SCI Flashcards
Deterioration
Deterioration of the neurologic status may be secondary to a tethered cord, syringomyelia, or peripheral problems, such as median or ulnar nerve entrapment, or other musculoskeletal complications.
“Four D Syndrome”
A person who sustains a SCI is at risk for the “four D syndrome”; dependency, depression, drug addiction, and, if married, divorce.
Risk factors for depression
Risk factors for depression include
- a prior history or
- family history of depression,
- pain,
- female gender,
- lack of social support,
- multiplicity of life stresses,
- concurrent medical illness, and
- alcohol or substance abuse.
Additional factors include having
- a complete neurological injury,
- medical comorbidity with TBI,
- a low level of autonomy,
- poor education,
- unemployment,
- having a poor social network and family support,
- few financial resources,
- architectural barriers,
- vocational difficulties, and
- the need for personal and transportation assistance.
QOL
Individuals injured at a younger age tend to experience successful adjustment and a better QOL than older individuals . This may be due to their flexible use of coping strategies, and the development of a self-concept that includes the knowledge of future limitations . Additional variables associated with lower QOL scores included presence of neurogenic pain, spasticity, and bowel and bladder problems. Conversely, those who are married, currently employed, more highly educated, female, and Caucasian are more likely to have higher QOL scores
Incidence
Cervical lesions (approximately 50%) followed by thoracic and then lumbosacral lesions. The C5 segment is the most common lesion level, followed by C4, C6, T12, C7, and L1
Percentages
Incomplete tetraplegia (34%), followed by complete paraplegia (23%), incomplete paraplegia (18.5%), and complete tetraplegia (18.3%). Less than 1% of persons experience complete neurologic recovery at discharge.
Predictors of RTW
Predictors of returning to work include
- greater formal education,
- being of younger age (with employment rates declining particularly after age 50),
- male,
- Caucasian,
- married,
- employed at the time of injury,
- AIS D injury,
- having greater motivation to return to work, nonviolent SCI etiology,
- able to drive,
- lower level of social security disability benefits,
- calendar year after the passage of the Americans with Disabilities Act, and a
- greater elapsed time postinjury
Mortality
Mortality rates are significantly higher during the first year after injury than during subsequent years, particularly for severely injured persons.
Predictors of mortality after injury include
- male gender,
- advanced age,
- ventilator dependence,
- injured by an act of violence,
- high injury level (particularly C4 or above),
- a neurologically complete injury,
- poor self-rated adjustment to disability,
- poor community integration,
- poor economic status indicators, and
- having either Medicare or Medicaid third-party sponsorship of care
Cause of Death
- Diseases of the respiratory system are the leading cause of death following SCI, with pneumonia being the most common.
- Heart disease ranks second,
3, followed by septicemia (usually associated with pressure ulcers [PUs], urinary tract or respiratory infections), and - Cancer. The most common location of cancer is the lung, followed by bladder, prostate, and colon/rectum.
Initial Treatment
- The treatment of a traumatic SCI begins at the scene
- As such all trauma victims should have their spine immobilized, preferably with a rigid cervical collar with supportive blocks on a backboard, with straps to secure the entire spine in patients with a potential spinal injury (Three Point Fixation), and should be transferred onto a firm padded surface while maintaining spinal alignment to prevent skin breakdown. Movement should be via logrolling until spinal injury has been ruled out.
- After injury, prompt resuscitation, stabilization of the spine, and avoidance of additional neurologic injury and medical complications are of greatest importance.
Spinal Shock
During the first seconds after SCI, there is release of catecholamines with an initial hypertensive phase. This is rapidly followed by a state of spinal shock, defined as flaccid paralysis and extinction of muscle stretch reflexes below the injury level, although this may not occur in all patients.
Ditunno et al. proposed four phases of spinal shock from initial loss of reflex activity to hyperreflexia.
Neurogenic shock
Neurogenic shock, as part of the spinal shock syndrome, is a direct result of a reduction in sympathetic activity below the level of injury, consists of hypotension, bradycardia, and hypothermia, and is common in the acute postinjury period. Parasympathetic (PS) activity predominates, especially in persons with injuries at or above the T6 level.
Hypotension
- Treatment of hypotension involves fluid resuscitation (usually 1 to 2 L) to produce adequate urine output of greater than 30 cc/h. In neurogenic shock, further fluid administration must proceed cautiously, as the patient is at risk for neurogenic pulmonary edema, and vasopressors are utilized. Maintenance of mean arterial pressure at approximately 85 mm Hg during the first week postinjury has been associated with improved neurological outcomes
Bradycardia
Bradycardia is common in the acute period in cervical spinal level injury and may be treated, if below 40 per minute or if symptomatic, with intravenous (IV) atropine (0.1 to 1 mg). While significant bradycardia typically resolves within 6 weeks, episodes of persistent bradycardia beyond this time may occur in some severe injuries. Some patients may require implantation of a cardiac pacemaker to facilitate safe mobilization
Respiratory
Respiratory assessment is critical for acute SCI patients, and should include arterial blood gases and measurement of forced vital capacity (VC) as an assessment of respiratory muscle strength. A VC of less than 1 L indicates ventilatory compromise and the patient usually requires assisted ventilation.
