SPINAL CORD INJURY an insult to the spinal cord resulting in a change, either temporary or permanent, in its normal motor,

sensory, or autonomic function

Epidemiology World Health Organization (2013) 250000 500000 patients/year 1. Motor vehicular accidents 2. Falls 3. Violence (including self-harm) United States of America (2011) 265,000 patients/year (2010 ESTIMATE) 1. Motor vehicle accidents (40.4%) 2. Falls (27.9%) 3. Interpersonal violence (primarily gunshot wounds) (15.0%) 4. Sports (8.0%) 4 male: 1 female Average: 40.7 year-old 1. 16 and 30 years 2. older than 60 years 3. 15 years or younger

Incidence Etiology

Gender Age

2 male: 1 female Male: 20 29 y/o; 70+ y/o Female: 15- 19 y/o; 60+ y/o

Pathophysiology I. The pathophysiology of SCI can be divided into two parts: primary and secondary injury Primary injury occurs at the time of the traumatic insult a. Fracture, dislocation, or compression of the spinal vertebrae b. Contusion, compression, or laceration of the spinal cord

II.

Secondary injury occurs over hours to days as a result of a complex inflammatory process, vascular changes and intracellular calcium changes leading to edema and ischemia of the spinal cord a. Immune cells, which normally do not enter the spinal cord, engulf the area after a spinal cord injury. These immune cells respond as they normally would to inflammation in other parts of the body. However, some of the immune cells release regulatory chemicals, some of which are harmful to the spinal cord. b. Hypoperfusion of the spinal cord from microscopic hemorrhage and edema leads to ischemia. Ischemic areas develop at the injury site as well as one or two segments above and below the level of injury. c. The release of catecholamines and vasoactive substances (norepinephrine, serotonin, dopamine, and histamine) contributes to decreased circulation and cellular perfusion of the spinal cord. d. The release of excess neurotransmitters results in overexcitation of the nerve cells. Allows high levels of calcium to enter the cells, causing furtheroxidative damage and damage to mitochondria Damage oligodendrocytes, leading to demyelinated axons that are unable to conduct impulses Classification A. American Spinal Injury Association (ASIA) Impairment Scale A indicates a "complete" spinal cord injury where no motor or sensory function is preserved in the sacral segments S4-S5. B indicates an "incomplete" spinal cord injury where sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5. This is typically a transient phase and if the person recovers any motor function below the neurological level, that person essentially becomes a motor incomplete, i.e. ASIA C or D.

C indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade of less than 3, which indicates active movement with full range of motion against gravity. D indicates an "incomplete" spinal cord injury where motor function is preserved below the neurological level and at least half of the key muscles below the neurological level have a muscle grade of 3 or more. E indicates "normal" where motor and sensory scores are normal. Note that it is possible to have spinal cord injury and neurological deficits with completely normal motor and sensory scores.

B. Complete SCI vs Incomplete SCI (Extent of Injury) I. Complete SCI characterized clinically as complete loss of motor and sensory function below the level of the traumatic lesion can result to tetraplegia and paraplegia II. Incomplete SCI Variable neurologic findings with partial loss of sensory and/or motor function below the level of injury A. Central Cord Syndrome o Characteristics: motor deficits (in upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bladder dysfunction is variable or function may be completely preserved B. Anterior cord syndrome o Loss of pain, temperature, and motor function is noted below the level of the lesion; light, touch, position, and vibration sensation remain intact Brown-sequared syndrome (lateral cord syndrome) o Ipsilateral paralysis or paresis is noted together with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperatur

C.

Clinical Presentation Based On Level of Injury A. Cervical Cervical (neck) injuries usually result in full or partial tetraplegia (Quadriplegia). However, depending on the specific location and severity of trauma, limited function may be retained. o Injuries at the C-1/C-2 levels will often result in loss of breathing, necessitating mechanical ventilators or phrenic nerve pacing. o C3 vertebrae and above: Typically results in loss of diaphragm function, necessitating the use of a ventilator for breathing. o C4: Results in significant loss of function at the biceps and shoulders. o C5: Results in potential loss of function at the biceps and shoulders, and complete loss of function at the wrists and hands. o C6: Results in limited wrist control, and complete loss of hand function. o C7 and T1: Results in lack of dexterity in the hands and fingers, but allows for limited use of arms. Patients with complete injuries above C7 typically cannot handle activities of daily living making functioning independently difficult and not often possible. B. Thoracic Complete injuries at or below the thoracic spinal levels result in paraplegia. Functions of the hands, arms, neck, and breathing are usually not affected. o T1 to T8: Results in the inability to control the abdominal muscles. Accordingly, trunk stability is affected. The lower the level of injury, the less severe the effects. o T9 to T12: Results in partial loss of trunk and abdominal muscle control.

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Lumbosacral The effects of injuries to the lumbar or sacral regions of the spinal cord are decreased control of the legs and hips, urinary system, and anus. o dysfunction of the bowel and bladder, including infections of the bladder and anal incontinence, and sexual dysfunction

Effect to the Autonomic Nervous System A. Spinal Shock Occurs immediately or within several hours of a spinal cord injury and is caused by the sudden cessation of impulses from the higher brain centers. Signs and symptoms: loss of motor, sensory, reflex, and autonomic function below the level of the injury, with resultant flaccid paralysis, Loss of bowel and bladder function, loss of bodys ability to control temperature If the spinal cord injury produces an incomplete transection, the suppression of function below the level of injury is temporary, lasting a few days, to weeks or months Return of perianal reflex activity signals the end of the period of spinal shock B. Neurogenic Shock Develops due to the loss of autonomic nervous system below the function of the body Signs and symptoms: peripheral vasodilation, decrease cardiac output, venous pooling in the extremities, hypotension, bradycardia C. Autonomic Hyperreflexia Syndrome Associated with the bodys resolution of the effects of spinal shock Signs and symptoms: sudden hypertension, bradycardia, pounding headache, blurred vision, sweating and flushing of skin above the point of injury

Diagnostic Procedures A. B. C. D. Radiography Computed Tomography Scan Magnetic Resonance Imaging Myelogram

Medical Management (Acute Phase) Goal: Prevent further SCI and to observe for symptoms of progressive neurologic deficits A. Pharmacologic Therapy Administration of high-dose corticosteroids, specifically methylprednisone improve motor and sensory outcomes at 6 weeks, 6 months, and 1 year if given within 8 hours after injury B. Respiratory Therapy Oxygen is administered to maintain a high partial pressure of oxygen (Pao2); hypoxemia can create or worsen a neurologic deficit of the spinal cord Diaphragmatic pacing (electrical stimulation of the phrenic nerve) to stimulate the diaphragm to help the patient breath C. Skeletal Fracture Reduction and Traction Immobilization and reduction of dislocation and stabilization if vertebral column with the use of skeletal traction D. Surgery Goal: Thegoalofsurgicalintervention isspinalstabilizationanddecompressionofthespinalcord Topreventadditionalor ongoing injury

Lumbar discectomy surgical procedure used to remove all or part of a herniated or ruptured disc in the lower part of the spine Cervical discectomy surgery used to remove one or more discs from the neck Microdiscectomy Minimally invasive surgery on a ruptured disc in the neck or back. This procedure aims at removing a small part of the ruptured disc in order to alleviate pain while avoiding any possible instability in the spine. Spinal fusion Surgical procedure for fusing or joining two or more vertebrae. There are different types of this surgery for different areas of the spine: o Anterior Lumbar Interbody Fusion In this procedure, the spine is operated on from the front. The surgeon removes a disc from the lower part of the spine and replaces it with bone graft. The desired result is for the two surrounding vertebrae to grow or fuse together into one solid bone. o Posterior Lumbar Interbody Fusion This procedure is virtually the same as the anterior fusion except that the surgeon approaches the spine from the back. o Transforaminal Lumbar Interbody Fusion In this procedure, the spine is approached from the side. Laparoscopic Fusion A minimally invasive surgical alternative to open surgery that requires a much smaller incision in the back to gain access to the spine. Recuperation time and pain levels are significantly reduced compared to other types of spinal fusion surgery. Surgical Decompression A small portion of the bone over the nerve root is removed to allow more space for the nerve root while helping it to heal. There are different types of surgical decompression: o Foraminotomy The foramen, or opening where the nerve root comes out of the spinal column, is widened by shaving away a portion of the bone o Laminotomy Partial removal of the lamina, or bony arches in the canal of the spine o Laminectomy Complete removal of the lamina, or bony arches in the canal of the spine o Corpectomy The entire degenerated vertebrae is removed and replaced by bone graft o Laminoplasty The lamina, or bony arches in the spinal canal, is cut open on both sides to create an open flap to relieve pressure on the spinal cord. The bone flap is propped open with small wedges or pieces of bone.

. Nursing Management A. Nursing Diagnosis 1. Ineffective breathing patterns related to weakness or paralysis of abdominal and intercostal muscles and inability to clear secretions 2. Ineffective airway clearance related to weakness of intercostal muscles 3. Impaired bed and physical mobility related to motor and sensory impairment 4. Disturbed Sensory perception related to inability to void spontaneously 5. Constipation related to presence of atonic bowels as a result of autonomic disruption 6. Acute pain and discomfort related to treatment and prolonged immobility. B. Nursing Interventions 1. Promoting Adequate Breathing Detect potential respiratory failure by observing patient, measuring vital capacity, and monitoring oxygen saturation through pulse oximetry and arterial blood gas values. Prevent retention of secretions and resultant atelectasis with early and vigorous attention to clearing bronchial and pharyngeal secretions. Suction with caution, because this procedure can stimulate the vagus nerve, producing bradycardia and cardiac arrest. Initiate chest physical therapy and assisted coughing to mobilize secretions. Supervise breathing exercises to increase strength and endurance of inspiratory muscles, particularly the diaphragm. Ensure proper humidification and hydration to maintain thin secretions. Assess for signs of respiratory infection: cough, fever, and dyspnea.

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Improving Mobility Maintain proper body alignment; place patient in dorsal or supine position. Turn patient every 2 hours; monitor for hypotension in patients with lesions above the midthoracic level. Assist patient out of bed as soon as spinal column is stabilized. Do not turn patient who is not on a turning frame unless physician indicates that it is safe to do so. Apply splints to prevent footdrop and trochanter rolls to prevent external rotation of the hip joint; reapply every 2 hours. Perform passive range-of-motion exercises within 48 to 72 hours after injury to avoid complications such as contractures and atrophy. Provide a full range of motion at least every four or five times daily to toes, metatarsals, ankles, knees & hips. Maintaining Skin Integrity Change patients position every 2 hours and inspect the skin, particularly under cervical collar. Assess for redness or breaks in skin over pressure points; check perineum for soilage; observe catheter for adequate drainage; assess general body alignment and comfort. Wash skin every few hours with a mild soap, rinse well, and blot dry. Keep pressure sensitive areas well lubricated and soft with bland cream or lotion; gently perform massage using a circular motion. Promoting Urinary Elimination Perform intermittent catheterization to avoid overstretching the bladder and infection. If this is not feasible, insert an indwelling catheter. Show family members how to catheterize, and encourage them to participate in this facet of care. Teach patient to record fluid intake, voiding pattern, amounts of residual urine after catheterization, quality of urine, and any unusual feelings. Promoting Adaptation to Disturbed Sensory Perception Stimulate the area above the level of the injury through touch, aromas, flavorful food, conversation, and music. Provide prism glasses to enable patient to see from supine position. Encourage use of hearing aids, if applicable. Provide emotional support; teach patient strategies to compensate for or cope with sensory deficits. Improving Bowel Function Monitor reactions to gastric intubation. Provide a high-calorie, high-protein, and high-fiber diet. Food amount may be gradually increased after bowel sound resume. Administer prescribed stool softener to counteract effects of immobility and pain medications, andinstitute a bowel program as early as possible. Providing Comfort Reassure patient in halo traction that he/she will adapt to steel frame. Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for loosening; keep a torque screwdriver readily available. Assess skull for signs of infection, including drainage around halo-vest tongs. Check back of head periodically for signs of pressure. Massage at intervals, taking care not to move the neck. Shave hair around tongs to facilitate inspection. Avoid probing under encrusted areas. Inspect skin under halo vest for excessive perspiration, redness, and skin blistering, especially on bony prominences. Open vest at the sides to allow torso to be washed. Do not allow vest to become wet; do not use powder inside vest.