Spinal cord injury

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/