Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors Chris Puglia, MSN, RN, CEN Based on the Lecture by Lisa Randall, RN, MSN, ACNS-BC

Objectives Consider the risk factors, signs & symptoms, diagnostic tests, complications, and treatments of: Spinal cord injury Herniated disc Spinal cord tumors Prioritize nursing diagnoses Discuss legal and ethical issues Case study/questions Lewis 8th ed p. 1546-1564 spinal cord injury p. 1564-1565 spinal cord tumors p. 1628-1632 herniated disc

Spinal Cord Protection Bones- vertebral column 7 Cervical 12 Thoracic 5 Lumbar 5 Sacral Discs- between vertebra

Nervous System and the Spinal Cord ANS can be affected by Spinal Cord Injury (SCI) Sympathetic chains on both sides of the spinal column (T1-L2) Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4) Reflex Arc

Etiology of Traumatic SCI MVC: 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

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

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

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

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)

Classifications of SCI Mechanism of Injury (MOI) Skeletal and Neurologic Level Completeness (degree) of Injury Mechanism of Injury 1. Flexion 2. Hyperextension 3. Compression 4. Flexion /Rotation

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 Such as hit on head Or from below as landing on butt Usually affects the lumbar region

Pg. 1549, figure 61-6

Classification of SCI Level of Injury Spinal cord level When referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level The thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone

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 Motor weakness and sensory loss in all extremities Upper extremities affected more

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, pain and temperature perception below injury Retains posterior column function (sensations of touch, position, vibration, motion)

Classification of SCI Completeness (degree) of Injury Incomplete Posterior Cord Syndrome Least frequent syndrome Injury to the posterior (dorsal) columns Loss of proprioception Pain, temperature, sensation and motor function below the level of the lesion remain intact

Classification of SCI Completeness (degree) of Injury Incomplete Conus Medullaris Injury to the sacral cord (conus) and lumbar nerve roots Cauda Equina Injury to the lumbosacral nerve roots Result = areflexic (flaccid) bladder and bowel, flaccid lower limbs

Clinical Manifestations of SCI Skin: - pressure ulcers Neuro: - pain - sensory loss - upper/lower motor deficits - autonomic dysreflexia Cardio: - dysrhythmias - spinal shock - loss of SNS control over blood vessels - orthostatic hypotension, - poikilothermic

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

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

Common Manifestations/Complications Spinal cord injuries are described by the level of the injury the cord segment or dermatome level such as C6; L4 spinal cord injury 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 Consider level of independence

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

Immediate Care Emergency Care at Scene, ED & ICU MOI Transport with cervical collar (LOG ROLL) Assess ABC’s Suction PRN/Airway O2 BVM/Intubate IV x2 large bore Foley CMS

Diagnostic Studies for SCI X-ray of spinal column CT with and/or without contrast (depends on MOI) MRI Lab work Blood gases

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

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 Antispasmodics

Therapeutic Interventions Stabilization/ Immobilization Traction Gardner-wells tongs Halo Casts Splints Collars Braces

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 (SAMPLE) Description of how and when injury occurred (MOI) 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 Assess for Clonus

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 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; antispasmodic medications Assess skin breakdown & 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 Teach use of transfer board Assist Physical Therapy with tilt table as individual gradually gets use to being in an upright position

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 Respiratory rate, rhythm, depth, breath sounds, respiratory effort, ABG’s, O2 saturation Signs of impending extension of SCI up cord to phrenic nerve level (C3-5) Need for ventilatory assistance (tracheotomy, ventilator ) Quad cough (assistive cough) as needed

3. Impaired Skin Integrity Change position frequently Protection from extremes in temperature Inspect skin at least 2x/day especially over boney prominences Avoid shearing and friction to soft tissue with transfers Removal of TED hose every 8 hours/SCDs Nutritional status

4. Constipation Bowels 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 ileus!

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 catheterization 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 catheterization

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

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 year old males and generally risk takers This greatly affects their perception of life and rehabilitation

7. Ineffective Coping/Sexuality Male Female UMN lesion reflexogenic (S2,3,4) erections LMN lesion psychogenic erections (psychological stimulation) Ejaculation/fertility may be affected Hormones more than nerves regarding fertility C-section because of chance for autonomic dysreflexia during labor Lack of sensation/movement affects sexual performance

7. Ineffective Coping/Sexuality Assess readiness/knowledge/your ability to teach Use proper terminology Suggestions: empty bladder before sex withhold fluids and antispasmodics certain positions may increase spasms explore new erogenous zones penile implants Refer to specially trained counselor

Home Care Assess psychological & physiological resources Need for rehabilitation (in-house or out patient) Need for community resources Home assessment

What’s new in SCI treatment? Superman breather Superman Breather Kevin Everett Hypothermia for SCI Travis Roy 11 Seconds Travis Roy B.U. Stem Cell treatment for SCI Lipitor for SCI

CASE STUDY Patient Profile Mr. Porter is a 19-year-old man with a spinal cord injury (paraplegic), status post gunshot wound to the lumbar spine. His accident was 4 months ago, and he is in the rehabilitation unit.

Subjective Data States he is depressed and “is getting used to the idea of not walking again” Objective Data Physical Examination Vital signs: supine blood pressure 120/68, sitting blood pressure 114/62, pulse 68, temperature 99º F, respirations 16 Apical pulse: 69 Slight edema bilateral lower extremities Urine dark yellow in drainage bag Last bowel movement yesterday Coccyx with 2 cm red area Right heel with 1 cm red area Full passive range of motion in the bilateral lower extremities without crepitation Full active range of motion in the bilateral upper extremities without crepitation No sensation in bilateral lower extremities, normal sensation bilateral upper extremities

Diagnostic Studies White blood cells: 9500/µl Hemoglobin: 16 g/dl Hematocrit: 45%

Critical Thinking Questions What is the primary nursing concern for this patient? What nursing interventions are appropriate for impaired skin integrity? Based on all of the assessment data, what are other nursing priorities? What are appropriate nursing diagnoses for a patient with paraplegia?

Herniated Discs

Herniated Disc Herniated nucleus pulposus, (HNP) slipped disc, ruptured disc HNP- annulus becomes weakened/torn and the nucleus pulposus herniates through it Risk Factors Standing erect Aging changes Poor body mechanics Overweight Trauma

Common Manifestations/Complications HNP compresses Spinal nerve (sensory or motor component) as it leaves the spinal cord Or the cord itself (the white tracts within the cord) rare

Common Manifestations/Complications Sensory root or nerve usually affected pain, parenthesis, or loss of sensation Motor root or nerve may be affected paresis or paralysis Manifestations depend on what nerve root, spinal nerve is being compressed– which dermatomes Radiculopathy pathology of the nerve root

Common Manifestations/Complications Lumbar HNP Most common site for HNP L4-5 disc- the 5th lumbar nerve root posterior sensory nerve or root compressed Classic symptoms low back / sciatica pain pain increases with increase in intrathoracic pressure Herniated disc L4-L5

Other Symptoms Lumbar HNP Postural changes Urinary/male sexual function changes Paresis or paralysis Foot drop Paresthesias Numbness Muscle spasms Absent cord reflexes

Common Manifestations/Complications Cervical HNP C5-C6 disc- affects the 6th cervical nerve root Pain- neck, shoulder, anterior upper arm to thumb Absent/diminished reflexes to the arm Motor changes- paresis or paralysis Sensory- paresthesias or pain Muscle spasms

Therapeutic Interventions Diagnostic Tests X-ray identify deformities and narrowing of disk space CT MRI Myelogram Nerve conduction studies (EMG) detect electrical activity of skeletal muscles

Treatment: Conservative Bed rest with firm mattress log roll side lying position with knees bent and pillow between legs to support legs Avoid flexion of the spine brace/corset, cervical collar to provide support Medications non-narcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers

Treatment: Conservative Heat/cold therapy to decrease muscle spasms Break the pain-spasm-pain cycle Ultrasound, massage, relaxation techniques Progressive mobilization with approved exercise program –includes abdominal/thigh strengthening Teaching good body mechanics Weight loss TENS unit

Treatment: Surgery Laminectomy removal of a portion of the lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out Herniated disc repair Foraminotomy enlargement of the bony overgrowth at the opening which is compressing the nerve Microdiskectomy Use of electron microscope through a small incision to remove a portion of the HNP that is displaced Anterior cervical fusion If cervical HNP, usually use the anterior approach in the neck

Treatment: Surgery Spinal fusion removes most of the disc and replaces it with bone usually from the patient iliac crest fusion also with rods, pins, synthetic protein flexibility is lost at the site- requires longer hospital stay Artificial Disc combination of metal and plastic attached to vertebrae above and below

Prevention of HNP Back school approach Causes of HNP Learn how to prevent Good body mechanics Exercises to strengthen leg and abdominal muscles Change in life-style or occupation

Nursing Assessment Specific to HNP Health History Assess for risk factors The cumulative effect of standing erect and daily stress Aging changes in disc/ligaments Poor body mechanics Overweight Trauma Employment History of pain and other neuro changes

Nursing Assessment Specific to HNP Physical Exam Use similar methods to assess as utilized SCI Muscle strength and coordination Sensation sharp/dull of paperclip using dermatome as reference Pain evaluation- pain scale Pre/Post-op assessment

Post-Op Assessment for HNP Sensory/motor assessment be careful not to injure op site Assess for CSF drainage or bleeding from op site Encourage turn (log roll, cough, deep breath) Assess for postural hypotension especially if patient was on bed rest for several days/weeks prior to surgery

Post-op Assessment for HNP If Anterior Cervical Assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness) Assess respiration, neck size, swallowing and speech If Post-Op Lumbar Assess bowels sounds, voiding Minimize stress of post-op site- flat with pillow between knees, log roll, etc

Nursing Problems/Interventions 1. Acute Pain Post surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to ‘bounce’ back quickly Donor site (illiac crest) may cause more pain than laminectomy Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

2. Chronic Pain Surgery may not relieve pain Consider nonpharmalogical methods to control pain Pain clinic

Spinal Cord Tumors

Spinal Cord Tumors CNS is made up of neural tissue and support tissue These tissues undergo changes and result in spinal cord tumors Blood vessels and bone also can be part of the tumor

Classification by origin Primary originating in the spinal cord or meninges Secondary metastases from other parts of the body Most spinal cord tumors are found in the thoracic region Spinal cord tumors can compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction

Common Manifestations/Complications Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected Pain that is not relieved by bed rest is the most common presenting symptom Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

Common Manifestations/Complications Manifestations of thoracic cord tumor Paresis & spasticity of one leg then the other Pain back & chest, not relieved by bed rest Sensory changes Babinski reflex Bowel (ileus); bladder dysfunction (UMN in type)

Therapeutic Interventions Diagnostic tests include X-ray of the spinal column Myelogram Lumbar puncture with CSF analysis

Therapeutic Interventions Medications for spinal tumors Control pain narcotic analgesics, epidural catheter, PCA, NSAID’s Reduce cord edema and tumor size steroids- high dose Dexamethasone

Therapeutic Interventions Surgery for spinal cord tumors Laminectomy to remove or to decrease the size (decompression laminectomy) of the spinal cord tumor Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable Radiation to reduce size and control pain

Nursing Assessment Health history Physical exam Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex Physical exam Similar to physical assessment for HNP

Nursing Problems/Interventions 1. Anxiety Metatastic tumor vs benign spinal cord tumor Education and support system 2. Risk for constipation From spinal cord compression, narcotics, bed rest Adjust fluid and diet

Nursing Problems/Interventions 3. Impaired physical mobility From bed rest and motor involvement Basic nursing- ROM, etc 4. Acute pain From compression or invasion of tumor Assess and treat 5. Sexual dysfunction Male sacral reflex arc (S 2,3,4) interference Similar care as discussed with SCI

Nursing Problems/Interventions 6. Urinary retention Reflex arc (S2,3,4) interference can cause neurogenic bladder as discussed with SCI 7. Home care Rehabilitation Home evaluation Support groups

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? 1. Bladder distension 2. Neurological deficit 3. Pulse ox readings 4. The patient’s feelings about the injury

While in the ED, a patient with a C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? 1. Autonomic dysreflexia 2. Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism

A 22-year-old patient with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? 1. Place the client flat in bed 2. Assess patency of the indwelling urinary catheter 3. Give one SL nitroglycerin tablet 4. Raise the head of the bed immediately to 45-90 degrees

A patient with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? 1. To hasten wound healing 2. To immobilize the surgical spine 3. To prevent autonomic dysreflexia 4. To hold bony fragments of the skull together

A patient has a cervical spine injury at the level of C5 A patient has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? 1. Absent corneal reflex 2. Decerebrate posturing 3. Movement of only the right or left half of the body 4. The need for mechanical ventilation

The nurse is evaluating neurological signs of the male patient in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? 1. Positive reflexes 2. Hyperreflexia 3. Inability to elicit a Babinski’s reflex 4. Reflex emptying of the bladder

Your T1 spinal cord injured patient complains of a headache. You should 1. Give him prn Tylenol 2. Disimpact his bowels 3. Call the doctor 4. Take his blood pressure

Your patient has a malignant metastatic lesion at T8 and is in for palliative radiation. What is your main goal with this patient? 1. Teach patient self catheterization 2. Ensure patient receives pain medication as needed 3. Encourage patient to discuss fears 4. Ambulate twice a shift