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 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, 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
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
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. Motor loss- flaccid paralysis below level injury
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 1553 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

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

52. 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

53. Nursing assessment: Sensory assessment
With the sharp and dull ends of a Q-tip or paperclip have the individual, with their eyes closed identify
Use the dermatome as reference to identify level
C6 thumb; T4 nipple; T10 naval

54. Pertinent Nsg problems/intervention SCI Lewis p.1554-5 NCP: 61-1
Impaired gas exchange
Decrease CO
Impaired skin integrity
Constipation
Impaired urinary elimination
Risk for autonomic dysreflexia
Ineffective coping
Interrupted family process

55. Pertinent nursing problems/interventions Acute intervention: Immobilization
Log roll as a single unit; provide assistance as needed to keep alignment; teach patient
Care traction, special beds, 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)

56. 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

57. Pertinent nursing problems/interventions Respiratory
Phrenic nerve; thoracic and intercstal nerves; abdominal muscles
Monitor vital capacity, respiratory effort, ABG’s, O2 saturation, need for ventilator assistance
Assess for signs of impending extension of SCI up cord to phrenic nerve level (C3-5)
Quad cough (assistive cough) as needed

58. Pertinent nursing problems/interventions Acute intervention: Cardio/nutrition
Cardiovascular instablity
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
Fluid and nutritional maintenance
NG to suction in acute; monitor F&E
High protein/high calorie diet

59. Pertinent nursing problems/interventions Acute intervention: 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-Website http://www. rnceus. com/course_frame

62. 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

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

64. 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

65. 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

66. Pertinent nursing problems/interventions other
Bowels
Temperature control
Stress ulcer
Sensory deprivation
Reflexes- may see hyperreflexia as return of motor function
Rehabilitation and home care: Resp; neurogenic bladder/bowel; skin care; sexuality; grief/depression

67. 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!

68. 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

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

70. Low self-esteem
Assess thoughts on ‘quality of life’; body image; role changes
Physical and psychological support
Most common SCI is yeas old and generally a risk taker– this greatly affects their perception of life and rehabilitation progress

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