Module 11 - Spinal Cord Injury Flashcards
How does the Peripheral NS break up?
Peripheral NS –> Motor (Efferent) Neurons –> Autonomic and Somatic (voluntary)
ANS –> SNS and PNS
Peripheral NS –> Sensory (Afferent) Neurons
Efferent
goes from the brain to the periphery
efferent
Afferent
goes from the periphery to the brain
sensory
How many vertebrae are there
32 to 33
What is the order of the vertebrae types and their amounts
7 Cervical
12 Thoracic
5 Lumbar
5 Fused Sacral
3-4 Fused Coccygeal
The First spinal Nerves exit … and this pattern goes until…
exit ABOVE C1 and this goes through C7
Where does the C7 spinal nerve exit
above the C7 vertebrae
Where does the C8 spinal nerve exit
C8 exits below C7 vertebrae and above T1. From there T1 spinal exits below T1, and so on for the rest
Intervertebral Discs
spongy disks between the spinal column giving flexibility and allows us to not have bone grinding on bone
also allows load bearing
made up of the nucleus pulposus and the annulus fibrosis
Nucleus Pulposus
area of the intervertebral discs that is the pulpy part more medial/inside
Annulus Fibrosis
the thick fibrotic ring that is more firm on the outside of the intervertebral disk
What gives our spinal cord and vertebrae support?
Longitudinal Ligaments - they give longitudinal support
Ligaments connect __ to ___
bone to bone
tendons connect __ to __
muscle to bone
What do longitudinal ligaments do?
they keep vertebrae aligned properly to stay straight
very functional in keeping vertebrae slipping side to side as well
What is the problem with a longitudinal ligament though?
they are stronger on the front side than back side so a disk herniation is more likely to go backward
Types of Longitudinal Ligaments
Anterior Longitudinal
posterior longitudinal
supraspinal
interspinal
ligamentum flavum
What is an additional stabilizer for the back?
Back muscles which help us stand erect
Efferent goes ___ Afferent comes ___
away ; toward
The sensory cortex and motor cortex and their afferent/efferent connections are mostly made of what
white matter
Where are the cell bodies (Grey Matter) in the brain and spinal cord?
it is outside the brain and inside the spinal cord
Where are the axons (white matter) in the brain and spinal cord?
inside of the brain and outside of the spinal cord
How do motor neurons move down the body?
they initiate at the motor cortex and travel down where they cross at the medulla oblongata and go down the opposite side where they then exit at the ventral root of the spinal cord
so the left arm is controlled by right motor nerves at the medulla oblongata level
How do sensory neurons move up the body?
Some will go up on the same side (ipsilaterally) while others go up the other side (contralateral)
What is an example of an ipsilateral sensation?
tickle
What is an example of a contralateral sensation?
pain
Why are men 4x more likely to have spinal cord injuries
males are more likely to engage in risk taking behaviors as young men
What age group tends to see more spinal injuries
younger adults to adults
average age is 33.4 with a median of 26 and a modal of 19
Causes for Serious Spinal Injury
motor vehicle accidents
falls
gunshot or stab wounds
sports injuries (diving 66%)
Causes for Less Serious Spinal Injury
lifting heavy objects
minor falls
The most common cause of spinal injury is …
motor vehicle accidents
-plegia
Paralysis
Monoplegia
paralysis in one limb
Hemiplegia
paralysis in both limbs on one side
Paraplegia
paralysis in both upper OR both lower limgs
Quadriplegia/Tetraplegia
Paralysis in all four limbs
-paresis
weakness
Ipsilateral
same side
Contralateral
opposite side
Hypotonia
less than normal muscle tone
Flaccidity
absent muscle tone
Hypertonia
excessive muscle tone
Spasticity
stiff awkward movement
Rigidity
immovable stiffness
Tetany
intermittent tonic spasms - paroxysmal
Vertebral Fracture
fragmentation of vertebral bone
can be the pedicle, lamina, or processes
What are the thin parts of a vertebrae
the pedicle and lamina
Laminectomy
surgical removal of part of the vertebral bone allowing for a disk to have some room if it is enlarged and swollen so it does not pinch any nerves
Vertebral Dislocation
displacement of the vertebral body
Vertebral Subluxation
partial dislocation of the vertebral bone
Types of Vertebral column Injuries
Flexion
Extension
Compression
Axial Rotation
Flexion Injury
flex the spine forward and cause an injury anteriorly
Extension Injury
extend the spine back and cause compression injuries in the back of the spinal cord
Compression Injury
When one vertebrae jams into another one
very dangerous
can occur in diving if landing on your head
Axial rotation injury
Twisting of the neck that kills someone
also though of with shaken baby syndrome
Extent of spinal injury depends on ___ and ___
location and severity
The higher the injury of the spinal cord…
the greater the chance of autonomic injury
Spinal cord injuries commonly involve…
both sensory and motor function
Spinal cord injury is…
mechanical disruption of neurons
Spinal cord injury can lead to…
injury related ischemia and hypoxia contributing to local infarction
development of micro hemorrhages or edema that causes interruption of neuronal function
You can have ___ without ischemia, but cannot have ischemia without ___
hypoxemia; hypoxemia
The two step pathophysiology of spinal cord injuries
- primary –> initial injury –> small hemorrhages in grey matter –> edematous changes in white matter –> necrosis of neural tissue –> IRREVERSIBLE DAMAGE
- secondary –> progressive neurologic damage leading to vascular damage, neuronal injury, and release of vasoactive agents and cellular enzyme
Secondary vascular damage in spinal cord injuries can lead to
ischemia
increased vascular permeability
edema
Secondary Neuronal injury in spinal cord injuries can lead to
loss of reflexes below the level of injury
Secondary release of vasoactive agents and cellular enzymes in spinal cord injuries can lead to
delayed swelling
demyelination
necrosis
Secondary progressive neurologic damage can become…
a cycle that repeats
Spinal Shock
where the spinal cord stops working below the level of a spinal cord injury
As swelling goes down some function can return but…
only if this is secondary damage, as primary is irreversible and never returns
Types of Spinal Cord Injury
Incomplete transection
Complete transection
Incomplete Transection
partial preservation of sensory and motor function as only part of spinal cord is damaged through
Central cord syndrome, anterior cord syndrome, brown-sequard syndrome, conus medullaris syndrome
Complete Transection
absence of sensory and motor function due to the spinal cord basically being severed
If complete transection is above T1 what occurs
Quadriplegia
If complete transection is below T1 what occurs
Paraplegia
Ventral Root
the anterior part in the spine
corticospinal tracts (motor) go to the ventral area at the anterior horn
Dorsal/Posterior Horn
sensory tracts ipsilateral or contralateral are at the dorsal column or dorsal root of the spinal nerve
Possible effects if spinal cord injury is at or above C5
respiratory paralysis - inability to respirate
quadriplegia
Possible effects of spinal cord injury between C5 and C6
paralysis of legs, wrists, hands
weakness of shoulder abduction and elbow flexion
loss of brachioradialis reflex
Possible effects of spinal cord injury between C6 and C7
paralysis of legs wrists and hands
Should and elbow movement and flexion still possible
loss of bicep jerk reflex
Possible effects of spinal cord injury between C7 and C8
paralysis of the legs and hands
Possible effects of spinal cord injury at C8 to T1
Horner’s syndrome (constricted pupil, ptosis, facial anhidrosis)
paralysis of legs
Possible effects of spinal cord injury between T11 and T12
paralysis of leg muscles above and below the knee
Possible effects of spinal cord injury at T12 to L1
paralysis below the knee
Possible effects of spinal cord injury at the Cauda Equina
hyporeflex or areflexic paresis of the lower extremities
usually pain and hyperesthesia in the distribution of the nerve roots
usually loss of bowel and bladder control
Possible effects of spinal cord injury at S3 to S5 or at the conus medullaris at L1
complete loss of bowel and bladder control
The most life threatening spinal cord injuries are…
are at the highest points in the cervical vertebrae
The higher the spinal cord injury the more likely…
you will need ventilator support for life and become quadriplegic
Hyperesthesia
abnormal increase in sensitivity to stimulation - particularly touch
also higher pain
Central Cord Syndrome - Nature of Injury
Damage to central gray or white matter of cord (central means the grey matter is most effected in the spine)
Central Cord Syndrome - Areas MOST affected
Motor function of upper extremities - paresis, paralysis of extremities, or loss of fine motor function
Central Cord Syndrome - Areas less or not affected
Motor function of lower extremities
Bowel, bladder, sexual function
Central Cord Syndrome - Recovery
Often recover to the point of being ambulatory and controlling bowel and bladder, but often are not able to perform detailed or intricate work with their hands
People seem to recover well
Who often has Central Cord Syndrome
elders with osteoporosis or vertebrae degeneration
Anterior Cord Syndrome - Nature of Injury
Infarction of anterior spinal artery resulting in damage to the anterior 2/3 of cord
This impacts the front of the spinal cord - facing our front
Anterior Cord Syndrome - Areas MOST affected
Loss of motor function by corticospinal (motor) tracts
Loss of pain and temperature sensation from damage to lateral spinothalamic tracts
Reduction in or loss of local reflexes & localized LMNs (lower motor neurons) of the anterior horn
Anterior Cord Syndrome - Areas less or not affected
Posterior 1/3 of cord
Dorsal column axons conveying position, vibration, and touch sensation
Anterior Cord Syndrome - Recovery
Tend to do poorly
Brown-Sequard Syndrome - Nature of Injury
Damage to a hemi-section (half) of the anterior and posterior cord
This is a rare syndrome and impacts half the body - vertically split, half the body does not work
Brown-Sequard Syndrome - Areas MOST Affected
Loss of voluntary motor function from the corticospinal tract
Proprioreception loss from the ipsilateral side of the body
Contralateral loss of pain and temperature sensation from the lateral spinothalamic tracts for all levels below the lesion
Lose one arm and one leg movement
Brown-Sequard Syndrome - Recovery
Many patients can improve at least enough to ambulate and to control bowel and bladder function
They must relearn to walk and control bladder and bowel though
Anterior Cord Syndrome cause
Lesions disproportionately affecting the anterior spinal cord, commonly due to infarction (e.g., caused by occlusion of the anterior spinal artery)
Brown Sequard Syndrome cause
Unilateral spinal cord lesions, typically due to penetrating trauma
Anterior Cord Syndrome S/S
All tracts malfunction except the posterior columns, thus sparing position and vibratory sensation
Brown Sequard Syndrome S/S
Ipsilateral paresis
Ipsilateral loss of touch, position, and vibratory sensation
Contralateral loss of pain and temperature sensation*
Central Cord Syndrome cause
Lesions affecting the center of the spinal cord, mainly central gray matter (including spinothalamic tracts, which cross), commonly due to trauma, syrinx, or tumors in the central spinal cord
Conus Medullaris Syndrome cause
Lesions around L1
central cord Syndrome S/S
Paresis tending to be more severe in the upper than in the lower extremities and sacral regions
Tendency to lose pain and temperature sensation in a capelike distribution over the upper neck, shoulders, and upper trunk, with light touch, position, and vibratory sensation relatively preserved (dissociated sensory loss)
Conus Medullaris Syndrome S/S
Distal leg paresis
Perianal and perineal loss of sensation (saddle anesthesia)
Erectile dysfunction
Urinary retention, frequency, or incontinence
Fecal incontinence
Hypotonic anal sphincter
Abnormal bulbocavernosus and anal wink reflexes
Conus Medullaris
end of the major spinal cord that becomes the spray of nerves not encased in the spinal cord at the tail
talks about low spinal cord activity
Cauda Equina
The very end of the spinal cord looking like a horses tail with the nerves spread out
Conus Medullaris Syndrome - Nature of Injury
Damage to the conus medullaris or the sacral cord and lumbar nerve roots within the neural canal
Conus Medullaris Syndrome - Areas MOST affected
Flaccid bowel, bladder, and sexual function
Motor function in the legs and feet
Conus Medullaris Syndrome - Areas less or not affected
Preserved reflexes if only conus is involved
May not have significant sensory impairment
Cauda Equina Syndrome - Nature of Injury
Damage to the lumbosacral nerve roots within the canal
this is the nerve roots getting hurt
Cauda Equina Syndrome - Areas MOST affected
Various patterns of asymmetric flaccid paralysis, sensory impairment, and pain
Damage to the conus medullaris or cauda equina often result in …
bowel, bladder, and sexual dysfunction
What to do for a neurologic examination
mental status and speech check
cranial nerve check
Central and peripheral sensory function check
motor function check
cranial and peripheral reflex assessment
cerebellar function and gait
A lot of the neurological examination can be done…
just in non formal ways through conversation and watching via indirect discussion
Spinal X Ray can…
provide details of the bone structures in the spine
can rule out instability, tumors, and fractures
Spinal X rays are not good at…
capturing disc and nerve root structures
not good at soft tissue findings
Spinal X rays cannot diagnose…
lumbar disc herniation or other causes of nerve pinching
Computed Tomography (CT)
fancy x ray that can take cross section images of the body
will image large disc herniations but can miss smaller ones
CT with Myelogram
radiopaque dyes injected into the sac around the nerve roots which lights up the nerve roots
provides substantial information on nerve roots
very sensitive test for nerve impingement and can pick up even very subtle lesions
MRI
the gold standard of spinal cord injury diagnosis - but its very expensive
single most useful imaging study available for spine surgery
aids in the assessment of certain conditions by providing detail of the disc and nerve roots
provides highly refined detail of the spine’s anatomy
may not be first ordered
Electromyography (EMG)
assesses the electrical activity of a nerve root
useful to distinguish nerve degeneration (neuropathy) from nerve root compression (radiculopathy)
Its like an EKG for nerve roots in the spine - can tell us if nerve roots are working
Somatosensory Evoked Potentials (SSEP)
assesses speed of electrical conduction across the spinal cord
if spinal cord is significantly pinched, the electric signals will travel slower than usual
Also used to monitor spinal cord function during surgical procedures
Why is EMG and SSEP seen less often?
Because MRI is used more
The goal of spinal injury management is…
reduce neurological deficits and prevent additional ones
Ways to Manage Spinal Cord Injuries
Immobilization with neck collars and back boards to limit movement, stabilize spinal column, and prevent further damage
Log-roll and secure head with straps or tape
Cervical: Cervical traction
Thoracic & lumbar: Bedrest & logrolling
High dose methylprednisolone w/in 8 hours- Stabilizes cell membranes, enhances impulse generation, improves blood flow, inhibits free radical formation
CURRENT RESEARCH: neuron regeneration with stem cells
Prevention, early detection, prompt intervention, rehabilitation
What is the time frame to give methyl prednisone or steroids to stabilize cell membranes, improve blood flow, inhibit free radical formation, and enhance impulse generation in the spine? But keep in mind…
8 hours
but keep in mind that it can have impacts on the immune system and make people ill as a SE or increase GI bleeding
Alterations in Functional Abilities as a Result of Spinal injury
Alterations in spinal reflexes
alterations in ventilation and communication dysfunctions
ANS system dysfunction - vasovagal response, autonomic dysreflexia, postural hypotension
Alteration in temperature regulation
circulatory system dysfunction
sensorimotor dysfunction
alterations in skin, pain, bladder function, bowel elimination, and sexual function
Alterations in Spinal reflexes due to Upper Motor neuron lesions occur in what region and result in what?
affected by any injury T12 and above
Results in SPASTIC PARALYSIS of affected skeletal muscle groups, and muscles that control bowel, bladder, and sexual function - injury can still have reflex arc so muscles become painful and spastic but are less likely to do so
Alterations in Spinal reflexes due to Lower Motor neuron lesions occur in what region and result in what?
affected by any injuries below T12
Results from damage to the peripheral nerves that exit each segment of the spinal cord
Causes FLACCID PARALYSIS of involved skeletal muscle groups and muscles that control bowel, bladder, and sexual function - no reflex arc d/t no innervations
So, Spastic paralysis indicates __ damage and flaccid paralysis indicates __ damage
upper; lower
Spinal or Neurogenic Shock
state of areflexia that occurs post spinal injury - they are the first complication of symptoms after an injury
involves the loss of all or most of the spinal reflexes below the level of the injury and also involves motor pathways
Manifestations of Spinal Shock
flaccid paralysis
lack of tendon reflexes
and lack of autonomic function
A “waiting game” to see
How long does Spinal Shock last
may last minutes, hours, days, or weeks, but is usually self limiting (inflammation goes down and the body regains some function)
Areflexia
no reflex arcs below level of injury
The diaphragm is innervated by __ to __ via __ nerves
by C3 to C5 by phrenic nerves
Intercostal Muscles are innervated by __ to __
T1 to T7
Major Muscles of Expiration are innervated by __ to __
T6 to T12
Injury to C1 to C3 area leads to what Ventilation Dysfunctions
lack of respiratory effort
requires assisted ventilation dependence
there is respiratory paralysis
injury to C3 to C5 leads to what Ventilation Dysfunctions
allows partial or full diaphragmatic function, but ventilation is diminished
Injury below C5 leads to what Ventilation dysfunctions
ability to take a deep breath and cough less impaired - so the function is there
Any damage to the __ region can impact ventilation dunction
chest
Ways to meet communication needs for spinal injuries that are Verbal
Fenestrated tracheostomy tubes
Provide airflow for vibration of the vocal cords
Talking tracheostomy tubes
Diaphragmatic pacing
Electrolarynx-type devices
Mechanical ventilation with an air leak
Ways to meet communication needs for spinal injuries that are Non-verbal
communication via boards or cards
computerized scanning programs
Mouth stick control devices
How is afferent and efferent flow above the level of injury?
unaffected so there is normal function
What occurs to ascending and descending transmissions below the injury?
They are blocked –> this causes uncontrolled spinal and autonomic reflexes (ANS dysfunction)
What are the most severe ANS dysfunctions of spinal cord injury?
Autonomic regulation of circulatory function and thermoregulation are the most severe problems
The higher the level the injury, the more profound the ANS dysfunction effect, especially above __
T6 (d/t diminished innervation of the carotid, diaphragm, and intercostal baroreceptors)
A normal body without injury can have vasovagal responses from what nerve working through the PNS?
Nerve X (Vagus)
Those with spinal injuries tend to have what more often
vasovagal responses
The vagus nerve has what effect on heart rate?
a continuous inhibitory effect
Vagal Stimulation in a Spinal injury region –> Vasovagal Response –> ?
Bradycardia or Asystole (in spinal injuries, normally it is just slowing heartrate)
normally the heart slowing down will have the SNS fix the response but the SNS response cannot get through the damaged area in this case
We need to be careful doing what with spinal injury patients?
doing things that can cause a vasovagal response
What are some things that can cause a vasovagal response?
Deep tracheal Suctioning - must hyperoxygenation with O2 to help
Rapid position changes - avoid d/t postural hypotension
What can be done if a person begins to have a vasovagal response with a spinal cord injury
you can give anticholinergic drugs to work against the PNS via the cholinergic system
Autonomic Dysreflexia
Acute episode of exaggerated sympathetic reflex responses that is a classic complication of spinal injury
“Autonomic Hyper Dysreflexia”
What may cause Autonomic Dysreflexia
visceral (organ) stimuli that normally cause pain or discomfort in the abdominopelvic region
Why does it take time before autonomic dysreflexia can occur after an injury?
It cannot occur until spinal shock is resolved and autonomic reflexes return - within 6 months of injury
Autonomic Dysreflexia is __ in the first year and can occur___
unpredictable; lifelong
Autonomic Dysreflexia occurs in spinal injuries that happen at what region and higher?
T6 and higher
___ lesions can still have reflex arcs, but a ___ lesion means there is no reflex arc and no innervation for the reflex
UMN; LMN
What is the Triad of characteristics for Autonomic Dysreflexia
HTN (signal to slow HR and lower pressure cannot get down to the area causing this)
Bradycardia (attempt to lower HTN)
Headache (vasodilation in the head causes a person to be red above the injury level and pale below the injury level from vasoconstriction)
Autonomic Dysreflexia: Unregulated SNS activity –> Vasospasms, HTN, Skin pallor, Piloerection –> ?
baro-reflex mediated vagal bradycardia, vasodilation, flushed skin, profuse sweating above the level of injury, nasal congestion
Causes for Autonomic Dysreflexia
- Visceral Distention (full bladder or rectum)
- Pain - pressure ulcers, ingrown toenails, dressing changes, diagnostic or operative procedures (cannot feel it but signals still sent)
- Visceral contractions - ejaculations, bladder spasms, uterine contractions
The causes of Autonomic Dysreflexia can lead to what ultimate complications?
Convulsions, decreased LOC, and Death
Interventions for Autonomic Dysreflexia
monitor BP every 5 minutes
remove stimulus and correct cause
position them upright
Remove AE hose (allows venous pooling to drop blood pressure)
IV peripheral vasodilators like apresoline and hyperstat
A straight catheter may cause a vasovagal response while trying to intervene on autonomic dysreflexia, is that ok?
yes, it is a trade off
We would rather have that than AD
What is unique to Autonomic Dysreflexia interventions?
Removal of AE hose is wanted to allow venous pooling
What do IV vasodilators do in autonomic dysreflexia?
They lower BP to prevent a potential stroke
What spinal injuries cause Postural Hypotension
occurs in persons with injuries at T4 to T6 and above
Postural Hypotension
cannot maintain BP when changing position
related to interruption of descending control of sympathetic outflow to blood vessels in the extremities and abdomen (cannot vasoconstrict when position changing to keep BP up)
results in pooling of blood which decreases cardiac output
Signs of Postural Hypotension
Dizziness
pallor
excessive sweating above the level of the lesion
blurred vision
fainting
Prevention of Postural Hypotension
slow changes in position
measures to promote venous return (like putting on AE hose before getting them up
Spinal injuries of any kind often cause what?
Alterations in temperature regulation
this is because of an SNS malfunction in regulation of body temperature, not infection
Central mechanisms for temperature regulation are located…
in the hypothalamus
When cold what signals does the hypothalamus cause
vasoconstriction and shivering –> conservation and production of heat
When hot what signals does the hypothalamus cause
vasodilation and sweating –> dissipative and evaporative heat loss
What happens to temperature regulation in spinal cord injury
sympathetic effector responses below the level of the injury are disrupted
this means a lack of ability to conserve and dissipate heat and sweat
Higher levels of spinal injury cause…
greater disturbances in temperature regulation
Poikilothermy
when someone assumes the external temperature for their body temperature below the level of a spinal injury
Education for temperature regulation in spinal injury patients
clothing and awareness of environment
they can still get frostbite and heat stroke but they wont feel it
What are common circulatory system dysfunctions with spinal cord injury
edema and DVT
Decreased PVR, areflexia or hypotonia, and immobility in spinal injury –> ??
increased venous pressure and pooling of blood in the abdomen, lower limbs and extremities
Orthostatic or dependent edema in spinal injury should have what intervention occur
elevation and compression via AE hose`
DVT should have what interventions occur
low dose heparin
ROM
compression devices
assessment
Sensorimotor dysfunction occurs in what way after spinal injury?
After spinal shock, isolated reflex activity + muscle tone not under control of higher centers returns
Results in hypertonia or involuntary spasticity of skeletal muscles below the level of injury
May be tonic (sustained tone) or clonic (intermittent)
What are the benefits of Tonic (sustained tone) in a spinal injury
sustained tone
prevention of atrophy (shrinkage)
helps with venous return
What are the downfalls of Tonic (sustained tone) in a spinal injury
contractures
skin breakdown
greater injury risk than clonic
Spasticity occurs in injuries of what areas?
Injuries above T12
Why do injuries below T12 not cause spasticity
Below T12 controls reflex responses and with that damaged it leads to flaccidity not spasticity
What are some stimuli that could cause spasms in sensorimotor dysfunction and muscle tone?
muscle stretching
bladder infections
bowel distension or impaction
pressure areas
infections
Interventions for Spasticity in Muscel Tone
PROM
avoid stimuli
antispasmodics on hand
What innervates skin
cranial and spinal nerves in dermatomes
afferent/sensory info –> brain –> efferent/motor control and reflex activity at each dermatome
What is one of the most preventable complication of spinal cord injury
skin dysfunction
Normal SNS control of Skin does what?
controls vasomotor and sweat glands providing adequate circulation, excretions’ of body fluids and temp regulation
What occurs with SNS control and skin with spinal injury
major risk for altered skin integrity from sweatiness uncontrolled or pressure or shearing forces when turning, trauma, and infection
Factors that cause Skin Dysfunction and altered integrity
pressure
shearing forces
trauma
irritation
Interventions for the Skin in a spinal cord injury patient
relieve pressure
encourage circulation
inspect for breakdown
How can pain differ in a spinal cord injury
It can be one of many diverse and unpredictable pain syndromes such as mechanical/fracture pain, radicular or spinal nerve root pain, visceral pain, or central pain
basically they may not feel much or feel excessive pain
Mechanical or Fracture Pain
dull, aching pain occurring at level of spinal injury from soft tissue damage
Radicular or Spinal nerve Root pain
aching or shooting pain radiating along distribution of nerves
Visceral pain
poorly localized pain
burning abdominal/pelvic discomfort related to bladder distension or UTI
Central Pain
diffuse burning sensation below level of injury
aggravated by touch, movement, and visceral distension
Interventions for Pain in spinal injuries
TENS units - help with nerve pain
TCAs (tricyclic antidepressants and antiepileptics)
NSAIDS
PT
Normal bladder sensation comes what …
sensory signals from bladder stretch receptors S2 to S4 –> go to a reflex voiding center –> go to motor neurons S2 to S4 allowing voiding
SNS and Bladder function
detrusor relaxation - bladder filling
PNS and bladder function
detrusor contraction - voiding
UMN Injury and Bladder Function
SPASTIC bladder dysfunction
lack awareness of bladder filling and voluntary control of voiding –> leads to incontinence
LMN injury and Bladder function
FLACCID bladder dysfunction
lack awareness of bladder filling and lack of bladder tone –> unable to void –> retention and overflow –. potential for UTI
Interventions for Bladder function in Spinal injury patients
continuous or intermittent drainage via catheter
external collection
manual techniques
teach them about catheters
SNS and Bowel Elimination
T6 to L3 –> decrease intestinal motility and increase internal sphincter tone
PNS and Bowel Elimination
S2 to S4 –> Increase intestinal motility and decrease internal sphincter tone
How is bowel elimination affected in spinal injuries at S2 to S4
flaccid functioning of the defecation reflex and loss of voluntary control of the external anal sphincter
causes constipation from loss of control or bowel incontinence - can be either thing
How is bowel elimination affected in spinal injuries above S2 to S4
spastic functioning of the defecation reflex and loss of anal sphincter tone –> intrinsic contractile responses intact but no defecation reflex
Has no defecation reflex leading to constipation
Interventions for spinal cord injury bowel elimination
high fluids
high fiber diet
mobility
consistent pattern
privacy
positioning
laxatives
digital stimulation (questionable - can cause vasovagal response)
What areas of the spine control mental stimuli or psychogenic sexual response
T11 to L2
What areas of the spine controls sexual touch or reflexogenic sexual response
S2 to S4
With sexual function, spinal cord injury at any level…
disrupts neural pathways (S2 to S4) between genitals and higher centers
Where would a UMN lesion be and what would it cause for sexual dysfunction
T10 or higher
reflex sexual response to touch can occur, but there is no response to mental stimuli - a spinal lesion is blocking the pathway
Where would a LMN lesion be and what would it cause for sexual dysfunction
T12 or below
sexual reflex center may be damaged –> no response to touch; below T12 sexual arousal by mental stimuli; L1 to L2 may have sexual responses to mental or touch stimuli
Interventions for Spinal injury sexual function
erectile aids
lubricants
Despite Sexual dysfunction, what may not be lost with spinal injury
fertility
for this reason pregnancy, labor, and birth control requires caution
Does Viagra work for someone with a spinal cord issue?
No d/t circulation impairment
Herniated Disk
disk exploding beyond where it should be
can push on nerves and hurt
can come from trauma or aging from drying of disk, but any time the nucleus is pushed out of place its very painful
nurses have a high rate of this
What are some reasons for disk herniation
50% of the time is from trauma
aging
degenerative disorders
The most common direction of disk herniation
posterior and oblique toward the intervertebral foramen and contained spinal nerve root, and dorsal root ganglion
So it heads backward and up at an angle into the space where the nerves are
The most common kind of disk herniation
Lumbar Disk herniation - 90 to 95%
This tends to only effect one leg usually tho
Where do lumbar disk herniations mostly occur
L4 to L5
OR
L5 to S1
What can L5 nerve impingement from disk herniation cause
weakness in extension of the big toe and potentially in the ankle (foot drop)
numbness and pain can be felt on top of the foot, and the pain may also radiate into the buttocks
What can S1 nerve impingement from disk herniation cause
loss of the ankle reflex and/or weakness in ankle push
numbness and pain can radiate down to the sole or outside of the foot
Cervical Disk Herniation - Most common regions
C6 to C7
AND
C5 to C6
What can C5 nerve impingement from disk herniation cause
shoulder pain
deltoid weakness
possible a small area of numbness in the shoulder
on physical exam, patient biceps reflex may be diminished
What can C6 nerve impingement from disk herniation cause
weakness in the biceps and wrist extensors
pain and numbness that runs down the arm to the thumb
on physical exam, the brachioradialis reflex (mid forearm) may be diminished
What can C7 nerve impingement from disk herniation cause
pain and numbness that runs down the arm to the middle finger
on physical exam, triceps reflex may be diminished
What can C8 nerve impingement from disk herniation cause
hand dysfunction (this nerve supplies innervation to the small muscles of the hand)
pain and numbness that can run to the outside of the hand (little finger) and impair its reflex
The key to cervical disk herniation…
the further the herniation is away from the top, the less severe it is
As the herniation goes down the cervical disk herniation though, the worse the hand is considered though
Manifestations of (all) Disk herniations
1 PAIN - intensified by coughing sneezing, straining, stooping, standing, jarring
The pain is radiating
slight motor weakness
paresthesia and numbness
decreased reflexes
Diagnosis of Disk herniation involves
A good H&P
Neurological Assessment
Diagnostic Testing
What sort of things are included in the neurologic assessment for disk herniation
mental status and speech check
cranial nerve check
central and peripheral sensory function check
motor function check
cranial and peripheral reflex check
cerebellar function and gait
straight leg raise (SLR)
If there is a disk herniation, what will occur during a straight leg raise
there will be sciatic pain from the leg to the calf
What are some Diagnostic tests for Herniated Disks
X ray
CT
CT With myelogram
MRI
EMG
SSEP
X ray and CT may not tell much but MRI and CT w/ Myelogram can
Management of Herniated Disks
Analgesics
Anti Inflammatory meds
Muscle Relaxants
conditioning exercises
PT
chiropractic manipulations
education
surgery
What analgesics are used with herniated disks
NSAIDS and short term opiods
What anti inflammatory meds are used with herniated disks
oral steroids
epidural (cortisone) injections
What is included in education for herniated disks
correct mechanics for lifting
methods for protecting your back
What are some surgical indications for herniated disk management
documented herniation
consistent pain or neurologic deficit
failure to respond to conservative therapy
incontinence
foot drop
What may be able to get a herniated disk back into place?
PT
