Spinal Cord Injury

Etiology of Traumatic Spinal Cord Injury MVA- most common cause Other: falls, violence, sport injuries SCI typically occurs from indirect injury from vertebral bones compressing cord SCI frequently occur with head injuries Cord injury may be caused by direct trauma from knives, bullets, etc

Etiology of Traumatic Spinal Cord Injury 78% people with SCI are male Typically young men – 16-30 Number of older adults rising (>61 yr) Greater complications Life Expectancy 5 years less than same age without injury 90% go home

Pathophysiology anatomy of the spine

Pathophysiology Normal Spinal Cord Spinal cord begins at the foramen magnum in the cranium Cord ends at the L1-L2 vertebra level Spinal nerves continue to the last sacral vertebra

Pathophysiology Normal Spinal Cord Vertebral Column 8 Cervical 12 Thoracic 5- Lumbar 5- Sacral

Protection of Spinal Cord from Injury Bones- vertebral column Discs- between vertebra Internal and external ligaments Dura

Protection of Spinal Cord from Injury Internal and external ligaments Dura Meninges CSF in subarachnoid space allow for movement within spinal canal

Nervous System and the Spinal Cord ANS can be affected by SCI Sympathetic chains on both sides of the spinal column Parasympathetic nervous system is the cranial-sacral branch

Normal Spinal Cord

Normal spinal cord Dermatones Skin innervated by sensory spinal nerves

Normal Spinal Cord Reflex Arc Where sensory and motor nerves arise from cord Sensory fibers enter posterior Motor fibers leave from anterior Once outside cord join form spinal nerve reflex movement

Normal Spinal Cord White tracts send messages to and from the brain Pyramidal- Voluntary movements Posterior column (Dorsal)- touch, proprioception, and vibration sense Lateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord) voluntary movement

Spinal Cord Injury- SCI Compression Interruption of blood supply Traction Penetrating Trauma

Spinal Cord Injury Primary Secondary Initial mechanism of injury Ongoing progressive damage Ischemia Hypoxia Microhemorrhage Edema

Spinal Cord Injury Hemorrhage and edema occur in the cord post injury, causing more damage to cord Extension of the cord injury from cord edema can occur over the first few days- watch the phrenic nerve! Initially SCI experience spinal shock- depression of all cord & ANS function below injury. Lasts from few min to wks

Classifications of SCI 1. Mechanism of Injury 2. Skeletal and Neurologic Level 3. Completeness (degree) of Injury

Classifications of SCI Mechanism of Injury Flexion Hyperextension Flexion Rotation Compression

Classifications of SCI Mechanism of Injury Flexion (hyperflexion) Most common because of natural protection position. Generally cause neck to be unstable because stretching of ligaments

Classifications of SCI Mechanism of Injury Hyperextention Caused by chin hitting a surface area, such as dashboard or bathtub Usually causes central cord syndrome symptoms

Classifications of SCI Mechanism of Injury Compression Caused by force from above, as hit on head Or from below as landing on butt Usually affects the lumbar region

Classifications of SCI Mechanism of Injury Flexion/Roatation Most unstable Results in tearing of ligamentous structures that normally stabilize the spine Usually results in serious neurologic deficits

Classification of SCI- Level of Injury Spinal cord level When referring to spinal cord level, it is the reflex arc level not the vertebral or bone level. Note that the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of there respective vertebral bone

Classification of SCI- Level of Injury Spinal cord injuries are described by the level of the injury– the cord segment or dermatome level Such as C6; L4 spinal cord injury

Classifications of SCI Completeness (Degree) of Injury Incomplete Central cord syndrome Anterior Cord syndrome Brown-Sequard Syndrome Posterior Cord Syndrome Cauda Equina and Conus Medullaris

Classification of SCI Completeness (degree) of Injury Complete (transection) After spinal shock: Motor deficits- spastic paralysis below level of injury Sensory- loss of all sensation perception Autonomic deficits- vasomotor failure and spastic bladder

Classification of SCI Completeness (degree) of Injury Incomplete Central Cord Syndrome Injury to the center of the cord by edema and hemorrhage Weakness in both upper extremities- legs are spared Varied loss of sensation

Classification of SCI Completeness (degree) of Injury Incomplete Brown-Séquard Syndrome Hemisection of cord Ipsilateral paralysis Ipsilateral superficial sensation, vibration and proprioception loss Contralateral loss of pain and temperature perception

Classification of SCI Completeness (degree) of Injury incomplete Anterior Cord Syndrome Injury to anterior cord Loss of voluntary motor (Pyramidal track) below Loss of pain and temperature perception Retains posterior column function

Classification of SCI Completeness (degree) of Injury incomplete Posterior Cord Syndrome Least frequent syndrome Injury to the posterior columns results in proprioceptive loss (dorsal columns) Pain, temperature, touch are preserved. Motor function is preserved to varying degrees.

Classification of SCI Completeness (degree) of Injury incomplete Conus Medullaris Syndrome Injury to the sacral cord (conus) and lumbar nerve roots within the spinal canal, usually results in are-flexic bladder and bowel, and lower limbs (in low-level lesions) Cauda Equina Syndrome Injury to the lumbosacral nerve roots within the neural canal, results in areflexic bladder, bowel, lower limbs

Common Manifestations/Complications Terms used to describe motor deficits Prefix: para- meaning two extremities; tetra- or quadra- all four extremities Suffix –paresis meaning weakness; -plegia meaning paralysis Quadraparesis means what?

Common Manifestations/Complications C1-3 usually fatal- Loss of phrenic innervation ventilator dependent No B/B control Spastic paralysis Electric w/c with chin/mouth control

Common Manifestations/Complications C6- weak grasp Has shoulder/biceps to transfer & push w/c No bowel/bladder control. Considered level of independence

Common Manifestations/Complications T1-6- full use of upper extremity Transfer Drive car with hand controls and do ADL’s No bowel/bladder control

Clinical Manifestations of SCI Skin: pressure ulcers Neuro: pain; sensory loss; upper/lower motor deficits; autonomic dysreflexia Cardio: dysrhythmias; spinal shock; loss of sympathetic nervous system control over blood vessels (vasomotor control)- decreased venous return, orthostatic hypotension, poikilothermic (takes on temp of room)

Clinical Manifestations of SCI Respiratory: decrease chest expansion; cough reflex & vital capacity; diaphragm function-phrenic nerve GI: stress ulcers; paralytic ileus; bowel- impaction & incontinence GU: upper/lower motor bladder; impotence; sexual dysfunction Musculoskeletal: joint contractures; bone demineralization; osteoporosis; muscle spasms; muscle atrophy; pathologic fractures; para/tetraplegia

Spinal and Neurogenic shock Spinal Shock Decreased reflexes and loss of sensation below the level of injury Motor loss- flaccid paralysis below level injury Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury Lasts days to months

Spinal and Neurogenic Shock Due to loss of vasomotor tone SNS loss results in parasympathetic dominance with vasomotor failure Loss of SNS innervation causes peripheral pooling and decreased cardiac output Hypotension and Bradycardia Orthostatic hypotension and poor temperature control (poikilothermic- takes on temp of environment)

How do you know spinal shock is over? Clonus is one of the first signs Hyperreflexia of foot Test by flexing leg at knee & quickly dorsiflex the foot Rhythmic oscillations of foot against hand clonus

Common Manifestation/Complications Upper and Lower Motor Deficits Upper motor deficits result in spastic paralysis Lower motor deficits result in flaccid paralysis and muscle atrophy

Diagnostic Studies for SCI X-ray of spinal column CT/MRI Blood gases

Collaborative Care Emergency Care at Scene, ER & ICU Transport with cervical collar Assess ABC’s; O2; tracheotomy/vent IV for life line NG to suction Foley

Therapeutic Interventions Medications IV methylprednisolone (Solu-Medrol) within 8 hrs to decrease cord edema

Therapeutic Interventions Medications To control or to prevent complications of SCI and immobility: Vasopressors to maintain perfusion Histamine H2 blockers to prevent stress ulcers Anticoagulants Stool softeners Antispastomotics

Therapeutic Interventions Stabilization/immobilization Traction with Gardner-Wells tongs

Therapeutic Interventions External traction Halo device For patients who do not have motor deficits Experience less immobility complications

Therapeutic Interventions Casts; splints; collars; braces

Therapeutic Interventions Special Beds for SCI To decrease immobility complications Rotorest is a common one used- rotates 23 hrs a day

Therapeutic Interventions Surgery for SCI Manipulation to correct dislocation or to unlock vertebrae Decompression laminectomy Spinal fusion Wiring or rods to hold vertebrae together

Nursing Management Assessment Health History Description of how and when injury occurred Other illnesses or disease processes Ability to move, breathe, and associated injury such as a head injury, fractures

Nursing Management Assessment PHYSICAL EXAM LOC and pupils- may have indirect SCI from head injury Respiratory status- phrenic nerve (diaphragm) and intercostals; lung sounds Vital signs Motor Sensory Bowel and bladder function

Nursing Management Assessment Motor Assessment Upper Extremity Movement, strength and symmetry Hand grips Flex and extend arm at elbow- with and without resistance

Nursing Management Assessment Motor Assessment Lower Extremity Flex and extend leg at knee with and without resistance Planter and dorsi flexion of foot

Nursing Management Assessment Motor assessment- Clonus Clonus- hyperreflexia Flex knee and quickly dorsiflex the foot with your hand If has return of reflex function the foot will have repetitive movements against you hand Spinal shock is over

Nursing Management Assessment Sensory assessment With the sharp and dull ends of a paperclip have the individual, with their eyes closed identify Use the dermatome as reference to identify level C6 thumb; T4 nipple; T10 naval

Nursing Problems/Interventions 1.Impaired mobility 2.Impaired gas exchange 3. Impaired skin integrity 4. Constipation 5. Impaired urinary elimination 6. Risk for autonomic dysreflexia 7. Ineffective coping

1. Impaired Physical Mobility Log roll as a single unit; provide assistance as needed to keep alignment; teach patient Care traction, collars, splints, braces, assistive devices for ADL’s Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)

1. Impaired Physical Mobility Spastic Paralysis- Assess for clonus Prevent spasms by avoiding; sudden movements or jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmotic medications Assess skin break down thrombophlebitis; remove TED hose at least every shift

1. Impaired Physical Mobility Prevent/treat orthostatic hypotension Abdominal binder, calf compressors, TED hose when individual gets up Assess BP, especially when rising Assist Physical Therapy with tilt table as individual gradually gets use to being in an upright position

1. Impaired Physical Mobility Use of transfer board

2. Impaired Gas Exchange Phrenic nerve (C3-5) controls the diaphragm bilaterally. If nerve is nonfunctioning then individual is ventilator dependent. Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing

2. Impaired Gas Exchange Assess respiratory rate, rhythm, depth, and breath sounds Monitor vital capacity, respiratory effort, ABG’s, O2 saturation Assess for signs of impending extension of SCI up cord to phrenic nerve level (C3-5) Assess need for ventilatory assistance, tracheotomy, ventilator Quad cough (assistive cough) as needed

3. Impaired Skin Integrity Change position frequently Removal of TED hose every 8 hours Nutritional status Protection from extremes in temperature

3. Impaired Skin Integrity Inspect skin at least 2x/day especially over boney prominences Avoid shearing and friction to soft tissue with transfers

4. Constipation Bowel rely more on bulk than on nerves Stimulate bowels at the same time each day. Best after a meal when normal peristalsis occurs Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation Assess bowel sounds prior to giving food for the first time– paralytic illus!

5. Impaired Urinary Elimination Bladder function SCI Upper/Lower Motor Bladder reflex arc- sacral 2,3,4

5. Impaired Urinary Elimination Flaccid bladder (lower motor neuron lesion) No reflex from S2,3,4 Automatic empting of bladder Urine fills the bladder and dribbles out Need foley or freq intermittent self catherization Spastic bladder (upper motor neuron lesion) Reflex arc but no connection to or from brain Reflex fires at will Bladder training- trigger points to stimulate empting; self catherization

5. Impaired Urinary Elimination Use bladder scan to see amount of urine in bladder Goal- residual <100ml/20% bladder capacity Some individuals may need suprapubic catheter Assess effectiveness of medication Urecholine to stimulate bladder contraction Urinary antiseptic

6. Risk for Autonomic Dysreflexia SCI above T6 Results in loss of normal compensatory mechanisms when sympathetic nervous system is stimulated Life threatening- if goes unchecked BP can result in cerebral hemorrhage Vasodilatation symptoms above SCI Vasoconstriction symptoms below SCI The cause of SNS stimulation

6. Risk for Autonomic Dysreflexia Elevate head of bed- causes orthostatic hypotension Identify cause/alleviate- if full bladder- cath; if skin- remove pressure, if full bowel- empty, etc Remove support hose/abdominal binder Monitor blood pressure- can get > 300 S Give PRN medication to lower BP If above not effective– call physician

7. Ineffective Coping Grief and Depression Sexuality

7. Ineffective Coping Grief and Depression Assess thoughts on ‘quality of life’; body image; role changes Physical and psychological support Most common SCI is 15-30 yeas old and generally a risk taker– this greatly affects their perception of life and rehabilitation

7. Ineffective Coping Sexuality Assess readiness/knowledge/your ability Male sexual function- reflexogenic (S2,3,4) erections; psychogenic erections (psychological stimulation) Ejaculation/fertility may be affected Female- hormones more than nerves regarding fertility. C-section because of chance for autonomic dysreflexia during labor. Lack of sensation/movement affects sexual performance Suggestions: empty bladder before sex; withhold fluids and antispasmodics; certain positions may increase spasms; explore new erogenous zones; penile implants

Home Care Assess psychological, physical resources, need for rehabilitation (in-house or outpatient); need for community resources Home evaluation

What’s new in SCI treatment? Superman breather YouTube - Superman breather – USA Kevin Everett hypothermia treatment for SCI Standing Tall Travis Roy- 11 Seconds Stem Cell treatment for SCI Lipitor for SCI

NCLEX questions/ case study

Case study- Jim Valdez 1. Why does Jim have flaccid paralysis on admission to ICU? 2. What symptoms indicate that he is in spinal shock? What was done about these symptoms? 3. How will we know when he is out of spinal shock? 4. How does progressive mobilization assist with orthostatic hypotension? What else can be done? 5. What are realistic functional goals for Jim?