Spinal Cord Injury: What Now? Expected Outcomes.

 Maura

Nee RNP  Elizabeth Tammaro RN, CRRN
VA Boston Healthcare System SCI Out Patient Clinic

Objectives: 
Discuss

Anatomy and Physiology of the Spinal Cord  Understand the Impact of Neurologic Level of Injury (LOI) and ASIA Classification  Discuss Expected Functional Outcomes Specific to LOI  Understand Role of the Nurse in Achieving Functional Outcomes

SCI Statistics (2002) 
    

250,000 in USA Paraplegic: 52% Quadriplegia: 47% New SCI/yr: 11,000 Male: 82% 16yr-30yr: 56% 

Causes
± ± ± ± ± MVA: 37% Violence: 28% Falls: 21% Sports: 6% Other: 8% 

89%: D/C¶d home

Anatomy of the Spine 
Vertebrae

± Body
‡ Front section, shaped like drum ‡ Supports weight

± Lamina
‡ Towards the back ‡ Boney arch surrounds spinal canal

± Spinous process
‡ Boney process from arch ‡ Points of attachment for muscles and ligaments 

Discs
‡ Cushions between vertebrae

Anatomy of the Spine 

Vertebrae:
± 7 Cervical
‡ Flexion, extension, bending and turning of head

± 12 Thoracic
‡ Chest region, allows mostly for rotation

± 5 Lumbar
‡ Larger boney structures to support added wgt

± 5 Sacral
‡ Fused together

± Coccyx

Anatomy of the Cord 
Cervical

Cord

± C1-C2: ± C3-4: Phrenic nucleus ± C4: Deltoids ± C4-5: Biceps ± C6: Wrist extensors ± C7: Triceps ± C8: Wrist extensors ± C8-T1: Hand muscles

Anatomy of the Cord 
Thoracic

Cord

‡ Intercostal muscles and associated dermatones 

Lumbarsacral
‡ Starts at T9 and continues to L2 ‡ Innervates hips, legs, buttocks and anal region 

Cauda

Equina (horses tail)

‡ Spinal cord ends at L2 ‡ Tip called conus, below conus a spray of spinal roots

Dermatomes/Sensory Level 
Dermatome:

± patch of skin innervated by a given spinal cord level

C2 to C4. The C2 dermatome

Myotomes/Motor Level 
Myotome:

± Spinal nerve roots which innervates muscles groups ± Most muscles are innervated by more than one root

ASIA Impairment Scale
± ASIA A: Complete: no motor or sensory function is preserved in the sacral segments S4-S5 ± ASIA B: Incomplete: sensory but NOT motor function is preserved below the neurological level and includes the sacral segments ± ASIA C: Incomplete: motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade <3 ± ASIA D: Incomplete: motor function is preserved w/ muscle grade > 3 ± ASIA E: Normal

Definition of Disability 
Tetraplegia

(preferred to quadriplegia)

± Refers to impairment or loss of motor/sensory function in cervical segments of the spinal cord ± Impairment of function in arms, trunk, legs and pelvic organs ± ASIA Scale vs quadriparesis

Definition of Disability 
Paraplegia

± Refers to impairment or loss of motor/sensory function in thoracic, lumbar or sacral segments of the spinal cord ± Arm function spared ± Possible impairment of function in trunk, legs and pelvic organs ± ASIA Scale vs paraparesis

Clinical Syndromes
± Central Cord Syndrome:
‡ lesion occurring almost exclusively in the cervical region ‡ Sacral sensory sparing ‡ Weakness > UE vs LE

± Brown-Sequard Syndrome:
‡ Lesion that produces ipsilateral, proprioceptive and motor loss and contralateral loss of sensitivity to pain and temp

Clinical Syndromes
± Anterior Cord Syndrome:
‡ Lesion that produces variable loss of motor function and of sensitivity while preserving proprioception

± Cauda Equina Syndrome:
‡ Injury to the lumbosacral nerve roots w/ in the neurocanal resulting in areflexive bladder, bowel and lower limbs

Achievement of Functional Goals 
   

Age Body type Comorbidities Prior athletic sense Fatigue level 

   

Type of stabilization HX HO/POA Spasticity Psychosocial factors Nutrition

Functional Outcomes 
Motor/sensory

recovery  Ability to perform or direct ADLs  Social reintegration  Quality of life

Functional Outcomes 
LEVEL

C1-C3

± Limited head/neck movement ± Rotate/flex neck (sternocleidomastoid) ± Extend neck (cervical paraspinals) ± Speech and swallowing (neck accessories) ± Total paralysis of trunk,UE and LE

LEVEL: C1-3
± 24 hr care needs ± Able to direct care needs 
ADLs

± Ventilator dependent ± Impaired communication ± Dependent for all care needs 
Mobility

± Power wheelchair ± Hoyer lift

LEVEL: C1-C3 
Equipment

Needs

± Adapted computer ± Bedside/portable ventilator ± Suction machine ± Specialty bed ± Hoyer ± Reclining shower chair

Functional Outcomes 
LEVEL:

C4

± Head and neck control (cerv paraspinals) ± Shoulder shrug (upper traps) ± Inspiration(diaphragm) ± Lack of shoulder control (deltoids) ± Paralysis of trunk, UE and LE ± Inability to cough, low respiratory reserve

LEVEL: C4
± 24 hr care needs ± Able to direct care needs 
ADLs

± May or may not be vent dependent ± Improved communication ± Assisted cough ± Dependent for all care needs 
Mobility

± Power wheelchair ± Hoyer lift

LEVEL: C4 
Equipment

Needs

± Adapted computer ± Bedside/portable ventilator as needed ± Suction machine ± Specialty bed ± Hoyer ± Reclining shower chair

Functional Outcomes 
LEVEL:

C5

± Shoulder control (deltoids) ± Elbow flexion (biceps/elbow flexors) ± Supinate hands (brachialis and brachioradialis) ± Lack elbow extension and hand pronation ± Paralysis of trunk and LE

LEVEL: C5
± 10hrs personal care need ± 6 hrs homemaking assistance 
ADLs

± Set-up/equipment: eating, drinking, face wash and teeth ± Assisted cough ± Dependent for bowel, bladder and lower body hygiene ± Dependent for bed mobility and transfers

LEVEL: C5 
Mobility

± Hoyer or stand pivot ± Power wheelchair w/ hand controls ± Manual wheelchair ± Drive motor vehicle w/ hand controls 
Equipment

Needs

± Power and manual wheelchairs ± Adaptive splints/braces ± Page turners/computer adaptations

Functional Outcomes 
LEVEL:

C6

± Wrist extension (extensor carpi ulnaris and extensor carpi radialis longus/brevis) ± Arm across chest (clavicular pectrocialis) ± Lack elbow extension (triceps) ± Lack wrist flexion ± Lack hand control ± Paralysis of trunk and LE

LEVEL: C6
± 6 hrs personal care needs ± 4hrs homemaking assistance 
ADLs

± Assisted cough ± Set-up for feeding, bathing and dressing ± Independent pressure relief, turns and skin assessment ± May be independent for bowel/bladder care

LEVEL: C6

Mobility
± Independent slide board transfer ± Manual wheelchair ± Drive with adaptive equipment

Functional Outcomes 
LEVEL:

C7

± Elbow flexion and extension (biceps/triceps) ± Arm toward body (sternal pectoralis) ± Lack finger function ± Lack trunk stability

LEVEL: C7
± 6hrs personal care needs ± 2hrs homemaking assistance 
ADLs

± More effective cough ± Fewer adaptive aids ± Independent w/ all ADLs ± May need adaptive aids for bowel care

LEVEL: C7 
Mobility

± Manual wheelchair ± Transfers without adaptive equipment

Functional Outcomes 
LEVEL:
‡ ‡ ‡ ‡

C8-T1

± Increased finger and hand strength
Finger flexion (flexor digitorum) Finger extension (extensor communis) Thumb movement (policus longis brevis) Separate fingers (introssi separates)

LEVEL: C8-T1
± 4hrs personal care needs ± 2hrs homemaking assistance 
ADLs

± Independent w/ or w/o assistive devices ± Assist w/ complex meal prep and home management 
Mobility

± Manual wheelchair

Functional Outcomes 
LEVEL:

T2-T6

± Normal motor function of head, neck, shoulders, arms, hands and fingers ± Increased use of intercostals ± Increase trunk control (erector spinae)

LEVEL: T2-T6
± 3hrs personal care needs/homemaking 
ADLs

± Independent in personal care 
Mobility

± Manual wheelchair ± May have limited walking with extensive bracing ± Drive with hand controls

Functional Outcomes 
LEVEL:

T7-T12

± Added motor function ± Increased abdominal control ± Increased trunk stability

LEVEL: T7-T12
± 2 hrs personal care needs/homemaking 
ADLs

± Independent ± Improved cough ± Improved balance control 
Mobility

± Manual wheelchair ± May have limited walking with bracing ± Driving with hand controls

Functional Outcomes 
LEVEL:
‡ ‡ ‡ ‡

L2-L5

± Added motor function in hips and knees
L2 Hip flexors (iliopsas) L3 Knee extensors (quadriceps) L4 Ankle dorsiflexors (tibialis anterior) L 5 Long toe extensors (ext hallucis longus)

LEVEL: L2-L5
± May need 1hr personal care/homemaking 
ADLs

± Independent 
Mobility

± Manual wheelchair ± May walk short distance with braces and assistive devices ± Driving with hand controls

Functional Outcomes 
LEVEL:

S1-S5

± Ankle plantar flexors (gastrocnemius) ± Various degrees of bowel, bladder and sexual function ± Lower level equals greater function

LEVEL: S1-S5
± No personal or homemaker needs 
ADLs

± Independent 
Mobility

± Increased ability to walk with less adaptive/supportive devices ± Manual w/c for distance

Functional Outcomes 
Achieving

maximum functional outcomes provides the opportunity to reach the highest level of independence and quality of life

Functional Outcomes 
Power

Point presentation can be found:

www1.va.gov/spinalcordboston/

Sign up to vote on this title
UsefulNot useful