Cervical spine

At the scene of the accident, emergency medical professionals exercise extreme caution to immobilize the injured patient and prevent excessive movement. If there is compression of neurological tissue, vertebral fracture, or dislocation, reduction must occur to minimize ischemia and edema formation.³⁵ In the emergency department, reduction is accomplished by cervical traction with the goal of immediate and proper alignment of bone fragments and decompression of the spinal cord until further stabilization.^34,36,37 The most widely used traction method is the Gardner-Wells tongs (Figure 16-2), which are inserted into the skull. Weights are added at approximately 5 pounds of traction per level of injury to achieve reduction of the dislocation and to maintain alignment.³⁶

Precautions must be taken during therapy to prevent unnecessary movement at the injury site. The traction rope must be kept in alignment with the long axis of the cervical spine, and the weights must be allowed to hang freely. Cervical rotation must be prevented. In addition, continued traction should be maintained at all times.

When surgical stabilization is indicated, common surgical protocols include posterior and anterior approaches. Figure 16-3 shows radiographs of a person who had an anterior and lateral cervical fusion at C3-C4. Unstable compression injuries are usually managed by a posterior procedure except when there is a deficient anterior column. Anterior approaches are indicated for patients with evidence of residual anterior spinal cord or nerve root compression and persistent neurological deficits.³⁴

After cervical surgical stabilization, a hard collar such as a Philadelphia collar (Figure 16-4) or sternal-occipital-mandibular immobilizer (SOMI) brace is used until solid bony fusion has developed. The Aspen collar also provides this stability (Figure 16-5). The solid bony fusion usually takes 6 to 8 weeks. Postoperatively, care must be taken to protect the bony fusion.

When surgery is not indicated, or when more postoperative stabilization is required, halo traction may be indicated. The halo device restricts more movement in the upper cervical spine compared with the lower cervical spine.³⁸ The halo traction device consists of three parts: the ring, the uprights, and the jacket (Figure 16-6). The ring fits around the skull, just above the ears. It is held in place by four pins that are inserted into the skull. The uprights are attached to the ring and jacket by bolts. The jacket is usually made of polypropylene and lined with sheepskin. This equipment is left in place for 6 to 12 weeks until bony healing is satisfactory.⁵ The advantage of using the halo device is the ability to mobilize the client as soon as the device has been applied without compromising spinal alignment. This allows the rehabilitation program to commence more rapidly. It also allows for delayed decision making regarding the need for surgery.

The disadvantage of the halo device is that pressure and friction from the vest or jacket may lead to altered skin integrity.⁷ Special attention must be given to ensure the skin remains intact. During more active phases of the rehabilitation process, the halo device may slow functional progress because of added weight and interference with the middle to end range of upper-extremity movement. In a small percentage of patients, there are complications of dysphagia and temporomandibular joint dysfunctions associated with wearing the halo device.⁷

Thoracolumbar spine

Internal fixation of the thoracolumbar region is necessary when stability and distraction cannot be maintained by other means.³⁹ Common thoracic stabilization procedures include transpedicular screws (Figure 16-7) and a hybrid type of instrumentation.

Postoperatively, an external trunk support may be necessary to limit excessive vertebral motion and to maintain proper thoracic and lumbar alignment.³⁹ This may be achieved by a custom thoracolumbosacral orthosis (Figure 16-8) or a Jewett brace (Figure 16-9). Initially the client’s activity may be limited to allow for a complete fusion to take place and to minimize the possibility of rod displacement. All spinal limitations should be discussed with the surgeon postoperatively.

The goals of the operative procedures at any spinal level discussed are to reverse the deforming forces, to restore proper spinal alignment, and to stabilize the spine.⁴⁰ All these procedures have advantages and disadvantages. The surgeon, client, and family must be involved in the decision-making process to select the most appropriate method of treatment. This will allow the therapeutic rehabilitation process to begin.

Adaptive shortening or adaptive lengthening of muscles

Although isolated joint ROM should be normal for all patients, allowing adaptive shortening or adaptive lengthening of particular muscles is recommended to enhance the achievement of certain functional skills.^69,74 Likewise, unwanted shortening or lengthening of muscles should be prevented. The following section reviews a few examples of these concepts as they relate to SCI.

Tenodesis is described as the passive shortening of the two-joint finger flexors as the wrist is extended. This action creates a grasp, which assists performance of ADLs (Figure 16-11).^69,75 A patient with mid to low tetraplegia may rely on adaptive shortening of these long finger flexors to replace active grip.⁶⁹ If the finger flexors are stretched across all joints during ROM exercises, the achievement of some functional goals may be limited. ROM to the finger flexors should be applied only while the wrist is in a neutral position. There is controversy over shortening of the flexor tendons. Some clinicians argue that the client can develop a fixed flexion contracture of the proximal interphalangeal joints, interfering with future surgical attempts to restore finger function.³⁸ It is recommended to promote tenodesis functioning via adaptive shortening while maintaining joint suppleness.

In the presence of weakened or paralyzed elbow extensors, shortening of the elbow flexors should be prevented because it will impair ADL function and transfer skills.^7,69 Contracted elbow flexors or pronator muscles in a client with an SCI level of C6 can cost this client his or her independence. Likewise, the rotator cuff and the other scapular muscles should be assessed for their length-tension relationships and their ability to generate force. Normal length of these muscles should be maintained. For example, achieving external rotation of the shoulder (active and passive) is critical for clients with low-level tetraplegia. Shortening of the subscapularis and other structures can quickly result in a decrease in motion, limiting bed mobility, transfers, feeding, and grooming skills. Patients with complete paraplegia who are candidates for ambulation require normal ROM in the lower extremities. If the hip flexors or knee flexors are allowed to shorten, achieving standing and ambulation goals will be more difficult.

The combination of lengthened hamstrings and tight back extensor muscles provides stability for balance in the short- and long-sitting positions. This aids in the efficiency of transfers and bowel and bladder management. Balance in long sitting assists with lower-extremity dressing and other ADLs. Hamstrings should be lengthened to allow 110 to 120 degrees of straight leg raising without overstretching back extensor muscles.

Splinting to prevent joint deformity

Deformity prevention is the first goal of splinting.⁷⁶ Patients with cervical spinal cord injuries may have lost normal neural input to musculature in their wrists and hands. Other clients may have partial motor control, which may lead to muscle imbalances and loss of ROM. In the absence or weakness of elbow extensors, a bivalve cast or an elbow extension splint at night may be beneficial to prevent joint contractures. At the wrists, a volar wrist support is commonly used initially and may be progressed to a longer-term option of a definitive wrist orthosis. Other splints often used for deformity prevention of the hands include resting hand splints with proper positioning to maintain the support of the wrist and web space (Figure 16-12, A).⁷⁷ Another hand-based option is the intrinsic plus splint (Figure 16-12, B), which places the metacarpophalangeal joints closer to 90 degrees of flexion and decreases intrinsic hand muscle tightness.

Another goal of splinting in the SCI population is to increase function. Patients with tetraplegia at the C5 level rely on an orthosis to be independent with communication, feeding, and hygiene. They must have joint stability and support at the wrist and the hand to perform these skills. The splint is often adapted with a utensil slot or cuff so that the client can effectively perform the skills mentioned previously.

Patients who are not strong enough to use their wrists for tenodesis may require splinting to support their wrists until they can perform wrist extension against gravity. Long opponens splints can be used to position the thumb for function but support the weak wrist (Figure 16-13). Once the wrist muscles strengthen, the long opponens splint can be cut down to a hand-based short opponens to maintain proper web space and thumb positioning while maximizing tenodesis.

As mentioned previously, clients with injuries at the C6 level can use their wrists for a tenodesis grasp.^75,78,79 Critical components of the splint assessment for these clients are the positioning of the thumb, web space, and index finger observed during the grasp. It is recommended that the client’s hand be positioned with the thumb in a lateral pinch position because this is the most commonly used prehension pattern to pick up objects. Clients who are not splinted may not have the proper positioning to pick up objects because their tenodesis is “too tight” or “too loose.”

Clients with C8 to T1 injuries or clients who have incomplete injuries may have “clawing” or hyperextension of the metacarpophalangeal joints. This is caused by finger extensor musculature that is stronger than finger flexor musculature.^75,80 To prevent this, a splint can be made to block the metacarpophalangeal joints and promote weak intrinsic muscle function. Depending on the extent of the imbalance, these splints can be used during function or worn only at night. Cost, time, material, and clinician experience are important considerations when deciding between custom and prefabricated splints. A well fitting, prefabricated splint can be as effective as a custom-fabricated splint in certain situations. Custom splints require additional resources and clinician expertise. One way to minimize time spent in fabrication of splints is to use a good pattern and premade straps. Finally, educating the client on the splint-wearing schedule, skin checks, and splint care is important for preventing skin breakdown.

Treatment for joint deformity

If a joint contracture occurs despite preventive measures, more aggressive treatments are necessary. This may include more aggressive use of splinting, plaster or fiberglass casting techniques, or botulinum toxin type A (Botox) injections.81–83 When splinting is not effective, fabrication of serial or bivalve casts may be indicated. The client with minimal ROM limitations may require only one cast. Most commonly, the client has a significant limitation and requires serial casts, in which several casts are applied and then removed over a period of weeks to increase extensibility in the soft tissues surrounding the casted joint.⁸⁴ The involved joint is placed at submaximal ROM.⁸⁵ Once the cast is removed, the joint should have an increase of approximately 7 degrees of ROM.⁸⁵ This process continues until the deformity is minimized or resolved. The final cast is a bivalve so that the cast can act as a positioning device that can be easily removed. Casting contraindications are skin compromise over the area to be casted, heterotopic ossification, edema, decreased circulation, severe fluctuating tone, and inconsistent monitoring systems. The elbow, wrist and hand, and finger joints are the most common joints casted for clients with SCI. Casting for most of these clients may be the last resort to regain increased ROM before a client can begin using feeding, grooming, or communication skills. Long-arm casts are used when elbow and wrist contractures must be managed simultaneously. If evaluation of the upper extremity reveals a pronation or supination contracture, a long-arm cast would also be the cast of choice. Dropout casts are used with severe elbow flexor or extensor contractures, but the patient should be in a position in which gravity can assist. Wrist-hand and finger casts are indicated for contractures that prevent distal upper-extremity function. Most commonly, a client will have a wrist flexion-extension contracture or have finger flexor-extensor tone and will require a cast to use the tenodesis or individual fingers for fine motor skills. Sometimes wrist casts with finger shells or resting hand extensions on casts are needed to ensure that the hand, fingers, and web space are maintained in a position of optimal function. Casting is an expensive and labor-intensive treatment modality, but if indicated and used appropriately it can assist a client in regaining lost joint ROM needed for increased independence and function.

Botox may be used in conjunction with casting. In a study conducted by Corry and colleagues⁸³ tone reduction was evident when botulinum toxin type A was used; however, ROM and functional improvement varied among subjects. Pierson and co-workers⁸² found that, with careful selection, subjects who received botulinum toxin type A had significant improvements in active and passive ROM. Research indicates that patients who have flexor spasticity without fixed contracture will benefit the most.

Surgical intervention may be recommended by an orthopedic physician in severe cases of joint contracture.⁸⁶ Some of the more commonly used surgical options include joint manipulation under anesthesia, arthroscopic surgical releases, open surgical releases, and rotational osteotomy.

Inspiratory muscle training

Inspiratory muscle training may be used to train the diaphragm and the accessory muscles that are weakened by partial paralysis, disuse from prolonged artificial ventilation, or prolonged bed rest. In the presence of significant impairments, it is generally recommended that training be initiated in the supine or side-lying position and progressed to the sitting position when tolerated. When training a moderately weak diaphragm, gentle pressure during inspiration may be used to facilitate the muscle (Figure 16-14). Accessory muscle training may be facilitated with the client in the supine position while a slight stretch is placed on these muscles.⁷⁴ The stretch is accomplished by shoulder abduction and external rotation, elbow extension, forearm supination, and neutral alignment of the head and neck. A more challenging position incorporates upper thoracic extension. The clinician’s hands are placed directly over the muscle to be facilitated. The patient is instructed to breathe into the upper chest (Figure 16-15). As the treatment progresses, the diaphragm may be inhibited for short training periods by applying pressure over the abdomen in an upward direction. Care must be taken to avoid excessive pressure to prevent occlusion of vital arteries.

As the inspiratory muscles strengthen, resistive inspiratory devices may be used. Inspiratory devices are relatively inexpensive and most function similarly. Most devices have a one-way valve that closes when the patient inspires, forcing him or her to breathe either through a small aperture or against a spring-loaded resistance. Although evidence fully supporting this intervention remains inconclusive,⁹⁸ some researchers have shown improvements in total lung capacity⁹⁹ and improved endurance measures.¹⁰⁰ The diaphragm may also be trained by using weights on the abdominal wall with the client positioned supine. Derrickson and colleagues¹⁰¹ concluded that both inspiratory muscle training devices and abdominal weights are effective in improving ventilatory mechanics. Muscle trainers, however, appear to promote more of an endurance effect than the use of abdominal weights.

Diaphragm and phrenic nerve pacing

When the primary inspiratory muscles are no longer volitionally active as a result of SCI, diaphragm or phrenic nerve pacing may be used to cause the diaphragm to contract. These interventions are most commonly indicated when the lesion is at or above the C3 level.101–106 Electrical stimulation may be applied directly or indirectly through a vein wall or the skin or directly to the phrenic nerve via thoracotomy. Transdiaphragmatic pacing, in which electrodes are placed laparoscopically on the diaphragm, is also an option.¹⁰⁷ Transdiaphragmatic pacing is less invasive than direct phrenic nerve pacing, may be implanted and initiated on an outpatient basis, and may result in improved outcomes. Both of these procedures require a reconditioning program that involves extensive caregiver and client training. Many clients require some residual use of mechanical ventilation even after maximal tolerance has been achieved so as not to overfatigue the phrenic nerve. Other researchers are considering also pacing intercostal muscles¹⁰⁸ or using a combination of diaphragmatic and intercostal pacing. There is limited evidence comparing the outcomes associated with these devices in isolation or in combination therapies.

Glossopharyngeal breathing

Glossopharyngeal breathing is another way of increasing vital capacity in the presence of weak inspiratory muscles.^90,94,97 Moving the jaw forward and upward in a circular opening and closing manner traps air in the buccal cavity. A series of swallowing-like maneuvers forces air into the lungs, increasing the vital capacity. This technique has been reported to increase vital capacity by as much as 1 L.⁷⁴ Although this technique is rarely used to sustain ventilation for long periods of time,¹⁰⁹ it may be used in emergency situations and to enhance cough function. The client with high tetraplegia should attempt to master this skill.

Secretion clearance

Ventilatory impairment occurs when the client is unable to clear secretions.^87,110 Factors such as artificial ventilation and general anesthesia hamper secretion mobilization. With artificial ventilation, clients may require an artificial airway.^110,111 The presence of this airway in the trachea is an irritant, and the client subsequently produces more secretions.⁸⁷ A description of various types and parameters of ventilation is beyond the scope of this chapter. Clinicians working with clients requiring artificial ventilation are referred to other publications.^110,112

Secretions are most commonly removed by tracheal suctioning, unassisted coughing, or assisted coughing. Recently there has been a resurgence of previously used technologies that provide rapidly alternating pressures through a mouthpiece or an endotracheal tube to remove secretions. This is commonly referred to as insufflation-exsufflation.¹¹³ To date, conclusive research determining which single technique or combination of techniques achieves the best outcome is not available. Insufflation-exsufflation may result in fewer complications and is reported to be more comfortable to the client. Barriers to implementation of these techniques may include expense of the equipment and competency barriers in that training is required. Postural drainage, percussion or clapping, and shaking or vibration are used to assist with moving secretions toward larger airways for expectoration.^17,69,79

Assisted coughing is typically used with people who are unable to generate sufficient effort.⁹⁷ The assistant places both hands firmly on the abdominal wall. After a maximal inspiratory effort, the patient coughs and the assistant simply supports the weakened wall. A gentle upward and inward force may be used to increase the intraabdominal pressure, yielding a more forceful cough (Figure 16-16).^84,97 Excessive pressure over the xiphoid process should be avoided to prevent severe injury.

Patients may learn independent coughing techniques. In preparation for a cough, the patient positions an arm around the push handle of the wheelchair, opening the chest wall to enhance inspiratory effort. The other arm is raised over the head and chest during inspiration. This procedure is followed by a breath hold, strong trunk flexion, and then a cough (Figure 16-17).⁹⁷ Another technique for independent coughing is accomplished by placing the forearms over the abdomen and delivering a manual thrust during cough. This technique is more difficult and may not provide an inspiratory advantage.