Spinal Cord Injury

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Spinal Cord Injury
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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

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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

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Pathophysiology

• anatomy of the spine

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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

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PathophysiologyNormal Spinal Cord

• Vertebral Column
• 8 Cervical
• 12 Thoracic
• 5- Lumbar
• 5- Sacral

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Protection of Spinal Cord from Injury

• Bones- vertebral column
• Discs- between vertebra
• Internal and external ligaments
• Dura

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Protection of Spinal Cord from Injury

• Internal and external ligaments
• Dura
• Meninges
• CSF in subarachnoid space allow for movement
  within spinal canal

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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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Normal Spinal Cord
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Normal spinal cord

• Dermatones

• Skin innervated by sensory spinal nerves

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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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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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Spinal Cord Injury- SCI

• Compression
• Interruption of blood supply
• Traction
• Penetrating Trauma

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Spinal Cord Injury

• Primary
• Initial mechanism of injury
• Secondary
• Ongoing progressive damage
• Ischemia
• Hypoxia
• Microhemorrhage
• Edema

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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

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Classifications of SCI

• 1. Mechanism of Injury
• 2. Skeletal and Neurologic Level
• 3. Completeness (degree) of Injury

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Classifications of SCIMechanism of Injury

• 1. Mechanism of Injury
• Flexion
• Hyperextension
• Flexion Rotation
• Compression

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Classifications of SCIMechanism of Injury

• Flexion (hyperflexion)

• Most common because of natural protection
  position.
• Generally cause neck to be unstable because
  stretching of ligaments

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Classifications of SCIMechanism of Injury

• Hyperextention

• Caused by chin hitting a surface area, such as
  dashboard or bathtub
• Usually causes central cord syndrome symptoms

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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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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?

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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

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Common Manifestations/Complications

• C6- weak grasp
• Has shoulder/biceps to transfer push w/c
• No bowel/bladder control.
• Considered level of independence

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Common Manifestations/Complications

• T1-6- full use of upper extremity
• Transfer
• Drive car with hand controls and do ADLs
• No bowel/bladder control

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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)

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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

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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

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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)

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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

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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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Diagnostic Studies for SCI

• X-ray of spinal column
• CT/MRI
• Blood gases

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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

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Therapeutic Interventions

• Medications
• IV methylprednisolone (Solu-Medrol) within 8 hrs
  to decrease cord edema

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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

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Therapeutic Interventions

• Stabilization/immobilization
• Traction with Gardner-Wells tongs

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Therapeutic Interventions

• External traction

• Halo device
• For patients who do not have motor deficits
• Experience less immobility complications

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Therapeutic Interventions

• Casts splints collars braces

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Therapeutic Interventions

• Special Beds for SCI

• To decrease immobility complications
• Rotorest is a common one used- rotates 23 hrs a
  day

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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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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

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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

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Nursing ManagementAssessment

• Motor Assessment Upper Extremity

• Movement, strength and symmetry
• Hand grips
• Flex and extend arm at elbow- with and without
  resistance

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Nursing Management Assessment

• Motor Assessment Lower Extremity

• Flex and extend leg at knee with and without
  resistance
• Planter and dorsi flexion of foot

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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

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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

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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

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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)

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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

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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

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1. Impaired Physical Mobility

• Use of transfer board

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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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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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3. Impaired Skin Integrity

• Change position frequently
• Removal of TED hose every 8 hours
• Nutritional status
• Protection from extremes in temperature

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3. Impaired Skin Integrity

• Inspect skin at least 2x/day especially over
  boney prominences
• Avoid shearing and friction to soft tissue with
  transfers

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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!

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5. Impaired Urinary Elimination

• Bladder function SCI
• Upper/Lower Motor
• Bladder reflex arc-
  sacral 2,3,4

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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

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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

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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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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

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7. Ineffective Coping

• Grief and Depression
• Sexuality

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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

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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

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Home Care

• Assess psychological, physical resources, need
  for rehabilitation (in-house or outpatient) need
  for community resources
• Home evaluation

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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

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• NCLEX questions/ case study

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• 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?