Neurosensory: Traumatic Spinal Cord Injury

A. Pathophysiology/etiology Normal spinal cord as it relates to SCI 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

Normal protection of spinal cord from injury: Bones- vertebral column

Protection of spinal cord from injury Disc between vertebra Internal and external ligaments

Protection of Spinal Cord from Injury Meninges CSF in subarachnoid space allow for movement within spinal canal

Normal spinal cord as relates SCI: Autonomic Nervous System & Cord ANS can be affected by SCI Sympathetic chains on both sides of the spinal column Parasympathic nervous system is the cranial-sacral branch

Normal spinal cord: White tracks 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)

Normal spinal cord: Reflex ark in center of the spinal cord Where sensory and motor nerves arise from cord Motor fibers leave posterior Sensory fibers enter from anterior Once outside cord join form spinal nerve

Dermatones

Normal spinal cord: Spinal cord level When referring to spinal cord level, it the reflex ark level not the vertebral or bone level. Note that the thoracic, lumbar & sacral reflex arks are higher than were the spinal nerves actually leave through the opening of there respective vertebral bone

Patho: Forces resulting in SCI Flexion (hyperflexion) Most common because of natural protection position. Generally cause neck to be unstable because stretching of ligaments

Patho/forces: Hyperextention Caused by chin hitting a surface area, such as dashboard or bathtub Usually causes central cord syndrome symptoms

Patho/forces: Compression Caused by force from above, as hit on head Or from below as landing on butt Usually affects the lumbar region

Classification of spinal cord injury: 1. Complete (transection) spinal cord inj After spinal shock: Motor deficits- spastic paralysis below level of injury Sensory- loss of all sensation perception Autonomic deficits- vasomotor failure and spastic bladder

2. Incomplete spinal cord injury- what white tracks are working after spinal shock is over?

Incomplete spinal cord injury: 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

Incomplete spinal cord injury: Anterior Cord Syndrome Injury to anterior cord Loss of voluntary motor (Pyramidal track) below Loss of pain and temperature perception Retains posterior column function

Incomplete spinal cord injury: Brown-Sequard Syndrome Hemisection of cord Ipsilateral paralysis Ipsilateral superficial sensation, vibration and proprioception loss Contralateral loss of pain and temperature perception

Horner’s Syndrome

Classification of spinal cord injury- 3. by level of spinal cord injury In addition to complete or incomplete- Spinal cord injuries are also described by the level of the injury– the cord segment or dermatome level Such as C6; L4 spinal cord injury

Common manifestations/complications: Spinal shock- depression of cord & ANS Motor loss- flaccid paralysis below level injury Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury Sympathetic NS loss results in parasympathic dominance with vasomotor failure- Neurogenic shock, bradycardia, orthostatic hypotension and poor temperature control (poikilothermic- takes on temp of environment) Parasympathetic NS loss of the S 2,3,4 reflex arks results in flaccid bladder

Spinal shock lasts from few minutes to weeks 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

Common manifestation/complications: Upper and Lower Motor Deficits Upper motor deficits results in spastic paralysis Lower motor deficits are flaccid paralysis and muscle atrophy

Common manifestations/complications: Functional Goals for Spinal Cord Injury C1-3 usually fatal- loss phrenic innervation; ventilator dependent; no B/B control; spastic paralysis; electric w/c with chin/mouth control C6- weak grasp; has shoulder/biceps to transfer & push w/c; no bowel/bladder control. Considered level of independence T1-6- full use of upper extremity; transfer; drive car with hand controls and do ADL’s; no bowel/bladder control

C. Therapeutic Interventions for SCI: Diagnostic tests X-ray of spinal column CT/MRI Blood gases

Transporting a SCI

Traction

Casts; splints; collars; braces

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 assessment: Motor assessment Movement, strength and symmetry Hand grips Flex and extend arm at elbow- with and without resistance

Nursing assessment: Motor assessment lower extremity Flex and extend leg at knee with and without resistance Planter and dorsi flexion of foot

Nursing 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 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

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

Phrenic nerve

Intercostal nerves

Quad cough (assistive cough)

4. 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

Autonomic Dysreflexia- assess Vasodilatation symptoms above SCI Vasoconstriction symptoms below SCI The cause of SNS stimulation

A. upper motor bladder B. lower motor bladder

Bladder functioning: exam_id=56&directory=uro exam_id=56&directory=uro

Additional Critical thinking questions LeMone p 1334: Nursing Care Plan: A Client with a SCI 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?