1. Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

2. 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

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

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

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

6. 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

7. 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)

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

9. Normal spinal cord: Dermatones Skin innervated by sensory spinal nerves

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

11. 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

12. 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

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

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

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

16. 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

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

18. 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

20. 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

21. 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

22. Incomplete cord injury: Horner’s Syndrome Injury to the cervical sympathetic nerves Ipsilateral ptosis of the eyelid Constriction of the pupil (miosis) Facial anhidrosis

23. Horner’s Syndrome

24. 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

25. B. Common Manifestations and Complications by body systems 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)- dec venous return, orthostatic hypotension, poikilothermic (takes on temp of room)

26. Body system cont. Resp: decrease chest expansion; cough reflex & vital capacicty; 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

27. 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

28. 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

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

30. Common manifestation/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?

31. 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

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

33. Therapeutic interventions: Emergency care at scene, ER & ICU Transport with cervical collar Assess ABC’s; O2; tracheotomy/vent IV for life line NG to suction Foley

34. Therapeutic interventions: Medications IV metylprednisone (Solu-Medrol) within 8 hrs to decrease cord edema Medications to control or to prevent complications SCI and immobility: Vasopressors treat bradycardia or hypotension Histamine H2 blockers to prevent stress ulcers Anticoagulants Stool softeners Antispastomotics

35. Therapeutic interventions: Stabilization/immobilization Traction with Gardner-Wells tongs

36. Traction

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

38. Therapeutic interventions: Casts; splints; collars; braces

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

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

42. D. Nursing Assessment specific to SCI Health History Description of how and when injury occurred Other illnesses or disease processes Ability to move, breath, and associated injury such as a head injury, fractures

43. Nursing Assessment specific SCI 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

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

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

46. 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

47. 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

48. E. Pertinent nursing problems/interventions 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)

49. 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

50. 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

51. Use of transfer board

52. 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

53. Phrenic nerve

54. 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) Quad cough (assistive cough) as needed

55. 3. Ineffective breathing patterns Assess respiratory rate, rhythm, depth, and breath sounds Assess need for ventilatory assistance, tracheotomy, ventilator

56. 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

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

58. Autonomic Dysreflexia- treatment 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

59. 5. Altered urinary elimination/constipation Bladder Bladder reflex ark- sacral 2,3,4 Flaccid bladder (lower motor neuron lesion) has no reflex from S2,3,4. Have automatic empting of bladder. Urine fills the bladder and dribbles out. Need foley or freq intermittent self catherization Spastic bladder (upper motor neuron lesion) has reflex ark, but no connection to or from brain. Reflex fires at will. Bladder training- trigger points to stimulate empting; self catherization

60. Upper/lower motor bladder

61. Bladder functioning: http://www.rnceus.com/course_frame.asp? exam_id=56&directory=uro http://www.rnceus.com/course_frame.asp? exam_id=56&directory=uro

62. 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 the parasympathic S 2,3,4 reflex to fire and cause bladder contraction Urinary antiseptic

63. Bowel 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 ducolax suppository to glycerin then to gloved finger for digital stimulation Assess bowel sounds prior to giving food for the first time– paralytic illus!

64. 6. Sexual dysfunction 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

65. Suggestions: empty bladder before sex; withhold fluids and antispasmodics; certain positions may increase spasms; explore new erogenous zones; penile implants

66. 7. Low self-esteem 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 progress

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

69. Case Study PDS– Spinal Cord Injury http://www.softwarefornurses.com/access/ind ex.asp

70. LeMone- Blackboard Case Study & Media links http://wps.prenhall.com/chet_lemone_medical surg_3/0,7859,757263-,00.html http://www.apacure.com/ http://spinalcord.org/

71. Nursing Care Plan: A Client with a SCI LeMone p. 1334 http://wps.prenhall.com/wps/media/objects/ 737/755395/sci.pdf http://wps.prenhall.com/wps/media/objects/ 737/755395/sci.pdf

72. 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?

73. Case Study SCI http://www.pitt.edu/~rhe001/ugcs96.htm