Spinal Cord Injury SCI

Concept Map: Selected Topics in Neurological Nursing PATHOPHYSIOLOGY Traumatic Brain Injury Spinal Cord Injury Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation ICP Monitoring “Neuro Checks” Lab Monitoring PHARMACOLOGY --Decrease ICP --Disease / Condition Specific Meds Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, Discharge Planning, more…based On Nursing Process: A_D_P_I_E Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary

Objectives Explain pathophysiology of various SCIs and related conditions Detail signs & symptoms and functionality of different level SCIs Differentiate between Neurogenic Shock and Spinal Shock Explain Autonomic Dysreflexia / Hyperreflexia and list appropriate nursing interventions Discuss overall medical & nursing management of SCIs

Motor function Sensory function Reflexes Control of elimination SCI Involves loss of: Motor function Sensory function Reflexes Control of elimination

Common Causes SCI Motor vehicle accidents (MVA) - Auto and motorcycle accidents the leading cause of spinal cord injuries Acts of Violence – mostly gunshot wounds Falls – SPI after age 65 is often caused by a fall Sports and recreation injuries - Impact sports and diving in shallow water * ATV * Diseases - Cancer, infections, arthritis and inflammation

Breakdown of Road Traffic Accident Statistics Breakdown of Sports Statistics Breakdown of Fall Statistics

SCI Type Incomplete / Partial spinal cord injury - Spinal cord is able to convey some messages to or from the brain. Therefore, retain some sensation and possibly some motor function below the affected area Complete injury - Complete loss of motor function and sensation below the area of injury **** Even in a complete injury, the spinal cord is almost never completely cut in half. Doctors use the term "complete" to describe a large amount of damage to the spinal cord. It's a key distinction because many people with partial spinal cord injuries are able to experience significant recovery, while those with complete injuries are not

Complete or Partial ?

Compressison / Wedge Fracture As the forces push forwards and backwards, pressure is applied to the front and/or back of the spinal bones causing damage in these areas as indicated by the arrow In these injuries, direct compression forces downwards literally squash the bones, resulting in a loss of height seen on x-ray. This x-ray also shows a chip fracture at the front of the lumbar vertebrae (green arrow) (See how much bigger and stronger this bone is compared to the cervical bone in the picture on the left)

Spinal Cord Injury Most trauma to the spinal cord causes permanent disability or loss of movement (paralysis) and sensation below the site of the injury Paralysis can involve all four extremities, a condition called quadriplegia or tetraplegia, or only the lower body, a condition called paraplegia

C4 C6 T6 L1

SCI Causal Categories Traumatic spinal cord injury may stem from: - Sudden, traumatic blow that fractures, dislocates, crushes or compresses one or more of vertebrae - Gunshot or knife wound that penetrates and cuts your spinal cord - Additional (secondary) damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around spinal cord Non-traumatic spinal cord injury may be caused by arthritis, cancer, blood vessel problems or bleeding, inflammation or infections, or disk degeneration of the spine

Risk factors Gender - Spinal cord injury affects a disproportionate amount of men Age – (Young adults and seniors) - Between ages 16 and 35 / MVA leading cause - Another peak in people older than 60 / falls leading cause People active in sports – High risk athletic activities include football, rugby, wrestling, gymnastics, diving, surfing, ice hockey and downhill skiing Predisposing conditions - A relatively minor injury can cause spinal cord injury in people with conditions that affect their bones or joints, such as arthritis or osteoporosis

At the Scene 1. Maintaining ability to breathe Priorities 2. Preventing shock 3. Immobilization to prevent further spinal cord damage (Backboard & C-Collar)

Vertebrae Commonly Involved

Baseline Assessment At Scene & Upon Arrival to ER ABCs / ATLS assessment includes Vital Signs & Glasgow Coma Score Neck / Spine stabilization Maintaining BP Multisystem support May be sedated

Diagnosis X-Ray C-Spine FIRST !! Swimmer’s View

Be Vigilant ! Spinal cord injury isn't always obvious Numbness or paralysis may result immediately after a spinal cord injury or gradually as bleeding or swelling occurs in or around the spinal cord In either case, time between injury and treatment is a critical factor that can determine the extent of complications and the level of recovery It's safest to assume that trauma victims have a spinal cord injury until proved otherwise If you suspect that someone has a back or neck injury Spinal Immobilization STAT !

History of Injury Loss of Consciousness? Other victims seriously hurt? Mechanism of injury? Driver / passenger / seatbelt ? Fall height / what caused fall? Hit where and with what? Gunshot / impaled object ?

Different mechanism of injury

CT Scan

MRI

Continued… MRI – For identifying herniated disks, blood clots or other masses that may be compressing the spinal cord. But… MRI can't be used on people with pacemakers or on trauma victims who need certain life-support machines or cervical traction devices Myelography - Dye injected into spinal canal then X-rays or CT scan can suggest a herniated disk or other lesions. Used when MRI isn't possible

Primary Spinal Injury Result of initial trauma Injury usually permanent ©2000 Brian Smith Greg Louganis's Diving Accident, 1988 Sports Illustrated

Secondary Spinal Injury Occurs after Spinal cord trauma Damage at cellular level Necrosis (Cells swell, burst and leak toxic substances to other cells) Apoptosis (Programmed cell death / cell suicide to prevent bursting)

Secondary SCI

Secondary SCI

Injuries (lesion) higher in the spinal cord produce more paralysis SCI Disability 1. Depends on Location Injuries (lesion) higher in the spinal cord produce more paralysis

SCI Disability 2. Depends on type of injury

Spinal Cord - Horizontal View

American Spinal Injury Association (ASIA) Classification

Incomplete / Partial SCI Central Lateral / Brown-Sequard Syndrome Anterior Posterior

Anterior Cord Syndrome Damage o front 2/3 of spinal cord, loss of pain and temperature sensation, and motor function below level of injury Light touch (pressure) and position and vibration sensation preserved Possible for some people with this injury to later recover some movement

Central Cord Syndrome Usually with unbelted MVA and falls of elderly Typically results greater weakness in arms vs lower extremities Sensory loss varies but more severe in upper extremities Control over the bowel and bladder varies and may be preserved Possible for some recovery from this type of injury, usually starting in the legs, gradually progressing upwards

Brown-Sequard Syndrome Usually stab or GSW Damage is towards one side of the spinal cord Ipsilateral (same side as the cord injury) Impaired or loss of movement, touch, pressure and vibration ** (Hemiparaplegia) Contralateral (opposite side of cord injury) loss of pain and temperature sensation ** (Hemianesthesia)

Posterior Cord Syndrome Damage is towards the back of the spinal cord May leave the person with good muscle power, pain and temperature sensation However they may experience difficulty coordinating movement of their limbs

Motor (blue) and Sensory (red) axons in the spinal cord and peripheral nerves. Sensory neurons reside in the dorsal root ganglia (DRG) while Motoneurons reside in the spinal cord and innervate muscle (yellow).

SCI Goals of Care There's no way to reverse damage Treatment focuses on: 1. Preventing further injury 2. Enabling people to return to an active and productive life within the limits of their disability