Scribd
Upload
364 views17 pages

Case Presntation 6

This 19-year-old female sustained a spinal cord injury at T5 resulting in complete loss of sensation and motor function below the nipple line. She has poor sitting balance and is dependent on assistance for transfers and wheelchair mobility. The primary goal is to improve her sitting balance as all other goals rely on this. Long-term goals include achieving full independence with daily activities and returning to university studies.

Uploaded by

Raghu Nadh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
364 views17 pages

Case Presntation 6

This 19-year-old female sustained a spinal cord injury at T5 resulting in complete loss of sensation and motor function below the nipple line. She has poor sitting balance and is dependent on assistance for transfers and wheelchair mobility. The primary goal is to improve her sitting balance as all other goals rely on this. Long-term goals include achieving full independence with daily activities and returning to university studies.

Uploaded by

Raghu Nadh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
You are on page 1/ 17

CASE STUDY 6 SPINAL CORD INJURY

AT T5
The following patient has recently been transferred to a rehabilitation
unit following a period of care for a spinal fracture at T5. Surgical
intervention was required to stabilize the fracture site and decompress
the spinal cord. The patient is now wearing a brace, which is due to be
reviewed in the next few weeks.
Subjective assessment
PC 19-year-old female who suffered a crush fracture with
spinal cord compression at T5 following a fall while
rock climbing 4/52 ago
Wearing brace which needs to be worn for 3/12 to
maintain alignment at fracture site
Recently transferred to rehabilitation unit for intensive
rehabilitation
Wheelchair has been prescribed. Having difficulty self propelling
due to poor sitting balance and atrophy of all upper limb muscles
Transferring with assistance of one or two with banana
board
Anxious to be discharged – university course recommences in
2 months time and wants to return
Has made enquiries at local university about the possibility of
transferring studies so that she can live with parents
HPC Sustained a complete disruption of spinal cord at T5
No sensory function or motor function present below nipple
line
Surgical intervention required to stabilize anteriorly and
posteriorly following injury
Provided with a self-propelling wheelchair 2/52 ago with
pressure relieving cushion in situ. Difficulty in self-propelling
due to poor sitting balance
Becoming increasingly frustrated with lack of independence
Recently had catheter removed, now intermittent self catheterisation
with assistance from nursing staff with a view to
full independence. Currently hampered by poor sitting balance
Treated initially at regional spinal unit. Requested transfer to
local rehabilitation unit to be closer to family and friends
PM: Nil of note
DH: Nil of note
SH ;Lives with parents in terraced house. All facilities upstairs.
Parents have converted second reception room on ground floor
into bedroom which is separate to main living areas
Occupational therapists have undertaken an initial home
assessment and temporary ramps and a commode have been
provided. Referral to social services occupational therapy for
assessment for home adaptations has been arranged
Keen to commence weekend leave from the rehabilitation unit
Student at university studying law. Lives in halls of residence, but
was due to move into shared housing with friends at start of next
academic year
Has been in contact with local university about the possibility of
transferring her studies to allow her to live at home. Agreement
has been reached re: transferring studies. New academic year
starts in 2/12 time, though can delay starting second year of
studies for a year to allow further time for recovery
Both parents work full-time, younger brother who also lives at
home is due to start college in 1/12
Active sportswoman enjoys rock-climbing, netball and hockey
and represented university sports teams in the previous year
Objective assessment
Brace in situ throughout assessment.
Lying :Supine
Full range of movement both upper limbs (within
limits of position)
Patient reports decreased muscle strength throughout
upper limbs (Grade 4+ Oxford Scale) and atrophy
Previously had good upper-limb strength due to rock
climbing
Full passive range of movement available in both
lower limbs, low tone throughout. No active
movement or sensory discrimination evident on full
assessment
Lying to sitting: With assistance from one, able to push through upper
limbs to move into long sitting
Requires assistance from one to move lower limbs
over edge of bed to achieve sitting. Able to adjust
sitting position by pushing through upper limbs to
lift trunk. Facilitation from one required to maintain
balance during transfer
Unsupported sitting:
Able to maintain sitting posture through overuse of
upper limbs to increase base of support
Overuse of thoracic and cervical extension to
maintain sitting posture
Unable to move within base of support in sitting or
release upper limbs to enable function
Transfers: Requires maximum assistance of two to transfer
weight laterally and place banana board
Able to initiate movement along banana board by
pushing through upper limbs though requires
facilitation to maintain balance and reposition lower
limbs during transfer
Questions
1. What problems can be associated with spinal cord
injury at T5?
2. This patient has a complete disruption of the
spinal cord, what pattern of dysfunction might
you see had she sustained an incomplete
disruption?
3. What would your problem list be for this patient?
4. How would you prioritise these goals and why?
5. What long-term goals are relevant for this
patient?
1. Spinal nerves T2–T11 are known as intercostal nerves as they do not
enter into plexuses. These nerves are distributed directly to the
structures which they innervate and pass in the intercostal spaces,
therefore the effects of disruption of the spinal cord between T2 and
T11 are more straightforward to establish than might be the case for
levels where spinal nerves enter into plexuses.
Dermatome distribution for T5 is at approximately the nipple line,
therefore for this patient’s sensation below this line is lost (Drake et al
2004). It is possible that motor control will remain in the back
extensors (Stokes 2004), which would indicate that full wheelchair
independence should be achieved. No motor control will be evident
within the lower limbs.

2. Spinal cord injuries are classified as complete or incomplete based


on assessment with the American Spinal Injuries Association (ASIA)
Impairment scale (ASIA 1992) Lesions are classed as incomplete if
sensory or motor functions are detectable in the sacral segment S4–S5.
(Sacral sensation includes perianal and deep anal sensation. Voluntary
contraction of the anal sphincter muscle is used to demonstrate
preserved muscle function.) Preservation of sacral sensation or
motor activity can be a positive indicator of neurological recovery
as it suggests that long tracts have been preserved through the
level of the spinal cord injury.
Incomplete lesions are referred to clinically as syndromes or
injuries, as patterns of symptoms present dependent on the
anatomical area of the spinal cord injured. The five identified clinical
syndromes are outlined briefly below:
Central cord syndrome – Occurs almost exclusively in the cervical region.

Central cord syndrome indicates there is an injury to the central


grey structures of the spinal cord and is most commonly seen in
older patients with cervical spondylosis. Osteophytes, possible disc
bulges and spondylitic joint changes and thickening of the ligamentum
flavum all combine to compress the cord in the canal
and can lead to compression of the cord. Central cervical tracts
are predominantly affected. There is greater weakness in the upper
limbs than in the lower limbs with preservation of sacral sensation.

Brown–Sequard syndrome – Caused by an injury to only half of the spinal


cord. This results in motor loss on the same side as the lesion
and sensory loss on the opposite side due to the crossing of the
spinothalamic tract. This syndrome is very often associated with
fairly normal bowel and bladder function and has a good prognosis
in terms of return of ambulatory function (Johnston 2001).
Anterior cord syndrome – Also known as anterior spinal artery syndrome,
refers to damage to the anterior spinal artery which originates
from the vertebral arteries and basal artery at the base of
the brain. It supplies the anterior two-thirds of the spinal cord
to the upper thoracic region. There is complete loss of motor
control below the lesion and loss of pain and temperature sensation
due to the anatomical position of these tracts in the spinal
cord. As the posterior columns are unaffected proprioception
and vibration are unaffected.

Conus medullaris syndrome – Injury of the sacral cord and lumbar


nerve roots within the neural canal. Bladder and bowel dysfunctions
are usually present with bilateral lower limb
impairment, though the extent of involvement of the lower
limbs is variable.

Cauda equina syndrome – Flaccid paralysis of the lower limbs. 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 (Stokes 2004).
3. Problems identified for this patient are:
l poor sitting balance
l dependence in wheelchair mobility
l dependence on one to two with transfers
l requirement of assistance from one to self-catheterise
l decreased strength in upper limbs
l eagerness to be discharged
l university course commencement in 2/12 time
l decreased social activity.

4. Prioritisation should be given to improving sitting balance for this


patient as all other goals are dependant on improvement in this
area. While focus should be maintained on sitting balance,
treatment programmes directed at achieving increased upper limb
strength, independence in transfers and wheelchair mobility
could also be structured to address the goal of improved sitting
balance.
5. Long-term goals for this patient should focus on full independence
within personal and domestic activities of daily living, vocational
and social activities. The National Service Framework for Long Term
Conditions (DoH 2005) sets out eleven standards with the aim of
supporting people with long-term conditions to live as
independently as possible. While all quality requirements need to be
taken account of during this patient’s rehabilitation, long-term
rehabilitation in particular needs to reflect Quality Requirement 6,
which aims to ensure that people with a long-term neurological
condition are enabled to work or engage in alternative occupations
(DoH 2005). For this patient this would include active efforts to
support her in returning to university studies. As the patient has a
desire to return home as soon as possible, long-term rehabilitation
in the community would also have to be a focus of long-term
treatment planning. This is in line with Quality Requirement 5 of
the NSF for Long Term Conditions which aims to enable and
support people with long-term neurological conditions to lead a full
life in the community. Early liaison with community rehabilitation
services to ensure continuity of care following discharge would be
advised.

You might also like