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Spinal Cord Issues

A. Leah Kelly, EdD, APNC

The Cord
* Two views

The Cord
* Whats in the cord? * 33 vertebrae to protect and support * 7 cervicals-neck, most unstable * 12 thoracics- chest * 5 lumbars- support back- again pain * 5 sacrals

* Coccyx * Vertebrae separated by discsshock absorbers * Inner core of disc is NP * Cord has CSF & meninges * Contains ascending sensory & descending motor tracts

Cord in sections
* 4 basic divisions * Cervical * Thoracic * Lumbar * Sacrococcygeal

* Intervertebral discs wh

absorb shock, resist compression, allow flexibility

Cord Problems
* From progressive neuropathy,Osteoporosis * Cancer,Lower back pain with muscle strain- pain worse oft at rest * So get locus, radiation, duration of pain, paresthesias, muscle weakness and report anything rapid or worsening

Damage Temp or Perm


* Related to level and area of injury * Cervical issues =some degree quadriplegia * T/LS injury= varying degrees of paraplegia * Need to worry about this in falls, trauma, mets>> get baseline and then address change * X-Ray tells fx; CT tells cord edema; MRI tells degree/locus of compression injury

Cord Psychosocial
* Will always give change in

body image and perception


* What happens with mobility

issues
* What about self concept &

powerlessness
* Anxiety * Can also alter family

structure, home management, adls

Congenital Problems
* Will also be addressed in

Pedi

* Spina Bifida, Meningocele,

Meningomyelocele
* Congenital deficits of neural

closure
* Normal bones and

meninges but bony structures are abnormal


* Can be the whole cord or

just a small area

Spina Bifida Occulta


* Failed closure at arches but

no cord herniation
* Not visible except as a dent

of pimple

* Few physical

manifestations - occ gait, bowel or bladder problems

With bigger problems


* Have both sensory and

motor problems
* If below L2 are flaccid,

areflexic with lower extremity paralysis


* Oft overflow incontinence of

bladder and bowel


* If below S3 will have no

motor impairment but still have bladder issues

Meningocele
* Sac is filled with spinal fluidlooks like a cyst * Mass will transilluminate * May see this on prenatal ultrasound * Will also see > AFP so now know ahead of time

Meningomyelocele
* This is worse with protrusion of meninges, fluid and cord * Very disrupted * Will have neurogenic bladder & oft ongoing UTIs

* May need intermittent cath programs * Surgery later with artificial sphincters * Probanthine, urecholine as pt ages

Care in these
* Genetic c viral trigger* so counseling

* Most lumbar & oft assoc

with hydrocephalus, scoliosis and congenital hip issues

* Goal > prevent infection, >

safety, maintain tissue perfusion


* In parents- issues will be

psych

Care in these
* Keep sac sterile & moist * Saline towels to cover-occ

silver nitrate
* Q 2 hr checks -? leak,

irritation & infection


* Keep Prone pre-op to

prevent pressure on sac

* No diaper either but touch

for bonding

Hydrocephalus
* See c previous- if before suture close, then skull can expand and will not herniate * As usual worse danger is if CSF accumulates too rapidlyfrom blockage or defective reabsorption * See with trauma, infection, genetics * Will need to shunt this- place ventriculostomy

Hydrocephalus and shunt


* This is before fontanelles

close

Lower back pain


* Covered in ortho- everyone gets it once * 80% of adults c 1 + episodes5% of all doc visits> leading cause of job disability * 90% resolve in 6 weeks c/s Tx * 5-10% will need surgery * Red flag> immed MRI

* Sudden weakness, anesth, bowel/bladder stuff get MRI * Recent trauma with back injuryhad films * Ca or infection> get CBC, UA

Sciatica
* Pain in lower back, radiating down posterior, lateral thigh * Only 45% will have herniation detectable on xray- pain can be severe, functionally limiting- usu worse in leg

* Straight leg test is most sensitive- supine or seated- pain at 30-70 degrees of hip flexionthen do crossed leg- lift opp leg & get pain in affected leg

locus
* L3-4> ankle dorsiflexion,

sensory loss at medial malleolus


* L4-5> great toe

dorsiflexion, middle metatarsal sensory loss


* L5-S1- ankle plantar flexion

with sensory loss on side

Sciatica
* Improves in 90% at 6

weeks
* Bed rest is out- mobility in * No steroids, opiates initially

but not chronically- !!!!!


* If not better in 6 weeks then

get MRI

So do you have it yet


* Remember- muscles,

nerves, bones

MRI cross section Herniated Disc

* Disk is shock absorber to provide a cushion & give flexibility, distributed load * Gelatinous center surrounded by fibro cartilage ring * Disk can get weak with age, excess movement * A rupture will allow gelatinous center to pour out, exude & compress root

Anatomy
* many processes protruding from vertebral segments. * The facet joints are held together with capsular ligaments.

* The spinous processes are held together by the interspinous ligaments.

Anatomy
* The facet joints > held together capsular ligaments.

* The spinous processes > held


together by inter-spinous ligaments.

* The transverse processes are


secured by the intertransverse ligaments and membrane.

* anterior & posterior longitudinal


ligaments running along the front and bock of the vertebral bodies, respectively, holding the bodies together.

* All held in place by the e tensive


muscular network of the low back, clearly seen above.

HNP happens
* Could be at any level but in general where the spine has most movt- at L4-5 or L5-S1 * Other issues are at C5-7 * In anyone with active life, falls * Poor abdominal tone * Risk factors

Disc herniate Assessment for disc

* Sx: low back pain radiating down thigh oft down 1 dermatome * Pain is sharp, numbing, stabbing, burning oft with paresthesias * Oft a while after injury * See muscle spasm * If herniate centrally may get issues with urination, incontinent or impotence * Aggrav with strain, cough, straight leg raising,

diagnostics

* Can tell best with MRI- hi res, contrast or not but what will insurance company bear- super details of nerves * SPECT- can distinguish benign from malignant lesionstechnetium or gallium scan that gets uptake in hydroxyapatite crystals in new bone- tells tumors, fx, mets

Tests
* XRAY-lateral ray of lumbar spine - e cellent for determining alignment > tells !ompression fractures, collapse of the disk spaces

* Myelogram>LP c dye if MRI inconclusive shows lateral or central herniation - also if cannot do MRI- contrast into subarachnoid space- can irritate

Discogram
* A discogram " study of radio opa#ue dye injected into the disk space. * both anatomical study & functional study.

* looks at anatomy of disk space > can show when dye leaks through rents in the annulus fibrosis. * Also functional test > patient reports, on a scale from $ to $%, how much pain has been produced.

Disc neck pain


* May see as numbness or

pain in arms, shoulder or occiput


* Can radiate to

hands/fingers
* Neck movement restricted

> mobility, spasms

* Weak biceps, triceps

Dermatomes
* Levels of nerve distribution * Damage follows the levels

Feet issues
* Sensory loss * Paresthesias * Motor problems

Cord sensory loss


* As it comes up to parietal

thru cord

IDET

* IDET =intradiscal

electrothermoplasty. to reduce or eliminate back pain caused by disc degeneration.


* uses heat to seal cracks or

fissures in the disc wall, thus reducing bulging of inner disc material & impingement on nerve diminishes
* done outpatient c local

anesthesia

Other treatments

* http://www.spineandscoliosi

s.com/animation.php? pn=artificialdisc
* http://www.spineandscoliosi

s.com/animation.php? pn=discmicro

Blue hand dilantin


* Added it

Red Flags
* Fecal incontinence, saddle

anesthesia and urinary retention> cauda equina sndrome

* Fxp from steroids, infection,

osteoprorosis

The PE
* Diminished reflexes * Paresthesias in

dermatomes
* Cannot straight leg raise

without pain & cannot dorsiflex the foot

Or Lumbar Stenosis
* Under pressure

Lumbar or spinal stenosis

* narrowing of space thru wh nerves go to legs * Gets smaller if bone there grows * Causes leg pain, mobility problems * Arthritis, falls, wear cause itget back pain,leg pain, weakness * Pain worse with activity- tx exercise, PT, surgery to open up canal

Spinal stenosis
* Affects 1.2 million- oft from degeneration

* Pain described as problem when exercise- pain is burning, cramped, weak, a neural claudication- may feel better if get in fetal position- to open space * Few studies but epidurals do not help- expect surgery in moderate pain or at least a neurogenic regional block

Spinal stenosis
* Can treat with pain meds or

decompression surgery
* Local anesthetic block * Seems best results after

surgery

* New procedure- MILD- min

invasive decompressiondevice to elim compression


* http://www.mildprocedure.co

m/the-mild-procedure.html

Mild procedure
* http://www.youtube.com/wa

tch?v=fE8BJMJmjM0
* http://www.youtube.com/wa

tch?v=QMee68ZuRIo

Tx Disc

* Conservative Tx is best & firstno longer a long time of bed rest now up and moving * Deep ultrasonic heat, exercise, progressive muscle work, energy, massage, ice to reduce spasm * Bed avoid prone and pillows * Williams position * PT for back class and exercises * Roll to move- log roll

Back Class
* Stretch- proper body

mechanics
* The way to bend

* Review the mobility video * Strengthen abdominal

muscles- sit ups, crunchers, pelvic tilts, gluteal sets


* Sit with knees higher than

hips

Posture Meds for low back pain


* Analgesics> Tylenol, NSAIDS for reduced inflammation * Muscle relaxants>all reduce spasm, watch drowsiness, fatigue, dry mouth

* Steroids * Facet joint injections * Epidurals * Trigger point injections * Lidoderm patches

Back Surgery
* For scoliosis, tumors, HNP,

fusions for instability


* Discectomy, laminectomy,
* Percutaneous, laser varies

with site and doc * Chymopapain injections

now in Canada

* Again now need lots of

approvals

Laminectomy
* Remove posterior arch of vertebrae * Fusion = to ensure stability by inserting bone grafts into interspace and immobilize the area * Will do this when conservative Tx ineffective * Pre-Op> usu now is EMA so will need good teaching
* assessment is get baseline of pain, motor, sensory function

* Teach roll, turn cough deep breathe

Post Op Laminectomy
* Vitals, movement, voiding, pain, sensation * Cervical
* Flat, worry for laryngeal nerve damage * Hoarse, difficulty swallowing, signs of dependent bleeding

* Lumbar
* Oft flat in bed for period of time, log roll * Check for bleeding, paresthesias

* Will log roll in 1st 2 hrs- flat minimizes CSF leakage * Keep pillow between legs, arms across chest

Post op Laminectomy
* Care is changing and oft varies with surgeon- may stay 48 hrs or go home at 24 * Always get OOB on 1st day so need to pay close attention to body mechanics * You need specific positioning orders * Log roll with extra help

* Cervical fusion will need to watch swallow, increasing edema, stridor, distress

Specific Lami assessments


* Watch for new or increasing neuro deficits and report promptly * If anterior cervical discectomy> assess ability to breathe and watch for resp paralysis * Watch for CSF leakage, hemorrhage- the checks are for motor and sensation q 2-4 hrs * Edema could worsen SX

* Can also get pain and spasm wh is depressing to pt as thought this would end with surgery * Import of maintaining alignment

Teaching Laminectomy
* Body mechanics * Seat belts * Wt loss * Williams exercises- pelvic

tilt, knee chest, nose to chest


* crunches

Disc surgeries
* http://www.youtube.com/wa

tch? v=pAwod39nlFo&feature=re lated


* http://www.youtube.com/wa

tch?v=EvQPZxXr3Rs
* http://www.youtube.com/wa

tch? v=fL3V1Z7BehQ&feature=r elated

SCI Spinal cord injury

* Every year there are 14,000. Esp in age 16-30 group more in men, risky business * 35% are MVA, 20% are falls, 30% violence * 33% are thoracic/cervical * Mostly young men in July * Cervicals become quadriplegics or tetraplegics- these are most common * Also related to knives, guns, osteoporosis, tumors, vasc disease with infarcts

Some at Health South


* These come form mild flexion -extension issues

* Whiplash to complete transections * Any level but particularly Cspine C1-2, C4-6, T11-12 where spine is most mobile * Trauma to tissue and then tissue death * This then becomes a chronic illness or disability

Christopher Reeves
* Got a lot of money from NIH and his foundation so things are moving * Private money, Medicaid or whatever it will bear

* Group homes - mobilize- can they live alone * Care is complex, overwhelming, and demanding * Cost for a quad in 1st year is over $500,000

At Risk
* Those with feelings of immortality, PSA * Bikes, motorcycles * Prevention is oft lost on those who need it but better with helmets, seat belts * Secondary prevention-stabilize cord on scene- so may need to hold traction & avoid twisting

* Tertiary prevention-prevent respiratory, cardiac, urinary compromise, promote skin integrity

The spine
* So any * Or all * What is innerv * How impacted

Injury from
* Transection * Compression * Infarction
* Look at motor and sensory loss

* C1-C4= Quadriplegia- loss of resp * C4-C5= Quadriplegia- phrenic involved * C5-6= gross arm movt, diaphragm breathing * C7-8= Quad> triceps & biceps, no hand * T1-2= Paraplegia- some intercostal & abd

ASIA classifications
* A= complete lesion- no

motor or sensory preserved

* B=incomplete lesion-

sensation below lesion but no function or motor behavior


* C= incomplete motor

preserved below lesion but non functional


* D=preservation of some

motor with reasonable motor function

Terms
* Paraplegia- both lower extremities * Quadriplegia- involves all 4 extremities

* Complete lesion- above C6 with no potential for independence * Use of dermatomes to describe the loss- sensory loss to the spinal nerve
* Could be a different level for sensory and for motor

* Damage can be primary or from edema & inflammation > idea of ischemic penumbra again

Cord made of white & gray

* Gray is in inner areas of

cord and comprises anterior, lateral and posterior hornssensory fx arises from dorsal gray matter- ventral gray matter is motor function
* Viscera and body get

innervated from this- and activation of symp and paraasym autonomic ns occur in white and gray matter

SNS

* SNS makes catechols for

adrenal release> work on rate, ventil, perfusion,


* SNS responses orig in gray

matter of cord and go from thoracic to lumbar- damage to cord affects sns response

White matter in cord


* Outer c paths for ascending

& descending tracts


* Corticospinal tract> motor

activity transmission- orig in brain and crosses over in brainstem to innervate opp side of body

* Spinothalam tract orig in

cord- crosses within 2 segments and up to thalamus c pain and temp


* Posterior column relays

position, vibration and touch

Spinal nerves
* Correspond to spinal &

vertebral segments
* Dorsal roots send sensory

input up to CNS
* Ventral roots send motor

from cord to body


* Also are plexes to innervate

areas

* Cervical for neck/shoulder,

phrenic

Vertebral column
* 7 cervicals-neck, most

unstable
* 12 thoracics- chest * 5 lumbars- support back-

again pain
* 5 sacrals * Coccyx * Cord is vulnerable so

vertebrae supp by ant and post ligamens- to stabilize

* Also stability thru

intervertebral discs

Cervical Vertebrae
* Must allow head movt-

innately unstable
* Easily rotate, much risk for

injury
* Other issues in SCI are

related to motor neurons

Upper Motor Neurons

* Upper motor neuron comes down from brain > travels in corticospinal/ corticobulbar tracts * Synapse with lower motor neurons * Job to suppress firing of lower motor neuorn * If no suppression, LMN will fire spontaneousl and lead to spasticity- so UMN controls primitive responses and reflex arcs * So if UMN is lost pt gets spastic paralysis coz of hyperactive response of reflex arcs to stim

UMN from motor strip dwn


* Comes down from above with motor output

Lower Motor Neuron


* Anterior horn cells that originate in spinal cord Transmit nerve impulses to nerve & muscle * These are the motor paths from cord and are the spinal nerves wh supply peripheral nerves * Impulses from stim outside cord come in thru reflex arc and synapse with these and then go back to muscle

* This reflex arc that control invol response * Damage then abolishes voluntary and reflex response to muscles/organs

Lower motor neuron Bowel & bladder issues


* -UMN bowel is reflex incontinence
* So us suppositories and digital stimulation to initiate defecation * Stretch initiates peristalsis

* - LMN_ get non reflex flaccid bowel-

* flaccid bowel with urinary retention, overflow incontinence and fecal retention and fecal impaction
* Here need straining of musculature

Pathophysiology
* Result of the injury to the

vertebrae
* Think of how the injury

happened
* Acceleration * Deceleration * Compression * Tearing

* shearing

Hyperextension
* Get this in elderly with degen vertebrae when hit windshield * Or in a diving injury * Cord is stretched against ligamentum flavae and get a dorsal column injury with a posterior dislocation * Or transect cord * Will lose all voluntary below and reflexes in the injured segment

Hyperextension Injury Compression Injury

* Here pt falls on feet or butt * Fx to vertebrae wh then compress cord * Fragments jammed into cordat lumbar/thoracic * Mostly incomplete injury with edema, bleed with some loss of sensation and function * Hard to know what will be permanent * Eventual death at 48hrs & neuron sheath destruction * Petechial hemorrhage with swelling and diffuse scars

Compression injury

* Two ways

Hyperflexion Injury
* How could this be

Lateral injury
* With a twist

Flexion-rotation dislocation
* turning

Class by level of injury


* Level of SCI injury determined by most distal uninvolved segment of cord

* Function depends on if lesion complete or not * Incomplete injury> some preservation of sensory, motor or both below level of lesion * Complete > total loss of motor, sensory or both below injury * Could be orthopedically at C5 but neurol intact to C6

Types of injury
* Complete cord transection
* Flaccid paraly c total loss of

motor and sensory below level of injury * Incomplete injury

* Partial transection of cord-

some tracts intact with varying loss of motor and sensory function

Examples
* C spine injuries> quads
* C1-C4 =fatal s vent
* Loss of diaphragm innervation and no intercostals so no bellows effect * Trapezius, sternocleidomastoid, and platysma function * Sensory loss to occiput, ears and face but will need an attendant for ADLs * Electric wheelchair with hi back for head , vent or breath control or head and shoulder controls``

Injury at C4

* Here can come off vent for

a while
* Have better head control * Have some diaphragm- but

are dependent on others for ADLs,


* Will need electric

wheelchair, breath, head and shoulder controls

C5
* Where can live c independence * See intestinal paralysis and gastric dilatation * Upper extremities rotate out so shoulders are elevated

* May have exagg reflexes below the lesion * Some sensation in neck and upper arm * Can do some feeding, writing and transfer

C6
* Here still resp distress and intestinal paralysis * Lack inhibition of deltoid and biceps so arms must be positioned correctly with forearms in extension and arm in adduction * Person does have sensation

* There is more independence and can dress, feed and even drive a car with hand controls

C7
* Here can live independently

and transfer
* Perform own ADLs * Get a fusion

T2-L
* These are paraplegic levels

of injury
* Will do diaphragmic

breathing with more inspiration depth

* Have postural hypotension * Have sensory issues with

loss of touch, pain and temp

Relook at levels
* see

Injuries above T12


* These are called upper

motor neuron syndromes


* Pts are spastic and

hyperreflexic

Injuries below T12


* These are the lower motor

neuron disorders

* These pts have flaccid

paralysis and hypo or arreflexia

Spinal cord syndromes


* These are incomplete

lesions that have recognizable patterns relative to the area damaged


* Any concussion or bruise

could have one of these presentations so the ER nurse needs to assess for this

* Most injury today is partial

and 1st hr is crucial

The typical syndromes


* Central Cord Syndrome * Anterior Cord Syndrome * Posterior Cord Syndrome * Brown Sequard * Complete Transection * Have a familiarity here

Cord loss

Central Cord Syndrome


* Central damage in cord as

result of hyperextension & hyperflexion


* Also hemorr, contusion,

edema * Weak to paralyzed arms

but oddly no leg or bladder deficits


* Hands weak, some bowel &

bladder
* From damage to the

cervical tracts
* This is most common injury

Central Cord problems Anterior Cord Syndrome


* Anterior part of cord so get complete motor paralysis because this takes out the corticospinal tracts * From Flexion with forward dislocation & damage to ant spinal artery * Lose pain, temp, and touch as the spinothalamic tracts are knocked out

* Pt retains light touch, proprioception and position sense as posterior columns are spared

Anterior Cord Posterior Cord Syndrome


* Hyperextension injury at

cervical spine
* Lose position sense, light

touch and vibration sense below the injury

Brown Sequard

* This is lateral hemisection of the


cord from a bullet or knife injury

* Get either increased or decrease


sensation of pain, temp, touch on the same side as lesion

* Also some motor loss on same side


below lesion

* Limb with best motor ability has less


sensation

Complete Transection
* Immediate loss of sensation and voluntary muscle below the transaction * All reflex activity is lost initially * The reflexes will come back and my be hyperactive because there is no inhibition from above

* Have loss brain influence of cord * So the spinal automatisms are left to own devices

Same as always
* Primary injury with initial

damage
* Secondary injury from cell

and vascular changes edema, lyte issues, release of catecholamines, toxic metabolites, hypoxia

Given all those possibilities


* Initial assessment of SCI is important

* Get ABCs

* Look at neuro signs- alert, responsive * Check motor and sensory * ? Incontinence * Pain * Will immediately be hypotensive so will need immediate fluids * Will need a hard C-spine collar til C level injury is eliminated

So Acute Injury Phase


* Time is crucial

* Spare the damage * Acute interventions

Cord presents to ER
* Will need CT and

immediate C- spine X-ray


* Watch for hemodynamic

and pulmonary instability


* Will do peritoneal lavage to

r/o intraperitoneal injury- is it bloody?


* ? Flexor withdrawal, reflex

emptying of bowel/bladder

Will need Immediate Immobilization

* Allow no flexion or rotation * All needs to be in neutral

position in alignment
* Make sure have a rigid

cervical collar in place- tape head to board


* Then place on some sort of

Stryker, Rotorest to ensure contd immobilization

DX test
* Xray is key test * C Spine and then thoracic,

lumbar and sacral

* Protect pt during xray

process
* Mri ok for soft tissue

damage
* CT for extent of injury

So then- you the nurse


* Get Hx - vitals, odors, do thorough neuro exam * Get chest injury films * NG or Foley now but careful insertions * Digital rectal exam to tell if complete injury

* Incomplete injury if can feel finger or can contract rectal sphincter * This is a better prognosis

More immediate care


* First hour counts- influences the extent of injury and deficits * Immobilize on firm surface * ? Other injuries- DPL * Turn with others using logroll * Watch for any respiratory distress-C3 is level of phrenic nerve-

* IV fluids> pump, I&O as pt is in spinal shock and this will maintain perfusion

Early Neuro Exam


* What sensation and what

motor is present
* Think and document by

dermatomes
* Look for symmetry * What is spared and what is

retained
* Document locus, symmetry,

strength

* Look at spontaneous

movement, response to pinprick

In Any C injury
* Place in Halo or tongs-

Gardner Wells, Crutchfield etc- tongs becoming obsolete


* Skeletal traction to

immobilize spine
* Reduce fractures with

some 10-20 lb wts


* Keep body in good

alignment

Tongs

* Tippy Wells

Gardner Wells

Drugs in early SCI


* Osmotic Diuretics * Antacids- PPI, H2 * Vasoactive blood pressure support-dopamine * Steroids- oft with Solumedrol at 30mg/kg
* Prevents lipid peroxidation, prevents calcium buildup, glutamate antagonists

* Urinary anti-infectives * Anticoagulants* Laxatives- stool softeners

* Antispasmodics- like Lioresal

High dose initial steroids


* Methylprednisolone- IV 30

mg/Kg/ bolus followed by 5.4 mg/kg/hr for 23 hrs


* Improves neuro recovery if

get within 8 hrs of injuryevidence based


* And can continue for up to

48 hrs

* Reduces edema, reduces

wbc in area, inhibs breakdown of phospholipids- > blood flow and blox inflamm cascades

More Initial Tx
* Will also need aggressive respiratory therapy- hi levels will be on vent * NG decompression of stomach during spinal shock phase * Bladder decompression in early phase * Start initial PROM on all joints then move to active ROM * SCDS

* Some centers using FESfunctional electrical stim to create contraction, relax with hope to walk * Gene therapy to allow axon growth

Experimental tx
* Growing myelin cells in lab

& then transplant into injured area works in animals


* Bone marrow stem cells

into CSF migrate to injured area works in animals too

* Also new drug 4AP with

signif improvt in sensory and motor function

Biggest initial problem- Spinal Shock


* Normal function of cord depends on contd tonic excitation of nerves that enter cord from higher centers- so no excitability * Loss of sympathetic transmission leads to unopposed parasympathetic activity

* Blood pools, vasodilate, bradycardia, from reflex vagal stimuli * This is immediate response to transection * Gives total loss of skeletal muscle function

Spinal shock is Neurogenic Shock


* Arterial BP falls to 40/D because the SNS is blockedHYPOTENSION * Flaccid paralysis without reflexes * Loss of bowel/bladder tone from sacral reflex blockade

* Loss of sexual function * Loss of autonomic function * Loss of venous return so hypotension * BRADYCARDIA

Spinal Shock
* Have lost hypothalamic control so you cant use vasoconstriction or increased metabolism * So client assumes temperature of surrounding air * Starts within 30 mins-Lasts week to a few months * Ends when reflexes return

* Had been flaccid> now are hyperreflexic * So bladder starts to empty reflexly * Flexors come back 1ts and respond to cutaneous stimulation * Notice the Babinski

Spinal Shock
* Orthostatic hypotension is

big!!! And no ability to respond to compensate for position change


* Getting no vasoconstricting

message from medulla

* Will need to treat this with

atropine or some vasoconstrictor

Early Surgery
* Controversial but common in university setting * Also do in any progressive neuro deficit * Also in any compound fx, and penetrating wounds with fragments * May have to do a decompression laminectomy
* Remove lamina of vertebrae to min pressure on cord

Early surgery
* Or in some settings will do

immediate spinal fusion with plates/screws


* Oft use anterior approach so

return with chest tubes


* Log roll, manage pain

Neurosurgery
* Oft with cameras * Fine and delicate

Placing a Halo
* Other pts will be immobilized in halo device

* Fit to skull with pins to maintain alignment * Need wrench taped to front of jacket for immediate access * Never hold by rods when turning * Halo changes center of gravity so also danger of falls, balance * Pt will need to move as a unit * Check pins for tightness and report to doc

Halo 2
* Clean pin sites BID with prescribed solution

* Cork pin ends to protect & minimize sound magnification * Rolled towel behind neck * 1 finger breadth under vest to avoid breakdown * Check sheets for drainage * Encourage to sleep prone with pillows under hips with specific orders from doc * Keep buckles tight * Will have to have PT work with positioning

Halo 3

* Danger of resp distress and compromise from hyperextension of neck * Many think halo will cure any deficits and expect to walk after brace off so need teaching * Will also have vision obstruction * Continue to assess for ability of sensation * Expect post halo depression

Initial Cord Problems


* Expect resp issues in hi C

injury

* Always anticipate resp

failure- if on vent watch tidal volume, vital capacity, breath sounds


* How is diaphragm,

intercostals?
* Also at risk for code, bleed

with Lovenox, even quad assist cough like a Heimlich

Initial Cord Issues


* Will also have paralytic

ileus and gastric distention which will increase respiratory embarrassment

* Danger of starvation so will

have to worry about food

Respiratory Issues early cord


* Can also get ascending edema wh compromises cord so may be on vent for time * SCI oft has paraly of inspir/exp muscle
* Intercostals are gone * So are predisposed to atelectasis * No cough- so hand under diaphragm > push in on exhalation * Keep suction equip and pulse OX * Pulmonary toileting, turn, cough, oob

* Who will feed patient

Temperature Control
* There is disconnect from

thalamus so poor thermoregulation


* Cant sweat to get rid of

body heat
* Cant shiver coz no

vasoconstriction
* Worse the higher the injury * Hypothermia/hypothermia * Try to keep temp at 97

Worry DVT and Circ


* Low molec wt heparin

* Teds or SCDs * Roto-Rest or Passive

Motion Beds
* Electrical stim to cause

muscles to contract
* Watch pooling and

hypotension

Beds- in cord
* Roto-Rest * Stryker

Alt Skin Integrity


* Major danger of pressure

sores

* No more than 30 mins til

start to breakdown
* Turn q 2 so make a turning

sheet and adhere to it


* Get someone to order a

kinetic bed

Early Mobility
* PROM early to maintain and prevent contractures * mid hi sneakers, moon boots to prevent drop as well as splints * Get PT/OT involved * If OOB get straight back chair with reposition q 1hrs and check for breakdown

* Braden scale to monitor skin breakdown

Early Meds
* IM & SC are not absorbed

well coz no muscle tone so must rotate sites


* Sensation is also limited * Watch any narcotics so

position change is very important


* Best IV site is subclavian-

higher flow here & less chance for thrombosis

Constipation

* Start a bowel program

immediately
* Look for distention, check

bowel sounds
* Watch N,V and fecal

impaction
* May need enemas but only

small volume enema as atony can result in megacolon

Early Psych
* Hope * Denial * Family issues

* Stages of grieving * Dont ignore it

Chronic Cord
* Begins as spinal shock dissipates * Pressure and temp is more normal * Less vasodilated * Now will look at how much function is present * What will rehab plan be * All need family involvement * All need a motivated client

* REHAB BEGINS AT ADMISSION

SO REFLEXES RETURN
* This is not movement - it is

automaticity

The reflex arcs


* Which we test * Or see with stim

Spasms
* This will present after a complete transection * Will expect painful intense spasms of lower extremities

* Could be from a twitch to wild horrid spasms * So may have to pad side rails to protect patient

* Spasms are triggered by cold, long sitting, emotion etc * This is not movement returning

Psych is even more key


* Unique to each person * Patient will go back and forth between stages * Emotions predominate here * Shock and disbelief give way to being overwhelmed

* Will I live?, how dependent will I be? * Staff is overwhelmed too

* Still will be in denial of at least some aspects of situation- will I walk> how can I do it?

Psych
* Will also begin to see the

full impact here- severe depression, loss of motivation and any involvement
* Will talk of suicide * Will need to be mobilized

and start to problem solve

* Might get possessive of

nurse
* Work on coping skills

The other famous SCI problem


* Autonomic Hyperreflexia or Dysreflexia
* A cluster of clinical manifestations resulting from simultaneous discharge of multiple spinal cord autonomic responses> Massive SNS response * With HTN, Tachycardia, headache * See in SCI with injury above T7 for at least 6-15 yrs after injury

* Results from exaggerated sympathetic discharge response to noxious stimuli


* As from bowel/bladder distention. Ulcers, pain, pressure, cramps * Also form phlebitis, menses, tight clothes, sexual impulses, temp changes

Autonomic hyperreflexia
* The blood vessels below the injury vasoconstrict * This causes extreme hypertension 130/150 * A pounding headache, flushing, sweating above level of injury

* Nasal stuffiness, blurred vision, Goosebumps * Nausea, dilated pupils s

So think about AD
* Any time the quad feels

weird, upset, looks strange, says I have a terrible headache


* What to do is intervene

immediately to prevent a CVA, seizures, brain damage


* Intervene and then check it

out

* Need outcome of normal

BP and no headache, odd feelings


* So remove noxious stimuli

Emergency interventions AD
* If you suspect AD raise HOB immediately to 90 degrees or assist to upright to drop BP * Remove TEDS, SCDS * Now check BP and continue q 2-3 mins * Stay c pt but get help to call doc

* Speed is essential but you stay calm * No Crede, remove kinks- if no cath may have to immed straight cath if bladder distended

Interventions Autonomic Dysreflexia


* Remove noxious stimuli* Establish good bowel regime so this doesnt happen * Handle pressure areas/ulcersturn off area * Loosen clothing, bed sheets

* Check skin surfaces and may need topical anesthetic * Give ordered antihypertensives- nitrates, Nifedipine (procardia) apresoline

Constipation
* Obviously this can become serious problem * May need manual disimpactions,or enema but watch for AD

* If UMN issue will eventually have a reflex bladder so use reflex to help empty- warm drink, increase intraabdom pressure, Crede, insure enough fluid intake, suppositories, anesthetic jelly * If no risk for AD, can use digital stim and disimpaction

Airway issues
* Depends on level of injury * Goal of RR 12-20, lungs clear, no adventitious * Head neutral, suction available

* If in halo will need to frequently check breathing, incentive spirometry to encourage * Assisted coughing as you hold you hand on pt diaphragm and have them exhale as you press up on diaphragm to make forceful cough

Disuse Issues
* Will want complete ROM of all parts * Position change* Hand splints with spasticity issues

* Find out triggers of spasmscold, anxiety, fatigue, emotion, infection, distention, tight clothes, lack of position change * Position, ROM frequently, heat, vibration, touch is more firm and deep to prevent spasms

Promote Mobility
* Monitor for tendon contractures, joint ankylosis, muscle shortening * Supports to match the deficits so appropriate use of adaptive devices * Cushions to prevent ulcerations * Proper fitting wheelchairs

* Strengthen muscles and support with braces * Active and passive conditioning

Muscle Weakness & fatigue


* Continue to watch wrists

and foot drop


* Arm slings- a lot is similar

to stroke
* Exercise to tolerance- what

can pt do
* Wt bear if any possibility- to

stimulate osteoblasts
* Tilt tables, stand and prone

to prevent hip contractures

* Shoes that fit

Pain
* Almost all of these patients have pain- so pain clinic but danger of opiod dependency * Dysesthetic pain- distal to injury
* Like phantom pain- disabling * NSAIDs, elavil, neurontin, lyrica, tegretol,Tens * Follows the dermatome * Goal is to verbalize pain relief

Spasticity

* As recovery progresses- get stronger flexors begin to contract and extensor muscle spasms * Spasticity is increased muscle tone wh results in stiffness * Can initiate spastic behaviors even with emotion, touch, temp * Can optimize and recruit spasticity for trunk support, to hold position and to help urinate

Spasticity

* But painful recurrent spasm

with forced flexion or adduction of lower limbs can interfere with sitting or ambulating
* Nurses job is to decrease

noxious stimulation
* So need ROM- ongoing PT * Meds> Baclofen, Dantrium,

Klonopin ( danger)

Neurogenic Bladder
* In early phase were atonic- and cathed for months with danger or stone, UTI
* Cath was to prevent overdistention

* Now u still check for distention, I&O, asepsis * Keep urine acidic * Give enough fluids * Then now move into 2 types of bladder
* UMN * LMN

UMN- spastic Bladder


* This is spastic reflex bladder * Will be incontinent, dribbling, oft wet * Goal it a routine train bladder to void on time or on cue

* This bladder can be TRAINED so wont need cath


* Tap suprapubic, bear down, lean on commode and anal stretch * Baclofen helps here * Valsalva to empty as well

Flaccid Bladder- LMN


* This is like an old sac- S

injury from disrupted reflex arcs


* Increase intrabdominal

pressure to overcome sphincter


* Crede method * Or may need intermitt cath

Heterotopic Ossification
* Form bone in abnormal loci

like hips and knees


* Note this on bone scan * Give ROM * May take med didronel to

resorpt bone

What do you think are long term issues


* Mainly are disuse

syndromes

* Paralysis, immobilization,

spasticity
* Worry decubiti * Worry UTI * Prevent spasms-cold, anx,

fatigue, infection, ulcers, tight clothes, staying in one space


* Cooling, icing, heat,

vibration, massage,

SEX
* All think about it but may

not verbalize it directly

* Nurse must address as you

are there
* Goal is a personally

satisfying relationship
* So need to verbalize needs * If they PICK YOU_ YOU

TALK
* And then get some help with

what you cant do

Sex
* Will need to examine own

values- elicit pt concerns, ask questions, listen

* Expect acting out- will need

to set limits but understand from whence

Sex
* Psychogenic erection- from sexual thoughts- this is lesion above T11-L2- above this will not get idea thru damage * Reflexogenic erection- this is from penile stimulation - may get with a cath change or bath
* Length will vary as will presentation r/t level of injury * Cervical and thoracics get better erections * LS damage may destroy the reflex arc

* Spontaneous erection- oft happens when bladder is full and causes internal stimulationthis is a S2-4 level

Sex and Women


* May have trouble with

lubrication, orgasm but generally will ovulate- can become pregnant, deliver vaginally- uterine contractions can cause AD
* Will need to think birth

control,
* Worry UTI, pressure sores,

anemia

* Labor will be painless or

terrible

Goals then
* Maintain optimal function

with the most independence possible


* Mobility, transfer, feed,

ADLs
* Work, computer * Normal psych and coping

Spinal Cord Tumors


* Or infarcts * Can be intradural or extradural * Primary or metastatic

* Prognosis depends on site and type * If get spinal cord compression will need immediate relief
* Steroids will remove swelling and then get to surgery to decompress

* So how would you know, assess, chart

Spinal cord compression


* This is a medical emergency * Will need OR ASAP * See in mets from breast, lung, prostate, kidney * 85% will go to vertebral body

* Get edema, inflammation , nerve entrapment * Presents as back pain, motor weakness or decreased sensation * Can take months to develop

Late signs of compression


* Motor, sensory, Proprioceptive, vibration loss * Dysfunction of bowel/bladder * All have back pain, usu localized * Constant pain wh worsen in supine position

* Also burning, shooting * Motor weakness is heavy, stiff, paralysis, once motor have 75% blockage of cord * Sensory with paresthesia, decreased temp * So will need X-Ray, MRI, find those at risk

Tx of Spinal Cord Compression


* Steroids immediately

reduce edema
* Radiation therapy to

decompress over a 2-4 weeks above and below

* Or surgery * Will also need pain

management
* Tricyclics, Dilantin,

neurontin, tegretol
* Prevent neuron firing,

potentiate analgesia
* Will also elevate mood

So think rehab
* And Health South