Spinal Cord Injury Flashcards
Anatomy review
- spinal cord runs through the vertebral column with spinal cords extending out, into the body
- 31 pairs of spinal nerves
- 33 vertebrae in total
The vertebrae
-when talking about SCI we identify the level of injury by the vertebrae
Cervical: C1-C7
Thoracic: T1-T12
Lumbar: L1-L5
Sacrum: (S1-S5)–all 5 are fused
Coccyx: CO1-CO4–all 4 are fused
How many new incidents per year
12k
plurability are related to…
MVAs
Falls account for…
second highest incidence
Biggest at risk groups are…
men, young adults 16-30, Caucasians
Most SCIs occur at…
C1-5, T12, L1-3
Patho of SCIs
- initial trauma which kills neuron, initiates inflammatory response
- reduced blood flow due to trauma, swelling, edema
- compression due to swelling from injury and inflammation
- WBCs bleeding into spinal cord causing more inflammation. Cytokine release may lead to scar tissue formation
- early intervention and tx can help limit degree of damage to spinal cord
Etiology of SCIs
-excessive force to the spinal column in one of several ways
Hyperflexion
bend neck forwards
hyperextension
bend neck backwards
compression
landing on head or butt
rotational
bend neck to side or turn to side
transection
partial or complete severance
Grade A ASIA
- complete
- no sensory or motor fx preserved in sacral segments S4-S5
Grade B ASIA
- incomplete
- sensory but not motor fx preserved below the neurologic level and extending through sacral segments S4-S5
Grade C ASIA
- incomplete
- motor fx preserved below the neurologic level
- majority of key muscle have a grade less than 3
Grade D ASIA
- incomplete
- motor fx preserved below the neurologic level
- majority of key muscles have a grade greater than 3
Grade E
normal motor and sensory fx
Complete SCIs
-total loss of fx below level of injury
Incomplete SCIs
some feeling or movement remains
- central cord
- anterior cord
- posterior cord
- brown-sequard syndrome
- conus medullaris syndrome and cauda equina
Central cord damage
- more severe motor loss in UE than LE
- bladder dysfunction, retention
- almost all will have some degree of recovery, usually starting in LE
Anterior cord damage
- damage to anterior 2/3rds of cord
- loss of fx below level of injury
- loss of pain, temp sensations
- keep proprioception
- poor prognosis, some motor recovery may be possible
Posterior cord damage
- very rare, damage to posterior portion of spinal cord
- most have good motor, pain, and temp control
- mainly loss of proprioception, light touch
Brown-Sequard Syndrome
- hemisection of spinal cord
- same side (ipsilateral) motor paralysis
- loss of proprioception below LOI
- opposite side (contralateral) loss of pain and temp sensation below LOI
- best prognosis, majority will be able to ambulate independently eventually with tx
Conus Medullaris Syndrome and Cauda Equina
- injury to tapered end of spinal cord (L1, rarely L2)
- not a true SCI, injury to spinal nerves branching from SC
- partial or complete loss of sensation below LOI, saddle anesthesia, low back pain
bladder and bowel incontinence, constipation, etc
-prognosis is poor for complete recovery, some possible
saddle anesthesia
loss of feeling/sensation in areas you’d feel when sitting on a saddle
Spinal shock
- not a true shock of the neurogenic, septic, etc
- occurs in about half of all SCI
- occurs immediately after SCI, within a few mins to hours
- even undamaged nerves lose fx for a bit
- loss of nervous system functioning due to decreases reflexes below level of injury, loss of sensation, flaccid paralysis below level of injury
Spinal Shock Tx and Management
- lasts between a week up to several months
- difficult to assess degree of permanent or chronic injury/loss of fx during this time
- want to avoid exacerbating injury
- immobilize spine and be careful moving
-steroids to reduce swelling
(typically methylprednisone titrated to pt weight)
Primary or initial injury
-disrupts or severs nerve connections in one of the ways mentioned before
secondary injury
- progressive damage which occurs after initial injury
- swelling, edema, clotting, phagocytosis, etc. all may lead to impaired perfusion to nerve cells, loss of fx
scar tissue formation
cannot conduct nerve signals
Effects of SCI
- generally speaking, all body systems and their fx will be inhibited in some form below the level of injury
- paraplegia/tetraplegia
Circulatory Characteristics to SCI
- injury higher than T5, inhibits SNS influence
- prone to bradycardia
- peripheral vasodilation…hypotension
- autonomic dysreflexia
Circulatory Care
- TED/SCD
- anticoag therapy
- cardiac monitoring
- fluids
- change position slowly for orthostatic hypotension
Respiratory Care
- vent if needed
- suction
- pulse ox
- blood gases
- quad cough
- pulmonary toilet
quad cough
press abdomen inward during cough helps clear secretions
pulmonary toilet
- bronchodilators
- mucolytics
- chest physiotherapy
- breathing exercises
- IS
- all to clear secretions from airway
Bowel/Bladder Characteristics
- incontinence
- loss of urge
- constipation
- autonomic dysreflexia
- urinary stasis–UTIs/kidney stones
Reflexic
higher than T12
- keeps reflex but spastic bladder
- small uncontrolled voids
Areflexic
lower than T12
- flaccid bladder
- no voluntary voiding
- overflow incontinence
Bowel/Bladder Care
- toilet frequently/bowel and bladder training
- intermittent cath
- foley/rectal tube
- sx–cystostomy
- anticholinergics–reduce contractions (Detrol)
GI Characteristics
- decreased GI
- monitor electrolytes if gastric suctioning present
- pt may need swallow studies
- high calorie, protein, and bulk diet
Neurological
- neuro checks
- poor thermoregulation
- pain–psychotropic meds: Neurontin very common
Neurontin
- anticonvulsant
- txs nerve pain as well
- monitor pts mood
- motor coordination
- eye movement*****!!!!!!
Mobility
- paraplegia/quadriplegia/hemiplegia
- proprioception
- pain, touch, pressure, etc
Mobility Care
- immobilization of neck
- orthostatic hypotension
- PT/Rehab/OT
- toilet frequently
- monitor for skin breakdown
- ROM passive/active
Psychosocial
- high level cervical may impede ability to speak
- anxiety/depression related to prognosis/lifestyle changes
- disengagement from aspects of care they can manage or complete
Emergency Management
- maintain airway
- prevent further injury
- prevent spinal shock
Initial Management
-airway stays a priority
(O2 per NC, intubation)
- 1/3 will need intubation, especially high cervical injuries
- immobilize neck (rigid collar, spine board, log roll to turn, maintain neutral position, etc.)
Care in Hospital
- MRI, CT, Xray
- neuro checks
- foley
- methyprednisone
- hazards of immobility
hazards of immobility
- DVT management
- pressure ulcers
- continence/incontinence
- atelectasis
Traction
immobilization
- skeletal traction
- used to realign or reduce fracture
- must be maintained at all times
- do not change amount of weight
- weights must be free hanging
- if dislodged, stabilize and call for help
Most common for cervical injuries
halos
-external fixation
Care of Ext Fixators
- do not grab or lift by fixator
- clean pins around skin using saline + antibiotic cream
- keep wrench nearby, monitor pin placement
- if displaced, stabilize head of device with towels
Medical Emergency care for SCIs
- maintain airway
- prevent movement/immobilize site of injury
- prevent shock
Pharmacological Tx for SCIs
-generally symptom management with exception of methylprednisone
Laminectomy
-removes lamina (back part of spinal vertebrae, to decompress spinal cord
Vertebral fusion
joins vertebrae together
