1. Spinal Cord Injury

2. 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

3. 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

4. Pathophysiology
anatomy of the spine

5. 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

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

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

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

11. 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

13. Normal Spinal Cord

14. Normal spinal cord
Dermatones
Skin innervated by sensory spinal nerves

15. 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

18. 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

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

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

22. 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

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

24. Classifications of SCI Mechanism of Injury
Flexion
Hyperextension
Flexion Rotation
Compression

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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.

37. 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

39. 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?

40. 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

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

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

43. 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)

44. 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

45. 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

46. 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)

47. 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

48. 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

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

51. 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

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

53. 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

54. Therapeutic Interventions
Stabilization/immobilization
Traction with Gardner-Wells tongs

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

56. Therapeutic Interventions
Casts; splints; collars; braces

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

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

60. 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

61. 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

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

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

64. 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

65. 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

66. 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

67. 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)

68. 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

69. 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

70. 1. Impaired Physical Mobility
Use of transfer board

71. 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

73. 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

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

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

77. 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!

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

79. 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

80. 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

81. 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

83. 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

84. 7. Ineffective Coping
Grief and Depression
Sexuality

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

86. 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

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

88. 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

89. NCLEX questions/ case study

91. 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?