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Care of Patients with Problems of the Central

Nervous System: The Spinal Cord

Chapter 45

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Spinal Cord

QuickTime™ and aYUV420 codec decompressor

are needed to see this picture.

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Lumbosacral Back Pain (Low Back Pain)

Herniated nucleus pulposus

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Health Promotion and Maintenance

Good posture Proper lifting Exercise Ergonomics

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Patient-Centered Collaborative Care

Assessment Diagnostic assessment

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Nonsurgical Management

Positioning Drug therapy Heat therapy Physical therapy Weight control Complementary and alternative therapies

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Surgical Management

Minimally invasive surgery: Percutaneous lumbar diskectomy Thermodiskectomy Laser-assisted laparoscopic lumbar

diskectomy Conventional open surgical procedures:

Diskectomy Laminectomy Spinal fusion

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Postoperative Care

Prevention and assessment of complications

Neurologic assessment; vital signs Patient’s ability to void Pain control Wound care CSF check Patient positioning and mobility

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Community-Based Care

Home care management Health teaching Health care resources

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Cervical Neck Pain

Conservative treatment is the same as described for back pain except that the exercises focus on shoulder and neck.

If these treatments do not work, soft collar may be used at night for a period of no longer than 10 days.

If conservative treatment is ineffective, surgery such as an anterior cervical diskectomy and fusion is commonly performed.

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Spinal Cord Injuries

Hyperflexion injury Hyperextension injury Axial loading injury or vertical compression

such as those that occur in jumping Excessive rotation of the head beyond its

range Penetration injury, such as those wounds

caused by a bullet or a knife

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Spinal Cord Injuries (Cont’d)

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Spinal Cord Injuries (Cont’d)

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Common Spinal Cord Syndromes

Complete lesion Anterior cord syndrome Posterior cord lesion Brown-Séquard syndrome Central cord syndrome

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Common Spinal Cord Syndromes (Cont’d)

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Anterior Cord Syndrome

Damage to the anterior portion of both gray and white matter of the spinal cord

Usually a result of decreased blood supply Motor function and pain and temperature

lost below the level of the injury Sensations of touch, position, and

vibration remain intact

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Posterior Cord Lesion

Damage to the posterior gray and white matter of the spinal cord

Motor function remains intact Patient experiences loss of vibratory

sense, touch, and position sensation

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Brown-Séquard Syndrome

Results from penetrating injuries that cause hemisection of the spinal cord, or injuries that affect half of the spinal cord.

Motor function, proprioception, vibration, deep touch sensations are lost on the same side (ipsilateral) of the body as the lesion.

Opposite side (contralateral) of the body sensations of pain, temperature, light touch are affected.

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Central Cord Syndrome

Lesions of the central portion of the spinal cord.

Loss of motor function is more pronounced in the upper extremities than in the lower extremities.

Varying degrees and patterns of sensation remain intact.

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SCI: Etiology

Trauma is the leading cause Incidence/prevalence

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Patient with SCI: Initial Assessment

First priority is assessment of the patient’s airway, breathing pattern, and circulation status

Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites

Assessment of level of consciousness using Glasgow Coma Scale

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Initial Assessment (Cont’d)

Establishment of level of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, and paraparesis

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Spinal Shock/Spinal Shock Syndrome

This condition occurs immediately as a concussion response to the injury. The patient has: Flaccid paralysis Loss of reflex activity below the level of the

lesion Usually resolves within 24 hours Muscle spasticity begins in patients with

cervical or high thoracic injuries

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Assessment of Sensory and Motor Ability

Hypoesthesia Hyperesthesia

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Cardiovascular and Respiratory Assessment

Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system especially if the injury is above the 6th thoracic vertebra.

Cardiac dysrhythmias may result. Systolic BP below 90 requires treatment

because lack of perfusion to the spinal cord could worsen the patient’s condition.

Hypothermia.

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Cardiovascular and Respiratory Assessment (Cont’d)

Patients with cervical SCI are at risk for respiratory problems resulting from immobility or from an interruption of spinal innervations to the respiratory muscles.

Continued respiratory assessment including vital capacity and minute volume.

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Gastrointestinal and Genitourinary Assessment

Assess abdomen for indications of hemorrhage, distention, or paralytic ileus.

Assess for reflex or hypotonic bowel. Assess for areflexic bladder, which later

leads to urinary retention. Assess for neurogenic bladder.

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Other Assessments

Lower motor neuron assessment Upper motor neuron assessment Skin assessment Heterotrophic ossification assessment Psychosocial assessment Laboratory assessment Imaging assessment

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Nonsurgical Management

Constant assessment Assess for neurogenic shock. Neurogenic

shock is spinal shock with: Bradycardia Decreased or absent bowel sounds Warm, dry skin Hypothermia Hypotension

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Immobilization for Cervical Injuries

Fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury

Halo fixation and cervical tongs Stryker frame, rotational bed, kinetic

treatment table Pin site care and monitoring of traction

ropes

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Immobilization of Thoracic and Lumbosacral Injuries

For patients with thoracic injuries—bedrest and possible immobilization with a fiberglass or plastic body cast

For patients with lumbar and sacral injuries—immobilization of the spine with a brace or corset worn when the patient is out of bed; custom-fit thoracic lumbar sacral orthoses preferred

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Drug Therapy

Methylprednisolone (controversial) Dextran Atropine sulfate Dopamine hydrochloride Tizanidine Intrathecal baclofen

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Surgical Management

Emergency surgery necessary for spinal cord decompression

Decompressive laminectomy Spinal fusion Harrington rods to stabilize thoracic spinal

injuries

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Ineffective Airway Clearance and Breathing Pattern

Interventions for the patient with spinal cord injury: Airway management is the priority. Patients with injuries at or above the 6th

thoracic vertebra are especially at risk for respiratory complications.

Provide measures to maintain airway.

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Ineffective Airway Clearance and Breathing Pattern (Cont’d)

Assisted coughing, quad cough, cough assist Use of incentive Spiro meter

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Impaired Physical Mobility; Self-Care Deficit

Interventions include: In patients with spinal cord injury, monitor for

risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli.

Proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings.

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Impaired Physical Mobility; Self-Care Deficit (Cont’d)

Prevent orthostatic hypotension. Promote self-care.

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Impaired Urinary Elimination; Constipation

Interventions include: A bladder retraining program Spastic bladder—manipulating external area Flaccid bladder—Valsalva maneuver Encouraging consumption of 2000 to 2500 mL

of fluid daily to prevent urinary tract infection

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Impaired Urinary Elimination; Constipation (Cont’d)

Long-term renal complication Signs and symptoms of urinary tract

infection not perceived by the patient

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Autonomic Dysreflexia

Commonly seen in patients with upper spinal cord injury

Severe hypertension Bradycardia Severe headache Nasal stuffiness Flushing Treatment

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Establishing a Bowel Retraining Program

Consistent time for bowel elimination High fluid intake High-fiber diet Rectal stimulation (with or without

suppositories) Stool softener medications, as needed

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Impaired Adjustment

Interventions include: Invite patients to ask questions about

significant life changes; reply openly and honestly.

Encourage patients to discuss their perceptions of their situation and coping strategies that can be used.

Begin a patient education program to clarify misconceptions.

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Community-Based Care

Home care management Health teaching Health care resources

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Spinal Cord Tumors Primary spinal cord tumors Intramedullary tumors Extramedullary tumors

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Patient-Centered Collaborative Management

Assessment Diagnostic assessment Surgical management—need for

emergency surgery Nonsurgical management—radiation,

chemotherapy

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Community-Based Care

Home care management Health teaching Health care resources

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Multiple Sclerosis

Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the CNS

Characterized by periods of remission and exacerbation

Inflammatory response resulting in random or patchy areas of plaque in the white matter of the CNS

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Multiple Sclerosis (Cont’d)

Etiology Genetic risk Incidence Prevalence

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Major Types of Multiple Sclerosis

Relapsing-remitting Primary progressive Secondary progressive Progressive-relapsing

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Patient-Centered Collaborative Care

Patient history Physical assessment/clinical

manifestations Fatigue

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Common Physical Assessment Findings include:

Flexor spasms at night Intention tremor Dysmetria Blurred vision, diplopia, decreased visual

acuity, scotomas, nystagmus Hypalgesia, numbness, tingling, or burning Bowel and bladder dysfunction

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Assessment

Psychosocial assessment Laboratory assessment Other diagnostic tests

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Drug Therapy Therapies include:

Interferon beta Monoclonal antibodies Copaxone Novantrone Immunosuppressive therapy Methylprednisolone

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Drug Therapy (Cont’d)

Muscle relaxants Treatment of paresthesia Treatment of bladder dysfunction

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Other Interventions

Promoting mobility Managing symptoms Complementary and alternative therapies

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Community-Based Care

Home care management Health teaching Health care resources

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Amyotrophic Lateral Sclerosis

Known as Lou Gehrig’s disease, an adult onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity eventually leading to paralysis

Early symptoms—fatigue while talking, tongue atrophy, dysphagia, weakness of the hands and arms, fasciculations, nasal quality of speech, dysarthria

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Interventions

No known cure, no treatment, no preventive measures

Riluzole, only drug approved by FDA to extend survival time

Exercise and mobility program Management of swallowing difficulties Respiratory support