sensory function on both sides of the body. The motor level is similarly defined with respect to motor function. These "levels" are determined by neurological examination of (1) a key sensory point within each of 28 dermatomes on the right and 28 dermatomes on the left side of the body, and (2) a key muscle within each of 10 myotomes on the right and 10 myotomes on the left side of the body.

Incomplete SCI

If partial preservation of sensory and/or motor functions is found below the neurological level and includes the lowest sacral segment, the injury is defined as incomplete. Sacral sensation includes as well as deep anal sensation. Voluntary contraction of the anal sphincter muscle is used to demonstrate preserved muscle function.

Complete SCI

This term is used when there is an absence of sensory and motor function in the lowest sacral segment. The neurological level is given as the lowest level where there is still some evidence of muscle function or sensation, but no preservation in the sacral area.

Zone of Partial Preservation

Refers to those dermatomes and myotomes below the neurological level that remain partially innervated. When some impaired sensory and/or motor function is found below the lowest normal segment, the exact number of segments so affected make up the ZPP. The term is used only with incomplete injuries.

Neurological Examination

The neurological examination allows a physician to classify a person's spinal cord injury into broad categories and types. This helps in determining the prognosis and current status of the individual with SCI. The exam has two components (sensory and motor), which are separately described below. The neurological examination has both required and optional elements. The required elements are used in determining the sensory/motor/neurological levels, in generating scores to characterize sensory/motor functioning, and in determining completeness of the injury. The optional measures, though not used in scoring, may add to a specific patient's clinical description.

Sensory Exam

The required portion of the sensory examination is completed through the testing of a key point in each of the 28 dermatomes on the right and left sides of the body. At each of these key points, two aspects of sensation are examined: sensitivity to pinprick and to light touch. Testing for pin sensation is usually performed with a disposable safety pin; light touch is tested with cotton.

In addition to bilateral (both sides) testing of the 28 key points, the external anal sphincter is tested for sensation to help determine the completeness/incompleteness of the injury. Optional (though strongly recommended) elements of the sensory examination include position senses and awareness of deep pressure/deep pain.

Motor Exam.

The required portion of the motor examination is completed through testing of a key muscle (one on the right and one on the left side of the body) in the 10 paired myotomes. As with the sensory examination, the external anal sphincter is also tested to help determine the completeness of injury.

Other muscles are often evaluated, but their scores are not used in determining the motor score, motor level, or completeness of injury. As warranted, it is suggested that the following muscles be tested: (1) diaphragm, (2) deltoid and (3) lateral hamstrings.

ASIA Impairment Scale

The ASIA Impairment Scale uses the findings from the neurological examination to categorize injury types into specific categories. These categories allow researchers to identify the outcome of different injuries and degrees of spinal cord damage.

The following scale is used in grading the degree of impairment:

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

B =Incomplete. Sensory but not mr function is preserved below the neurological level and extends through the sacral segments S4-S5.

C =Incomplete. Motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade less than 3.

D =Incomplete. Motor function is preserved below the neurological level, and the majority of key muscles below the neurological level have a muscle grade greater than or equal to 3.

E = Normal. Sensory and motor function are normal.

Clinical Syndromes

Central Cord Syndrome

A lesion, occurring almost exclusively in the cervical region, that produces sacral sensory sparing and greater weakness in the upper limbs than in the lower limbs. A central cord syndrome indicates there is an injury to the central structures of the spinal cord. This is most commonly seen in older patients with cervical arthritis and may occur in the absence of spinal fracture.

Cauda Equina Syndrome

Cauda Equina syndrome refers to injury to the nerves still within the spinal cord as they form a "horse's tail" to exit the lumbar and spinal regions. This usually occurs with fractures below the L2 level and results in flaccid-type paralysis. The type of bladder and bowel impairment that results from such an injury depends on the level of the injury and can be problematic, particularly for women, who may have difficulty with urinary drainage and incontinence.

Anterior Spinal Artery Syndrome (also known as Anterior Cord Syndrome)

Anterior spinal artery syndrome refers to the anterior spinal artery that originates from the vertebral arteries and basal artery at the base of the brain and supplies the anterior two-thirds of the spinal cord to the upper thoracic (chest) region The lesion produces variable loss of motor function and of sensitivity to pinprick and temperature, while preserving proprioception (position sense).

Brown-Sequard Syndrome

The Brown-Sequard syndrome is caused by a functional section of half of the spinal cord. This results in motor loss on the same side as the lesion and sensory loss on the opposite side. This syndrome is very often associated with fairly normal bowel and bladder function and does not prevent the person from being able to walk, although some functional bracing or ambulatory device such as a cane or crutch may be necessary.

Conus Medullaris Syndrome

Injury of the sacral cord (conus) and lumbar nerve roots within the neural canal, which usually results in an areflexic bladder, bowel and lower limbs. Sacral segments may occasionally show preserved reflexes with higher lesions.

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://www.spineuniverse.com/pdf/traumaguide/3.pdf

http://www.sci-info-pages.com/glossary.html

http://www.vard.org/jour/05/42/3%20suppl%201/ditunno.html

http://www.thejns-net.org/spine/issues/v96...df/s0960259.pdf

http://www.appneurology.com/showArticle.jh...icleId=57703078

http://jnnp.bmjjournals.com/cgi/content/full/69/2/275

http://www.nlm.nih.gov/medlineplus/print/e...icle/003190.htm

http://www.iscos.org.uk/home.html

http://www.co-neurology.com/pt/re/coneuro/...9856145!8091!-1

Hope this Helps,

ACE844

[explenture]

Just curious, how did he say he broke his femur?

Going down a slide at a water park.