Traumatic Spinal Cord Injury

1. TraumaticSpinal Cord Injury Marnie Quick, RN, MSN, CNRN

2. A. Pathophysiology/etiologyNormal 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 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. Upper and Lower Motor Neurons • Upper motor deficits results in spastic paralysis • Lower motor deficits are flaccid paralysis and muscle atrophy

12. Etiology of traumatic spinal cord injury • MVA- most common cause • Other: falls, violence, sport injuries • Typically occurs from indirect injury from displaced vertebral bones compressing cord • Frequently occurs with head injuries • Less frequent cord torn/cut, as from direct trauma from knives or bullets

13. Hemorrhage/edema occurs secondary in cord post injury, causing more damage to cord • Extension of cord injury from cord edema can occur over 1st 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 • Risk factors- male, 16-30 yr, risk taker • 90% discharged home; 10% chronic care facility

14. Events leading to spinal cord ischemia and hypoxia of 2nd injury

15. Classification of SCI: 1. Mechanism of Spinal Cord Injury

16. Mechanism of Injury SCI: Flexion (hyperflexion) • Most common because of natural protection position. • Generally cause neck to be unstable because stretching of ligaments • Flexion with rotation can also occur

17. Mechanism of SCI: Hyperextention • Caused by chin hitting a surface area, such as dashboard or bathtub • Usually causes central cord syndrome symptoms

18. Mechanism of SCI: Compression • Caused by force from above, as hit on head • Or from below as landing on butt • Usually affects the lumbar region

19. Classification of SCI: 2. Level of skeletal injury

20. Classification of spinal cord injury-3. Level of Injury to the spinal cord Neurologic level of Injury • Neurologic level or the lowest cord segment (reflex) or dermatone level functioning • Such as C6; L4 SCI • Prefix: Para-, quad- • Suffix:-paresis,-plegia

21. Classification of SCI: Level of SCI Neurologic level

22. Classification 4. Degree of completeness inj: 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 (orthostatic hypotension, poikilothermic) and spastic bladder

23. Classification of SCI:Incomplete spinal cord injury- what white tracks are working after spinal shock is over?

24. Classification of SCI: Degree of completeness Incomplete spinal cord injury

25. 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

28. 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

29. 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

30. Classification of SCI:5. American Spinal Injury Association Impairment Scale

32. Clinical Manifestations & Complications Spinal Cord Injury • Depends on extent and level of injury • Higher cord injury more serious sequelae • Resp: decrease chest expansion (intercostals); decrease cough reflex & Vital capacity; diaphragm function controlled by phrenic nerve (C3-5); may need mechanical ventilation

33. Clinical Manifestations & Complications Spinal Cord Injury continued • Cardio: dysrhythmias; bradycardia; loss SNS control bl vessels spinal shock; loss of sympathetic nervous system control over blood vessels (vasomotor control)- dec venous return, orthostatic hypotension; dec CO; poikilothermic (takes on temp of room) • GU: upper/lower motor bladder; impotence; sexual dysfunction • GI: stress ulcers; paralytic ileus; bowel- impaction & incontinence

34. Clinical Manifestations & Complications Spinal Cord Injury continued • Skin: pressure ulcers can lead to infection/sepsis • Thermoregulation: poikilothermic (take on temp of environment) Unable to sweat or shiver below level of SCI. Occurs due to SNS interruption; Degree depends level inj • Metabolic needs: Nasogastric suctioning may lead to metabolic alkalosis (Paralytic ileus). Nutritional needs to deep body wt and prevent complications- need positive nitrogen, high-protein diet • Peripheral vascular: DVT; pulmonary embolism

35. Clinical Manifestations & Complications Spinal Cord Injury continued • Neuro: pain at the level of injury; sensory loss; upper/lower motor deficits; autonomic dysreflexia; spinal shock • Musculoskeletal: joint contractures; bone demineralization; osteoporosis; muscle spasms; muscle atrophy; pathologic fractures; para/tetra/Quad; plegia/paresis

36. Spinal shock: result of inflammatory process in cord after injury, causing depression of cord & ANS function below level of injury. Approx 50% develop • 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 • Distributive shock symptoms

37. Spinal shock lasts from few minutes to wks 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

38. Common manifestations&complications: Functional Goals for Spinal Cord Injury • C1-3 usually fatal- loss phrenic inervation; 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; can use assistive devices; dec resp reserve; loss vasomotor; no bowel /bladder control. • T1-6- full use of upper extremity; transfer; drive car with hand controls and do ADL’s; dec trunk stability; no bowel/bladder control

39. C6 SCI using a transfer board

40. Collaborative Care for SCI: Diagnostic tests • Comprehensive neuro exam • X-ray of spinal column • CT/MRI • Blood gases

41. Collaborative Care: Emergency care at scene, ER & ICU • Initial goals- sustain life and prevent further cord damage • Transport with cervical collar • Assess ABC’s; O2; tracheotomy/vent • IV for life line- to give meds • NG to suction • Foley- flaccid bladder

42. Collaborative Care: Stabilization & immobilization with traction

43. Collaborative Care: Gardner-Wells tongs

44. Collaborative Care: External traction • Halo device • For patients who have few motor deficits • Experience less immobility complications

45. Collaborative Care: Casts; splints; collars; braces

46. Collaborative Care: Special Beds for SCI • To decrease immobility complications • Rotorest bed provides for lateral rotation • 23 hrs a day

47. Collaborative Care: Surgery for SCI • Manipulation to correct dislocation or to unlock vertebrae • Decompression laminectomy • Spinal fusion • Wiring or rods to hold vertebrae together

48. Collaborative Care: Drug Therapy • IV metylprednisone (Solu-Medrol) within 8 hrs to decrease cord edema/inflammation • Medications to control or to prevent complications SCI and immobility: • Vasopressors treat bradycardia or hypotension • Histamine H2 blockers to prevent stress ulcers • Anticoagulants- immobility • Stool softeners • Antispastomotics • BP meds (Procardia) if sym persists with autonomic dysreflexia

49. Nursing Assessment Specific to SCI Lewis 1597 Table 61-6 • Subjective data: • Important health info- health history; cause of SCI • Function health patterns-activity; perceptual;coping • Objective data: • By systems • LOC/pupils- R/O head injury • VS- bradycardia • Motor & Sensory • Clonus & spontaneous movement

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