Spinal Cord Injury: What Now Expected Outcomes'

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Spinal Cord Injury What Now?Expected Outcomes.

• Maura Nee RNP
• Elizabeth Tammaro RN, CRRN
• VA Boston Healthcare System
• SCI Out Patient Clinic

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Objectives

• Discuss Anatomy and Physiology of the Spinal Cord
• Understand the Impact of Neurologic Level of
  Injury (LOI) and ASIA Classification
• Discuss Expected Functional Outcomes Specific to
  LOI
• Understand Role of the Nurse in Achieving
  Functional Outcomes

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SCI Statistics (2002)

• 250,000 in USA
• Paraplegic 52
• Quadriplegia 47
• New SCI/yr 11,000
• Male 82
• 16yr-30yr 56

• Causes
• MVA 37
• Violence 28
• Falls 21
• Sports 6
• Other 8
• 89 D/Cd home

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Anatomy of the Spine

• Vertebrae
• Body
• Front section, shaped like drum
• Supports weight
• Lamina
• Towards the back
• Boney arch surrounds spinal canal
• Spinous process
• Boney process from arch
• Points of attachment for muscles and ligaments
• Discs
• Cushions between vertebrae

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Anatomy of the Spine

• Vertebrae
• 7 Cervical
• Flexion, extension, bending and turning of head
• 12 Thoracic
• Chest region, allows mostly for rotation
• 5 Lumbar
• Larger boney structures to support added wgt
• 5 Sacral
• Fused together
• Coccyx

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Anatomy of the Cord

• Cervical Cord
• C1-C2
• C3-4 Phrenic nucleus
• C4 Deltoids
• C4-5 Biceps
• C6 Wrist extensors
• C7 Triceps
• C8 Wrist extensors
• C8-T1 Hand muscles

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Anatomy of the Cord

• Thoracic Cord
• Intercostal muscles and associated dermatones
• Lumbarsacral
• Starts at T9 and continues to L2
• Innervates hips, legs, buttocks and anal region
• Cauda Equina (horses tail)
• Spinal cord ends at L2
• Tip called conus, below conus a spray of spinal
  roots

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Dermatomes/Sensory Level

• Dermatome
• patch of skin innervated by a given spinal cord
  level

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                                   C2 to C4. The
C2 dermatome
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Myotomes/Motor Level

• Myotome
• Spinal nerve roots which innervates muscles
  groups
• Most muscles are innervated by more than one root

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ASIA Impairment Scale

• ASIA A Complete no motor or sensory function is
  preserved in the sacral segments S4-S5
• ASIA B Incomplete sensory but NOT motor
  function is preserved below the neurological
  level and includes the sacral segments
• ASIA C Incomplete motor function is preserved
  below the neurological level and more than half
  of key muscles below the neurological level have
  a muscle grade lt3
• ASIA D Incomplete motor function is preserved
  w/ muscle grade gt 3
• ASIA E Normal

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Definition of Disability

• Tetraplegia (preferred to quadriplegia)
• Refers to impairment or loss of motor/sensory
  function in cervical segments of the spinal cord
• Impairment of function in arms, trunk, legs and
  pelvic organs
• ASIA Scale vs quadriparesis

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Definition of Disability

• Paraplegia
• Refers to impairment or loss of motor/sensory
  function in thoracic, lumbar or sacral segments
  of the spinal cord
• Arm function spared
• Possible impairment of function in trunk, legs
  and pelvic organs
• ASIA Scale vs paraparesis

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Clinical Syndromes

• Central Cord Syndrome
• lesion occurring almost exclusively in the
  cervical region
• Sacral sensory sparing
• Weakness gt UE vs LE
• Brown-Sequard Syndrome
• Lesion that produces ipsilateral, proprioceptive
  and motor loss and contralateral loss of
  sensitivity to pain and temp

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Clinical Syndromes

• Anterior Cord Syndrome
• Lesion that produces variable loss of motor
  function and of sensitivity while preserving
  proprioception
• Cauda Equina Syndrome
• Injury to the lumbosacral nerve roots w/ in the
  neurocanal resulting in areflexive bladder, bowel
  and lower limbs

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Achievement of Functional Goals

• Age
• Body type
• Comorbidities
• Prior athletic sense
• Fatigue level

• Type of stabilization
• HX HO/POA
• Spasticity
• Psychosocial factors
• Nutrition

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Functional Outcomes

• Motor/sensory recovery
• Ability to perform or direct ADLs
• Social reintegration
• Quality of life

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Functional Outcomes

• LEVEL C1-C3
• Limited head/neck movement
• Rotate/flex neck (sternocleidomastoid)
• Extend neck (cervical paraspinals)
• Speech and swallowing (neck accessories)
• Total paralysis of trunk,UE and LE

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LEVEL C1-3

• 24 hr care needs
• Able to direct care needs
• ADLs
• Ventilator dependent
• Impaired communication
• Dependent for all care needs
• Mobility
• Power wheelchair
• Hoyer lift

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LEVEL C1-C3

• Equipment Needs
• Adapted computer
• Bedside/portable ventilator
• Suction machine
• Specialty bed
• Hoyer
• Reclining shower chair

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Functional Outcomes

• LEVEL C4
• Head and neck control (cerv paraspinals)
• Shoulder shrug (upper traps)
• Inspiration(diaphragm)
• Lack of shoulder control (deltoids)
• Paralysis of trunk, UE and LE
• Inability to cough, low respiratory reserve

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LEVEL C4

• 24 hr care needs
• Able to direct care needs
• ADLs
• May or may not be vent dependent
• Improved communication
• Assisted cough
• Dependent for all care needs
• Mobility
• Power wheelchair
• Hoyer lift

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LEVEL C4

• Equipment Needs
• Adapted computer
• Bedside/portable ventilator as needed
• Suction machine
• Specialty bed
• Hoyer
• Reclining shower chair

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Functional Outcomes

• LEVEL C5
• Shoulder control (deltoids)
• Elbow flexion (biceps/elbow flexors)
• Supinate hands (brachialis and brachioradialis)
• Lack elbow extension and hand pronation
• Paralysis of trunk and LE

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LEVEL C5

• 10hrs personal care need
• 6 hrs homemaking assistance
• ADLs
• Set-up/equipment eating, drinking, face wash and
  teeth
• Assisted cough
• Dependent for bowel, bladder and lower body
  hygiene
• Dependent for bed mobility and transfers

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LEVEL C5

• Mobility
• Hoyer or stand pivot
• Power wheelchair w/ hand controls
• Manual wheelchair
• Drive motor vehicle w/ hand controls
• Equipment Needs
• Power and manual wheelchairs
• Adaptive splints/braces
• Page turners/computer adaptations

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Functional Outcomes

• LEVEL C6
• Wrist extension (extensor carpi ulnaris and
  extensor carpi radialis longus/brevis)
• Arm across chest (clavicular pectrocialis)
• Lack elbow extension (triceps)
• Lack wrist flexion
• Lack hand control
• Paralysis of trunk and LE

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LEVEL C6

• 6 hrs personal care needs
• 4hrs homemaking assistance
• ADLs
• Assisted cough
• Set-up for feeding, bathing and dressing
• Independent pressure relief, turns and skin
  assessment
• May be independent for bowel/bladder care

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LEVEL C6

• Mobility
• Independent slide board transfer
• Manual wheelchair
• Drive with adaptive equipment

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Functional Outcomes

• LEVEL C7
• Elbow flexion and extension (biceps/triceps)
• Arm toward body (sternal pectoralis)
• Lack finger function
• Lack trunk stability

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LEVEL C7

• 6hrs personal care needs
• 2hrs homemaking assistance
• ADLs
• More effective cough
• Fewer adaptive aids
• Independent w/ all ADLs
• May need adaptive aids for bowel care

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LEVEL C7

• Mobility
• Manual wheelchair
• Transfers without adaptive equipment

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Functional Outcomes

• LEVEL C8-T1
• Increased finger and hand strength
• Finger flexion (flexor digitorum)
• Finger extension (extensor communis)
• Thumb movement (policus longis brevis)
• Separate fingers (introssi separates)

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LEVEL C8-T1

• 4hrs personal care needs
• 2hrs homemaking assistance
• ADLs
• Independent w/ or w/o assistive devices
• Assist w/ complex meal prep and home management
• Mobility
• Manual wheelchair

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Functional Outcomes

• LEVEL T2-T6
• Normal motor function of head, neck, shoulders,
  arms, hands and fingers
• Increased use of intercostals
• Increase trunk control (erector spinae)

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LEVEL T2-T6

• 3hrs personal care needs/homemaking
• ADLs
• Independent in personal care
• Mobility
• Manual wheelchair
• May have limited walking with extensive bracing
• Drive with hand controls

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Functional Outcomes

• LEVEL T7-T12
• Added motor function
• Increased abdominal control
• Increased trunk stability

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LEVEL T7-T12

• 2 hrs personal care needs/homemaking
• ADLs
• Independent
• Improved cough
• Improved balance control
• Mobility
• Manual wheelchair
• May have limited walking with bracing
• Driving with hand controls

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Functional Outcomes

• LEVEL L2-L5
• Added motor function in hips and knees
• L2 Hip flexors (iliopsas)
• L3 Knee extensors (quadriceps)
• L4 Ankle dorsiflexors (tibialis anterior)
• L 5 Long toe extensors (ext hallucis longus)

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LEVEL L2-L5

• May need 1hr personal care/homemaking
• ADLs
• Independent
• Mobility
• Manual wheelchair
• May walk short distance with braces and assistive
  devices
• Driving with hand controls

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Functional Outcomes

• LEVEL S1-S5
• Ankle plantar flexors (gastrocnemius)
• Various degrees of bowel, bladder and sexual
  function
• Lower level equals greater function

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LEVEL S1-S5

• No personal or homemaker needs
• ADLs
• Independent
• Mobility
• Increased ability to walk with less
  adaptive/supportive devices
• Manual w/c for distance

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Functional Outcomes

• Achieving maximum functional outcomes provides
  the opportunity to reach the highest level of
  independence and quality of life

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Functional Outcomes

• Power Point presentation can be found
• www1.va.gov/spinalcordboston/