1. Spinal Cord Injury

2. Pathophysiology Normal 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
The Human Spine

3. Spinal Cord
Gray matter- cell bodies of voluntary and autonomic motor neurons
White matter axons of ascending and descending motor fibers

4. Upper Motor Neurons
UMN
Originate in cerebral cortex
Project downward
Result in skeletal muscle movement
Injury = SPASTIC paralysis
Lower Motor Neurons
LMN
Originate at each vertebral level
Project to specific parts of the body
Result in movement /sensation
Injury = FLACCID paralysis

6. Normal Spinal Cord Dermatones Skin innervated by sensory spinal nerves
Myotome- muscle group innervated by motor neurons

7. Nervous System and the Spinal Cord
ANS can be affected by SCI
Sympathetic chains on both sides of the spinal column (T1-L2)
Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)

8. Spinal Cord Protection
Bones- vertebral column
7 Cervical
12 Thoracic
5- Lumbar
5- Sacral
Discs-
between
vertebra

9. Spinal Cord Protection
Internal and external ligaments
Dura
Meninges
CSF in subarachnoid space allow for movement within spinal canal

10. Etiology of Traumatic SCI
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

11. Etiology of Traumatic SCI
78% people with SCI are male
Typically young men – 16-30
Number of older adults rising (>61 yr)
Greater complications

12. Spinal Cord Injury- SCI
Compression
Interruption of blood supply
Traction
Penetrating Trauma

13. Spinal Cord Injury Primary Initial mechanism of injury Secondary
Ongoing progressive damage
Ischemia
Hypoxia
Microhemorrhage
Edema

14. 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

15. Spinal and Neurogenic Shock
Due to loss of vasomotor tone
peripheral pooling and decreased cardiac output
Hypotension and Bradycardia
Orthostatic hypotension and poor temperature control (poikilothermic)

16. 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

17. Classifications of SCI
Mechanism of Injury
Skeletal and Neurologic Level
Completeness (degree) of Injury
Flexion
Hyperextension
Compression
Flexion /Rotation

18. Classifications of SCI Mechanism of Injury
Flexion (hyperflexion)
Most common because of natural protection position.
Generally cause neck to be unstable because stretching of ligaments

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

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

21. Classifications of SCI Mechanism of Injury
Flexion/Roatation
Most unstable
Results in tearing of ligamentous structures that normally stabilize the spine
Usually results in serious neurologic deficits

22. Levels of Function in Spinal Cord Injury
Skeletal level
Vertebral level where the most damage to the bones
Neurologic level
The lowest segment of the spinal cord with normal sensory and motor function on both sides of the body
Levels of Function in Spinal Cord Injury

23. Classification of SCI- Level of Injury
Spinal cord level
When referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level.
the thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone

24. Classifications of SCI Completeness (Degree) of Injury
Incomplete
Central cord syndrome
Anterior Cord syndrome
Brown-Sequard Syndrome
Posterior Cord Syndrome
Cauda Equina and Conus Medullaris

25. 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

26. Classification of SCI Completeness (degree) of Injury
Incomplete
Central Cord Syndrome
Injury to the center of the cord by edema and hemorrhage
Motor weakness and sensory loss in all extremities
Upper extremities affected more

27. 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

28. Classification of SCI Completeness (degree) of Injury
incomplete
Anterior Cord Syndrome
Injury to anterior cord
Loss of voluntary motor, pain and temperature perception below injury
Retains posterior column function (sensations of touch, position, vibration, motion)

29. Classification of SCI Completeness (degree) of Injury
incomplete
Posterior Cord Syndrome
Least frequent syndrome
Injury to the posterior (dorsal) columns
Loss of proprioception
Pain, temperature, sensation and motor function below the level of the lesion remain intact

30. Classification of SCI Completeness (degree) of Injury
incomplete
Conus Medullaris
Injury to the sacral cord (conus) and lumbar nerve roots
Cauda Equina
Injury to the lumbosacral nerve roots
Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs

32. Clinical Manifestations of SCI
Skin:
pressure ulcers
Neuro:
pain
sensory loss
upper/lower motor deficits
autonomic dysreflexia
Cardio:
dysrhythmias
spinal shock
orthostatic hypotension,

33. Respiratory- GI GU Musculoskeletal
decrease chest expansion, cough reflex & vital capacity
diaphragm function-phrenic nerve GI
stress ulcers
paralytic ileus
bowel- impaction & incontinence GU
upper/lower motor bladder
sexual dysfunction
Musculoskeletal
joint contractures
bone demineralization
osteoporosis
muscle spasms
muscle atrophy
pathologic fractures
para/tetraplegia

34. 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

35. Common Manifestations/Complications
Spinal cord injuries are described by the level of the injury– the cord segment or dermatome level
Such as C6; L4 spinal cord injury
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?

36. Immediate Care Emergency Care at Scene, ER & ICU
Transport with cervical collar
Assess ABC’s; O2; tracheotomy/vent
IV for life line
NG to suction

37. Diagnostic Studies for SCI
X-ray of spinal column
CT/MRI
Blood gases

38. Therapeutic Interventions
Medications
IV methylprednisolone (Solu-Medrol) within 8 hrs to decrease cord edema

39. Therapeutic Interventions
Stabilization/
Immobilization
Traction-
Gardner-wells tongs
Halo
Casts
Splints
Collars
Braces

40. Therapeutic Interventions
Surgery for SCI
Manipulation to correct dislocation or to unlock vertebrae
Decompression laminectomy
Spinal fusion
Wiring or rods to hold vertebrae together

41. Nursing Management Assessment
HEALTH HISTOY
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

42. 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

43. Nursing Management Assessment
Motor Assessment Upper Extremity
Movement, strength and symmetry
Hand grips
Flex and extend arm at elbow- with and without resistance

44. Nursing Management Assessment
Motor Assessment Lower Extremity
Flex and extend leg at knee with and without resistance
Planter and dorsi flexion of foot
Assess for Clonus

45. 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

46. 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

47. 1. Impaired Physical Mobility
provide assistance as needed to keep alignment; teach patient
Care traction, 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)

48. 1. Impaired Physical Mobility
Spastic Paralysis
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; antispasmodic medications
Assess skin break down thrombophlebitis; remove TED hose(compression stockings) at least every shift

49. 1. Impaired Physical Mobility
Prevent/treat orthostatic hypotension
Abdominal binder, calf compressors, TED hose when individual gets up
Assess BP, especially when rising
Teach use of transfer board
Assist Physical Therapy with tilt table as individual gradually gets use to being in an upright position

50. 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

51. 2. Impaired Gas Exchange
Respiratory rate, rhythm, depth, breath sounds, respiratory effort, ABG’s, O2 saturation
Need for ventilatory assistance tracheotomy, ventilator
Quad cough (assistive cough) as needed

52. 3. Impaired Skin Integrity
Change position frequently
Protection from extremes in temperature
Inspect skin at least 2x/day especially over boney prominences
Avoid shearing and friction to soft tissue with transfers
Removal of TED hose every 8 hours
Nutritional status

53. 4. Constipation Bowels 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 ileus!

54. 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 catheterization
Spastic bladder (upper motor neuron lesion)
Reflex arc but no connection to or from brain
Bladder training- trigger points to stimulate empting; self catheterization

55. 5. Impaired Urinary Elimination
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 bladder contraction
Urinary antiseptic

56. 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 > 300 S
Give PRN medication to lower BP
If above not effective– call physician

57. 7. Ineffective Coping/ Grief and Depression
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

58. THANK YOU