1. Spinal Cord Injury By Dr. Hanan Said Ali

2. Objectives Define spinal cord injury. Identify the Aetiology of spinal cord injury. Describe the mechanisms of injury. Identify the types of spinal cord damage. Explain the Pathophysiology of injury. Define the Spinal Shock. Identify the Clinical Manifestations of Spinal cord Injury. Describe the emergency management of cord injury.

3. Spinal Cord Injury The spinal column is a circular bony ring that provides excellent protection for the spinal cord from most low- intensity injury. The close anatomical proximity of the spinal cord to the vertebrae, muscles and ligaments increases the chance of injury to any of the supporting structures will also result in injury to the cord itself.

4. Spinal Cord Injury Cont. Aetiology Excessive flexion, hyperextension, compression or rotation. The population at risk young adult men 15- 30 years with motor cyclists, skydivers, football players, police personnel. Sudden and often violent external trauma. Arthritis, osteoporosis are risk for injury.

5. Spinal Cord Injury Cont. Mechanisms of Injury Hyper flexion Result of sudden deceleration as in a head on collision or from a sever blow to the back of the head. These injuries are seen in C-5-6 area of the cervical spine. These may result in fracture of the vertebrae dislocation and or tearing of the posterior ligaments

6. Spinal Cord Injury Cont. Mechanisms of Injury Cont. Hyperextension It is result of falls in which the chin is forcibly struck, C-4-5 is the area commonly affected. Compression injuries Blows to the top of the head and forceful landing on the feet or buttocks can result in it It affect both the cervical and thoracolumbar regions of the spine.

7. Spinal Cord Injury Cont. Mechanisms of Injury Cont. Rotational injuries are caused by extreme lateral flexion or twisting of the head and neck. The tearing of ligaments can easily result in dislocation as well as fracture. Soft tissue damage frequently complicates the primary injury.

8. Spinal Cord Injury Cont. Types of Spinal cord damage  Cord Concussion The cord is severely jarred or squeezed as seen with sport- related injuries e.g. Football No pathological change in the cord but a temporary loss of motor or sensory function or both can occur. The dysfunction resolves spontaneously within 24- 48 hours.

9. Spinal Cord Injury Cont. Types of Spinal cord damage Cont.  Cord Contusion It caused by compression. Bleeding into the cord results in bruising and oedema. The extent of damage reflects the adequacy of the overall perfusion to the cord and then severity of the inflammatory response.

10. Spinal Cord Injury Cont. Types of Spinal cord damage Cont.  Cord Transection Complete or incomplete severing of the spinal cord with loss of neurological function is below the level of the injury. The cord segment in which neurological function is preserved.

11. Spinal Cord Injury Cont. Pathophysiology The primary compression, stretching, jarring or tearing of the spinal cord causes small haemorrhages in the gray matter of the cord. Oedema causes the blood flow to the cord to slow in a matter of minute. Hypoxia develops rapidly which often leads to tissue necrosis.

12. Spinal Cord Injury Cont. Pathophysiology Cont. Secondary cord injury results from the body’s natural responses to injury and inflammation. Capillary permeability increases in response to trauma which allows fluid to move into interstitial spaces. Oedema impairs the microcirculation and worsens the ischemia.

13. Spinal Cord Injury Cont. Pathophysiology Cont. The developing hypoxia stimulates the release of vasoactive substances such as catecholamines, histamin, which decreases blood flow in the microcirculationa and may induce vasosoasm. Blood flow to the injured spinal cord is further compromised by the upset of spinal shock

14. Spinal Cord Injury Cont. Spinal Shock It represents a temporary but profound disruption of spinal cord functions, occur immediately after injury, within 30- 60 min. It causes a complete loss of the motor, sensory, reflexes, and autonomic functioning

15. Spinal Cord Injury Cont. Spinal Shock Clinical Manifestations Flaccid paralysis: Affects all skeletal muscles below the level of injury. Loss of spiral reflex activity: Paralytic ileus, loss of bowel and bladder tone. Sensory loss below the level of injury: pain, temp., touch, pressure.

16. Spinal Cord Injury Cont. Spinal Shock Clinical Manifestations Bradycardia result from venous pooling in lower extremities, splanchnic circulation, and loss of vasomotor tone Loss of temperature control  Warm, dry skin.  Inability to shiver or perspire.  Poikilothermia: the body assumes the temperature of the external environment.

17. Spinal Cord Injury Cont. Clinical Manifestations of Spinal cord Inj. Polikilothermia and warm. Dry- flushing extremities Clinical Manifestations  Lesion at C1 to C3 apnoea, inability to cough  Lesion above T5 decreased or absent bowel sounds, abd. distension, constipation, fecal incontinence & impac  Lesion at C4 poor cough, diaphragmatic breathing.  Lesion T1,L2 flaccid bladder, spasticity with reflex bladder emptying.  Lesion at C5 to T6 hypoventilation,decreased respiratory reserve.  Lesion above C8 flaccid paralysis and anesthesia tetraplegia (Previously quadriplegia)  Lesions aboveT5 bradycardia, hypotension, Postural hypotension.  Lesion below C8 Hyperactive deep tendon reflexes, bilaterally positive Babinkis test.

18. Spinal Cord Injury Cont. Emergency Management Assessment of all findings Ensure patent airway Stabilize cervical spine Administer oxygen via nasal cannula or mask Establish IV with two large- bore catheter (normal saline or Ringer’s solution) Assess for other injuries. Control external bleeding.

19. Spinal Cord Injury Cont. Emergency Management Obtain cervical spine radiography or CT. Prepare for stabilization with cranial tong and traction. Administer high- dose methyl prednisolone: Monitor vital signs,LOC, oxygen saturation, cardiac rhythm, urine output. Keep warm. Monitor for urinary retention and hypertension Anticipate need for intubation.

20. Spinal Cord Injury Cont. Emergency Management Prepare and assess the client for: Complete neurological examination. ABG Electrolytes, glucose, haemoglobin, haematocrit, urine analysis. Anteroposterior, lateral spinal x- ray, CT. Myelography, MRI.

21. Spinal Cord Injury Cont. Emergency Management for cervical cord inj Immobilisation of vertebral column by skeletal traction Maintenance of heart rate and blood pressure Methylprednisolon therapy to reduced oedema. Insertion of nasogastric tube, attachment to suction and intubation

22. Spinal Cord Injury Cont. Emergency Management for cervical cord inj Administration of oxygen by high humidity mask. Introduction of indwelling catheter. Administration of IV fluids Ambulatory care should be followed: Stress ulcer prophylaxes. Physical therapy (range of motion exercises) Occupational therapy(splints and ADL training)

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