Spinal Cord Injury Flashcards
- Major health problem
- Over 200,000 people living w/a SCI in the US
- 12,000-14,000 new injuries each year
- 1/2 of all SCI occur to the cervical spine & another large portion to the T11-L2 area
- Trauma is the leading cause of SCI
- Occurs more in males
> Traumatic injury r/t inc risk-taking behavior - Ages 16-30 account for more than 1/2 of new SCI each yr
- ETOH/substance use
- Warmer mos
Non-traumatic injury etiology incl
- osteoporosis fx’s
- tumors
- infarction & hemorrhage
- myelitis from infection or non-infection
- spondylosis
- syringomyelia
- Spinal nerves exit between vertebrae
- There’s a sensory & a motor axon
- Sensory stimulation from the receptors in the skin/organs send a signal to the brain & back down the motor neuron to illicit a purposeful movement (e.g., writing, catching a ball, putting on clothes, etc.)
Autonomic reflexes
- Peripheral sensory nerve impulses arc around spinal cord & return to the muscles in a particular organ, via motor neuron bypassing the brain
- This is a much faster process but not controlled; e.g., touching a hot pan
- The sensory root sends the signal around the spinal cord & back to the motor neuron to contract the muscle, moving the hand away from the hot pan
Spinal Cord
! W/trauma, fractured pieces may be sharp & sever or crush nerve tissue
Level of injury we need to consider location
- Cervical 1-7
- Thoracic 1-12
- Lumbar 1-5
- Sacral 1-5
Mechanisms of Injury: Primary
- Hyperflexion
- Hyperextension
- Axial loading (vertical compression)
- Excessive rotation
- Penetrating injury
2 Categories of Injury: Primary
- Is c/b the acceleration/deceleration applied to the spine
Secondary
- Is c/b hemorrhage, ischemia, hypovolemia, & general impaired tissue perfusion from neurogenic shock
- Local edema peaks in 2-3 days & subsides in 7; causes pressure on the cord & dec perfusion
- Microvascular destruction causes more neuronal damage
- The manifestations of SCI will depend on the type & lvl of injury
> Incomplete
- Some function preserved below the lesion
> Complete
- Paraplegia & tetraplegia
SCI - Level of Injury
- Area of actual injury, NOT area of function
- Inj classified according to the area of damage
> Central, lateral, anterior, or peripheral - Damage may have occurred @ C4 but able to move muscles below lvl of inj if inj was incomplete
- Neurologic lvl
> The lowest lvl @ which functions are normal
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Is utilized to determine the highest neurological lvl of normal function & is NOT the lvl of inj; spec neurological function is determined by following the body’s dermatomes
ASIA scale
Dermatomes that map sensation for incomplete injuries
These syndromes are exceptions to sensation & function
- Anterior cord syndrome
- Central cord syndrome
- Posterior cord syndrome
- Brown-Sequard syndrome
- Cauda Equina syndrome
SCI - Anterior Cord
- Usually from the anterior spinal artery syndrome; there’s an artery that feeds the anterior portion of the spinal cord & a problem w/perfusion & circulation to this artery will lead to this
SCI - Central Cord
- Loss of sensation greater in upper extremities
SCI - Posterior Cord
- Damage @ the back of the spinal cord
- Pt may have good muscle power
- Pain & temp sensation
- May have difficulty w/coordination of limbs
SCI - Brown-Sequard
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Loss of motor/sensory function in various patterns w/the potential for recovery w/regeneration of peripheral nerves; neurogenic bladder/bowel
Etiology
- pressure on nerves r/t trauma, fx, abscess, hematoma, ruptured disc, tumor, foreign object
Sx’s
- Incl lbp, alteration in LE sensation, dec motor strength LE, neurogenic bladder, loss of anal wink (aka anal reflex), saddle area numbness
Treatment = surgical decompression
Cauda equina syndrome
SCI - Diagnostics
- x-ray, CT, MRI
- Myelogram (examines subarachnoid space)
- Continuous ECG monitoring
- Sensory/motor function assessment
- Reflex assessment
Emergency Management
- ABC’s incl signs of hemorrhage
- Think about jaw thrust vs. head tilt technique (CPR)
- Maintain c-spine
- Log rolling
- 1 person must always assume control of the head
- LOC (GCS)
- Determine lvl of inj
Documentation of Consciousness
- Pain is elicited by sternal rub (can cause bruising), supraorbital pressure, trapezius muscle squeeze or mandibular pressure
- GCS: 15 is best score, 3 is worst score
SCI: Acute Phase - Management
! Prevent further inj
- May or may not see methylprednisolone use (some recent research doesn’t recommend; inc hyperglycemia & stress ulcers)
- Oxygen/mech support
- Skeletal fx reduction & traction
- NGT & Foley
- Ventilation - may not be able to endotracheal intubate d/t cervical inj (do not want to hyperextend); may need tracheostomy
- NGT for dec peristalsis (build-up of gastric juices)
- Foley for bladder flaccidity
- These are from spinal shock
- Hemodynamic monitoring
> may need dextran or other volume expanders or vasopressors (dopamine HCl (inotropin); isoproterenol)
___ and possible ___ for bradycardia
atropine sulfate; pacemaker
SCI - Traction
- HOB raised; bed on casters so that it can be wheeled to x-ray dept; awaiting poss MRI or surgery
- Raise the bed to apply counter traction; skin care as ordered
Halo Fixation w/Jacket
- Often used s/p fx or arthrodesis
- Bone fragments or laminae (discs) laminectomy may be surgically removed to prevent further inj
- Pins are inserted into the skull - monitor for loosening pins or manifestations of infection may lead to osteomyelitis & subdural abscess
- Pin care by hospital policy or physician order
- Do not loosen screws that hold device in place
- Check skin for breakdown = 1 finger breadth
SCI - Complications
! Spinal shock
! Neurogenic shock
! DVT & thrombophlebitis
! Orthostatic hypotension
! Autonomic dysreflexia
! Pressure ulcers
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Complete but temporary loss of autonomic, reflex, motor & sensory activity below the lvl of injury; 2° to damage of the cord
Often lasts <48 hrs but may last for wks
! Flaccid paralysis
! Loss of DTRs & perianal reflexes
! Loss of motor & sensory function
Spinal shock
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Loss of ANS function below the lvl of inj
Can lead to cardiovascular changes
! Orthostatic hypotension
! Bradycardia
! Inability to sweat below the lvl of inj
Neurogenic shock
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A true medical emergency
Exaggerated autonomic response to stimuli
! Pulsating HA
! Piloerection
! Diaphoresis (forehead)
! Bradycardia
Autonomic dysreflexia
Autonomic dysreflexia - Treatment
✔️ Remove triggers
✔️ Sit pt up
✔️ Vasodilators (Nifedipine, nitrates)
Prevent AD
- Loose clothing
- Meticulous skin care and bowel & bladder care
Pressure sores
- Decubiti r/t dec sensation & failure of motor function
- Special air/gel/sand beds
- Repositioning & chair padding
- Electronic chairs may be shifted to lean back to change pressure points
Other problems & treatments
! Spasticity
* baclofen (Lioresal); tizanidine (Zanaflex)
- intrathecal baclofen pump - directly released into CSF & pump placed in abd
s/e: if d/c’d too abruptly, client may have seizures or hallucinate
! if too much circulating systemically, may cause sedation, changes in mental status & fatigue
! Sexual dysfunction
* sildenafil (Viagra)
Complications
! Osteopenia/osteoporosis
- Vertical weight-bearing; PT to slow bone & muscle loss & contractures
- Vit D & Ca supplements; Boniva
! Heterotrophic ossifications
- celecoxib (Celebrex) prevents boney overgrowth
! Renal stones
! Psychosocial
- Depressed over many losses = body functions, freedom to move around, career, family dynamics, sexual intimacy, etc.
! DVT
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Is an anticholinergic for spastic bladder; helps to dec bladder spasms & inc bladder capacity
s/e: dizziness, drowsiness, agitation, headache, constipation, dry mouth, tachycardia, blurred vision, urine retention, hyperthermia
Detrol
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Cholinergic used for dec bladder tone
Urinary retention c/b neurogenic bladder
s/e: HA, lacrimation, abd discomfort, diarrhea, salivation, urgency, flushing, sweating, hypothermia
urecholine (Bethanechol, Duvoid)
- Bladder schedule - offer scheduled times to void; straight cath @ scheduled times
- Possibly bladder scan post voids if distention or discomfort
- Goal = to dec risk of AD & poss bladder perforation
- Teach pts manifestations of UTI’s & pyelonephritis
! Watch for skin breakdown
Complications - Neurogenic Bowel
Colonic stimulants
- Inc peristalsis
- bisacodyl (Dulcolax), senna (Senokot)
Hyperosmolar
- fleet enema
Bulking agents
- Metamucil, Citrucel = inc fiber & fecal content; promotes bacterial growth
Stool softeners
- Colace, Surfak
- Osmotic agents
> Isotonic less risk for dehydration & electrolyte imbalance than other laxatives (hyperosmolar, colonic stimulants)
- Bowel schedule
> Sit @ reg times
Cervical injuries
! C2 through C3 usually fatal
- C4 - phrenic nerve disrupted = diaphragm & resp muscles involved
- C5 & below = movement @ shoulder lvl
Thoracic injuries
- Depending on lvl of inj, there may be loss of movement w/chest, trunk, bladder, & legs
- Paraplegia
- Autonomic dysreflexia w/T6 & above
Lumbar & Sacral injuries
- Loss of movement & sensation to LE
- Neurogenic bladder w/S2 & S3 inj
- Sexual dysfunction in males above S2
