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


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.

and vibration sensation remain intact Brown-sequared syndrome (lateral cord syndrome) o Ipsilateral paralysis or paresis is noted together with ipsilateral loss of touch. B. position. limited function may be retained. Note that it is possible to have spinal cord injury and neurological deficits with completely normal motor and sensory scores. o T9 to T12: Results in partial loss of trunk and abdominal muscle control. necessitating mechanical ventilators or phrenic nerve pacing. o T1 to T8: Results in the inability to control the abdominal muscles. o C5: Results in potential loss of function at the biceps and shoulders. Accordingly. Thoracic  Complete injuries at or below the thoracic spinal levels result in paraplegia. E indicates "normal" where motor and sensory scores are normal.  Patients with complete injuries above C7 typically cannot handle activities of daily living making functioning independently difficult and not often possible. the less severe the effects.  Incomplete SCI Variable neurologic findings with partial loss of sensory and/or motor function below the level of injury A. trunk stability is affected. depending on the specific location and severity of trauma. o C3 vertebrae and above: Typically results in loss of diaphragm function. sensory loss varies but is more pronounced in the upper extremities). Anterior cord syndrome o Loss of pain. arms. Cervical  Cervical (neck) injuries usually result in full or partial tetraplegia (Quadriplegia). . and motor function is noted below the level of the lesion. The lower the level of injury. light. and breathing are usually not affected. touch. neck. B. and vibration and contralateral loss of pain and temperatur C. o C4: Results in significant loss of function at the biceps and shoulders. o Injuries at the C-1/C-2 levels will often result in loss of breathing. bladder dysfunction is variable or function may be completely preserved B.   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. Functions of the hands. and complete loss of hand function. o C7 and T1: Results in lack of dexterity in the hands and fingers. necessitating the use of a ventilator for breathing. However. Clinical Presentation Based On Level of Injury A. pressure. o C6: Results in limited wrist control. which indicates active movement with full range of motion against gravity. but allows for limited use of arms. Central Cord Syndrome o Characteristics: motor deficits (in upper extremities compared to the lower extremities. and complete loss of function at the wrists and hands. temperature. 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. 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. Complete SCI vs Incomplete SCI (Extent of Injury) I.

including infections of the bladder and anal incontinence. blurred vision. Loss of bowel and bladder function. decrease cardiac output. 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. the suppression of function below the level of injury is temporary. specifically methylprednisone improve motor and sensory outcomes at 6 weeks. hypotension. Skeletal Fracture Reduction and Traction  Immobilization and reduction of dislocation and stabilization if vertebral column with the use of skeletal traction D. and 1 year if given within 8 hours after injury B. with resultant flaccid paralysis. 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. Autonomic Hyperreflexia Syndrome  Associated with the body’s resolution of the effects of spinal shock  Signs and symptoms: sudden hypertension. o dysfunction of the bowel and bladder. reflex. D. and sexual dysfunction Effect to the Autonomic Nervous System A. venous pooling in the extremities. C. B. sensory. Neurogenic Shock  Develops due to the loss of autonomic nervous system below the function of the body  Signs and symptoms: peripheral vasodilation. sweating and flushing of skin above the point of injury Diagnostic Procedures A. bradycardia. 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. and anus. 6 months. lasting a few days. to weeks or months  Return of perianal reflex activity signals the end of the period of spinal shock B. bradycardia C. Pharmacologic Therapy  Administration of high-dose corticosteroids. and autonomic function below the level of the injury. Respiratory Therapy  Oxygen is administered to maintain a high partial pressure of oxygen (Pao2). loss of body’s ability to control temperature  If the spinal cord injury produces an incomplete transection. Surgery Goal: Thegoalofsurgicalintervention isspinalstabilizationanddecompressionofthespinalcord Topreventadditionalor ongoing injury .  Signs and symptoms: loss of motor. urinary system.C. pounding headache.  Lumbosacral The effects of injuries to the lumbar or sacral regions of the spinal cord are decreased control of the legs and hips.

Ineffective airway clearance related to weakness of intercostal muscles 3.      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.  Assess for signs of respiratory infection: cough. Promoting Adequate Breathing  Detect potential respiratory failure by observing patient. or bony arches in the canal of the spine o Laminectomy – Complete removal of the lamina.  Suction with caution. 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. Acute pain and discomfort related to treatment and prolonged immobility. Nursing Diagnosis 1. Spinal fusion – Surgical procedure for fusing or joining two or more vertebrae. . Recuperation time and pain levels are significantly reduced compared to other types of spinal fusion surgery. Impaired bed and physical mobility related to motor and sensory impairment 4. o Transforaminal Lumbar Interbody Fusion – In this procedure. or bony arches in the spinal canal. There are different types of this surgery for different areas of the spine: o Anterior Lumbar Interbody Fusion – In this procedure. is cut open on both sides to create an open flap to relieve pressure on the spinal cord. or opening where the nerve root comes out of the spinal column. Nursing Interventions 1. The desired result is for the two surrounding vertebrae to grow or fuse together into one solid bone. 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. Nursing Management A. Constipation related to presence of atonic bowels as a result of autonomic disruption 6. and monitoring oxygen saturation through pulse oximetry and arterial blood gas values. There are different types of surgical decompression: o Foraminotomy – The foramen. producing bradycardia and cardiac arrest. measuring vital capacity.  Supervise breathing exercises to increase strength and endurance of inspiratory muscles. is widened by shaving away a portion of the bone o Laminotomy – Partial removal of the lamina.  Prevent retention of secretions and resultant atelectasis with early and vigorous attention to clearing bronchial and pharyngeal secretions. B. fever.  Ensure proper humidification and hydration to maintain thin secretions. the spine is operated on from the front. because this procedure can stimulate the vagus nerve. the spine is approached from the side.  Initiate chest physical therapy and assisted coughing to mobilize secretions. 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. 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. Ineffective breathing patterns related to weakness or paralysis of abdominal and intercostal muscles and inability to clear secretions 2. The bone flap is propped open with small wedges or pieces of bone. . particularly the diaphragm. and dyspnea. Disturbed Sensory perception related to inability to void spontaneously 5. 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. The surgeon removes a disc from the lower part of the spine and replaces it with bone graft.

Provide a full range of motion at least every four or five times daily to toes. and high-fiber diet. rinse well. and pain.       3. and observe for redness. if applicable. Encourage use of hearing aids. knees & hips. conversation. Providing Comfort Reassure patient in halo traction that he/she will adapt to steel frame. Assist patient out of bed as soon as spinal column is stabilized. quality of urine.    7.     6. and any unusual feelings. voiding pattern. Provide a high-calorie. and music. ankles. Improving Bowel Function Monitor reactions to gastric intubation. high-protein. especially on bony prominences. Administer prescribed stool softener to counteract effects of immobility and pain medications.2. Do not turn patient who is not on a turning frame unless physician indicates that it is safe to do so.    4. gently perform massage using a circular motion. Keep pressure sensitive areas well lubricated and soft with bland cream or lotion. including drainage around halo-vest tongs. check perineum for soilage. observe catheter for adequate drainage. metatarsals. and skin blistering. Wash skin every few hours with a mild soap. aromas.        Improving Mobility Maintain proper body alignment. teach patient strategies to compensate for or cope with sensory deficits. and encourage them to participate in this facet of care. Do not allow vest to become wet. assess general body alignment and comfort. Massage at intervals. redness. Provide emotional support. andinstitute a bowel program as early as possible. keep a torque screwdriver readily available. Inspect skin under halo vest for excessive perspiration. and blot dry. Maintaining Skin Integrity Change patient’s position every 2 hours and inspect the skin. monitor for hypotension in patients with lesions above the midthoracic level. Assess skull for signs of infection. Perform passive range-of-motion exercises within 48 to 72 hours after injury to avoid complications such as contractures and atrophy. Avoid probing under encrusted areas. Turn patient every 2 hours. Assess for redness or breaks in skin over pressure points. . Food amount may be gradually increased after bowel sound resume. Open vest at the sides to allow torso to be washed.    5. Apply splints to prevent footdrop and trochanter rolls to prevent external rotation of the hip joint. If this is not feasible. Provide prism glasses to enable patient to see from supine position. observe for loosening. Teach patient to record fluid intake. do not use powder inside vest. taking care not to move the neck. Check back of head periodically for signs of pressure. Promoting Adaptation to Disturbed Sensory Perception Stimulate the area above the level of the injury through touch. amounts of residual urine after catheterization. drainage. insert an indwelling catheter. Cleanse pin sites daily. Shave hair around tongs to facilitate inspection. Show family members how to catheterize. flavorful food. place patient in dorsal or supine position. Promoting Urinary Elimination Perform intermittent catheterization to avoid overstretching the bladder and infection. particularly under cervical collar. reapply every 2 hours.

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