1. Spinal Cord Injury SCI

2. Concept Map: Selected Topics in Neurological Nursing
PATHOPHYSIOLOGY
Traumatic Brain Injury
Spinal Cord Injury
Specific Disease Entities:
Amyotropic Lateral Sclerosis
Multiple Sclerosis
Huntington’s Disease
Alzheimer’s Disease
Myasthenia Gravis
Guillian-Barre’ Syndrome
Meningitis
Parkinson’s Disease
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
ICP Monitoring
“Neuro Checks”
Lab Monitoring
PHARMACOLOGY
--Decrease ICP
--Disease / Condition Specific Meds
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, Discharge Planning, more…based
On Nursing Process: A_D_P_I_E
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary

3. Objectives
Explain pathophysiology of various SCIs and related conditions
Detail signs & symptoms and functionality of different level SCIs
Differentiate between Neurogenic Shock and Spinal Shock
Explain Autonomic Dysreflexia / Hyperreflexia and list appropriate nursing interventions
Discuss overall medical & nursing management of SCIs

5. Motor function Sensory function Reflexes Control of elimination
SCI Involves loss of:
Motor function Sensory function Reflexes Control of elimination

6. Common Causes SCI
Motor vehicle accidents (MVA) - Auto and motorcycle accidents the leading cause of spinal cord injuries
Acts of Violence – mostly gunshot wounds
Falls – SPI after age 65 is often caused by a fall
Sports and recreation injuries - Impact sports and diving in shallow water * ATV *
Diseases - Cancer, infections, arthritis and inflammation

7. Breakdown of Road Traffic Accident Statistics
Breakdown of Sports Statistics
Breakdown of Fall Statistics

9. SCI Type Incomplete / Partial spinal cord injury
- Spinal cord is able to convey some messages to or from the brain. Therefore, retain some sensation and possibly some motor function below the affected area
Complete injury
- Complete loss of motor function and sensation below the area of injury
**** Even in a complete injury, the spinal cord is almost never completely cut in half. Doctors use the term "complete" to describe a large amount of damage to the spinal cord.
It's a key distinction because many people with partial spinal cord injuries are able to experience significant recovery, while those with complete injuries are not

10. Complete or Partial ?

11. Compressison / Wedge Fracture
As the forces push forwards and backwards, pressure is applied to the front and/or back of the spinal bones causing damage in these areas as indicated by the arrow
In these injuries, direct compression forces downwards literally squash the bones, resulting in a loss of height seen on x-ray. This x-ray also shows a chip fracture at the front of the lumbar vertebrae (green arrow) (See how much bigger and stronger this bone is compared to the cervical bone in the picture on the left)

12. Spinal Cord Injury
Most trauma to the spinal cord causes permanent disability or loss of movement (paralysis) and sensation below the site of the injury
Paralysis can involve all four extremities, a condition called quadriplegia or tetraplegia, or only the lower body, a condition called paraplegia

15. C4 C6 T6 L1

16. SCI Causal Categories Traumatic spinal cord injury may stem from:
- Sudden, traumatic blow that fractures, dislocates, crushes or compresses one or more of vertebrae
- Gunshot or knife wound that penetrates and cuts your spinal cord
- Additional (secondary) damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around spinal cord
Non-traumatic spinal cord injury may be caused by arthritis, cancer, blood vessel problems or bleeding, inflammation or infections, or disk degeneration of the spine

17. Risk factors
Gender - Spinal cord injury affects a disproportionate amount of men
Age – (Young adults and seniors)
- Between ages 16 and 35 / MVA leading cause
- Another peak in people older than 60 / falls leading cause
People active in sports – High risk athletic activities include football, rugby, wrestling, gymnastics, diving, surfing, ice hockey and downhill skiing
Predisposing conditions - A relatively minor injury can cause spinal cord injury in people with conditions that affect their bones or joints, such as arthritis or osteoporosis

18. At the Scene 1. Maintaining ability to breathe Priorities
2. Preventing shock
3. Immobilization to prevent
further spinal cord damage
(Backboard & C-Collar)

20. Vertebrae Commonly Involved

21. Baseline Assessment At Scene & Upon Arrival to ER
ABCs / ATLS assessment includes Vital Signs & Glasgow Coma Score
Neck / Spine stabilization
Maintaining BP
Multisystem support
May be sedated

22. Diagnosis
X-Ray
C-Spine
FIRST !!
Swimmer’s View

23. Be Vigilant ! Spinal cord injury isn't always obvious
Numbness or paralysis may result immediately after a spinal cord injury or gradually as bleeding or swelling occurs in or around the spinal cord
In either case, time between injury and treatment is a critical factor that can determine the extent of complications and the level of recovery
It's safest to assume that trauma victims have a spinal cord injury until proved otherwise
If you suspect that someone has a back or neck injury
Spinal Immobilization STAT !

24. History of Injury Loss of Consciousness? Other victims seriously hurt?
Mechanism of injury?
Driver / passenger / seatbelt ?
Fall height / what caused fall?
Hit where and with what?
Gunshot / impaled object ?

25. Different mechanism of injury

26. CT Scan

27. MRI

28. Continued…
MRI – For identifying herniated disks, blood clots or other masses that may be compressing the spinal cord. But… MRI can't be used on people with pacemakers or on trauma victims who need certain life-support machines or cervical traction devices
Myelography - Dye injected into spinal canal then X-rays or CT scan can suggest a herniated disk or other lesions. Used when MRI isn't possible

29. Primary Spinal Injury Result of initial trauma
Injury usually permanent
©2000 Brian Smith Greg Louganis's Diving Accident, 1988 Sports Illustrated

30. Secondary Spinal Injury
Occurs after Spinal cord trauma
Damage at cellular level
Necrosis (Cells swell, burst and leak toxic substances to other cells)
Apoptosis (Programmed cell death / cell suicide to prevent bursting)

31. Secondary SCI

32. Secondary SCI

33. Injuries (lesion) higher in the spinal cord produce more paralysis
SCI Disability
1. Depends on Location
Injuries (lesion) higher in the spinal cord produce more paralysis

34. SCI Disability
2. Depends on type of injury

35. Spinal Cord - Horizontal View

36. American Spinal Injury Association (ASIA) Classification

37. Incomplete / Partial SCI
Central
Lateral / Brown-Sequard Syndrome
Anterior
Posterior

38. Anterior Cord Syndrome
Damage o front 2/3 of spinal cord, loss of pain and temperature sensation, and motor function below level of injury
Light touch (pressure) and position and vibration sensation preserved
Possible for some people with this injury to later recover some movement

39. Central Cord Syndrome Usually with unbelted MVA and falls of elderly
Typically results greater weakness in arms vs lower extremities
Sensory loss varies but more severe in upper extremities
Control over the bowel and bladder varies and may be preserved
Possible for some recovery from this type of injury, usually starting in the legs, gradually progressing upwards

40. Brown-Sequard Syndrome
Usually stab or GSW
Damage is towards one side of the spinal cord
Ipsilateral (same side as the cord injury) Impaired or loss of movement, touch, pressure and vibration
** (Hemiparaplegia)
Contralateral (opposite side of cord injury) loss of pain and temperature sensation ** (Hemianesthesia)

41. Posterior Cord Syndrome
Damage is towards the back of the spinal cord
May leave the person with good muscle power, pain and temperature sensation
However they may experience difficulty coordinating movement of their limbs

43. Motor (blue) and Sensory (red) axons in the spinal cord and peripheral nerves. Sensory neurons reside in the dorsal root ganglia (DRG) while Motoneurons reside in the spinal cord and innervate muscle (yellow).

44. SCI Goals of Care There's no way to reverse damage
Treatment focuses on:
1. Preventing further injury
2. Enabling people to return to an active and productive life within the limits of their disability