SPINAL CORD INJURY

Submitted by: Celeste, Ranier & Cenabre, Paul Allan P. Submitted to: Prof. Christopher Evangelista RN, MAN

the 12th thoracic. sports-related injury and minor trauma. Males are affected four times more often than females. and the 1st lumbar. and alcohol and drug use. The principal risk factors for SCI include age. Incomplete spinal cord lesions are classified according to the area of spinal cord damage: central.   Injury can be categorized as primary which is usually permanent or secondary wherein nerve fibers swell and disintegrate as a result of ischemia. hypoxia. which is paralysis of the lower body or quadriplegia which is the paralysis . 6th and 7th cervical. lateral. These vertebrae are the most vulnerable because there is a greater range of mobility in the vertebral column in these areas.Spinal Cord Injury  Injuries affecting the spinal cord commonly results from trauma. gender. There is a high frequency of associated injuries and medical complications The most common vertebrae involved in SCI are the 5th. gunshot wounds and motor vehicle accidents. anterior. The type of injury on the other hand.  The most common cause of SCI is motor vehicle crashes. refers to the extent of injury to the spinal cord itself. or peripheral. Over half of the victims are 16 to 30 years of age. laceration and compression of the cord substance. with falls causing 19% and sports-related injuries causing 8% (CDC. 2001). A complete spinal cord injury can result in paraplegia. and hemorrhagic lesions. edema. Many cases of SCI are caused by falls. which account for 35% of the injuries. to contusion. Violence-related injures account for nearly as many SCIs (30%). to complete transection of the cord. Damage to the spinal cord ranges from transient concussion.

 extremities. of all four .

or shear tissues . or deformation forces (usually applied at a distance) compress the tissues.Pathophysiology Acceleration. pull or exert tension on the tissues. deceleration.

or both fracture & dislocation simple fracture compressed/ wedged vert. ligaments. and compression of the cord substance (either alone or in combination).frac. dislocation of elements.(slide tissues into one another) bones. Primary injuries are the result of the initial insult or . SCIs can be separated into two categories: primary injuries and secondary injuries (Porth. 2002). comminuted/ burst fracture dislocation microscopic hemorrhages appear in the central gray matter & pia-arachnoid (increases in size until the gray matter is hemorrhagic & necrotic) edema in white matter occurs (impairing microcirculation of the cord) reduced vascular perfusion & development of ischemic areas (oxygen tension in the tissue at the injury site is decreased) cellular & subcellular alterations & tissue necrosis occurs increases degree of dysfunction (permanent/temporary)  Damage to the spinal cord ranges from transient concussion(from which the patient fully recovers) to contusion. joints of the vertebral column are damaged through fracture & compression of one or more elements. to complete transection of the cord (which renders the patient paralyzed below the level of the injury). laceration.

 Neurologic Level The neurologic level refers to the lowest level of the injury of the cord. loss of sweating and vasomotor tone. Secondary injuries are usually the result of a contusion or tear injury.trauma and are usually permanent. patient may speak of fear that neck or back is broken Respiratory Problems • • Related to compromised respiratory function. severity depends on level of injury Acute respiratory failure is the leading cause of death in high cervical cord injury   Incomplete spinal cord lesions are classified according to the area of spinal cord damage: central. hypoxia. edema. • • • • • the  Total sensory and motor paralysis below the neurologic level Loss of bladder and bowel control (usually with urinary retention and bladder distention) Loss of sweating and vasomotor tone below the neurologic level Marked reduction of blood pressure from loss of peripheral vascular resistance If conscious. These secondary reactions. Therefore. if the cord has not suffered irreparable damage. lateral. and marked reduction of blood pressure from loss of peripheral vascular resistance. The type of injury refers to the extent of injury to the spinal cord itself. are now thought to be reversible 4 to 6 hours after injury. 2003). some method of early treatment is needed to prevent partial damage from developing into total and permanent damage (see the section on management) (Zafonte et al. Below the neurologic level. anterior. in which the nerve fibers begin to swell and disintegrate. A secondary chain of events produces ischemia. loss of bladder and bowel control (usually with urinary retention and bladder distention). believed to be the principal causes of spinal cord degeneration at the level of injury. “Neurologic level” refers to the lowest level at which sensory and motor functions are normal. and hemorrhagic lesions. or peripheral. A complete spinal cord lesion can result in paraplegia (paralysis of the  . which in turn result in destruction of myelin and axons (Hickey. 1999). patient reports acute pain in back or neck. there is total sensory and motor paralysis. Clinical Manifestations  Manifestations depend on the type and level of injury..

In milder injury. since significant spinal cord damage may exist even in the absence of bony injury. acute respiratory failure is the leading cause of death. commonly to the head and chest. In high cervical cord injury. it may radiate to other body areas such as the legs. Often the patient speaks of fear that the neck or back is broken. Effects of Spinal Cord Injuries Central Cord Syndrome • Characteristics: Motor deficits (in the upper extremities compared to the lower extremities. Anterior Cord Syndrome . however. and a careful assessment of the spine should be done in the face of any significant mechanism of injury. In cervical fractures. does not rule out spinal injury. Respiratory dysfunction is related to the level of injury. because spinal trauma often is accompanied by concomitant injuries. Continuous electrocardiographic monitoring may be indicated if a cord injury is suspected since bradycardia (slow heart rate) and asystole (cardiac standstill) are common in acute spinal injuries. pain may cause point tenderness. which may radiate along the involved nerve.If conscious. Assessment and Diagnostic Findings  A detailed neurologic examination is performed. • Cause: Injury or edema of the cord.  Mild paresthesia to quadriplegia and shock. lower body) or quadriplegia (paralysis of all four extremities). the patient usually complains of acute pain in the back or neck. in dorsal and lumbar fractures. such symptoms may be delayed several days or weeks.  Specific signs and symptoms depend on injury type and degree. usually of the cervical area. The muscles contributing to respiration are the abdominals and intercostals (T1 to T11) and the diaphragm. Signs and symptoms  Muscle spasm and back pain that worsens with movement. if the injury damages the spinal cord. A search is made for other injuries. Absence of pain. Diagnostic x-rays (lateral cervical spine x-rays) and CT scanning are usually performed initially. An MRI scan may be ordered as a further workup if a ligamentous injury is suspected.

temperature. and vibration and contralateral loss of pain and temperature. a contact sports injury. and transportation to the most appropriate medical facility. a fall. usually as a result of a knife or missile injury. because improper handling can cause further damageand loss of neurologic function. nor should the . position. this is done by placing the hands on both sides of the patient’s head at about the ear to limit movement and maintain alignment while a spinal board or cervical immobilizing device is applied. or possibly an acute ruptured disk. and motor function is noted below the level of the lesion. stabilization or control of life-threatening injuries. the patient is kept on the transfer board. to prevent an incomplete injury from becoming complete. fracturedislocation of a unilateral articular process. Any twisting movement may irreversibly damage the spinal cord by causing a bony fragment of the vertebra to cut into. light touch. immobilization. together with ipsilateral loss of touch. or extension. pressure. The patient must be referred to a regional spinal injury or trauma center because of the multidisciplinary personnel and support services required to counteract the destructive changes that occur in the first few hours after injury. Any patient involved in a motor vehicle or diving injury. One member of the team must assume control of the patient’s head to prevent flexion. at least four people should slide the victim carefully onto a board for transfer to the hospital. rotation. During treatment in the emergency and x-ray departments. • Cause: The syndrome may be caused by acute disk herniation or hyperflexion injuries associated with fracture-dislocation of vertebra. or any direct trauma to the head and neck must be considered to have SCI until such an injury is ruled out. crush. or sever the cord completely. Brown-Sequard Syndrome (Lateral Cord Syndrome) •Characteristics: Ipsilateral paralysis or paresis is noted. • Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south).• Characteristics: Loss of pain. Emergency Management The immediate management of the patient at the scene of the injuryis critical. At the scene of the injury. If possible. extrication. No part of the body should be twisted or turned. the patient must be immobilized on a spinal (back) board. The patient must always be maintained in an extended position. with head and neck in a neutral position. and vibration sensation remain intact. Initial care must include a rapid assessment.

the patient may be placed on a rotating bed or in a cervical collar. 2003). PHARMACOLOGIC THERAPY  In some studies. has been found to improve motor and sensory outcomes at 6 weeks. If endotracheal intubation is necessary. and 1 year if given within 8 hours of injury (Hickey. . little improvement was found (Short et al. Management of Spinal Cord Injuries (Acute Phase) The goals of management are to prevent further SCI and to observe for symptoms of progressive neurologic deficits. corticosteroids. 2001).. if SCI and bone instability have been ruled out.patient be allowed to sit up. and new treatment methods are continually being investigated. The patient is resuscitated as necessary. 2000). specifically methylprednisolone. Once the extent of the injury has been determined. In high cervical spine injuries. is accepted as standard therapy in many countries and remains an established clinical practice in most institutions in the United States (Bracken. 2000.SCI continues to be a devastating event. Treatments such as hypothermia. Later. of these. the patient can be moved to a conventional bed or the collar removed without harm. extreme care is taken to avoid flexing or extending the patient’s neck. a corticosteroid. Use of highdose methylprednisolone. Many changes in the treatment of SCI have occurred during the past 20 years. Hickey.. the patient should be placed in a cervical collar and on a firm mattress with a bedboard under it. which can result in an extension of a cervical injury. and oxygenation and cardiovascular stability are maintained. the administration of high-dose corticosteroids. but their use remains controversial (Short et al. which stimulates the diaphragm. 6 months. Currently. If a rotating bed is needed but not available. In other studies. and naloxone were investigated and used during the 1980s. 2003). RESPIRATORY THERAPY Oxygen is administered to maintain a high arterial PO2 because hypoxemia can create or worsen a neurologic deficit of the spinal cord. regeneration therapy is being investigated. this involves transplanting fetal tissue into the injured spinal cord in hopes of regenerating the damaged tissue (Vacanti et al. high-dose corticosteroids have shown the most promise.. is lost. spinal cord innervation to the phrenic nerve. 2000).

A halo device may be used initially with traction or may be applied after removal of the tongs. as verified by cervical spine x-rays and neurologic examination. Traction is not indicated either before or after surgery.Diplacement. Traction is sometimes supplemented with manual manipulation of the neck by a surgeon to help achieve realignment of the vertebral bodies. A metal frame connects the ring to the chest. which suspends the weight of the unit circumferentially around the chest. The traction is then gradually increased by adding more weights. • The injury results in a fragmented or unstable vertebral body. suspected epidural hematoma. Vertebral bodies may also be surgically fused to create a stable spinal column. The ring is attached to a removable halo vest. Once reduction is achieved. the weights are gradually removed until the amount of weight needed to maintain the alignment is identified. • The injury involves a wound that penetrates the cord. It consists of a stainless-steel halo ring that is fixed to the skull by four pins. Reduction usually takes place after correct alignment has been restored. Surgical Management Surgery is indicated in any of the following instances: • Compression of the cord is evident. or to permit direct visualization and exploration of the cord. • There are bony fragments in the spinal canal. • The patient’s neurologic status is deteriorating. the spaces between the intervertebral disks widen and the vertebrae may slip back into position. A laminectomy (excision of the posterior arches and spinous processes of a vertebra) may be indicated in the presence of progressive neurologic deficit. Management of Complications of Spinal Cord Injury . Halo devices provide immobilization of the cervical spine while allowing early ambulation Thoracic and lumbar injuries are usually treated with surgical intervention followed by immobilization with a fitted brace. As the amount of traction is increased. The weights should hang freely so as not to interfere with the traction. or penetrating injuries thatrequire surgical debridement. Surgery is performed to reduce the spinal fracture or dislocation or to decompress the cord. The traction force is exerted along the longitudinal axis of the vertebral bodies. with the patient’s neck in a neutral position. bony fragments.

Crutchfield and Vinke ongs are inserted hrough holes made in the skull with a special drill under ocal anesthesia. 63-9). Cervical fractures are reduced and the cervical spine is aligned with some form of skeletal traction. paralyzed. causing the blood pressure and heart rate to fall. innervation to the major accessory muscles of respiration is lost and respiratory problems develop. and flaccid. therefore. These include decreased vital capacity. all of which involve fixation in the skull in some manner (Fig. Bowel distention and paralytic ileus can be caused by depression of the reflexes and are treated with intestinal decompression by insertion of a nasogastric tube (Hickey. Diaphragmatic pacing may be considered for the patient with a high cervical lesion but is usually carried out after the acute phase. aphragmatic pacing (electrical stimulation of the phrenic nerve) attempts to stimulate the diaphragm to help the patient breathe. 1999). Neurogenic shock develops due to the loss of autonomic nervous system function below the level of the lesion (Hickey.. the reflexes that initiate bladder and bowel function are affected. venous pooling in the extremities. retention of secretions. 2003). such as skeletal tongs or calipers. close observation is required for early detection of an abrupt onset of fever. In particular. The muscles innervated by the part of the spinal cord segment below the level of the lesion are without sensation. SKELETAL FRACTURE REDUCTION AND TRACTION Management of SCI requires immobilization and reduction of dislocations (restoration of normal position) and stabilization of the vertebral column. This loss of sympathetic innervation causes a variety Traction for cervical fractures may be applied with tongs. An addition. 2003). A variety of skeletal tongs are available. the patient does not perspire on the paralyzed portions of the body because sympathetic activity is blocked. or with use of the halo device. increased PaCO2 levels and . including a decrease in cardiac utput. With injuries to the cervical and upper thoracic spinal cord. and the reflexes are absent.SPINAL AND NEUROGENIC SHOCK The spinal shock associated with SCI represents a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. the amount depending n the size of the patient and the degree of fracture disof ther clinical manifestations. and eripheral vasodilation. raction is applied to the tongs by weights. The vital organs are affected. The Gardner-Wells tongs require no redrilled holes in the skull. Early surgical stabilization has reduced the need for cervical traction in many patients with cervical spine injuries (Gaebler et al.

Patients who develop DVT are at risk for pulmonary embolism (PE). Manifestations of PE include pleuritic chest pain. piloerection [“goose bumps”].. OTHER COMPLICATIONS In addition to respiratory complications (respiratory failure.decreased oxygen levels. bradycardia. and hypertension). shortness of breath. The patient may be unable to generate sufficient intrathoracic pressure to cough effectively. NURSING ALERT! Special attention also must be directed to the respiratory system. In some cases. Thigh and calf measurements are made daily. . The patient is evaluated for the presence of DVT if there is a significant increase in the circumference of one extremity. respiratory failure. a lifethreatening complication. NURSING ALERT ! The patient’s vital organ functions and body defenses must be supported and maintained until spinal and neurogenic shock abates and the neurologic system has recovered from the traumatic insult.3% for PE and 17. Chest physical therapy and suctioning may assist in clearance of pulmonary secretions. 2000). permanent indwelling filters may be placed in the vena cava to prevent dislodged clots (emboli) from migrating to the lungs and causing pulmonary emboli (Velmahos et al.4% for DVT (Velmahos et al. pneumonia) and autonomic dysreflexia (characterized by pounding headache. nasal congestion. along with thigh-high elastic compression stockings or pneumatic compression devices. and local infection at the skeletal traction pin sites) (Sullivan. other complications that may occur include pressure ulcers and infection (urinary. profuse sweating. that can take up to 4 months (Hickey.. Low-dose anticoagulation therapy usually is initiated to prevent DVT and PE. 2000). DEEP VEIN THROMBOSIS Deep vein thrombosis (DVT) is a potential complication of immobility and is common in patients with SCI. 1999). and abnormal blood gas values (increased PaCO2 and decreased PaO2). and pulmonary edema. respiratory. 2003). One estimate from a meta-analysis of recent studies of the incidence of DVT and PE in SCI patients put the rate at 6. anxiety.

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