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Spinal Cord Injury

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Title: Spinal Cord Injury


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 (gt61 yr)
  • Greater complications
  • Life Expectancy 5 years less than same age
    without injury
  • 90 go home

4
Pathophysiology
  • anatomy of the spine

5
PathophysiologyNormal 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
PathophysiologyNormal Spinal Cord
  • Vertebral Column
  • 8 Cervical
  • 12 Thoracic
  • 5- Lumbar
  • 5- Sacral

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

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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

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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

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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

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

21
Spinal Cord Injury
  • Primary
  • Initial mechanism of injury
  • Secondary
  • 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 SCIMechanism of Injury
  • 1. Mechanism of Injury
  • Flexion
  • Hyperextension
  • Flexion Rotation
  • Compression

25
Classifications of SCIMechanism of Injury
  • Flexion (hyperflexion)
  • Most common because of natural protection
    position.
  • Generally cause neck to be unstable because
    stretching of ligaments

26
Classifications of SCIMechanism of Injury
  • Hyperextention
  • Caused by chin hitting a surface area, such as
    dashboard or bathtub
  • Usually causes central cord syndrome symptoms

27
Classifications of SCIMechanism 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 SCIMechanism 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 SCICompleteness (Degree) of
Injury
  • Complete
  • 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

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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 ADLs
  • 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
  • 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

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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 ABCs 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

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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 ManagementAssessment
  • 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 ADLs
  • 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

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73
2. Impaired Gas Exchange
  • Assess respiratory rate, rhythm, depth, and
    breath sounds
  • Monitor vital capacity, respiratory effort,
    ABGs, 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

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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 lt100ml/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

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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 gt 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 15-30 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
Whats 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

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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?
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