3 Importance of NT/SCI Morbidity Loss of Function Cost of care weakness, neurogenic bladder / bowel, spasticity, infections, venous thrombosis, depressionLoss of Functionmobility, self-care, vocational, socialCost of carehospitalization, home, lost wages
4 Importance: NT/SCI (cont.) NT/SCI represents a significant % of SCI and of those undergoing SCI rehabCommon causes: Spinal Stenosis (SS), tumor, ischemiaPrior Literature: lacking for NT/SCI (demographics, clinical, outcomes) as opposed to Traumatic SCI (MVA, violence, falls)
5 Incidence: NT/SCI Kurtzke (1975): Incidence = 8/100,000 Gibson (1991): Stenosis 16%, Cancer 14% (SCI admissions)Murray (1994): NT/SCI 31% (less than 40)(87% greater than age 40)McKinley (1999): NT/SCI 39%, Stenosis 26%, Tumor 10%
7 Nontraumatic vs Traumatic SCI McKinley W, Seel R, Hardman J. Arch PM&R 80, , 1999(Five year perspective study (N=220))39% NT/SCI (26% SS, 10% tumor)(Comparison NT/SCI vs T/SCI)Demographics:Significantly (P < .01) older (61 yr vs 39yr), married (57% vs 38%), female (50% vs 16%), retired (76% vs 33%)
8 NT/SCI vs T/SCI (cont..) Injury characteristics: Outcomes: Significantly (P < .01) paraplegia (73% vs 55%)& incomplete SCI (91& vs 58%)Outcomes:Significant FIM gains (admit-disch.)Similar FIM efficiencySimilar discharge to home rates“Matching study”: shorter rehab LOS (rehab charges), similar FIM efficiency,
9 Conclusions: NT/SCI vs T/SCI Significant % of SCIRepresent different demographic make-up (older, married, not working)Less severe neurological presentation (paraplegia. Incomplete)Similar outcomes vs traumatic SCIFurther Studies: morbidity, long-term functional outcomes, cost, RTW, community reintegration
10 NT/SCI: Medical Complications NT/SCI (37) vs T/SCI (77)Spasticity* % %Orthostasis* % %DVT* % %Pneumonia* % %Aut. Dysreflexia* % %Wound infection % %Similar incidences: Pain, UTI, depression, pressure ulcers, GI bleeds, Het. Oss.
18 Metastatic Epidural SCC (MESCC) Vertebral mets - seen 15-40% (100,000 yr)Hemodynamic mets – bone marrowBatsons epidural venous plexus – pelvic, abdominal and thoracic (valsalva, coughing)Location: 85% vertebra, 10% paravert, 5% epiduralPrimary site: breast, lung, prostate 50% (others: lymphoma, renal, MM)9% of cases have unknown primary tumorChildren: neuroblastoma, sarcoma, lymphoma
19 MESCC (cont.) Epidural SCC occurs in 5% Path: cord compression/ischemiaedema, demyelination, hemorrhage, cystic necrosisClinical: Onset: days to weeks, localized pain (95%), worse w/ supine, paresis is rare initial clinical finding but 75% have at dx (50% unable to ambulate, 15% paraplegic)Thoracic 70%, Cervical 10%, Lumbar 20%
20 MESCC (cont.) Dx: MRI (contrast), CT, myelo, bone scan Rx: CSF chemo, steroids, XRTradiosensitive: breast, prostate, lymphomaSurgical considerations: tumor removal, diagnosis, deterioration after XRT, spinal instability or bony compressionPrognosis: neurological function at XRTAmbulation: 80% if ambulating at initiation, 50% if weak, <10% if paraplegic30-50% improvement in radiosensitive tumors
21 Rehabilitation of Neoplastic SCC Important considerations:Pain Rx, Psychological RxOutcome comparison w/ Traumatic SCI(McKinley, Wyneken, CIfu: Archive PM&R 1996(McKinley, Huang, Brunsvold. Archives PM&R 1999)older age (58yr vs 36yr), female (58% vs 18%), paraplegia (88% vs 52%), incomplete (88% vs 57%)Functional improvements (FIM) at DC & 3 mo f/uSimilar FIM Efficiency as Traumatic SCILOS shorter (25 vs 57 days)
22 Intradural/Extramedullary SCI Tumors Path: compression & ischemiaMeningiomaNeurofibromatosis- (cutaneous lesions, diagnosed by biopsy, early adulthood)Clinical : similar to MESCCoften benign
23 Intramedullary SCI Tumors Clinical: Males 56%, thoracic 50%,Path: Gliomas most common (ependymomas 60%, astrocytomas 25% (most common in children))Ependymomas – benign (ependymal cells line CNS)Astrocytomas – graded 1-4 (1 and 2 = 76%)Prognosis: 5 year survival 80% with grades 1 and 2, < one year survival with grades 3 and 4Rx: biopsy, XRT, surgical removal
25 Paraneoplastic myelitis Definition: “remote effects of tumor, not due to direct invasion/compressionPath: Subacute necrosis of gray/white matter, no evidence of infection , inflammation or ischemiaAssociated with lung cancer, LymphomaClinical: progressive weakness
26 Radiation Myelopathy Incidence 2-3% Path: delayed vascular necrosis of white/gray matterOnset occurs 6-48 months (usually 12-15) after XRTseen w/ total radsimportance: spacing & size of radiation fieldRec: total dose < 6000 rads (given over days, daily fraction < 200, weekly < 900 rads)Clinical: sensory changes, paresthesias, weakness with decreased reflexesRx: trial of steroids
27 Vascular “Ischemic” Myelopathy Incidence: 1% of all strokesEtiology: aortic dissection, embolism, vascular surgery, AVM, hypotension, hemorrhagePath: tissue vulnerability (inadequate anastamosis)No permanent damage < 30 minutes of interrupted blood supply (aortic clamping). gray matter more vulnerable (metabolic rate 3.5X white)Brain more vulnerable than Sp cord (brain TBF = 50ml/min, sp cord = 20 ml/min)
30 Aortic Aneurysm-related SCI Most common cause of vascular cord injuryPath: ischemia during surgery (1-2%) or dissection (2%)-occludes sp artClinical: anterior spinal artery (ASA) syndrome, sudden onset pain & paralysis, thoracic region primarily (lack of collateral circulation)
31 Embolic Ischemia Rare Path: atheromatous emboli “Caisson disease” (decompression sickness)Emobilization of anterior spinal arteryPath: embolic occlusion. of venous plexus by nitrogen bubbles during decompression.
32 Spinal HemorrhageEtiology: anti-coagulation (25-35%), AVM (SAH), coagulopathyClinical: sudden pain & neuro symptomsSite: Intramed., subarach, subdural, epidural>50% cervical, males 2:1, mean age 55Rx: prompt surgical evacuation of clotPrognosis: Decompression < 24 hrs yields full recovery in 50%
33 Rheumatoid - Arthritis & SCI RareAtlantoaxial subluxation in pts w/ RA (5-10%)Path: Loosening of transverse ligament & destruction of odontoid leads to displacement of atlas and SCC or ischemiaClinical: N/V, vertigo, neck pain, spasms, weaknessRx: surgical stabilization (40% improved post surgery)
34 Motor system disorders Amyotropic Lat. Sclerosis (ALS)Pseudobulbar Palsy - (medulla)Spinal Muscular Atrophy (SMA)Progressive Lateral Sclerosis (PLS) - (corticospinal pathways)
35 Amyotropic Lateral Sclerosis (ALS) Most frequent motor neuron diseasePath: Progressive degeneration of motor neurons in spinal cord, brain stemClinical: paralysis w/o sensory loss, spasticitybulbar muscles (pharynx, tongue), impaired speech, swallowing, respirationspares bladder/bowelDx: EMG/widespread denervation, biopsy- group atrophy, slightly increased CPKRx: maintenance, ? feeding tube, ventilator RxPrognosis: Life expectancy 4-7 years
41 Poliomyelitis Rare, anterior horn cell involvement Path: Poliovirus (enterovirus) is usually non-paralytic.Clinical: Paralytic illness develops early, mortality 5-25%, peaks in daysFever, HA, neck & back pain, asymmetric weakness w/sensory sparing, areflexia, may involve bulbar m’s (respiratory impairment)Dx: clinical, CSF w/inc cells, proteinRx: maintenance, salk vaccine prevention
42 Postpolio Syndrome (PPS) Def: clinical sx, 30+ yrs post-polioClinical: fatigue, weakness, paincold intol., sleep dist., swall. dysf.Path: unknown, ? late muscle denervation? Late functional loss in “Nonparalytic Polio”can see normal motor strength in 50% loss of anterior horn cells
43 Spinal (Epidural) Abscess rare (increasing with immunosuppressed patients)Path: extension of adjacent vertebral osteomyelitis (most common 25-50%) or hematogenous spread from distant infection (perinephric, pharyngeal, paraspinal) via arterial supply and Batsons PlexusClinical: onset-days-weeks, fever, pain, percussive tenderness, radicular pain, weaknessStaph Aureus (75% of acute), strep, e-coliLocation: posterior epidural space, thoracic...
44 Spinal Abscess (cont.)Dx: early Dx essential, fluid cx, CSF (increased protein and cells-contra level of infection), MRI (T1-hypointense), blood cx, ESR, X-ray (osteo or paravert mass), myelogramRx: surgical drainage and IV antibiotics (6-8 weeks). Antibiotics alone controversial (19% worsening)Prognosis: depends on neurological involvement.Good prognosis if treatment begun before weakness or < 36 hoursParaplegia >48 hours = poor prognosis for recovery
45 Chronic Abscess *Micobacterium Tuberculosis (TB) Other (breucellosis, actinomycosis)Path: hematogenous seeding, paravertebral epidural abscess w/vert. Body destruction with anterior SCC (mechanical vs ischemic)“Pott’s disease” (5-20% w/ neurological compromise)Clinical: fever, back pain, paresisDx: xray, myelogramRx: isoniazid/rifampin, ethambutol
47 Syphilis & SCI rare, < 2% of those w/primary infection Path: SC invasion by treponema parasite (tertiary stage), chronic inflammatory processsyphilitic meningitis, Sx: BS or ACStabes dorsalis – DRG (“Shingles”) + post columns, males, years post primary infClinical: pain, ataxia, incontinenceDx: VDRL in serum, FTA-ABS, CSF serologyRx: Penicillin
48 Acute Transverse Myelitis Path: Acute inflammatory lesions (auto immune response), not due to viral invasion of CNSperivascular demyelination and cord necrosis, edemaClinical: ascending flaccid paralysis, days to weeksviral sx (malaise-N/V-fever), LBP, urine retention, T8-12Dx: clinical presentation and exclusion of other dxddx: vascular, infection, MSpost-viral/vaccinal (33%)CSF nl, MRI (T-2 images hyperintense- inflammation)Rx: trial of steroidsPrognosis: poor with MRI changes, “severe” weakness and EMG denervation
53 Conclusions NT/SCI (cont.): Important medical morbidities, functional disabilitiessignificant % of rehab. AdmissionsEtiologies: spinal stenosis, tumor, vascularSuccessful rehabilitation outcomesFuture research necessary to study Nontraumatic spinal cord diseases & outcome
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