1. Spinal Cord Disorders and Injuries MSAL IV Neurological Disorders C. Calzolari Fall 2016

2. Herniated Disks Spinal Stenosis Traumatic Injuries

3. Herniated Disk

4. Spinal Stenosis

5. Spinal Cord Injury This is an injury caused by trauma, that damages the spinal cord and causes motor and sensory deficits below the level of injury.

6. Pathophysiology: begins with a sudden traumatic blow to the spine that fractures or dislocates vertebrae. The damage begins when displaced bone fragments, disc material or ligaments bruise or tear spinal cord tissue. Axons and neural cell membranes are damaged. Blood vessels may rupture. Swelling occurs in response to the injury. Body can lose ability to self- regulate and go into shock.

7. Causes Trauma  MVA – most common  Falls  Violence  Sports  Combat  Crushing injuries  Diving

8. Risk Factors Men > women Young adults and the elderly High risk athletic activities such as football, rugby, wrestling, gymnastics, diving, surfing, ice hockey and skiing. Bone disorders such as OA or osteoporosis

9. Signs/Symptoms: depends on location and severity of injury Severity: Partial- incomplete lesion- some motor and sensory function remains. Complete-no motor or sensory function below level of injury Location: cervical injuries are most severe.  Above C3 injuries are fatal  C4-5 causes quadriplegia and respiratory failure. Person will be dependent on ventilator.  Thoracic and lumbar injuries will result in paraplegia or paraparesis of lower extremities along with elimination dysfunction.  Sacral injuries cause bowel, bladder and sexual dysfunction.

11. Emergency Care DO NOT move someone with suspicious spinal cord injury. Wait for EMS to respond. Do not hyperextend the neck. EMS will place a special cervical collar and transport the injured person on a special backboard to minimize movement of the spinal cord. Log rolling is done by EMS. Once in the hospital, the collar is not removed until a spinal cord injury is ruled out.

12. Diagnostics Spinal X-ray CT MRI Myelogram

13. Spinal Shock Spinal shock occurs at the time of the injury. This is a transient state where there is complete loss of sympathetic reflex activity (sensiromotor function) below the level of injury. S/S: flaccid paralysis, absent deep tendon reflexes, hypotension, warm dry skin, urinary retention, erection, hypothermia Spinal shock usually resolves within 48 hours. Hallmark: return of bulbocaverosus reflex (anal sphincter contraction in response to squeezing the glans penis or tugging on foley catheter).

14. Neurogenic Shock Also occurs and is due to loss of sympathetic tone which leads to decreased systemic vascular resistance and increased vagal tone. Manifestation: a triad of hypotension, bradycardia, and hypothermia. Treated with volume resuscitation and use of pressor such as dopamine iv.

15. Treatment Spinal cord immobilization and stabilization IV steroids - Medrol Treat shock Surgery

16. Decompression laminectomy Remove bone fragments, disk fragments, foreign objects

17. Skeletal Traction for Cervical Injuries Crutchfield Tong Gardner-Wells Tong (does not require drilling of Burr holes) Skeletal traction devices used to stabilize cervical fractures. The device is inserted into holes drilled into the skull and attached to weights that provide traction to the spine.

18. Nursing Care Patient remains on bedrest. Make sure weights hang free. Never lift or remove the weights. Never increase or decrease the amount of weight. Keep the head and body in alignment and limit any movement. Daily pin care – cleanse and apply abx ointment to pin sites

19. Halo Vest Traction Another form of traction to stabilize a cervical injury. Typically used for 12 weeks. A ring is applied to the head using 4 skeletal pins Composed of 3 parts:  A ring around the head secured by skeletal pins  A vest with sheepskin lining  A set of 4 rods and 2 blocks that connect the ring to the vest

22. Care of the Person with a Halo Vest Traction Patient Education:  Person must sleep with vest on.  Minimize physical activity  Pin site care – report s/s infect to MD  Swallowing can be difficult at first  Sheepskin must be kept dry. If it gets wet, use the hair drier on cool setting  No bath or shower.  Hair washing is possible but difficult.  Can be a passenger in a car with a seatbelt.  Wear loose fitting clothes.

23. Other Problems and Treatments in the Acute Phase Respiratory failure with cervical injuries – mechanical ventilation Shock – treat with iv fluids and dopamine Ileus – nasogastric decompression Bladder dysfunction – failure to decompress the bladder can lead to autonomic dysreflexia. Insert foley catheter.

24. Complications Dependence on mechanical ventilation Arrythmias and orthostatic hypotension Paralysis Loss of bladder and bowel control Loss of sexual function Infections - pneumonia, UTI, decubiti ulcers, infection from invasive procedures Stress Ulcers – use of Protonix iv prophylaxis Muscle spacticity – use of muscle relaxants – Baclofen Pain - neurogenic Immobility-  Skin breakdown; prevent with use of turning frames  DVT  Pneumonia  Contractures

25. Autonomic Dysreflexia  A life-threatening reflex action.  It happens when there is an irritation, pain or stimulus to the nervous system blow the level of the injury. The irritated area tries to send a signal to the brain but cannot. A reflex action occurs without the brain’s regulation.  The most common trigger is an overdistended bladder.  S/S: Severe Hypertension Tachycardia Headache Nausea Blurred vision Anxiety

26. Nursing Diagnoses Airway clearance, ineffective Knowledge deficit Aspiration, risk of Anxiety Fluid volume deficit Pain Injury, risk for Infection, risk for Thermoregulation, inefective Impaired skin integrity Immobility

27. Prevention of Autonomic Dysreflexia Pain Management Monitor I/O Monitor for bladder distention Check patency of foley catheter Prevent constipation Monitor for s/s of UTI Assess nail and skin integrity

28. Rehabilitation PT/OT Bladder and bowel training programs Vocational rehabilitation Recreation therapy Counseling